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Li Y, Li J, Guan C, Su S, Wang Z, Liu H, Yang Y, Gao R, Yuan J, Zhao X. One-year clinical outcomes of bivalirudin versus unfractionated heparin in patients with type 2 diabetes undergoing elective percutaneous coronary intervention. Diabetes Metab Syndr 2023; 17:102858. [PMID: 37776692 DOI: 10.1016/j.dsx.2023.102858] [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: 07/03/2023] [Revised: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023]
Abstract
BACKGROUND Patients with diabetes and coronary artery disease have a higher risk of bleeding and thrombotic events. However, data on the safety and efficacy of bivalirudin in these patients undergoing elective percutaneous coronary intervention (PCI) are lacking. METHODS 1152 patients undergoing elective PCI anticoagulated with bivalirudin and 10,250 patients anticoagulated with unfractionated heparin (UFH) (with or without glycoprotein IIb/IIIa inhibitors [GPI]) were performed propensity-score matching method. The thrombotic endpoint was major adverse cardiovascular and cerebrovascular events (MACCE). The bleeding endpoint was according to the Bleeding Academic Research Consortium (BARC) 2, 3 or 5 bleeding. RESULTS Finally, 376 (bivalirudin group) and 878 (UFH group) patients with type 2 diabetes (T2D) were enrolled. After one-year follow-up, there were 130 (10.4%) MACCE and 27 (2.2%) bleeding events occurred. Multivariate COX regression analysis showed no significant difference for MACCE between bivalirudin group and UFH group (P > 0.05). Further analysis showed that there was a reduction in the risk of myocardial infarction (MI) between two groups (Hazard ratio [HR] = 0.199, 95% confidence interval [CI]: 0.047-0.845, P = 0.029), but not in the risk of death, revascularization, stent thrombosis or stroke (all P > 0.05). As for BARC 2, 3 or 5 bleeding, no significant difference was found between two groups (P > 0.05). CONCLUSIONS Although diabetes is considered a high-risk factor for poor prognosis, compared with UFH (with or without GPI), bivalirudin did not increase the risk of MACCE and even decreased the risk of MI in patients with T2D undergoing elective PCI, while the risk of bleeding was similar between two groups.
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Affiliation(s)
- Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Changdong Guan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Shuhong Su
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, 453000, Henan Province, China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang, 453000, Henan Province, China
| | - Haiwei Liu
- Department of Cardiology, Northern Theatre General Hospital, Shenyang, 110016, Liaoning Province, China
| | - Yuejin Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Runlin Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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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.
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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
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3
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Ge Y, He D, Shao Y, Wang L, Yan W. Percutaneous coronary intervention in insulin-treated diabetic patients: A meta-analysis. Ann Noninvasive Electrocardiol 2022; 27:e12953. [PMID: 35467783 PMCID: PMC9484026 DOI: 10.1111/anec.12953] [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] [Received: 02/15/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background This meta‐analysis of randomized controlled trials (RCTs) compared long‐term adverse clinical outcomes of percutaneous coronary intervention (PCI) in insulin‐treated diabetes mellitus (ITDM) and non‐ITDM patients. Methods This is a meta‐analysis study. The PubMed and Embase databases were searched for articles on long‐term adverse clinical outcomes of PCI in ITDM and non‐ITDM patients. The risk ratios (RR) and 95% confidence intervals (CI) were calculated. Results A total of 11 related RCTs involving 8853 DM patients were included. Compared with non‐ITDM patients, ITDM patients had significantly higher all‐cause mortality (ACM) (RR = 1.52, 95% CI: 1.25–1.85, pheterogeneity = .689, I2 = 0%), major adverse cardiac and cerebrovascular events (MACCE) (RR = 1.35, 95% CI: 1.18–1.55, pheterogeneity = .57, I2 = 0%), myocardial infarction (MI) (RR = 1.41, 95% CI: 1.16–1.72, pheterogeneity = .962, I2 = 0%), and stent thrombosis (ST) (RR = 1.75, 95% CI: 1.23–2.48, pheterogeneity = .159, I2 = 32.4%). No significant difference was found in the target lesion revascularization (TLR) and target vessel revascularization (TVR) between the ITDM and non‐ITDM groups. Conclusions The results showed that ITDM patients had significantly higher ACM, MACCE, MI, and ST, compared with non‐ITDM patients.
