1
|
Krucoff M, Spirito A, Baber U, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Ticagrelor with or without aspirin following percutaneous coronary intervention in high-risk patients with concomitant peripheral artery disease: A subgroup analysis of the TWILIGHT randomized clinical trial. Am Heart J 2024; 272:11-22. [PMID: 38458371 DOI: 10.1016/j.ahj.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The optimal antiplatelet regimen after percutaneous coronary intervention (PCI) in patients with peripheral artery disease (PAD) is still debated. This analysis aimed to compare the effect of ticagrelor monotherapy versus ticagrelor plus aspirin in patients with PAD undergoing PCI. METHODS In the TWILIGHT trial, patients at high ischemic or bleeding risk that underwent PCI were randomized after 3 months of dual antiplatelet therapy (DAPT) to aspirin or matching placebo in addition to open-label ticagrelor for 12 additional months. In this post-hoc analysis, patient cohorts were examined according to the presence or absence of PAD. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke. Endpoints were assessed at 12 months after randomization. RESULTS Among 7,119 patients, 489 (7%) had PAD and were older, more likely to have comorbidities, and multivessel disease. PAD patients had more bleeding or ischemic complications than no-PAD patients. Ticagrelor monotherapy compared to ticagrelor plus aspirin was associated with less BARC 2, 3, or 5 bleeding in PAD (4.6% vs 8.7%; HR 0.52; 95%CI 0.25-1.07) and no-PAD patients (4.0% vs 7.0%; HR 0.56; 95%CI 0.45-0.69; interaction P-value .830) and a similar risk of death, MI, or stroke in these 2 groups (interaction P-value .446). CONCLUSIONS Despite their higher ischemic and bleeding risk, patients with PAD undergoing PCI derived a consistent benefit from ticagrelor monotherapy after 3 months of DAPT in terms of bleeding reduction without any relevant increase in ischemic events. CLINICAL TRIAL REGISTRY INFORMATION:: https://www. CLINICALTRIALS gov/study/NCT02270242.
Collapse
Affiliation(s)
- Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital, Roslyn, Roslyn, NY
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang 110016, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
2
|
Marschall AF, Duarte Torres J, Biscotti Rodíl B, Gómez Sánchez I, Basabe Velasco E, Ramos Alejos-Pita C, López Soberón E, Suárez Cuervo A, Álvarez Antón S, de la Torre Hernández JM, Martí Sánchez D. PRECISE-DAPT, ARC-HBR, or Simplified Clinical Evaluation for the Prediction of Major Bleeding After Percutaneous Coronary Intervention in older Patients. Am J Cardiol 2024; 219:103-109. [PMID: 38552712 DOI: 10.1016/j.amjcard.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/01/2024] [Accepted: 03/17/2024] [Indexed: 04/11/2024]
Abstract
Older patients have been remarkably underrepresented in bleeding risk cohorts. Thus, the PRECISE-DAPT (Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy) and Academic Research Consortium for High Bleeding Risk (ARC-HBR) scores are not validated in older adults. Therefore, we sought to evaluate the PRECISE-DAPT and ARC-HBR scores in an exclusively older population and assess the prognostic value of a truly simplified clinical evaluation (SCE), consisting of only 3 binary clinical variables (hemoglobin <11 g/100 ml, previous bleeding, and anticipated use of anticoagulants). This is a retrospective analysis of the prospective single-center older-HCD registry. Consecutive patients aged ≥75 years who underwent percutaneous coronary intervention from 2012 to 2019 were included. The primary end point was postdischarge bleeding at 12 months of follow-up, defined according to the Bleeding Academic Research Consortium 3 or 5 criteria. A total of 693 patients with a mean age of 81 (±4.4) years were included in the study and 60 patients (6.8%) met the primary end point. The PRECISE-DAPT and ARC-HBR scores did not significantly predict postdischarge bleeding in the Cox regression models (hazard ratio 1.65 [0.78 to 3.42] and 1.46 [0.72 to 4.24], respectively), whereas the SCE outperformed both scores (hazard ratio 2.47, 1.34 to 4.49). All 3 scores exhibited a moderate discriminatory potential, as determined by a receiver-operating characteristic curve analysis (areas under the curve 0.601, 0.621, and 0.616, respectively), with no significant differences between them. The SCE showed an Integrated Discrimination Improvement of 0.25, p = 0.02 (SCE vs ARC-HBR) and 0.24, p = 0.01 (SCE vs PRECISE-DAPT), with an Net Reclassification Improvement of 6.54%, p = 0.37 and 7.12%, p = 0.43, respectively. In conclusion, the PRECISE-DAPT score and ARC-HBR criteria showed insufficient predictive value in older adults. A truly SCE consisting of 3 easily accessible variables not only provides equal discriminatory potential but also demonstrates superior predictive value, as determined by Cox regression models. This makes it a highly appealing tool for risk stratification, pending its evaluation in larger prospective studies.
Collapse
Affiliation(s)
- Alexander Felix Marschall
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain; University of Alcalá, Madrid, Spain.
| | - Juan Duarte Torres
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
| | | | - Inés Gómez Sánchez
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain
| | | | | | | | | | | | | | - David Martí Sánchez
- Department of Cardiology, Central Defense Hospital Gómez Ulla, Madrid, Spain; University of Alcalá, Madrid, Spain
| |
Collapse
|
3
|
Wang B, Su Y, Ma C, Xu L, Mao Q, Cheng W, Lu Q, Zhang Y, Wang R, Lu Y, He J, Chen S, Chen L, Li T, Gao L. Impact of perioperative low-molecular-weight heparin therapy on clinical events of elderly patients with prior coronary stents implanted > 12 months undergoing non-cardiac surgery: a randomized, placebo-controlled trial. BMC Med 2024; 22:171. [PMID: 38649992 PMCID: PMC11036782 DOI: 10.1186/s12916-024-03391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Little is known about the safety and efficacy of discontinuing antiplatelet therapy via LMWH bridging therapy in elderly patients with coronary stents implanted for > 12 months undergoing non-cardiac surgery. This randomized trial was designed to compare the clinical benefits and risks of antiplatelet drug discontinuation via LMWH bridging therapy. METHODS Patients were randomized 1:1 to receive subcutaneous injections of either dalteparin sodium or placebo. The primary efficacy endpoint was cardiac or cerebrovascular events. The primary safety endpoint was major bleeding. RESULTS Among 2476 randomized patients, the variables (sex, age, body mass index, comorbidities, medications, and procedural characteristics) and percutaneous coronary intervention information were not significantly different between the bridging and non-bridging groups. During the follow-up period, the rate of the combined endpoint in the bridging group was significantly lower than in the non-bridging group (5.79% vs. 8.42%, p = 0.012). The incidence of myocardial injury in the bridging group was significantly lower than in the non-bridging group (3.14% vs. 5.19%, p = 0.011). Deep vein thrombosis occurred more frequently in the non-bridging group (1.21% vs. 0.4%, p = 0.024), and there was a trend toward a higher rate of pulmonary embolism (0.32% vs. 0.08%, p = 0.177). There was no significant difference between the groups in the rates of acute myocardial infarction (0.81% vs. 1.38%), cardiac death (0.24% vs. 0.41%), stroke (0.16% vs. 0.24%), or major bleeding (1.22% vs. 1.45%). Multivariable analysis showed that LMWH bridging, creatinine clearance < 30 mL/min, preoperative hemoglobin < 10 g/dL, and diabetes mellitus were independent predictors of ischemic events. LMWH bridging and a preoperative platelet count of < 70 × 109/L were independent predictors of minor bleeding events. CONCLUSIONS This study showed the safety and efficacy of perioperative LMWH bridging therapy in elderly patients with coronary stents implanted > 12 months undergoing non-cardiac surgery. An alternative approach might be the use of bridging therapy with half-dose LMWH. TRIAL REGISTRATION ISRCTN65203415.
Collapse
Affiliation(s)
- Bin Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yanhui Su
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Cong Ma
- Health Management Institute, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Lining Xu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qunxia Mao
- National Research Institute for Family Planning, Beijing, China
| | - Wenjia Cheng
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Qingming Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Ying Zhang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Rong Wang
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Yan Lu
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Jing He
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Shihao Chen
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China
| | - Lei Chen
- Department of Thoracic Surgery of The First Medical Center, General Hospital of Chinese People's Liberation Army, Beijing, 100853, China.
| | - Tianzhi Li
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| | - Linggen Gao
- Department of Comprehensive Surgery, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, 100853, China.
| |
Collapse
|
4
|
d'Entremont MA, Alrashidi S, Seto AH, Nguyen P, Marquis-Gravel G, Abu-Fadel MS, Juergens C, Tessier P, Lemaire-Paquette S, Heenan L, Skuriat E, Tyrwhitt J, Couture ÉL, Bérubé S, Jolly SS. Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration. EUROINTERVENTION 2024; 20:66-74. [PMID: 37800723 PMCID: PMC10758987 DOI: 10.4244/eij-d-22-00809] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/01/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results. AIMS We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis. METHODS We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days. RESULTS A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009). CONCLUSIONS In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.
Collapse
Affiliation(s)
- Marc-André d'Entremont
- Population Health Research Institute, Hamilton, ON, Canada
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
- McMaster University, Hamilton, ON, Canada
| | | | | | - Phong Nguyen
- Western Sydney University, Campbelltown, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | | | - Mazen S Abu-Fadel
- Oklahoma Heart Hospital, Oklahoma City, OK, USA and University of Oklahoma, Norman, OK, USA
| | - Craig Juergens
- University of New South Wales, Sydney, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Pierre Tessier
- Hôpital du Sacré-Coeur-de-Montréal, Montreal, QC, Canada
| | | | - Laura Heenan
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Étienne L Couture
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Simon Bérubé
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
| |
Collapse
|
5
|
Otsuka Y, Ishii M, Ikebe S, Nakamura T, Tsujita K, Kaikita K, Matoba T, Kohro T, Oba Y, Kabutoya T, Kario K, Imai Y, Kiyosue A, Mizuno Y, Nochioka K, Nakayama M, Iwai T, Miyamoto Y, Sato H, Akashi N, Fujita H, Nagai R. BNP level predicts bleeding event in patients with heart failure after percutaneous coronary intervention. Open Heart 2023; 10:e002489. [PMID: 38065584 PMCID: PMC10711837 DOI: 10.1136/openhrt-2023-002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/15/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVE This study aimed to investigate the association between heart failure (HF) severity measured based on brain natriuretic peptide (BNP) levels and future bleeding events after percutaneous coronary intervention (PCI). BACKGROUND The Academic Research Consortium for High Bleeding Risk presents a bleeding risk assessment for antithrombotic therapy in patients after PCI. HF is a risk factor for bleeding in Japanese patients. METHODS Using an electronic medical record-based database with seven tertiary hospitals in Japan, this retrospective study included 7160 patients who underwent PCI between April 2014 and March 2020 and who completed a 3-year follow-up and were divided into three groups: no HF, HF with high BNP level and HF with low BNP level. The primary outcome was bleeding events according to the Global Use of Streptokinase and t-PA for Occluded Coronary Arteries classification of moderate and severe bleeding. The secondary outcome was major adverse cardiovascular events (MACE). Furthermore, thrombogenicity was measured using the Total Thrombus-Formation Analysis System (T-TAS) in 536 consecutive patients undergoing PCI between August 2013 and March 2017 at Kumamoto University Hospital. RESULTS Multivariate Cox regression showed that HF with high BNP level was significantly associated with bleeding events, MACE and all-cause death. In the T-TAS measurement, the thrombogenicity was lower in patients with HF with high BNP levels than in those without HF and with HF with low BNP levels. CONCLUSIONS HF with high BNP level is associated with future bleeding events, suggesting that bleeding risk might differ depending on HF severity.