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Affiliation(s)
- Ying Ge
- Department of General Practice, Jinshan Hospital of Fudan University, Shanghai, China
| | - Daikun He
- Department of General Practice, Jinshan Hospital of Fudan University, Shanghai, China.,Center of Emergency & Intensive Care Unit, Jinshan Hospital of Fudan University, Shanghai, China
| | - Yiru Shao
- Center of Emergency & Intensive Care Unit, Jinshan Hospital of Fudan University, Shanghai, China
| | - Lina Wang
- Department of General Practice, Jinshan Hospital of Fudan University, Shanghai, China
| | - Wei Yan
- Department of General Practice, Jinshan Hospital of Fudan University, Shanghai, China
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Li Y, Li J, Guan C, Su S, Wang Z, Liu H, Xu B, Yang W, Yang Y, Gao R, Yuan J, Zhao X. Impact of Diabetes Mellitus on One-Year Clinical Outcomes in Patients Anticoagulated with Bivalirudin Undergoing Elective Percutaneous Coronary Intervention. Clin Appl Thromb Hemost 2022; 28:10760296221113344. [PMID: 35942867 PMCID: PMC9373170 DOI: 10.1177/10760296221113344] [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] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Patients with diabetes mellitus (DM) are considered to
increase the risk of thrombosis and bleeding. However, whether DM is an
independent risk factor for events in patients anticoagulated with bivalirudin
during elective percutaneous coronary intervention (PCI) is not clear.
Methods: Patients anticoagulated with bivalirudin during
elective PCI from January 2017 to August 2018 in 3 centers were enrolled. The
primary endpoint of thrombotic events was major adverse cardiac and
cerebrovascular events (MACCE, including all-cause death, myocardial infarction,
ischemic revascularization, stent thrombosis, and stroke); the primary endpoint
of bleeding events was Bleeding Academic Research Consortium (BARC) 2, 3 or 5
bleeding. Results: 1152 patients were finally enrolled. After
one-year follow-up, 89 (7.7%) MACCE and 21 (1.8%) BARC 2, 3 or 5 bleeding
occurred. Multivariate Cox regression analysis showed DM was not an independent
risk factor for MACCE (hazard ratio [HR]: 1.029, 95% confidence interval [CI]:
0.674-1.573, P = .893), but peripheral artery disease (PAD)
history (HR: 2.200, 95%CI: 1.290-3.751, P = .004) was an
independent risk factor for MACCE. DM was not an independent risk factor for
BARC 2, 3 or 5 bleeding (HR: 0.732, 95%CI: 0.293-1.831,
P = .505), but PAD history (HR: 3.029, 95%CI: 1.102-8.332,
P = .032) and low hemoglobin level (HR = 0.972, 95%CI:
0.947-0.998, P = .036) were independent risk factors for BARC
2, 3 or 5 bleeding. Conclusions: DM was not an independent risk
factor for one-year thrombotic and bleeding events in patients anticoagulated
with bivalirudin during elective PCI. More attention should be paid to PAD
history and hemoglobin level to identify high-risk patients.
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Affiliation(s)
- Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, 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
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, 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
| | - Changdong Guan
- National Clinical Research Center for Cardiovascular Diseases, 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
| | - Shuhong Su
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang,
China
| | - Zhifang Wang
- Department of Cardiology, Xinxiang Central Hospital, Xinxiang,
China
| | - Haiwei Liu
- Department of Cardiology, Northern Theatre General Hospital,
Shenyang, China
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases, 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
| | - Weixian Yang
- National Clinical Research Center for Cardiovascular Diseases, 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
- National Clinical Research Center for Cardiovascular Diseases, 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
- National Clinical Research Center for Cardiovascular Diseases, 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
- National Clinical Research Center for Cardiovascular Diseases, 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, National Clinical Research
Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi
Road, Xicheng District, Beijing 100037, China.