Collapse
Affiliation(s)
- Yasuhiro Otsuka
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - So Ikebe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taishi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
- Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahide Kohro
- Department of Clinical Informatics, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yusuke Oba
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Yasushi Imai
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Arihiro Kiyosue
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiko Mizuno
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Tokyo, Japan
- Development Bank of Japan Inc, Tokyo, Japan
| | - Kotaro Nochioka
- Division of Cardiovascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Masaharu Nakayama
- Department of Medical Informatics, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Takamasa Iwai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yoshihiro Miyamoto
- Open Innovation Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Naoyuki Akashi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hideo Fujita
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Ryozo Nagai
- Jichi Medical University School of Medicine, Tochigi, Japan
| |
Collapse
|
6
|
Yamamoto M, Hayashida K, Hengstenberg C, Watanabe Y, Van Mieghem NM, Jin J, Saito S, Valgimigli M, Nicolas J, Mehran R, Moreno R, Kimura T, Chen C, Unverdorben M, Dangas GD. Predictors of All-Cause Mortality After Successful Transcatheter Aortic Valve Implantation in Patients With Atrial Fibrillation. Am J Cardiol 2023; 207:150-158. [PMID: 37741105 DOI: 10.1016/j.amjcard.2023.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/13/2023] [Indexed: 09/25/2023]
Abstract
Prevalent and incident atrial fibrillation are common in patients who undergo transcatheter aortic valve implantation and are associated with impaired postprocedural outcomes, including mortality. We determined predictors of long-term mortality in patients with atrial fibrillation after successful transcatheter aortic valve implantation. The EdoxabaN Versus standard of care and theIr effectS on clinical outcomes in pAtients havinG undergonE Transcatheter Aortic Valve Implantation-Atrial Fibrillation (ENVISAGE-TAVI AF) trial (NCT02943785) was a multicenter, prospective, randomized controlled trial in patients with prevalent or incident atrial fibrillation after successful transcatheter aortic valve implantation who received edoxaban or vitamin K antagonists. A Cox proportional hazard model was performed to identify predictors of all-cause mortality using a stepwise approach for multiple regression analysis. In addition, we assessed the performance of different risk scores and prediction models using ENVISAGE-TAVI AF data. Of 1,426 patients in ENVISAGE-TAVI AF, 178 (12.5%) died during the follow-up period (median 548 days). Our stepwise approach identified greater risk of mortality with older age, impaired renal function, nonparoxysmal atrial fibrillation, excessive alcohol use, New York Heart Association heart failure class III/IV, peripheral artery disease, and history of major bleeding or predisposition to bleeding. The present model (concordance statistic [c-statistic] 0.67) was a better discriminator than were other frequently used risk scores, such as the Society of Thoracic Surgeons score (c-statistic 0.56); Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke, Vascular disease, Age 65 to 74 years, and Sex category (CHA2DS2-VASc) score (c-statistic 0.54); or Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, and Drugs/alcohol concomitantly (HAS-BLED) score (c-statistic 0.58). In ENVISAGE-TAVI AF, several modifiable and nonmodifiable clinical characteristics were significantly associated with greater long-term all-cause mortality. Improved risk stratification to estimate the probability of mortality after successful transcatheter aortic valve implantation in patients with atrial fibrillation may improve long-term patient prognosis.
Collapse
Affiliation(s)
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University, Vienna, Austria
| | - Yusuke Watanabe
- Division of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands
| | - James Jin
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Shigeru Saito
- Division of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Marco Valgimigli
- Division of Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland; Department of Cardiology, University of Bern, Bern, Switzerland
| | - Johny Nicolas
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York
| | - Raul Moreno
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Cathy Chen
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Martin Unverdorben
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - George D Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York.
| |
Collapse
|
7
|
Paradies V, Maurina M, Tonino P, Hofma SH, Vos J, van Kuijk JP, Oemrawsingh RM, Mafragi AA, Spano F, Pisters R, Polad J, Ijsselmuiden S, Cambero MM, Smits PC. Comparison of Supraflex Cruz 60 μm Versus Ultimaster Tansei 80 μm Stent Struts in High Bleeding Risk PCI Patients: Study design and Rational of Compare 60/80 HBR trial. Am J Cardiol 2023; 206:230-237. [PMID: 37708755 DOI: 10.1016/j.amjcard.2023.08.046] [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] [Received: 06/09/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023]
Abstract
Up to 45% of patients who underwent percutaneous coronary intervention (PCI) may have a high bleeding risk (HBR), depending on the bleeding risk definition.1 This condition is often associated with an enhanced risk of thrombotic events with a negative impact on short- and long-term outcomes,2-8 making the choice of an appropriate antithrombotic regimen after PCI particularly challenging. Advances in stent technologies, in which the introduction of newer generations of thinner strut drug-eluting stents (DES), have significantly reduced the rate of thrombotic complications and may justify a shorter dual antiplatelet therapy (DAPT) duration. Both in vitro and in vivo studies have shown that local hemodynamic factors may critically affect the natural history of atherosclerosis. Strut thickness correlates with flow disturbances and endothelial shear stress. Flow separation within struts determines areas of recirculation with low endothelial shear stress which promotes local concentration of activated platelets.9 By mitigating inflammation, vessel injury, and neointimal proliferation, thin and streamlined struts have been associated with faster vascular healing and re-endothelization and have resulted in lower rates of thrombotic events after PCI.10,11 The use of thin strut and ultra-thin strut stents may lead to a favorable trade-off in bleeding and ischemic events in patients with HBR. However, dedicated studies evaluating the performance of thin strut versus ultrathin strut stents in patients with HBR are lacking.
Collapse
Affiliation(s)
- Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands
| | - Matteo Maurina
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; XXX, Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Pim Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Sjoerd H Hofma
- Department of Cardiology, Medical Centrum Leeuwarden, The Netherlands
| | - Jeroen Vos
- Department of Cardiology, Amphia Hospital, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Rohit M Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Amar Al Mafragi
- Department of Cardiology, Zorgsaam Hospital, Terneuzen, The Netherlands
| | - Fabrizio Spano
- Department of Cardiology, Meander Hospital, Amersfoort, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | | | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands.
| |
Collapse
|
8
|
Joodi G, Palimar S, Press MC. Percutaneous Coronary Interventions in Women. Curr Atheroscler Rep 2023; 25:829-837. [PMID: 37815649 PMCID: PMC10618306 DOI: 10.1007/s11883-023-01150-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
PURPOSEOF REVIEW Cardiovascular disease is the leading cause of morbidity and mortality among women globally. Numerous studies show ongoing disparities in diagnosis, management, and outcomes of ischemic heart disease in women compared to men. We aim to review the factors contributing to sex-based differential outcomes of percutaneous coronary interventions in women. RECENT FINDINGS Hormonal influence on coronary arteries and progression of atherosclerosis in women results in distinct coronary plaque characteristics and unique pathological process such as spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary arteries. During the presentation of acute coronary syndromes, women are older and have higher burden of comorbidities, with higher short- and long-term mortality. Awareness of differences in vascular biology and unique risk factors for cardiovascular disease in women is essential for sustained improvement in cardiovascular mortality. Better representation of women in trials is crucial to address the gaps in knowledge and allow for individualized treatment approaches in women.
Collapse
Affiliation(s)
- Golsa Joodi
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sristi Palimar
- Institute for Society and Genetics, UCLA, Los Angeles, CA, USA
| | - Marcella Calfon Press
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| |
Collapse
|
9
|
Bikdeli B, Erlinge D, Valgimigli M, Kastrati A, Han Y, Steg PG, Stables RH, Mehran R, James SK, Frigoli E, Goldstein P, Li Y, Shahzad A, Schüpke S, Mehdipoor G, Chen S, Redfors B, Crowley A, Zhou Z, Stone GW. Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials. Circulation 2023; 148:1207-1219. [PMID: 37746717 DOI: 10.1161/circulationaha.123.063946] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI. METHODS We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding. RESULTS A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up. CONCLUSIONS In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.
Collapse
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT (B.B.)
| | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, French Alliance for Cardiovascular Trials, L'Institut national de la santé et de la recherche médicale U-1148, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.)
- Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Rod H Stables
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | | | - Enrico Frigoli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | | | - Yi Li
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY (G.M.)
| | - Shmuel Chen
- Weill-Cornell Cornell Medical Center/ New York-Presbyterian Hospital, New York, NY (S.C.)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | | | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
| |
Collapse
|
10
|
Pemmasani G, Ashwath A, Aronow WS, Yandrapalli S, Leighton J, John S. Six-month cardiovascular prognostic impact of type 1 And type 2 myocardial infarction in patients hospitalized for gastrointestinal bleeding. Eur J Intern Med 2023; 116:51-57. [PMID: 37500309 DOI: 10.1016/j.ejim.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 06/25/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Patients with gastrointestinal bleeding (GIB) are at an increased risk of cardiovascular events and myocardial infarction (MI). Myocardial supply-demand mismatch results in type 2 MI(T2MI) and atherosclerotic plaque rupture leads to type 1 MI(T1MI). Data comparing the prognostic impact of these MI types in GIB are sparse. METHODS Patients hospitalized for GIB were identified in the 2019 US Nationwide Readmissions Sample. In this population, we studied the differences in management of T1MI and T2MI, and the association of these MI types with in-hospital mortality and risk for 6-month MI and MI-related mortality. RESULTS Of 444,475 patients admitted for a GIB, 12,860 (2.9%) had an MI (1.7% T2MI, 1.2% T1MI). Patients with T1MI were more likely to receive coronary angiography and revascularization than patients with T2MI. In-hospital mortality occurred in 2.0% patients, at a significantly higher rate in patients with an MI (7.9% vs 1.8%; P < 0.001), and higher with T1MI (11.9%) than T2MI (5.3%; P < 0.001). Among the survivors, 2.2% patient had an MI within 6 months, at a significantly higher rate in patients with index MI (13.1% vs 2.0%, adjusted OR 4.3 95% CI 3.83-4.90; P < 0.001). Mortality during the subsequent MI occurred in 0.3% of all patients (12% with an MI), at a 6-fold higher rate in patients with index MI (1.7% vs 0.3%; adjusted OR 3.69 95% CI 2.75-4.95; P < 0.001). The elevated risks were associated with both MI types. The risks for 6-month MI and related mortality were similar between T1MI and T2MI (6-month AMI: adjusted OR for T2MI = 1.03, 95% 0.83-1.29; fatal MI: adjusted OR for T2MI = 1.5, 95% CI 0.85-2.7). CONCLUSION The occurrence of an MI is associated with a substantially elevated risk for subsequent AMI and related mortality in patients hospitalized for a GIB. This future prognostic impact was similar between T1MI and T2MI.
Collapse
Affiliation(s)
- Gayatri Pemmasani
- Department of Medicine, SUNY Upstate Medical University, 750 E Adam St, Syracuse, NY 13202, United States.
| | - Ashwini Ashwath
- Department of Medicine, SUNY Upstate Medical University, 750 E Adam St, Syracuse, NY 13202, United States
| | - Wilbert S Aronow
- Westchester Medical Center and New York Medical College, Valhalla, NY, United States
| | - Srikanth Yandrapalli
- Division of Cardiology, Warren Alpert School of Medicine at Brown University, Providence, RI, United States
| | - Jonathan Leighton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Phoenix, AZ, United States
| | - Savio John
- Division of Gastroenterology, SUNY Upstate Medical University, Syracuse, NY, United States
| |
Collapse
|
11
|
Thalmann I, Preiss D, Schlackow I, Gray A, Mihaylova B. Quality of care for secondary cardiovascular disease prevention in 2009-2017: population-wide cohort study of antiplatelet therapy use in Scotland. BMJ Qual Saf 2023:bmjqs-2023-016520. [PMID: 37775268 DOI: 10.1136/bmjqs-2023-016520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/01/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Antiplatelet therapy (APT) can substantially reduce the risk of further vascular events in individuals with established atherosclerotic cardiovascular disease (ASCVD). However, knowledge regarding the extent and determinants of APT use is limited. OBJECTIVES Estimate the extent and identify patient groups at risk of suboptimal APT use at different stages of the treatment pathway. METHODS Retrospective cohort study using linked NHS Scotland administrative data of all adults hospitalised for an acute ASCVD event (n=150 728) from 2009 to 2017. Proportions of patients initiating, adhering to, discontinuing and re-initiating APT were calculated overall and separately for myocardial infarction (MI), ischaemic stroke and peripheral arterial disease (PAD). Multivariable logistic regression and Cox proportional hazards models were used to assess the contribution of patient characteristics in initiating and discontinuing APT. RESULTS Of patients hospitalised with ASCVD, 84% initiated APT: 94% following an MI, 83% following an ischaemic stroke and 68% following a PAD event. Characteristics associated with lower odds of initiation included female sex (22% less likely than men), age below 50 years or above 70 years (aged <50 years 26% less likely, and aged 70-79, 80-89 and ≥90 years 21%, 39% and 51% less likely, respectively, than those aged 60-69 years) and history of mental health-related hospitalisation (45% less likely). Of all APT-treated individuals, 22% discontinued treatment. Characteristics associated with discontinuation were similar to those related to non-initiation. CONCLUSIONS APT use remains suboptimal for the secondary prevention of ASCVD, particularly among women and older patients, and following ischaemic stroke and PAD hospitalisations.
Collapse
Affiliation(s)
- Inna Thalmann
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - David Preiss
- MRC Population Health Research Unit, Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Iryna Schlackow
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Alastair Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Borislava Mihaylova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Health Economics and Policy Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| |
Collapse
|
12
|
Spirito A, Koh WJ, Sartori S, Vogel B, Feng Y, Baber U, Nicolas J, Snyder C, Kamaleldin K, Pileggi B, Rezvanizadeh V, Sweeny J, Sharma SK, Kini A, Pocock SJ, Dangas G, Mehran R. Fatal, ischemic and bleeding risk of patients meeting the selection criteria of the TWILIGHT trial: Insights from a large PCI registry. Am Heart J 2023; 263:26-34. [PMID: 37094668 DOI: 10.1016/j.ahj.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND The TWILIGHT trial (NCT02270242) demonstrated that in selected high-risk patients undergoing percutaneous coronary intervention (PCI) ticagrelor monotherapy significantly reduced bleeding complications without ischemic harm as compared to ticagrelor plus aspirin after 3-month of dual antiplatelet therapy. The aim of this analysis was to assess the applicability of the findings TWILIGHT trial to a real-world population. METHODS Patients undergoing PCI at a tertiary center between 2012 and 2019 and not meeting any TWILIGHT exclusion criterion (oral anticoagulation treatment, ST-segment elevation myocardial infarction [MI], cardiogenic shock, dialysis, prior stroke, or thrombocytopenia) were included. Patients were stratified into 2 groups based on whether they fulfilled the TWILIGHT inclusion criteria (high-risk) or not (low-risk). The primary outcome was all-cause death; the key secondary outcomes were MI and major bleeding at 1 year after PCI. RESULTS Out of 13,136 included patients, 11,018 (83%) were at high risk. At 1-year, these patients had an approximately 3 folds greater hazard of death (1.4% vs 0.4%, HR 3.63, 95% CI 1.70-7.77) and MI (1.8% vs 0.6%, HR 2.81, 95% CI 1.56-5.04) and a nearly 2 folds higher risk of major bleeding (3.3% vs 1.8%, HR 1.86, 95% CI 1.32-2.62) as compared to low-risk patients. CONCLUSION Among patients not meeting the TWILIGHT exclusion criteria from a large PCI registry, the high-risk inclusion criteria of the TWILIGHT trial were met by the majority of patients and were associated with an increased risk of mortality and MI and a moderately elevated risk of bleeding.
Collapse
Affiliation(s)
- Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Won-Joon Koh
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Samantha Sartori
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Birgit Vogel
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Yihan Feng
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Johny Nicolas
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Clayton Snyder
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Karim Kamaleldin
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Brunna Pileggi
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Vahid Rezvanizadeh
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Joseph Sweeny
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Samin K Sharma
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Annapoorna Kini
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.
| |
Collapse
|
13
|
Lucà F, Oliva F, Rao CM, Abrignani MG, Amico AF, Di Fusco SA, Caretta G, Di Matteo I, Di Nora C, Pilleri A, Ceravolo R, Rossini R, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Appropriateness of Dyslipidemia Management Strategies in Post-Acute Coronary Syndrome: A 2023 Update. Metabolites 2023; 13:916. [PMID: 37623860 PMCID: PMC10456563 DOI: 10.3390/metabo13080916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/26/2023] Open
Abstract
It has been consistently demonstrated that circulating lipids and particularly low-density lipoprotein cholesterol (LDL-C) play a significant role in the development of coronary artery disease (CAD). Several trials have been focused on the reduction of LDL-C values in order to interfere with atherothrombotic progression. Importantly, for patients who experience acute coronary syndrome (ACS), there is a 20% likelihood of cardiovascular (CV) event recurrence within the two years following the index event. Moreover, the mortality within five years remains considerable, ranging between 19 and 22%. According to the latest guidelines, one of the main goals to achieve in ACS is an early improvement of the lipid profile. The evidence-based lipid pharmacological strategy after ACS has recently been enhanced. Although novel lipid-lowering drugs have different targets, the result is always the overexpression of LDL receptors (LDL-R), increased uptake of LDL-C, and lower LDL-C plasmatic levels. Statins, ezetimibe, and PCSK9 inhibitors have been shown to be safe and effective in the post-ACS setting, providing a consistent decrease in ischemic event recurrence. However, these drugs remain largely underprescribed, and the consistent discrepancy between real-world data and guideline recommendations in terms of achieved LDL-C levels represents a leading issue in secondary prevention. Although the cost-effectiveness of these new therapeutic advancements has been clearly demonstrated, many concerns about the cost of some newer agents continue to limit their use, affecting the outcome of patients who experienced ACS. In spite of the fact that according to the current recommendations, a stepwise lipid-lowering approach should be adopted, several more recent data suggest a "strike early and strike strong" strategy, based on the immediate use of statins and, eventually, a dual lipid-lowering therapy, reducing as much as possible the changes in lipid-lowering drugs after ACS. This review aims to discuss the possible lipid-lowering strategies in post-ACS and to identify those patients who might benefit most from more powerful treatments and up-to-date management.
Collapse
Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | - Fabrizio Oliva
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy;
| | | | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00100 Roma, Italy
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Concetta Di Nora
- Department of Cardiothoracic Science, Azienda Sanitaria Universitaria Integrata di Udine, 33100 Udine, Italy
| | - Anna Pilleri
- Cardiology Unit, Brotzu Hospital, 09121 Cagliari, Italy
| | - Roberto Ceravolo
- Cardiology Department, Giovanni Paolo II Hospital, 88046 Lamezia Terme, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00100 Roma, Italy
| | | |
Collapse
|
14
|
Yeh JS, Chen WT, Tomlinson B, Tam WC, Chien LN. Comparing the effectiveness and safety of dual antiplatelet with ticagrelor or clopidogrel in elderly Asian patients with acute myocardial infraction. Front Cardiovasc Med 2023; 10:1143509. [PMID: 37008324 PMCID: PMC10060791 DOI: 10.3389/fcvm.2023.1143509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/27/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundCurrent guidelines recommend potent P2Y12 inhibitors for patients after acute coronary syndrome. However, the data on the efficacy and safety of potent P2Y12 inhibitors in elderly Asian populations was limited. We aimed to investigate the major adverse cardiovascular events (MACE), bleeding events, and net adverse clinical events (NACE) with ticagrelor and clopidogrel in Taiwanese patients aged 65 and older after acute myocardial infarction (AMI).MethodsThis retrospective population-based cohort study was conducted using data from the National Health Insurance Research Database. The AMI patients aged ≥65 years who underwent percutaneous coronary intervention (PCI) and survived after 1 month were included. The patients were separated into 2 cohorts depending on the type of dual antiplatelet therapy (DAPT) they received: ticagrelor plus aspirin (T + A) or clopidogrel plus aspirin (C + A). We used inverse probability of treatment weighting to balance the difference between these 2 study groups. The outcome included all-cause mortality, MACE (cardiovascular death, nonfatal ischemic stroke, and nonfatal myocardial infarction), intracerebral hemorrhage, major bleeding, and NACE which is composed of cardiovascular death, ischemic and hemorrhagic events. The follow-up period was up to 12 months.ResultsFrom 2013 to 2017, a total of 14,715 patients who met the eligibility criteria were separated into 2 groups: 5,051 for T + A and 9,664 for C + A. Compared to patients with C + A, patients who received T + A had a lower risk of cardiovascular death and all-cause death, with an adjusted HR of 0.57 [95% confidence interval (CI), 0.38–0.85, p = 0.006] and 0.58 (95% CI 0.45–0.74, p < 0.001), respectively. No differences were found in MACE, intracranial and major bleeding between the 2 groups. In addition, the patients with T + A had a lower risk of NACE with an adjusted HR of 0.86 (95% CI 0.74–1.00, p = 0.045)ConclusionAmong elderly AMI patients receiving DAPT after successful PCI, ticagrelor was a more favorable P2Y12 inhibitor than clopidogrel because of lowering the risk of death and NACE without increasing the risk of severe bleeding. Ticagrelor is an effective and safe P2Y12 inhibitor in Asian elderly survivors after PCI.
Collapse
Affiliation(s)
- Jong-Shiuan Yeh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Ting Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Brian Tomlinson
- Faculty of Medicine, Macau University of Science and Technology, Macao SAR, China
| | - Weng-Chio Tam
- Department of Cardiology, Centro Hospitalar Conde São Januário, Macao SAR, China
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Correspondence: Li-Nien Chien
| |
Collapse
|
15
|
Chang DH, Dumanski SM, Ahmed SB. Female sex-specific considerations to improve rigor and reproducibility in cardiovascular research. Am J Physiol Heart Circ Physiol 2023; 324:H279-H287. [PMID: 36563011 DOI: 10.1152/ajpheart.00462.2022] [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: 12/24/2022]
Abstract
Cardiovascular disease is the leading cause of death in women. Despite recognition of sex-specific differences in cardiovascular health, females are underrepresented across all aspects of cardiovascular research, playing a key role in reducing rigor and reproducibility in cardiovascular research and contributing to these poorer health outcomes. Therefore, we propose a framework to capture factors associated with the female sex at the preclinical, recruitment, data collection, and data analysis stages. In preclinical cardiovascular research, female experimental models are commonly excluded despite similar variability in findings compared with males. To reduce this sex bias, the inclusion of female models and the incorporation of sex as a biological variable are critical to improve reproducibility and inform clinical research and care. Although funding agencies have mandated the inclusion of women in clinical trials, greater efforts are needed to achieve optimal participation-to-prevalence ratio to increase the generalizability of results to real-world settings. Female participants face more stringent exclusion criteria in research compared with males owing to sex-specific factors. However, their routine exclusion from cardiovascular research is not only unethical but limits generalizability and applicability to clinical practice. Identifying sex assigned at birth, collecting information on female sex-specific and -predominant factors associated with cardiovascular health and risk, and stratifying data by sex, including adverse events, are essential to ensure reproducibility and relevance of findings to target populations. Increasing female representation and the incorporation of female sex-specific cardiovascular risk factors in cardiovascular research will not only lead to enhanced rigor and reproducibility but improved cardiovascular health for all.
Collapse
Affiliation(s)
- Danica H Chang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M Dumanski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
16
|
Exploring the potential cost-effectiveness of a novel platelet assay for guiding dual antiplatelet therapy duration in acute coronary syndrome patients following percutaneous coronary intervention. Coron Artery Dis 2023; 34:24-33. [PMID: 36484217 DOI: 10.1097/mca.0000000000001194] [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] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) influences ischemic and bleeding events. Platelet expression of constant fragment of immunoglobulin, low affinity IIa, receptor (FcγRIIa) independently predicts risk of ischemic complications and is proposed as a tool to guide individualized care. METHODS We used a Markov model to predict lifetime ischemic and bleeding events and healthcare costs in acute myocardial infarction (MI) patients treated with PCI and DAPT and to project cost-effectiveness of platelet FcγRIIa-assay-guided care (30:3 months DAPT for patients at high: low ischemic risk) versus current standard care (12 months DAPT) from the perspective of the US healthcare system. Model inputs included assay sensitivity and specificity, ischemic and bleeding event rates, and impacts on quality of life, mortality, and costs. Assay cost was $90. Sensitivity analyses were conducted over a range of plausible clinical and cost assumptions. RESULTS Under base case assumptions, platelet FcγRIIa-assay-guided DAPT duration was projected to increase lifetime costs by $19 versus standard care, with an associated incremental cost-effectiveness ratio (ICER) of $436 per quality-adjusted life-year (QALY) gained. Assay-guided DAPT duration was consistent with high-value care (ICER < $50 000/QALY gained) over a broad range of alternative assumptions. CONCLUSION Based on a decision-analytic model, for patients with MI treated with PCI, the additional costs of the platelet FcγRIIa assay for guiding DAPT duration would be largely offset by reductions in downstream event-related costs, and assay-guided care would be highly cost-effective by current standards. These findings require confirmation in prospective studies and in a randomized clinical trial of assay-guided versus nonassay-guided DAPT duration.