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, 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, National Clinical Research
Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular
Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese
Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi
Road, Xicheng District, Beijing 100037, China.
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Hassan W, Saquib J, Khatri M, Kazmi SK, Kotak S, Hassan H, Ahmed J. Short- and long-term cardiovascular outcomes in insulin-treated versus non-insulin-treated diabetes mellitus patients after percutaneous coronary intervention: A systematic review and meta-analysis. Indian Heart J 2021; 74:13-21. [PMID: 34906538 PMCID: PMC8890999 DOI: 10.1016/j.ihj.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 09/20/2021] [Accepted: 12/10/2021] [Indexed: 12/30/2022] Open
Abstract
Aims This study aims to assess differences in severity of short-term (<1 year) and long-term (≥1 year) adverse CV outcomes after PCI in insulin-treated vs. non-insulin-treated diabetes mellitus (DM) patients. Methods A systematic search on Pubmed and Embase led to the incorporation of 29 studies that compared post-percutaneous coronary interventional outcomes in insulin-treated and non-insulin-treated diabetes mellitus. Diabetes mellitus (type 2) was defined as fasting blood glucose (FBG) level of >7.0 mmol/L or with an oral glucose tolerance test (OGTT) level of >11.1 mmol/L at least on two separate occasions. Adverse CV outcomes were assessed in insulin-treated and non-insulin-treated DM after the PCI procedure considered for the analyses were mortality, MACE, TLR, TVR, MI, stent thrombosis, target lesion failure (TLF), and need for-post PCI CABG. Data were pooled and analyzed using Review Manager 5.3, and risk ratios (RR) with respective 95% confidence intervals (CI) were calculated.The statistical analyses were carried out by Review Manager v.5.3, and the data were pooled using a random-effects model. Risk ratios (RRs) with 95% confidence intervals (CI) were reported along with forest plots. The chi-square test was performed to assess for differences between the subgroups. Heterogeneity across studies was evaluated using Higgins I2 statistics. Visual inspection of the funnel plot and Begg's regression test were used to assess publication bias. Results A total of 40,527 patients (11742 in the Insulin-treated diabetes mellitus group and 28785 in the non-insulin-treated DM group) who underwent PCI were included. The pooled analysis of short-term follow up outcomes preceding PCI demonstrated a significantly higher risk of mortality (RR = 1.75 [1.24,2.47]; p = 0.002), MI (RR = 1.81[1.14,2.87]; p = 0.01], stent thrombosis (RR = 1.63[1.13, 2.35]; p = 0.009) and target lesion revascularization (TLR) (RR = 1.29[1.02,1.63]; p = 0.03) in insulin-treated DM patients. Similarly, analysis of long-term follow-up studies depicted a significantly higher risk mortality (RR = 1.55 [1.22, 1.97]; p = 0.0003), MI (RR = 1.63 [1.35, 1.97]; p=<0.00001), MACE (R = 1.47 [1.31, 1.65]; p=<0.00001), stent thrombosis (RR = 1.54 [1.19,1.99]; p = 0.001), TLR (RR = 1.40 [1.18, 1.66]; p = 0.0001), target vessel revascularization (TVR) (RR = 1.35 [1.11, 1.64]; p = 0.003) in insulin-treated DM group after PCI versus non-insulin-treated DM patients. Conclusion Despite a tremendous technical success rate of multi-vessel stenting, people living with diabetes who were being treated with insulin had higher long-term, and short-term mortality rates, MI, TLR, TVR, and stroke compared to people living with diabetes who were being treated with means other than insulin and are more prone to detrimental cardiovascular outcomes.