Collapse
|
17
|
Madhavan MV, Howard JP, Brener MI, Der Nigoghossian C, Chen S, Makkar R, Osmancik P, Reddy VY, Holmes DR, Stone GW, Leon MB, Ahmad Y. Long-Term Outcomes of Randomized Controlled Trials Comparing Percutaneous Left Atrial Appendage Closure to Oral Anticoagulation for Nonvalvular Atrial Fibrillation: A Meta-Analysis. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100096. [PMID: 37275318 PMCID: PMC10236864 DOI: 10.1016/j.shj.2022.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/28/2022] [Accepted: 08/17/2022] [Indexed: 06/07/2023]
Abstract
Background Oral anticoagulation (OAC) has been considered the standard of care for stroke prophylaxis for patients with nonvalvular atrial fibrillation; however, many individuals are unable or unwilling to take long-term OAC. The safety and efficacy of percutaneous left atrial appendage closure (LAAC) have been controversial, and new trial data have recently emerged. We therefore sought to perform an updated meta-analysis of randomized clinical trials (RCTs) comparing OAC to percutaneous LAAC, focusing on individual clinical endpoints. Methods We performed a systematic search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from January 2000 through December 2021 for all RCTs comparing percutaneous LAAC to OAC in patients with nonvalvular atrial fibrillation. Fixed and random effects meta-analyses of hazard ratios (HRs) were performed using the longest follow-up duration available by intention-to-treat. The prespecified primary endpoint was all-cause mortality. Results Three RCTs enrolling 1516 patients were identified. The weighted mean follow-up was 54.7 months. LAAC was associated with a reduced risk of all-cause mortality (HR 0.76; 95% confidence interval [CI], 0.59-0.96; p = 0.023), hemorrhagic stroke (HR 0.24; 95% CI, 0.09-0.61; p = 0.003), and major nonprocedural bleeding (HR 0.52; 95% CI, 0.37-0.74; p < 0.001). There was no significant difference between LAAC and OAC for any other endpoints. Conclusions The available evidence from RCTs suggests LAAC therapy is associated with reduced long-term risk of death compared with OAC. This may be driven by reductions in hemorrhagic stroke and major nonprocedural bleeding. There were no significant differences in the risk of all stroke. Further large-scale clinical trials are needed to validate these findings.
Collapse
Affiliation(s)
- Mahesh V. Madhavan
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael I. Brener
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Der Nigoghossian
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Shmuel Chen
- Cardiovascular Research Foundation, New York, New York, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Vivek Y. Reddy
- The Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin B. Leon
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
18
|
Jiang Y, Liu Y, Jia X, Xin W, Wang H. The emerging role of adopting protamine for reducing the risk of bleeding complications during the percutaneous coronary intervention: A meta-analysis. J Card Surg 2022; 37:5341-5350. [PMID: 36352811 DOI: 10.1111/jocs.17139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The safety and the benefits of reducing the risk of bleeding complications via protamine administration during the percutaneous coronary intervention (PCI) remains unclear. This study aimed to systematically assessed the efficacy and safety of using protamine in PCI. METHOD Potential academic studies were identified from PubMed, Cochrane Library, EMBASE, and Web of Science. The time range we retrieved from was that from the inception of electronic databases to March 31, 2022. Gray studies were identified from the references of included literature reports. Stata version 12.0 statistical software (StataCorp LP) was used to analyze the pooled data. RESULTS A total of seven studies were involved in our study. The overall participants of the protamine group were 4983, whereas it was 1953 in the nonprotamine group. This meta-analysis indicated that protamine was preferable for PCI as its lower value of major bleeding (odds ratio [OR] = 0.489, 95% confidence interval [CI]: 0.362-0.661, p < .001) and minor bleeding (OR = 0.281, 95% CI: 0.123-0.643, p = .003). Additionally, the protamine did not tend to be related a higher incidence of mortality (p = .143), myocardial infarction (p = .990), and stent thrombosis (p = .698). CONCLUSIONS Based on available evidence, use of protamine may reduce the risk of bleeding complications without increasing the risk of mortality, myocardial infarction, and stent thrombosis. Given the relevant possible biases in our study, adequately powered and better-designed studies with long-term follow-up are required to reach a firmer conclusion.
Collapse
Affiliation(s)
- Yunshan Jiang
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Yuzhi Liu
- Department of Cardiology, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Xiaoli Jia
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| | - Wenqiang Xin
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongyan Wang
- Department of Pharmacy, Liaocheng People's Hospital, Liaocheng, People's Republic of China
| |
Collapse
|
19
|
Li J, Chen S, Ma S, Yang M, Qi Z, Na K, Qiu M, Li Y, Han Y. Safety and Efficacy of Bivalirudin versus Unfractionated Heparin Monotherapy in Patients with CAD and DM Undergoing PCI: A Retrospective Observational Study. Cardiovasc Ther 2022; 2022:5352087. [PMID: 36530956 PMCID: PMC9729030 DOI: 10.1155/2022/5352087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 10/24/2023] Open
Abstract
INTRODUCTION Optimal anticoagulants for patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) are unclear. This retrospective observational study is aimed at evaluating efficacy and safety of bivalirudin versus unfractionated heparin (UFH) monotherapy in patients with DM undergoing PCI. METHODS A total of 3890 diabetic patients receiving PCI in the General Hospital of Northern Theater Command were divided into the bivalirudin group (n = 869) and the UFH group (n = 3021) according to different anticoagulant therapy regimens. Indication for PCI was in accordance with current guidelines including national cardiovascular data registry. The primary endpoint was 30-day net adverse clinical events (NACEs). The secondary endpoints included 30-day major adverse cardiac and cerebral events (MACCEs), bleeding events defined according to the Bleeding Academic Research Consortium (BARC) definition, and stent thrombosis (ST). Patients were matched by propensity score at a ratio of 1 : 1. RESULTS After propensity score matching, the bivalirudin group was associated with a lower incidence of NACEs (3.0% vs. 6.0%, P = 0.003) than the UFH group. The incidence of MACCE (1.7% vs. 3.3%, P = 0.033) was significantly lower in the bivalirudin group, mainly due to a lower mortality rate (0.6% vs. 2.0%, P = 0.010). In addition, patients in the bivalirudin group had less bleeding (1.4% vs. 3.0%, P = 0.022) than those in the UFH group, although BARC 2, 3, and 5 bleeding (0.1% vs. 0.6%, P = 0.218) was numerically lower. CONCLUSION In diabetic patients undergoing PCI, bivalirudin was significantly associated with reduced risks of 30-day NACE and MACCE, mainly driven by the lower rates of bleeding and mortality, compared with heparin monotherapy.
Collapse
Affiliation(s)
- Jing Li
- The Graduate School of Harbin Medical University, Harbin, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Sanbao Chen
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Mingque Yang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| | - Yaling Han
- The Graduate School of Harbin Medical University, Harbin, China
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Province, China
| |
Collapse
|
20
|
Short dual antiplatelet therapy in patients with high bleeding risk undergoing percutaneous coronary intervention: a systematic review and meta-analysis. Coron Artery Dis 2022; 33:580-589. [DOI: 10.1097/mca.0000000000001180] [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: 11/03/2022]
|
21
|
Sun Y, Feng L, Li X, Wang Z, Gao R, Wu Y. In-hospital major bleeding in patients with acute coronary syndrome medically treated with dual anti-platelet therapy: Associated factors and impact on mortality. Front Cardiovasc Med 2022; 9:878270. [DOI: 10.3389/fcvm.2022.878270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveMajor bleeding is associated with poor hospital prognosis in patients with acute coronary syndrome (ACS). Despite its clinical importance, there are limited studies on the incidence and risk factors for major bleeding in ACS patients with dual anti-platelet therapy (DAPT) without access to revascularization.MethodsWe analyzed data from 19,186 patients on DAPT after ACS with no access to revascularization from Clinical Pathway for Acute Coronary Syndrome in China Phase 3 (CPACS-3) cohort, which was conducted from 2011 to 2014. Major bleeding included intracranial hemorrhage, clinically significant bleeding, or bleeding requiring blood transfusion. Factors associated with in-hospital major bleeding were assessed using Poisson regressions with generalized estimating equations to account for the clustering effect.ResultsA total of 75 (0.39%) patients experienced major bleeding during hospitalization. Among subtypes of ACS, 0.65% of patients with STEMI, 0.33% with NSTEMI, and 0.13% with unstable angina had in-hospital major bleeding (p < 0.001). The patients who experienced major bleeding had a longer length of stay (median 12 vs. 9 days, p = 0.011) and a higher all-cause in-hospital death rate (22.7 vs. 3.7%, p < 0.001). Multivariable analysis showed advancing age (RR = 1.52 for every 10 years increase, 95% CI: 1.13, 2.05), impaired renal function (RR = 1.79, 95% CI: 1.10, 2.92), use of fibrinolytic drugs (RR = 2.93, 95% CI: 1.55, 5.56), and severe diseases other than cardiovascular and renal diseases (RR = 5.56, 95% CI: 1.10, 28.07) were associated with increased risk of major bleeding, whereas using renin–angiotensin system inhibitors (RR = 0.54, 95% CI: 0.36, 0.81) was associated with decreased risk of major bleeding. These independent factors together showed good predictive accuracy with an AUC of 0.788 (95% CI: 0.734, 0.841).ConclusionAmong ACS patients on DAPT, advancing age, impaired renal function, thrombolytic treatment, and severe comorbidities were independently associated with a higher risk of in-hospital major bleeding.
Collapse
|
22
|
Yu XF, Chen HW, Xu J, Xu QZ, Zhang XH, Li BB, Xu BL, Ma LK. Bivalirudin vs. heparin on a background of ticagrelor and aspirin in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: A multicenter prospective cohort study. Front Cardiovasc Med 2022; 9:932054. [PMID: 36386368 PMCID: PMC9649932 DOI: 10.3389/fcvm.2022.932054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 10/05/2022] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE Current guidelines recommend potent P2Y12 inhibitors such as ticagrelor over clopidogrel as part of the dual antiplatelet therapy (DAPT) after ST-segment elevation myocardial infarction (STEMI), irrespective of final management strategy. The aim of this multicenter prospective cohort study was to examine the efficacy and safety of bivalirudin with background ticagrelor and aspirin therapy in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). METHODS A total of 800 patients with STEMI who were undergoing PPCI and receiving treatment with aspirin and ticagrelor from three Hospitals between April 2019 and September 2021 were included in this study. The patients were assigned, according to the perioperative anticoagulant, to the bivalirudin group (n = 456) or the heparin group (n = 344). In this study, the primary endpoint was 30-day net adverse clinical events (NACEs), a composite of major adverse cardiac or cerebral events (MACCEs, a composite of cardiac death, recurrent myocardial infarction, ischemia-driven target vessel revascularization, or stroke), or any bleeding as defined by the Bleeding Academic Research Consortium (BARC) definition (grades 1-5). RESULTS The patients were followed up for 30 days after PPCI. The incidence of NACE was significantly lower in the bivalirudin group than in the heparin group (11.2 vs. 16.0%, P = 0.042), and this significance was mainly a consequence of the reduction in BARC 1 bleeding events in the bivalirudin group compared to the heparin group (3.2 vs. 7.1%, P = 0.010). Results from multivariate Cox regression analysis showed that bivalirudin significantly reduced 30-day NACE (HR: 0.676, 95% CI: 0.462-0.990, P = 0.042) and BARC1 bleeding events (HR: 0.429, 95% CI: 0.222-0.830, P = 0.010). No significant between-group differences were observed for MACCE, all-cause mortality, cardiac death, recurrent myocardial infarction, stroke, target vessel revascularization, stent thrombosis, and BARC2-5 bleeding events at 30 days. CONCLUSION In patients with STEMI who were undergoing primary PCI and receiving treatment with aspirin and ticagrelor, bivalirudin was associated with decreased rates in NACE and minimal bleeding events without significant differences in the rates of MACCE or stent thrombosis when compared with heparin. Nevertheless, large randomized trials are warranted to confirm these observations. CLINICAL TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry (ChiCTR, http://www.chictr.org.cn; identifier [ChiCTR1900022529]). Registered on 15 April 2019. Registration title: Effect of bivalirudin combined with ticagrelor in patients with ST-segment elevation myocardial infarction during primary percutaneous coronary intervention.
Collapse
Affiliation(s)
- Xiao-Fan Yu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Hong-Wu Chen
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Jie Xu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Qi-Zhi Xu
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Xiao-Hong Zhang
- Department of Cardiology, The First People's Hospital of Hefei City, Hefei, China
| | - Bin-Bin Li
- Department of Cardiology, The First People's Hospital of Hefei City, Hefei, China
| | - Bang-Long Xu
- Department of Cardiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Li-Kun Ma
- Division of Life Sciences and Medicine, Department of Cardiology, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| |
Collapse
|
23
|
Rubinfeld GD, Berger JS, Smilowitz NR. Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence, Predictors, Management, and Outcomes. Am J Med 2022; 135:e263-e278. [PMID: 35469734 PMCID: PMC9761405 DOI: 10.1016/j.amjmed.2022.03.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/11/2022] [Accepted: 03/26/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Clinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding. METHODS Patients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment. RESULTS A total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01). CONCLUSION In the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.