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Affiliation(s)
- Wardah Hassan
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan.
| | - Javeria Saquib
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Mahima Khatri
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda Kanza Kazmi
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Sohny Kotak
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Hani Hassan
- Karachi Medical and Dental College, Karachi, Pakistan
| | - Jawad Ahmed
- Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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Zhuo X, Zhang C, Feng J, Ouyang S, Niu P, Dai Z. In-hospital, short-term and long-term adverse clinical outcomes observed in patients with type 2 diabetes mellitus vs non-diabetes mellitus following percutaneous coronary intervention: A meta-analysis including 139,774 patients. Medicine (Baltimore) 2019; 98:e14669. [PMID: 30813214 PMCID: PMC6408074 DOI: 10.1097/md.0000000000014669] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several studies have shown that patients with type 2 diabetes mellitus (T2DM) have worse clinical outcomes in comparison to patients without diabetes mellitus (DM) following Percutaneous Coronary Intervention (PCI). However, the adverse clinical outcomes were not similarly reported in all the studies. Therefore, in order to standardize this issue, a meta-analysis including 139,774 patients was carried out to compare the in-hospital, short-term (<1 year) and long-term (≥1 year) adverse clinical outcomes in patients with and without T2DM following PCI. METHODS Electronic databases including MEDLINE, EMBASE, and the Cochrane Library were searched for Randomized Controlled Trials (RCTs) and observational studies. The adverse clinical outcomes which were analyzed included mortality, myocardial infarction (MI), major adverse cardiac events (MACEs), stroke, bleeding, target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis. Risk Ratios (RR) with 95% confidence intervals (CI) were used to express the pooled effect on discontinuous variables and the analysis was carried out by RevMan 5.3 software. RESULTS A total number of 139,774 participants were assessed. Results of this analysis showed that in-hospital mortality and MACEs were significantly higher in patients with T2DM (RR 2.57; 95% CI: 1.95-3.38; P = .00001) and (RR: 1.38; 95% CI: 1.10-1.73; P = .005) respectively. In addition, majority of the short and long-term adverse clinical outcomes were also significantly higher in the DM group as compared to the non-DM group. Stent thrombosis was significantly higher in the DM compared to the non-DM group during the short term follow-up period (RR 1.59; 95% CI: 1.16-2.18;P = .004). However, long-term stent thrombosis was similarly manifested. CONCLUSION According to this meta-analysis including a total number of 139,774 patients, following PCI, those patients with T2DM suffered more in-hospital, short as well as long-term adverse outcomes as reported by most of the Randomized Controlled Trials and Observational studies, compared to those patients without diabetes mellitus.
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Affiliation(s)
- Xiaojun Zhuo
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Chuanzeng Zhang
- State Key Laboratory of Medicinal Chemical Biology, College of Pharmacy, Nankai University, the city of Tianjin, Tianjin, PR China
| | - Juan Feng
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Shenyu Ouyang
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Pei Niu
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
| | - Zhaohui Dai
- Department of Cardiology, Affiliated Changsha Hospital of Hunan Normal University, The Fourth Hospital of Changsha, Hunan, Changsha
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Mehrzad M, Tuktamyshov R, Mehrzad R. Safety, efficiency and cost effectiveness of Bivalirudin: A systematic review. World J Cardiol 2017; 9:761-772. [PMID: 29081910 PMCID: PMC5633541 DOI: 10.4330/wjc.v9.i9.761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review the early and more recent studies of Bivalirudin, to assess the safety, effectiveness, and cost benefits of this drug.
METHODS Literature search of MEDLINE and PubMed databases from 1990 to 2017 using keywords as “bivalirubin” and “angiomax”, combined with the words “safety”, “effectiveness”, “efficiency”, “side effects”, “toxicity”, “adverse effect”, and “adverse drug reaction”.
RESULTS A total of 66 publications were reviewed. The changes in clinical practice and differences in clinical protocols make it difficult to do direct comparisons of studies among each other. However, most trials showed decreased bleeding complications with bivalirudin, although ischemic complications and mortality were mostly comparable, with some favor towards bivalirudin.
CONCLUSION Bivalirudin and heparin are both acceptable options according to current ACA/AHA guidelines. Authors conclude however, that that due to bivalirudin safer bleeding profile, it should be the preferred medication for anticoagulation.