Collapse
Affiliation(s)
- Gregory D Rubinfeld
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Conn
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Department of Surgery, New York University School of Medicine, New York, NY
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; Cardiology Section, Department of Medicine, Veterans Affairs New York Harbor Health Care System, New York, NY.
| |
Collapse
|
24
|
Cao D, Camaj A, Mehran R. Balance of Ischemia and Bleeding in Selecting Intensity and Duration of Antithrombotic Regimens. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
25
|
Association Between Platelet Reactivity and Long-Term Bleeding Complications After Percutaneous Coronary Intervention According to Diabetes Status. Am J Cardiol 2022; 171:49-54. [PMID: 35277255 DOI: 10.1016/j.amjcard.2022.01.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022]
Abstract
The relation between diabetes mellitus (DM) and bleeding complications after percutaneous coronary intervention (PCI) is controversial. This study investigates the role of low platelet reactivity (LPR) in the bleeding risk stratification of patients who underwent PCI according to DM status. A total of 472 patients who underwent PCI on aspirin and clopidogrel were included retrospectively. Platelet reactivity was assessed using the VerifyNow P2Y(12) assay. LPR was defined as platelet reactivity unit ≤178. The primary end point was the occurrence of any bleeding at 5 years stratified by DM status and LPR. DM was present in 30.5% of patients. LPR was less frequent in patients with DM (p = 0.077). Overall, 11.9% of patients experienced a bleeding complication at 5 years. The incidence of bleeding did not differ in subjects with and without DM (p = 0.24). LPR had a similar value for stratifying the increased bleeding risk in patients with and without DM (interaction p between DM and LPR 0.69). A stepwise increase in the crude rates of bleeding complications was observed across patients with and without LPR and DM (log-rank p = 0.004), with those affected by both conditions having the highest crude incidence rate. In conclusion, on top of aspirin, approximately 1/3 of patients who underwent PCI on clopidogrel have LPR. Assessment of LPR provides a significant incremental value for predicting bleeding irrespective of DM status. Although the presence of DM per se does not increase the incidence of hemorrhagic complications, the coexistence of DM and LPR identifies the subgroup with the highest bleeding risk.
Collapse
|
26
|
Doolub G, Kobo O, Mohamed MO, Ullah W, Chadi Alraies M, Velagapudi P, Matula JS, Roguin A, Bagur R, Mamas MA. Outcomes of Percutaneous Coronary Intervention in Patients With Acquired Immunosuppression. Am J Cardiol 2022; 171:40-48. [PMID: 35303973 DOI: 10.1016/j.amjcard.2022.01.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 12/12/2022]
Abstract
There are limited data on the clinical outcomes of percutaneous coronary intervention (PCI) in patients with acquired immunosuppression who are frequently underrepresented in clinical trials. All PCI procedures between October 2015 and December 2018 in the Nationwide Inpatient Sample were retrospectively analyzed, stratified by immunosuppression status. Multivariable logistic regression models were performed to examine (1) the association between immunosuppression status and in-hospital outcomes, expressed as adjusted odds ratio (aOR) with 95% confidence intervals (CIs) and (2) predictors of mortality among patients with severe acquired immunosuppression. In this contemporary analysis of nearly 1.5 million PCI procedures, approximately 4% of patients who underwent PCI had acquired immunosuppression. Of these, chronic steroid use accounted for approximately half of the cohort who underwent PCI who had acquired immunosuppression, with the remainder divided between hematologic cancer, solid organ active malignancy, and metastatic cancer, with the latter group having the highest rates of composite of in-hospital mortality or stroke (9.3%) (mortality 7.5% and acute ischemic stroke 2.4%). In conclusion, immunosuppression was independently associated with increased adjusted odds of adverse clinical outcomes, specifically mortality or stroke (aOR 1.11, 95% CI 1.06 to 1.15, p <0.001) and in-hospital mortality (aOR 1.21, 95% CI 1.13 to 1.29, p <0.001), with outcomes dependent on the cause of immunosuppression.
Collapse
|
27
|
Nakanishi N, Kaikita K, Ishii M, Kuyama N, Tabata N, Ito M, Yamanaga K, Fujisue K, Hoshiyama T, Kanazawa H, Hanatani S, Sueta D, Takashio S, Arima Y, Araki S, Usuku H, Nakamura T, Suzuki S, Yamamoto E, Soejima H, Matsushita K, Tsujita K. Malnutrition-associated high bleeding risk with low thrombogenicity in patients undergoing percutaneous coronary intervention. Nutr Metab Cardiovasc Dis 2022; 32:1227-1235. [PMID: 35197212 DOI: 10.1016/j.numecd.2022.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/04/2021] [Accepted: 01/11/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Although antithrombotic treatments are established for coronary artery disease (CAD), they increase the bleeding risk, especially in malnourished patients. The total thrombus-formation analysis system (T-TAS) is useful for the assessment of thrombogenicity in CAD patients. Here, we examined the relationships among malnutrition, thrombogenicity and 1-year bleeding events in patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS This was a retrospective analysis of 300 consecutive CAD patients undergoing PCI. Blood samples obtained on the day of PCI were used in the T-TAS to compute the thrombus formation area under the curve. We assigned patients to two groups based on the geriatric nutritional risk index (GNRI): 102 patients to the lower GNRI group (≤98), 198 patients to the higher GNRI group (98<). The primary endpoint was the incidence of 1-year bleeding events defined by Bleeding Academic Research Consortium criteria types 2, 3, or 5. The T-TAS levels were lower in the lower GNRI group than in the higher GNRI group. Kaplan-Meier analysis showed worse 1-year bleeding event-free survival in the lower GNRI group compared with the higher GNRI group. The combined model of the GNRI and the Academic Research Consortium for High Bleeding Risk (ARC-HBR) had good calibration and discrimination for bleeding risk prediction. In addition, having a lower GNRI and ARC-HBR positivity was associated with 1-year bleeding events. CONCLUSION A lower GNRI could reflect low thrombogenicity evaluated by the T-TAS and determine bleeding risk in combination with ARC-HBR positivity.
Collapse
Affiliation(s)
- Nobuhiro Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Japan.
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Naoto Kuyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Noriaki Tabata
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Miwa Ito
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenshi Yamanaga
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadashi Hoshiyama
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoshi Araki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Taishi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hirofumi Soejima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| |
Collapse
|
28
|
Abu-Assi E, Raposeiras-Roubín S, Cespón Fernández M, Caneiro Queija B, Melendo Viu M, Íñiguez Romo A. Aplicabilidad de los criterios de alto riesgo hemorrágico del Academic Research Consortium al síndrome coronario agudo sometido a intervención coronaria percutánea. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
29
|
Motiwala A, Jneid H. Reflections on the association of thrombocytopenia with adverse outcomes after PCI. Catheter Cardiovasc Interv 2022; 99:1498-1499. [PMID: 35476287 DOI: 10.1002/ccd.30209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Afaq Motiwala
- Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
30
|
Keskin K, Sığırcı S, Gürdal A, Ser ÖS, Kilci H, Sümerkan MÇ, Er A, Alyan Ö. In-Hospital Bleeding in Elderly Patients With Acute Coronary Syndrome: Are Potent Antiplatelet Agents Safe? Angiology 2022; 73:827-834. [PMID: 35348027 DOI: 10.1177/00033197221075858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite implementation of new interventional techniques and therapeutic advances, elderly patients with acute coronary syndrome (ACS) continue to be susceptible to in-hospital bleeding compared with younger ones. Thus, we investigated the incidence of in-hospital bleeding events and associated risk factors in elderly (≥ 75°years) ACS patients. We also wanted to define the bleeding sites, characteristics, and associated mortality. Bleeding Academic Research Consortium (BARC) classification type 2, 3, or 5 was used to define bleeding events. Overall, 539 patients were included in the study (mean age: 82.5 ± 4.8°years; 282 (52.3%) females). Of these patients, 69 (12.8%) developed in-hospital bleeding. Factors that were independently related with in-hospital bleeding were age (odds ratio (OR): 1.08; 95% confidence interval (CI): 1.011.14, P = .01), acute kidney injury (OR: 3.66; 95% CI: 2.016.69; P < .01), tirofiban (OR: 4.43; 95% CI: 1.7810.99; P < .01), and ticagrelor (OR: 1.93; 95% CI: 1.013.73; P = .04) administration. The urinary tract was the most frequent bleeding site, followed by femoral arteries. In conclusion, ticagrelor and tirofiban should be used with caution in elderly ACS patients.
Collapse
Affiliation(s)
- Kudret Keskin
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey.,ŞiŞli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Serhat Sığırcı
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey.,ŞiŞli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Ahmet Gürdal
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey.,ŞiŞli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Özgür S Ser
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Hakan Kilci
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Mutlu Ç Sümerkan
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Arzu Er
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| | - Ömer Alyan
- Department of Cardiology, 64159Şişli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey.,ŞiŞli Hamidiye Etfal Education and Research Hospital, İstanbul, Turkey
| |
Collapse
|
31
|
Vallurupalli S, Hess E, Plomondon ME, Park K, Waldo SW, Agarwal S, Uretsky BF. Impact of severity of baseline thrombocytopenia on outcomes after percutaneous coronary interventions: Analysis from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program. Catheter Cardiovasc Interv 2022; 99:1491-1497. [PMID: 35253342 DOI: 10.1002/ccd.30142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 01/14/2022] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of the degree of severity of baseline thrombocytopenia (TCP) on outcomes after percutaneous coronary intervention (PCI) BACKGROUND: The association of TCP with clinical outcomes among patients undergoing coronary intervention has not been previously evaluated. METHODS Using data from the US Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) Program, we identified patients undergoing PCI between October 1, 2007, to September 30, 2017. The cohort was then stratified by platelet count, as no TCP (platelet count >150,000/mcl), mild TCP (100-150,000/mcl), or moderate-severe TCP (<100,000/mcl) and this was associated with clinical outcomes. RESULTS The cohort included 80,427 patients (98% male), of which 14.9% (13.2% mild, 1.7% moderate-severe) suffered from TCP at the time of PCI. Compared with mild or no TCP, moderate-severe TCP was associated with increased risk of post-PCI pericardiocentesis (0.6% vs. 0.2% vs. 0.2%, p = 0.018) and in-hospital mortality (1.5% vs. 0.7% vs. 0.7%) without a difference in postprocedure stroke (0.5% vs. 0.3% vs. 0.3%, p = 0.6). Over a median follow-up of 1729 days, time-to-repeat revascularization was significantly shorter in moderate-severe TCP (1080 vs. 1347 vs. 1467 days, p < 0.001) despite lower risk of revascularization. Both mild (adjusted HR: 1.11, 95% CI: 1.07-1.15, p < 0.001) and moderate-severe TCP (HR: 1.55, 95% CI: 1.43-1.69, p < 0.001) were associated with increased all-cause mortality compared with those without TCP. CONCLUSIONS Thrombocytopenia was associated with increased short- and long-term adverse events among patients undergoing PCI. Any degree of TCP was associated with increased long-term all-cause mortality while moderate-severe TCP was also associated with increased risk of periprocedural adverse events.
Collapse
Affiliation(s)
- Srikanth Vallurupalli
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Section of Cardiology, Central Arkansas Veteran Healthcare System, Little Rock, Arkansas, USA
| | - Edward Hess
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Mary E Plomondon
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA.,VA CART Program, VHA Office of Quality and Patient Safety, Washington, District of Columbia, USA
| | - Ki Park
- Divison of Cardiology, University of Florida, Gainesville, Florida, USA
| | - Stephen W Waldo
- Department of Medicine, VA Eastern Colorado Health Care System, Aurora, Colorado, USA.,VA CART Program, VHA Office of Quality and Patient Safety, Washington, District of Columbia, USA
| | - Shivkumar Agarwal
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Section of Cardiology, Central Arkansas Veteran Healthcare System, Little Rock, Arkansas, USA
| | - Barry F Uretsky
- Division of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.,Section of Cardiology, Central Arkansas Veteran Healthcare System, Little Rock, Arkansas, USA
| |
Collapse
|
32
|
Towashiraporn K, Krittayaphong R. Current Perspectives on Antithrombotic Therapy for the Treatment of Acute Coronary Syndrome. Int J Gen Med 2022; 15:2397-2414. [PMID: 35264877 PMCID: PMC8901254 DOI: 10.2147/ijgm.s289295] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/03/2022] [Indexed: 12/20/2022] Open
Abstract
Acute coronary syndrome (ACS) is one of the leading causes of death worldwide. Percutaneous coronary intervention (PCI) is the treatment of choice for ACS as this procedure reduces the morbidity and mortality rates of patients in clinical trials and daily practice. However, patients with a history of prior ACS who undergo PCI are still at high risk for recurrent major adverse cardiac events (MACE). Because the antithrombotic drugs reduce the rate of MACE and minimize stent-related complications such as target vessel failure or stent thrombosis, the utilization of these agents is the cornerstone treatment for secondary prevention of ACS patients after PCI. Unfortunately, using the antithrombotic agents may be associated with bleeding complications, including major or fatal bleeding. Therefore, premature discontinuation of antithrombotic regimens regarding the hemorrhagic events is sometimes inevitable and possibly leads to fatal complications such as stent thrombosis. To minimize the bleeding issues, shorten antithrombotic regimens have been proposed, which theoretically offers improved safety. Nevertheless, inappropriate withdrawal of antithrombotic drugs may increase the rate of ischemic events. On the other hand, an unnecessary prolonged antithrombotic regimen may cause avoidable bleeding. Balancing the risk of bleeding against the benefits of using antithrombotic drugs is therefore challenging especially for the patients who contain both bleeding and ischemic risks such as ACS patients who are concomitant using the anticoagulants. Currently, the treatment paradigms are shifting from the “one size fits all approach” toward the “tailored approach”. This means that the antithrombotic regimens can be adjustable individually. As a result, various clinical risk scoring systems have been established to help physicians with their decision-making. However, besides the development of these dedicated scoring tools, clinical judgment for balancing the safety versus the efficacy before deciding on the antithrombotic plan is still imperative.
Collapse
Affiliation(s)
- Korakoth Towashiraporn
- Her Majesty Cardiac Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rungroj Krittayaphong
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Correspondence: Rungroj Krittayaphong, Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkoknoi, Bangkok, 10700, Thailand, Tel +66 2-419-6104, Fax +66 2-412-7412, Email
| |
Collapse
|
33
|
Comparison of original and modified Academic Research Consortium for High Bleeding Risk definitions in real-world practice. J Cardiol 2022; 80:155-161. [DOI: 10.1016/j.jjcc.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
|
34
|
Byun S, Choo EH, Oh GC, Lim S, Choi IJ, Lee KY, Lee SN, Hwang BH, Kim CJ, Park MW, Park CS, Kim HY, Yoo KD, Jeon DS, Youn HJ, Chung WS, Kim MC, Jeong MH, Yim HW, Ahn Y, Chang K. Temporal Trends of Major Bleeding and Its Prediction by the Academic Research Consortium-High Bleeding Risk Criteria in Acute Myocardial Infarction. J Clin Med 2022; 11:jcm11040988. [PMID: 35207261 PMCID: PMC8875601 DOI: 10.3390/jcm11040988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 12/01/2022] Open
Abstract
Limited data exist on the temporal trend of major bleeding and its prediction by the Academic Research Consortium-High Bleeding Risk (ARC-HBR) criteria in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI). We investigated 10-year trends of major bleeding and predictive ability of the ARC-HBR criteria in AMI patients. In a multicenter registry of 10,291 AMI patients undergoing PCI between 2004 and 2014 the incidence of Bleeding Academic Research Consortium (BARC) 3 and 5 bleeding was assessed, and, outcomes in ARC-defined HBR patients with AMI were compared with those in non-HBR. The primary outcome was BARC 3 and 5 bleeding at 1 year. Secondary outcomes included all-cause mortality and composite of cardiovascular death, myocardial infarction, or ischemic stroke. The annual incidence of BARC 3 and 5 bleeding in the AMI population has increased over the years (1.8% to 5.8%; p < 0.001). At 1 year, ARC-defined HBR (n = 3371, 32.8%) had significantly higher incidence of BARC 3 and 5 bleeding (9.8% vs. 2.9%; p < 0.001), all-cause mortality (22.8% vs. 4.3%; p < 0.001) and composite of ischemic events (22.6% vs. 5.8%; p < 0.001) compared to non-HBR. During the past decade, the incidence of major bleeding in the AMI population has increased. The ARC-HBR criteria provided reliable predictions for major bleeding, mortality, and ischemic events in AMI patients.
Collapse
Affiliation(s)
- Sungwook Byun
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.B.); (H.-Y.K.)
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Gyu-Chul Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Sungmin Lim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.J.K.)
| | - Ik Jun Choi
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.J.C.); (D.S.J.)
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Su Nam Lee
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.N.L.); (K.-D.Y.)
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Chan Joon Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.L.); (C.J.K.)
| | - Mahn-Won Park
- Division of Cardiology, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Chul Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Hee-Yeol Kim
- Division of Cardiology, Department of Internal Medicine, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.B.); (H.-Y.K.)
| | - Ki-Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (S.N.L.); (K.-D.Y.)
| | - Doo Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (I.J.C.); (D.S.J.)
| | - Ho Joong Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Wook Sung Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
| | - Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Hyeon-Woo Yim
- Clinical Research Coordinating Center, Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Youngkeun Ahn
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju 61469, Korea; (M.C.K.); (M.H.J.); (Y.A.)
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (E.H.C.); (G.-C.O.); (K.Y.L.); (B.-H.H.); (H.J.Y.); (W.S.C.)
- Correspondence: ; Tel.: +82-2-2258-1139
| |
Collapse
|
35
|
Córdoba-Soriano JG, Gutiérrez-Díez A, Del Blanco BG, Núñez J, Amat-Santos IJ, Oteo JF, Romaguera R, Gallardo-López A, Lozano Ruíz-Poveda F, Baello P, Aguar P, Jerez-Valero M, Jiménez-Díaz VA, Serra B, Cascon JD, Morales-Ponce FJ, Portero-Portaz JJ, Melehi El Assali D, Cerrato-García P, Jiménez-Mazuecos J. Bioactive or Drug Eluting Stents in 75 years or older patients: The BIODES-75 Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:114-120. [DOI: 10.1016/j.carrev.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 11/27/2022]
|
36
|
Gragnano F, Spirito A, Corpataux N, Vaisnora L, Galea R, Gargiulo G, Siontis G, Praz F, Lanz J, Billinger M, Hunziker L, Stortecky S, Pilgrim T, Bär S, Ueki Y, Capodanno D, Urban P, Pocock S, Mehran R, Heg D, Windecker S, Räber L, Valgimigli M. Impact of clinical presentation on bleeding risk after percutaneous coronary intervention and implications for the ARC-HBR definition. EUROINTERVENTION 2021; 17:e898-e909. [PMID: 34105513 PMCID: PMC9725019 DOI: 10.4244/eij-d-21-00181] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The identification of bleeding risk factors in patients undergoing percutaneous coronary intervention (PCI) is essential to inform subsequent management. Whether clinical presentation per se affects bleeding risk after PCI remains unclear. AIMS We aimed to assess whether clinical presentation per se predisposes to bleeding in patients undergoing PCI and if the Academic Research Consortium (ARC) High Bleeding Risk (HBR) criteria perform consistently in acute (ACS) and chronic (CCS) coronary syndrome patients. METHODS Consecutive patients undergoing PCI from the Bern PCI Registry were stratified by clinical presentation. Bleeding events at one year were compared in ACS versus CCS patients, and the originally defined ARC-HBR criteria were assessed. RESULTS Among 16,821 patients, 9,503 (56.5%) presented with ACS. At one year, BARC 3 or 5 bleeding occurred in 4.97% and 3.60% of patients with ACS and CCS, respectively. After adjustment, ACS remained associated with higher BARC 3 or 5 bleeding risk (adjusted HR 1.21, 95% CI: 1.01-1.43; p=0.034), owing to non-access site-related occurrences, which accrued mainly within the first 30 days after PCI. The ARC-HBR score had lower discrimination among ACS compared with CCS patients, and its performance slightly improved when ACS was computed as a minor criterion. CONCLUSIONS ACS presentation per se predicts one-year major bleeding risk after PCI. The ARC-HBR score discrimination appeared lower in ACS than CCS, and its overall performance improved numerically when ACS was computed as an additional minor risk criterion.
Collapse
Affiliation(s)
- Felice Gragnano
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland,Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Alessandro Spirito
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Noé Corpataux
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland,University Heart Center Freiburg–Bad Krozingen, Bad Krozingen, Germany
| | - Lukas Vaisnora
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - George Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Jonas Lanz
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Billinger
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sarah Bär
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Yasushi Ueki
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, and Azienda Ospedaliero Universitaria Policlinico “G. Rodolico – San Marco”, University of Catania, Catania, Italy
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dik Heg
- Clinical Trials Unit (CTU) Bern, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Via Tesserete 48, CH-6900 Lugano, Switzerland
| |
Collapse
|
37
|
Shanmuganathan JWD, Kragholm K, Tayal B, Polcwiartek C, Poulsen LØ, El-Galaly TC, Fosbøl EL, D’Souza M, Gislason G, Køber L, Schou M, Nielsen D, Søgaard P, Torp-Pedersen CT, Mamas MA, Freeman P. Risk for Myocardial Infarction Following 5-Fluorouracil Treatment in Patients With Gastrointestinal Cancer. JACC CardioOncol 2021; 3:725-733. [PMID: 34988482 PMCID: PMC8702810 DOI: 10.1016/j.jaccao.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/05/2021] [Accepted: 11/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Myocardial infarction is a cardiac adverse event associated with 5-fluorouracil (5-FU). There are limited data on the incidence, risk, and prognosis of 5-FU-associated myocardial infarction. Objectives The aim of this study was to examine the risk for myocardial infarction in patients with gastrointestinal (GI) cancer treated with 5-FU compared with age- and sex-matched population control subjects without cancer (1:2 ratio). Methods Patients with GI cancer treated with 5-FU between 2004 and 2016 were identified within the Danish National Patient Registry. Prevalent ischemic heart disease in both groups was excluded. Cumulative incidences were calculated, and multivariable regression and competing risk analyses were performed. Results A total of 30,870 patients were included in the final analysis, of whom 10,290 had GI cancer and were treated with 5-FU and 20,580 were population control subjects without cancer. Differences in comorbid conditions and select antianginal medications were nonsignificant (P > 0.05 for all). The 6-month cumulative incidence of myocardial infarction was significantly higher for 5-FU patients at 0.7% (95% CI: 0.5%-0.9%) versus 0.3% (95% CI: 0.3%-0.4%) in population control subjects, with a competing risk for death of 12.1% versus 0.6%. The 1-year cumulative incidence of myocardial infarction for 5-FU patients was 0.9% (95% CI: 0.7%-1.0%) versus 0.6% (95% CI: 0.5%-0.7%) among population control subjects, with a competing risk for death of 26.5% versus 1.4%. When accounting for competing risks, the corresponding subdistribution hazard ratios suggested an increased risk for myocardial infarction in 5-FU patients, compared with control subjects, at both 6 months (hazard ratio: 2.10; 95% CI: 1.50-2.95; P < 0.001) and 12 months (hazard ratio: 1.39; 95% CI: 1.05-1.84; P = 0.022). Conclusions Despite a statistically significantly higher 6- and 12-month risk for myocardial infarction among 5-FU patients compared with population control subjects, the absolute risk for myocardial infarction was low, and the clinical significance of these differences appears to be limited in the context of the significant competing risk for death in this population.
Collapse
|
38
|
Salisbury AC, Safley DM, Kennedy KF, Bhardwaj B, Aronow HD, Jones WS, Feldman DN, Secemsky E, Tsai TT, Attaran RR, Spertus JA. Development and validation of a predictive model for bleeding after peripheral vascular intervention: A report from the National Cardiovascular Data Registry Peripheral Vascular Interventions Registry. Catheter Cardiovasc Interv 2021; 98:1363-1372. [PMID: 34569709 DOI: 10.1002/ccd.29961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/08/2021] [Accepted: 09/18/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To develop a model to predict risk of in-hospital bleeding following endovascular peripheral vascular intervention. BACKGROUND Peri-procedural bleeding is a common, potentially preventable complication of catheter-based peripheral vascular procedures and is associated with increased mortality. We used the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Interventions (PVI) Registry to develop a novel risk-prediction model to identify patients who may derive the greatest benefit from application of strategies to prevent bleeding. METHODS We examined all patients undergoing lower extremity PVI at 76 NCDR PVI hospitals from 2014 to 2017. Patients with acute limb ischemia (n = 1600) were excluded. Major bleeding was defined as overt bleeding with a hemoglobin (Hb) drop of ≥ 3 g/dl, any Hb decline of ≥ 4 g/dl, or a blood transfusion in patients with pre-procedure Hb ≥ 8 g/dl. Hierarchical multivariable logistic regression was used to develop a risk model to predict major bleeding. Model validation was performed using 1000 bootstrapped replicates of the population after sampling with replacement. RESULTS Among 25,382 eligible patients, 1017 (4.0%) developed major bleeding. Predictors of bleeding included age, female sex, critical limb ischemia, non-femoral access, prior heart failure, and pre-procedure hemoglobin. The model demonstrated good discrimination (optimism corrected c-statistic = 0.67), calibration (corrected slope = 0.98, intercept of -0.04) and range of predicted risk (1%-18%). CONCLUSIONS Post-procedural PVI bleeding risk can be predicted based upon pre- and peri-procedural patient characteristics. Further studies are needed to determine whether this model can be utilized to improve procedural safety through developing and targeting bleeding avoidance strategies.