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Affiliation(s)
- Melorin Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Rasikh Tuktamyshov
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Raman Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
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8
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Li N, Yang YG, Chen MH. Comparing the adverse clinical outcomes in patients with non-insulin treated type 2 diabetes mellitus and patients without type 2 diabetes mellitus following percutaneous coronary intervention: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:238. [PMID: 27887590 PMCID: PMC5124234 DOI: 10.1186/s12872-016-0422-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 11/22/2016] [Indexed: 12/16/2022] Open
Abstract
Background Several studies showed Type 2 Diabetes Mellitus (T2DM) to be associated with worse adverse clinical outcomes compared to non-T2DM (NDM) following Percutaneous Coronary Intervention (PCI). In addition, patients with insulin-treated T2DM (ITDM) showed worse clinical outcomes compared to patients with non-insulin treated T2DM (NITDM). Since NITDM and NDM have seldom been systematically analyzed, this study aimed to compare the short and long term adverse clinical outcomes observed in patients with NITDM and patients without T2DM following PCI. Methods Medline/PubMed, EMBASE and the Cochrane library were searched for Randomized Controlled Trials (RCTs) and observational studies comparing patients with (including ITDM and NITDM) and without T2DM following PCI. Endpoints included adverse clinical outcomes reported during a short and a long term follow up period. Odd Ratios (OR) and 95% Confidence Intervals (CI) in accordance with either a fixed or a random effects model appropriately, were calculated and the pooled analyses were performed with RevMan 5.3. Results Twelve studies consisting of a total number of 52,451 patients (14,863 NITDM and 37,588 NDM) were included. Patients with NITDM were found to have significantly higher short-term Major Adverse Cardiac Events (MACEs) and mortality with OR: 1.63, 95% CI (1.17, 2.27); P = 0.004 and OR: 1.71, 95% CI (1.40, 2.10), P < 0.00001 respectively and higher long-term MACEs and mortality with OR: 1.25, 95% CI (1.12, 1.40), P = 0.0001 and OR: 1.32, 95% CI (1.19, 1.47), P < 0.00001 respectively compared to NDM following PCI. In addition, compared to NDM, long-term Target Vessel Revascularization (TVR) and Target Lesion Revascularization (TLR) were significantly higher in the NITDM group with OR: 1.36, 95% CI (1.18, 1.56), P < 0.0001 and OR: 1.32, 95% CI (1.10, 1.59), P = 0.003 respectively. However, even if an increased long-term stent thrombosis was observed in the NITDM group with OR: 1.13; 95% CI (0.91, 1.40), P = 0.28, the result was insignificant. Conclusion Short and long term MACEs and mortality were significantly higher in patients with NITDM compared to patients without diabetes following PCI. Revascularization also significantly favored patients without T2DM. However, stent thrombosis was not significantly different.
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Affiliation(s)
- Nuo Li
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Ye-Gui Yang
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Meng-Hua Chen
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
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Safety and Efficacy of Bivalirudin in Patients With Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: From the REPLACE-2, ACUITY and HORIZONS-AMI Trials. Am J Cardiol 2016; 118:6-16. [PMID: 27181566 DOI: 10.1016/j.amjcard.2016.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 11/20/2022]
Abstract
Optimal antithrombotic pharmacotherapy in patients affected by diabetes mellitus (DM) undergoing percutaneous coronary intervention is unclear. We sought to evaluate the safety and efficacy of bivalirudin compared with heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) in patients with DM undergoing percutaneous coronary intervention. We pooled patient-level data from the Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events-2, Acute Catheterization and Urgent Intervention Triage strategy, and Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction trials. The primary efficacy end point was the incidence of major adverse cardiac events, defined as the composite of death, myocardial infarction, or unplanned revascularization at 30 days. The primary safety end point was the incidence of 30-day non-coronary artery bypass graft-related major bleeding. All-cause mortality was reported at 30 days and 1 year. Of the 14,737 patients included in the pooled database, 3,641 (24.7%) had DM. Patients with DM had higher rates of 30-day major bleeding and 30-day and 1-year all-cause mortality. There were no differences in 30-day major adverse cardiac events between bivalirudin versus heparin plus GPI in patients with DM (6.9% vs 7.8%; relative risk [RR] 0.89, 95% CI 0.71 to 1.12) or without DM (7.5% vs 6.7%; RR 1.11, 95% CI 0.97 to 1.27; pinteraction = 0.10). Bivalirudin treatment was associated with reduced risk of major bleeding in similar magnitude in patients with DM (4.3% vs 6.6% RR 0.68, 95% CI 0.51 to 0.89) or without DM (3.2% vs 6.1%; RR 0.51, 95% CI 0.43 to 0.61; pinteraction = 0.15). The hemorrhagic benefit of bivalirudin was noted for both access site- and non-access site-related bleeding. Overall, bivalirudin treatment was associated with a significant 1-year mortality benefit (2.7% vs 3.3%; RR 0.82, 95% CI 0.68 to 0.98; p = 0.03), which was consistent between patients with or without DM (pinteraction = 0.30). In conclusion, compared with heparin plus GPI, bivalirudin was associated with similar 30-day antithrombotic efficacy and better 30-day freedom from bleeding and 1-year mortality, irrespective of diabetic status.