Collapse
Affiliation(s)
- Adam C Salisbury
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - David M Safley
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | - Kevin F Kennedy
- Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| | | | - Herbert D Aronow
- Lifespan Cardiovascular Institute, Brown University, Providence, Rhode, USA
| | - William Schuyler Jones
- Division of Cardiology, Duke Heart Center, Duke University Health System, Durham, North Carolina, USA
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Thomas T Tsai
- University of Colorado Institute for Health Research and Kaiser Permanente, Denver, Colorado, USA
| | | | - John A Spertus
- University of Missouri-Kansas City, Kansas City, Missouri, USA.,Saint Luke's Mid-America Heart Institute, Kansas City, Missouri, USA
| |
Collapse
|
39
|
Wein B, Zaczkiewicz M, Graf M, Zimmermann O, Gori T, Nef HM, Kastner J, Mehilli J, Richardt G, Wöhrle J, Achenbach S, Riemer T, Hamm C, Torzewski J. No difference in 30-day outcome and quality of life in transradial versus transfemoral access - Results from the German Austrian ABSORB registry (GABI-R). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:144-149. [PMID: 34844868 DOI: 10.1016/j.carrev.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Radial (RA) instead of femoral access (FA) for coronary interventions has become a European Society of Cardiology Class-IA guideline recommendation. But when the decision on the access site is left to the discretion of the operator, differences in adverse event rates mitigate. METHODS We compared the 30-day outcome for RA and FA in all patients recruited for the observational German Austrian ABSORB Registry (GABI-R) in regard to all-cause mortality, stroke, myocardial infarction (MI), TIMI major bleedings (TMB) and quality of life (QoL). All patients were treated with a bioresorbable vascular scaffold. Access site was left to the discretion of the operator. RESULTS In total, 3137 patients included by 92 centers received percutaneous coronary interventions (PCI) for acute MI in 51.5% and non-acute settings in 48.5%. RA was performed in 47.8% and had a higher median radiation exposure (3896 vs. 3082 cGycm2, p < 0.001). There was no difference in the amount of contrast used. There was also no difference in all-cause mortality (0.53% vs. 0.49%, p = 0.86), the combination of death, MI and stroke (1.87% vs. 1.83%, p = 0.94), but a trend towards more TMB (0.47% vs. 1.04%, p = 0.07) with FA. These outcomes were consistent across the subgroups of patients with ST-elevation MI, non-ST-elevation-ACS and stable coronary artery disease. Finally, QoL did not differ between RA and FA. CONCLUSIONS In this contemporary GABI-R cohort, in which access site was left to the discretion of the operator, both access routes were safe and equal concerning QoL (ClinicalTrials.gov; NCT02066623).
Collapse
Affiliation(s)
- Bastian Wein
- Medical Department I, University Hospital Augsburg, Augsburg, Germany
| | | | - Matthias Graf
- Cardiovascular Center Oberallgaeu-Kempten, Kempten, Germany
| | | | - Tommaso Gori
- Department of Cardiology I, University Medical Center, Johannes Gutenberg University Mainz and DZHK Site Rhein Main, Germany
| | - Holger M Nef
- University of Giessen, Medizinische Klinik I, Department of Cardiology, Giessen, Germany
| | - Johannes Kastner
- Department of Cardiology, University of Vienna - Medical School, Vienna, Austria
| | - Julinda Mehilli
- Department of Cardiology, Pneumonology and Intensive Care Medicine - LAKUMED Hospital Landshut-Achdorf, Germany
| | - Gert Richardt
- Herzzentrum, Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | - Jochen Wöhrle
- Department of Cardiology, Angiology, Pneumonology and Intensive Care, Medical Campus Bodensee, Friedrichshafen, Germany
| | - Stephan Achenbach
- Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Medizinische Klinik 2, Erlangen, Germany
| | - Thomas Riemer
- IHF GmbH - Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Christian Hamm
- University of Giessen, Medizinische Klinik I, Department of Cardiology, Giessen, Germany; Kerckhoff Heart and Thorax Centre, Department of Cardiology, Bad Nauheim, Germany
| | - Jan Torzewski
- Cardiovascular Center Oberallgaeu-Kempten, Kempten, Germany.
| |
Collapse
|
40
|
Kumar A, Huded CP, Kassis N, Martin J, Puri R, Reed GW, Ziada KM, Krishnaswamy A, Khatri J, Lincoff AM, Nair R, Ellis SG, Kapadia SR, Khot UN. Feasibility of transradial primary percutaneous coronary intervention for
STEMI
complicated by cardiac arrest. Catheter Cardiovasc Interv 2021; 99:1363-1365. [DOI: 10.1002/ccd.30022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/04/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Anirudh Kumar
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Chetan P. Huded
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Nicholas Kassis
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Joseph Martin
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Rishi Puri
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Grant W. Reed
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Khaled M. Ziada
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Amar Krishnaswamy
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Jaikirshan Khatri
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - A. Michael Lincoff
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Ravi Nair
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Stephen G. Ellis
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Samir R. Kapadia
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| | - Umesh N. Khot
- Heart, Vascular, and Thoracic Institute Cleveland Clinic Foundation Cleveland Ohio USA
| |
Collapse
|
41
|
Li J, Yuan D, Jiang L, Tang X, Xu J, Song Y, Chen J, Qiao S, Yang Y, Gao R, Xu B, Yuan J, Zhao X. Similar Inflammatory Biomarkers Reflect Different Platelet Reactivity in Percutaneous Coronary Intervention Patients Treated With Clopidogrel: A Large-Sample Study From China. Front Cardiovasc Med 2021; 8:736466. [PMID: 34671655 PMCID: PMC8521006 DOI: 10.3389/fcvm.2021.736466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Platelet reactivity is closely associated with adverse events in percutaneous coronary intervention (PCI) patients. Inflammation plays a crucial role in the development of coronary heart disease (CHD). Aim: To investigate the association of inflammatory biomarkers such as leukocyte count and high-sensitivity C reactive proteins (hs-CRP) with platelet reactivity in PCI patients treated with clopidogrel. Method: We examined 10,724 consecutive PCI patients in Fuwai hospital from January 2013 to December 2013. High on-treatment platelet reactivity (HTPR) was defined as adenosine diphosphate (ADP)-induced platelet maximum amplitude [MA(ADP)] of thromboelastogram (TEG) > 47 mm, and low on-treatment platelet reactivity (LTPR) MA(ADP) < 31 mm. Results: Finally, 6,772 PCI patients treated with clopidogrel who had the results of postoperative TEG were enrolled. Among them, 2,070 (30.57%) presented HTPR and 2,568 (37.92%) presented LTPR. As for LTPR, multivariate logistic regression showed that leukocyte count (OR: 1.153, 95% CI 1.117–1.191) and hs-CRP (OR: 0.920, 95% CI 0.905–0.936) were independent predictors, along with diabetes mellites, hemoglobin, platelet count and glucose. As for HTPR, multivariate logistic regression showed that leukocyte count (OR: 0.885, 95% CI 0.854–0.917) and hs-CRP (OR: 1.094, 95% CI 1.077–1.112) were independent predictors, along with sex, hemoglobin, platelet count and glucose. Conclusions: This was the first large real-world study reporting that both leukocyte count and hs-CRP were the independent factors for platelet reactivity in PCI populations treated with clopidogrel, among which higher leukocyte count was associated with more LTPR while higher hs-CRP was associated with more HTPR, providing new insights on individualized antiplatelet therapy.
Collapse
Affiliation(s)
- Jiawen Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deshan Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Jiang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofang Tang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjing Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
42
|
Outcomes after ticagrelor versus clopidogrel treatment in end-stage renal disease patients with acute myocardial infarction: a nationwide cohort study. Sci Rep 2021; 11:20826. [PMID: 34675293 PMCID: PMC8531372 DOI: 10.1038/s41598-021-00360-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Clinical outcomes are unknown after ticagrelor treatment in patients with end-stage renal disease (ESRD) who are diagnosed with acute myocardial infarction (AMI). ESRD patients who were on hemodialysis and received dual antiplatelet therapy (DAPT) for AMI between July 2013 and December 2016 were identified in Taiwan's National Health Insurance Research Database. Using stabilized inverse probability of treatment weighting, patients receiving aspirin plus ticagrelor (n = 530) were compared with those receiving aspirin plus clopidogrel (n = 2462) for the primary efficacy endpoint, a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke, and bleeding, defined according to the Bleeding Academic Research Consortium. Study outcomes were compared between the two groups using Cox proportional hazards model or competing risk model for the hazard ratio or subdistribution hazard ratio (SHR). During 9 months of follow-up, ticagrelor was comparable to clopidogrel with respect to the risks of primary efficacy endpoint [11.69 vs. 9.28/100 patient-months; SHR, 1.16; 95% confidence interval (CI) 0.97–1.4] and bleeding (5.55 vs. 4.36/100 patient-months; SHR 1.14; 95% CI 0.88–1.47). In conclusion, among hemodialysis patients receiving DAPT for AMI, ticagrelor was comparable to clopidogrel with regard to the composite efficacy endpoint and bleeding.
Collapse
|
43
|
O’Donoghue M, Patel S. Walking the tightrope between ischaemia and bleeding. EUROINTERVENTION 2021; 17:527-529. [PMID: 34554092 PMCID: PMC9707433 DOI: 10.4244/eijv17i7a93] [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: 11/23/2022]
Affiliation(s)
- Michelle O’Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, 60 Fenwood Rd, 7th Floor, Boston, MA 02115, USA
| | - Siddharth Patel
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
44
|
Valgimigli M, Mehran R, Franzone A, da Costa BR, Baber U, Piccolo R, McFadden EP, Vranckx P, Angiolillo DJ, Leonardi S, Cao D, Dangas GD, Mehta SR, Serruys PW, Gibson CM, Steg GP, Sharma SK, Hamm C, Shlofmitz R, Liebetrau C, Briguori C, Janssens L, Huber K, Ferrario M, Kunadian V, Cohen DJ, Zurakowski A, Oldroyd KG, Yaling H, Dudek D, Sartori S, Kirkham B, Escaned J, Heg D, Windecker S, Pocock S, Jüni P. Ticagrelor Monotherapy Versus Dual-Antiplatelet Therapy After PCI: An Individual Patient-Level Meta-Analysis. JACC Cardiovasc Interv 2021; 14:444-456. [PMID: 33602441 DOI: 10.1016/j.jcin.2020.11.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/04/2020] [Accepted: 11/30/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents. BACKGROUND The role of abbreviated DAPT followed by an oral P2Y12 inhibitor after PCI remains uncertain. METHODS Two randomized trials, including 14,628 patients undergoing PCI, comparing ticagrelor monotherapy with standard DAPT on centrally adjudicated endpoints were identified, and individual patient data were analyzed using 1-step fixed-effect models. The protocol was registered in PROSPERO (CRD42019143120). The primary outcomes were the composite of Bleeding Academic Research Consortium type 3 or 5 bleeding tested for superiority and, if met, the composite of all-cause death, myocardial infarction, or stroke at 1 year, tested for noninferiority against a margin of 1.25 on a hazard ratio (HR) scale. RESULTS Bleeding Academic Research Consortium type 3 or 5 bleeding occurred in fewer patients with ticagrelor than DAPT (0.9% vs. 1.7%, respectively; HR: 0.56; 95% confidence interval [CI]: 0.41 to 0.75; p < 0.001). The composite of all-cause death, myocardial infarction, or stroke occurred in 231 patients (3.2%) with ticagrelor and in 254 patients (3.5%) with DAPT (HR: 0.92; 95% CI: 0.76 to 1.10; p < 0.001 for noninferiority). Ticagrelor was associated with lower risk for all-cause (HR: 0.71; 95% CI: 0.52 to 0.96; p = 0.027) and cardiovascular (HR: 0.68; 95% CI: 0.47 to 0.99; p = 0.044) mortality. Rates of myocardial infarction (2.01% vs. 2.05%; p = 0.88), stent thrombosis (0.29% vs. 0.38%; p = 0.32), and stroke (0.47% vs. 0.36%; p = 0.30) were similar. CONCLUSIONS Ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without a concomitant increase in ischemic events.