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Bundhun PK, Wu ZJ, Chen MH. Impact of Modifiable Cardiovascular Risk Factors on Mortality After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of 100 Studies. Medicine (Baltimore) 2015; 94:e2313. [PMID: 26683970 PMCID: PMC5058942 DOI: 10.1097/md.0000000000002313] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/05/2015] [Accepted: 11/24/2015] [Indexed: 02/06/2023] Open
Abstract
Modifiable cardiovascular risk factors such as obesity, hypertension, dyslipidemia, smoking, diabetes mellitus, and metabolic syndrome can easily give rise to coronary heart disease (CHD). However, due to the existence of the so-called "obesity paradox" and "smoking paradox," the impact of these modifiable cardiovascular risk factors on mortality after percutaneous coronary intervention (PCI) is still not clear. Therefore, in order to solve this issue, we aim to compare mortality between patients with low and high modifiable cardiovascular risk factors after PCI. Medline and EMBASE were searched for studies related to these modifiable cardiovascular risk factors. Reported outcome was all-cause mortality after PCI. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated, and the pooled analyses were performed with RevMan 5.3 software. A total of 100 studies consisting of 884,190 patients (330,068 and 514,122 with high and low cardiovascular risk factors respectively) have been included in this meta-analysis. Diabetes mellitus was associated with a significantly higher short and long-term mortality with RR 2.11; 95% CI: (1.91-2.33) and 1.85; 95% CI: (1.66-2.06), respectively, after PCI. A significantly higher long-term mortality in the hypertensive and metabolic syndrome patients with RR 1.45; 95% CI: (1.24-1.69) and RR 1.29; 95% CI: (1.11-1.51), respectively, has also been observed. However, an unexpectedly, significantly lower mortality risk was observed among the smokers and obese patients. Certain modifiable cardiovascular risk subgroups had a significantly higher impact on mortality after PCI. However, mortality among the obese patients and the smokers showed an unexpected paradox after coronary intervention.
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Affiliation(s)
- Pravesh Kumar Bundhun
- From the Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P.R. China
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Bundhun PK, Li N, Chen MH. Adverse cardiovascular outcomes between insulin-treated and non-insulin treated diabetic patients after percutaneous coronary intervention: a systematic review and meta-analysis. Cardiovasc Diabetol 2015; 14:135. [PMID: 26446829 PMCID: PMC4597459 DOI: 10.1186/s12933-015-0300-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/30/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) patients have worse adverse cardiovascular outcomes after Percutaneous Coronary Intervention (PCI). However, the adverse cardiovascular outcomes between insulin-treated and non-insulin treated DM patients have been a subject of debate. We sought to compare the short-term (<1 year) and long-term (≥1 year) cardiovascular outcomes between insulin-treated and non-insulin treated DM patients after PCI. METHODS Medline and Embase databases were searched for studies by typing 'diabetes and percutaneous coronary intervention/PCI' or 'insulin-treated and non-insulin treated diabetes mellitus and PCI'. Endpoints included adverse cardiovascular outcomes reported in these DM patients during the corresponding follow-up periods. Odd Ratio (OR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3. RESULTS 21 studies have been included in this meta-analysis consisting of a total of 21,759 diabetic patients (6250 insulin-treated and 15,509 non-insulin treated DM patients). Short term mortality, myocardial infarction, target lesion revascularization, major adverse cardiac effects and, stent thrombosis were significantly higher in insulin-treated diabetic patients (OR 1.69, 95% CI 1.40-2.04, p < 0.00001), (OR 1.40, 95% CI 1.16-1.70, p = 0.0005), (OR 1.37, 95% CI 1.06-1.76, p = 0.02), (OR 1.46, 95% CI 1.22-1.76, p < 0.0001) and (OR 1.66, 95% CI 1.16-2.38, p = 0.005) respectively. Long-term cardiovascular outcomes were also significantly higher in insulin-treated DM patients. CONCLUSION Insulin treatment in these DM patients was associated with a significantly higher short and long-term adverse cardiovascular outcomes after PCI compared to those DM patients not treated by insulin therapy.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
| | - Nuo Li
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
| | - Meng-Hua Chen
- Institute of Cardiovascular Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China.