Collapse
Affiliation(s)
- Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R da Costa
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Usman Baber
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Eùgene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Sergio Leonardi
- University of Pavia and Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Davide Cao
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - George D Dangas
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Gabriel P Steg
- Université de Paris and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Samin K Sharma
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christian Hamm
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital, Roslyn, New York, USA
| | - Christoph Liebetrau
- German Center for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany; Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | | | | | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University Medical School, Vienna, Austria
| | - Maurizio Ferrario
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - David J Cohen
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Aleksander Zurakowski
- Department of Interventional Cardiology Chrzanów, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Keith G Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Han Yaling
- General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Dariuz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Samantha Sartori
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Kirkham
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - Dik Heg
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Jüni
- Applied Health Research Centre of the Li Ka Shing Knowledge Institute, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
45
|
Thibert MJ, Fordyce CB, Cairns JA, Turgeon RD, Mackay M, Lee T, Tocher W, Singer J, Perry-Arnesen M, Wong GC. Access-Site vs Non-Access-Site Major Bleeding and In-Hospital Outcomes Among STEMI Patients Receiving Primary PCI. CJC Open 2021; 3:864-871. [PMID: 34401693 PMCID: PMC8347846 DOI: 10.1016/j.cjco.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/08/2021] [Indexed: 10/27/2022] Open
Abstract
Background Major bleeding (MB) is an independent predictor of mortality among ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Prevention of access-site MB has received significant attention. However, limited data have been obtained on the influence of access-site MB vs non-access-site MB and association with subsequent adverse in-hospital outcomes in the STEMI population undergoing pPCI. Methods We identified 1494 STEMI patients who underwent pPCI between 2012 and 2018. Unadjusted and adjusted differences among patients with no MB, access-site MB, non-access-site MB, and in-hospital clinical outcomes were assessed. The use of bleeding-avoidance strategies and their effects on MB were also evaluated. Results MB occurred in 121 (8.1%) patients. Access-site MB occurred in 34 (2.3%) patients, and non-access-site MB occurred in 87 (5.8%). The median reduction in hemoglobin was 31 g/L (interquartile range: 19-43) with access-site MB, and 44 g/L (interquartile range: 29-62) with non-access-site MB. After multivariable adjustment, non-access-site MB was independently associated with in-hospital death (adjusted odds ratio [aOR] 4.21; 95% confidence interval [CI] 2.04-8.68), cardiogenic shock (aOR 10.91; 95% CI 5.67-20.98), and cardiac arrest (aOR 5.63; 95% CI 2.88-11.01). Conversely, access-site MB was not associated with adverse in-hospital outcomes. Bleeding-avoidance strategies were used frequently; however, after multivariable adjustment, no single bleeding-avoidance strategy was significantly associated with reduced MB. Conclusions In STEMI patients undergoing pPCI, non-access-site MB was independently associated with adverse in-hospital outcomes, whereas access-site MB was not. Additional study of strategies to reduce the incidence and impact of non-access-site MB appears to be warranted.
Collapse
Affiliation(s)
- Michael J Thibert
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,University of British Columbia Faculty of Pharmaceutical Sciences, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Martha Mackay
- Providence Health Care Research Institute, University of British Columbia, Vancouver, British Columbia, Canada.,St Paul's Hospital Heart Centre, Vancouver, British Columbia, Canada.,University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wendy Tocher
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michele Perry-Arnesen
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,Burnaby Hospital, Fraser Health Authority, Burnaby, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
46
|
Sorrentino S, Salerno N, Leo I, Polimeni A, Sabatino J, Spaccarotella CAM, Mongiardo A, De Rosa S, Indolfi C. New antithrombotic strategies and coronary stent technologies for patients at high bleeding risk undergoing percutaneous coronary intervention. Curr Vasc Pharmacol 2021; 20:37-45. [PMID: 34370641 DOI: 10.2174/1570161119666210809163404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 05/11/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
Patients at high bleeding risk (HBR) are a sizable part of the population undergoing percutaneous coronary intervention (PCI) and stent implantation. This population historically lacks standardized definition, thus limiting trial design, data generalizability, and clinical decision-making. To overcome this limitation the Academic Research Consortium (ARC) has recently released comprehensive guidelines defining HBR criteria for study design purpose and daily clinical practice. Furthermore, several risk scores have been developed aiming to discriminate HBR patients and support physicians for clinical decision making when faced with this complex subset of patients. Accordingly, the first part of this review article will explore guideline-recommended risk scoring as well as ARC-HBR criteria and their relative application for daily clinical practice. The second part of this review article will explore the complex interplay between risk of bleeding, and coronary thrombotic events in patients deemed at HBR. Indeed, several features that identify these patients, are also independent predictors of recurrent ischemic events, thus challenging revascularization strategies and optimal antithrombotic therapy. Accordingly, several clinical trials have been conducted to evaluate the safety and efficacy of the new generation of coronary platforms and different antithrombotic strategies for HBR patients to minimize both ischemic and bleeding events. Accordingly, in this part we discuss current guidelines, trials and observational data evaluating antithrombotic strategies and stent technologies for patients at HBR.
Collapse
Affiliation(s)
- Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nadia Salerno
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Isabella Leo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| |
Collapse
|
47
|
Kumar A, Zhou L, Huded CP, Moennich LA, Menon V, Puri R, Reed GW, Nair R, Khatri JJ, Krishnaswamy A, Lincoff AM, Ellis SG, Ziada KM, Kapadia SR, Khot UN. Prognostic implications and outcomes of cardiac arrest among contemporary patients with STEMI treated with PCI. Resusc Plus 2021; 7:100149. [PMID: 34345872 PMCID: PMC8319445 DOI: 10.1016/j.resplu.2021.100149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/08/2021] [Accepted: 06/19/2021] [Indexed: 11/20/2022] Open
Abstract
Background Cardiac arrest (CA) complicating ST-elevation myocardial infarction (STEMI) is associated with a disproportionately higher risk of mortality. We described the contemporary presentation, management, and outcomes of CA patients in the era of primary percutaneous coronary intervention (PCI). Methods We reviewed 1,272 consecutive STEMI patients who underwent PCI between 1/1/2011-12/31/2016 and compared characteristics and outcomes between non-CA (N = 1,124) and CA patients (N = 148), defined per NCDR definitions as pulseless arrest requiring cardiopulmonary resuscitation and/or defibrillation within 24-hr of PCI. Results Male gender, cerebrovascular disease, chronic kidney disease, in-hospital STEMI, left main or left anterior descending culprit vessel, and initial TIMI 0 or 1 flow were independent predictors for CA. CA patients had longer door-to-balloon-time (106 [83,139] vs. 97 [74,121] minutes, p = 0.003) and greater incidence of cardiogenic shock (48.0% vs. 5.9%, p < 0.001), major bleeding (25.0% vs. 9.4%, p < 0.001), and 30-day mortality (16.2% vs. 4.1%, p < 0.001). Risk score for 30-day mortality based on presenting characteristics provided excellent prognostic accuracy (area under the curve = 0.902). However, over long-term follow-up of 4.5 ± 2.4 years among hospital survivors, CA did not portend any additional mortality risk (HR: 1.01, 95% CI: 0.56–1.82, p = 0.97). Conclusions In a contemporary cohort of STEMI patients undergoing primary PCI, CA occurs in >10% of patients and is an important mechanism of mortality in patients with in-hospital STEMI. While CA is associated with adverse outcomes, it carries no additional risk of long-term mortality among survivors highlighting the need for strategies to improve the in-hospital care of STEMI patients with CA.
Collapse
Affiliation(s)
- Anirudh Kumar
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Leon Zhou
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Chetan P Huded
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Laurie Ann Moennich
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Venu Menon
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Rishi Puri
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Grant W Reed
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Ravi Nair
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Jaikirshan J Khatri
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Amar Krishnaswamy
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - A Michael Lincoff
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Stephen G Ellis
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Khaled M Ziada
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Samir R Kapadia
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| | - Umesh N Khot
- Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH United States
| |
Collapse
|
48
|
Performance of the academic research consortium high-bleeding risk criteria in patients undergoing PCI for acute myocardial infarction. J Thromb Thrombolysis 2021; 53:20-29. [PMID: 34347202 DOI: 10.1007/s11239-021-02534-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
Patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) are at increased risk for thrombotic and bleeding complications compared to patients with chronic coronary syndrome (CCS). The academic research consortium (ARC) recently suggested a set of criteria to identify patients at high bleeding risk (HBR). We sought to evaluate the performance of the ARC-HBR criteria among patients undergoing PCI according to clinical presentation. We included all consecutive patients undergoing PCI at a tertiary-care center. Patients were deemed at HBR if they fulfilled ≥ 1 major or ≥ 2 minor ARC-HBR criteria. The primary bleeding endpoint was a composite of in-hospital or post-discharge bleeding at 1-year follow-up. Secondary outcomes included all-cause death and myocardial infarction. Out of 6068 patients, 1391 (22.9 %) presented with AMI and were more often at HBR than those with CCS (46.9 % vs. 43.0 %, p = 0.01). HBR patients had a higher risk for the primary bleeding endpoint than non-HBR, irrespective of the clinical indication for PCI (AMI: 19.5 % vs. 5.5 %; HR 3.86, 95 % CI 2.63-5.69; CCS: 6.8 % vs. 2.6 %; HR 2.65, 95 % CI 1.92-3.68; p-interaction = 0.11). Secondary outcomes followed a similar trend. After multivariable adjustment, AMI presentation remained significantly associated with increased risk for bleeding at 1 year (HR 1.64, 95 % CI 1.13-2.38, p = 0.01). The ARC-HBR criterion associated with the highest bleeding risk was severe/end-stage chronic kidney disease in AMI and moderate/severe anemia in CCS. The ARC-HBR framework successfully identified AMI and CCS patients with increased risk for bleeding complications at 1 year post-PCI. Figure prepared with BioRender.
Collapse
|
49
|
Alasnag M, Jones TL, Hanfi Y, Ryan N. Sex-based outcomes in contemporary antiplatelet therapy trials. Open Heart 2021; 8:openhrt-2021-001761. [PMID: 34321335 PMCID: PMC8320246 DOI: 10.1136/openhrt-2021-001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/12/2022] Open
Abstract
Balancing ischaemic and bleeding risks in high-risk populations undergoing percutaneous coronary interventions has become an everyday dilemma for clinicians. It is particularly difficult to make decisions concerning combinations and duration of antiplatelet regimens in women given the poor representation of women in trials that have shaped current practice. Several contemporary landmark trials have recently been presented at the American College of Cardiology. The trials included the Harmonising Optimal Strategy for Treatment of coronary artery diseases-EXtended Antiplatelet Monotherapy, Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention and the TicAgrelor versus CLOpidogrel in Stabilised Patients With Acute Myocardial Infarction. In this article, we summarise the main findings of these trials and include the The Polymer-free Drug-Coated Coronary Stents in Patients at High Bleeding Risk (LEADERS FREE) in search for evidence based best practices for women patients. Although some of these trials had prespecified a subanalysis of sex differences, women constituted only 17%–30% of participants making sex-specific analyses challenging. Data suggest that women benefit from de-escalation to both ticagrelor and clopidogrel monotherapy. However, given the increased bleeding risks observed in women further randomised controlled trials are necessary to determine the most appropriate combination and duration of dual antiplatelet therapy as well as maintenance single antiplatelet therapy.
Collapse
Affiliation(s)
- Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Tara L Jones
- Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah, USA
| | - Yasmin Hanfi
- Cardiology, Dallah Hospital, Riyadh, Saudi Arabia
| | - Nicola Ryan
- Cardiology, Aberdeen Royal Infirmary, Aberdeen, UK
| |
Collapse
|
50
|
Chaudry HI, Lee J, Li SX, Gasperetti A, Lee KM, Zbib NH, Amakiri IC, Andrus BW, DeVries JT. Sex Differences in Acute Bleeding and Vascular Complications Following Percutaneous Coronary Intervention Between 2003 and 2016: Trends From the Dartmouth Dynamic Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 28:32-38. [DOI: 10.1016/j.carrev.2020.07.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
|