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Bivalirudin Versus Heparin Plus Glycoprotein IIb/IIIa Inhibitors in Patients with Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. Am J Cardiovasc Drugs 2015; 15:275-85. [PMID: 25782437 DOI: 10.1007/s40256-015-0113-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Diabetes mellitus (DM) is a pro-thrombotic state with enhanced thrombin generation and platelet reactivity. For most patients undergoing percutaneous coronary intervention (PCI), bivalirudin demonstrates efficacy comparable with that of heparin and glycoprotein IIb/IIIa inhibitors (GPIs). Yet, because of their pro-thrombotic condition, we hypothesized that patients with DM may benefit from more aggressive dual antithrombin and antiplatelet therapy. The aim of this paper was to provide a systematic review comparing outcomes of PCI with bivalirudin versus heparin plus GPI in patients with DM using meta-analytical techniques. Eligible studies needed to have reported a subgroup analysis of outcomes among diabetic patients. Six trials comprising 5924 diabetic patients were eligible. At 30 days, bivalirudin was associated with a reduction in net adverse cardiac events [relative risk (RR) 0.81, 95 % confidence interval (CI) 0.70-0.93, p = 0.002] and major bleeds (RR 0.68, 95 % CI 0.49-0.95; p = 0.02), with no difference in composite ischemia (RR 0.92, 95 % CI 0.74-1.14; p = 0.43) or mortality (RR 0.71, 95 % CI 0.45-1.13; p = 0.15). At 1 year, bivalirudin was associated with a significant reduction in all-cause mortality (RR 0.73, 95 % CI 0.54-1.00, p = 0.05) despite similar composite ischemia (RR 1.02, 95 % CI 0.56-1.21, p = 0.811). In conclusion, thrombin inhibition with bivalirudin alone was associated with reduced 30-day major bleeding and 1-year all-cause mortality compared with heparin plus GPI in diabetic patients undergoing PCI.
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13
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Nairooz R, Sardar P, Amin H, Chatterjee S, Helmy T, Naidu SS. Short- and long-term outcomes in diabetes patients undergoing percutaneous coronary intervention with bivalirudin compared with heparin and glycoprotein IIb/IIIA inhibitors: A meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015; 86:364-75. [PMID: 25914388 DOI: 10.1002/ccd.25952] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diabetes patients undergoing percutaneous coronary intervention (PCI) have more complications than nondiabetes patients, including increased long-term mortality. Use of bivalirudin versus heparin and glycoprotein IIb/IIIa inhibitors (GPI) in diabetes patients undergoing PCI and its effect on long-term mortality were evaluated in few randomized trials, but with conflicting results. METHODS We searched the literature for randomized controlled trials that compared heparin and GPI therapy with bivalirudin in diabetes patients undergoing PCI. The incidence of major adverse cardiovascular events (MACE), death from any cause, myocardial infarction (MI), urgent revascularization, major and minor bleeding (at 30 days), as well as all-cause mortality at 1 year were included, and meta-analysis was performed. RESULTS A total of 5,137 patients with diabetes were included in four randomized trials. At 30 days, bivalirudin, compared with heparin and GPI, caused less major bleeding (odds ratio (OR), 0.68; 95% confidence interval (CI), 0.52-0.89; P = 0.005) and less minor bleeding (OR, 0.48; 95% CI, 0.41-0.57; P < 0.00001) and similar rates of MACE (OR, 0.87; 95% CI, 0.70-1.08; P = 0.21), MI (OR, 0.87; 95% CI, 0.68-1.10; P = 0.25), and urgent revascularization (OR, 1.12; 95% CI, 0.76-1.65; P = 0.57). Death from any cause at 30 day was numerically lower with bivalirudin use but not statistically significant (OR, 0.72; 95% CI, 0.46-1.13; P = 0.15). Mortality at 1 year was significantly lower in diabetes patients treated with bivalirudin compared with heparin and GPI (OR, 0.72; 95% CI, 0.52-0.99; P = 0.04). A secondary analysis suggests that the major bleeding benefit with bivalirudin may be driven by mandated use of GPI in heparin arm. CONCLUSION Among patients with diabetes undergoing PCI, bivalirudin caused less major and minor bleeding compared with heparin and GPI, with similar rates of MACE, death, MI, and urgent revascularization at 30 days, but significantly lower mortality rates at 1 year.
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Affiliation(s)
- Ramez Nairooz
- Department of Cardiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Partha Sardar
- Department of Cardiology, University of Utah, Salt Lake City, Utah
| | - Hossam Amin
- Department of Medicine, New York Medical College-Metropolitan Hospital Center, New York City, New York
| | - Saurav Chatterjee
- Department of Cardiology, St. Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York City, New York
| | - Tarek Helmy
- Department of Cardiology, University of Cincinnati, Cincinnati, Ohio
| | - Srihari S Naidu
- Department of Cardiology, Winthrop University Hospital, Mineola, New York
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Hoebers LP, Claessen BE, Woudstra P, DeVries JH, Wykrzykowska JJ, Vis MM, Baan J, Koch KT, Tijssen JGP, de Winter RJ, Piek JJ, Henriques JPS. Long-term mortality after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction in patients with insulin-treated versus non-insulin-treated diabetes mellitus. EUROINTERVENTION 2015; 10:90-6. [PMID: 24832639 DOI: 10.4244/eijv10i1a15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We investigated the impact of preadmission diabetic status on long-term outcome in patients with ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI), to improve risk stratification. METHODS AND RESULTS Between 1997 and 2007, 4,402 STEMI patients were admitted to our hospital and stratified as having insulin-treated diabetes mellitus (ITDM) (n=176), non-ITDM (NITDM) (n=354) and non-DM (n=3,872). Five-year mortality was significantly higher in patients with DM compared to non-DM (29% vs. 18%, p<0.01). After stratification for preadmission glucose-lowering therapy, five-year mortality was significantly higher in ITDM patients compared to NITDM (36% vs. 25%, p=0.01) and in NITDM patients compared to non-DM patients (25% vs. 18%, p<0.01). After adjustment for age and gender the mortality risk between patients with NITDM versus non-DM was comparable (HR: 1.1, 95% CI: 0.9-1.4, p=0.38), in contrast to patients with ITDM (HR: 1.9, 95% CI: 1.5-2.5, p<0.01) and ITDM versus NITDM (HR: 1.7, 95% CI: 1.2-2.4, p<0.01). After adjustment for all baseline characteristics, the results were comparable to the age and gender adjusted model. CONCLUSIONS ITDM was a strong predictor for long-term mortality when compared to non-DM and NITDM. The mortality between patients without DM and NITDM was comparable after adjustment for age and gender.
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Affiliation(s)
- Loes P Hoebers
- Department of Cardiology, Academic Medical Center - University of Amsterdam, Amsterdam, The Netherlands
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Baber U, Auguste U. Patients with chronic kidney disease/diabetes mellitus: the high-risk profile in acute coronary syndrome. Curr Cardiol Rep 2014; 15:386. [PMID: 23843182 DOI: 10.1007/s11886-013-0386-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Chronic kidney disease (CKD) and diabetes mellitus (DM) are highly prevalent, morbid diseases that are very common among patients presenting with acute coronary syndromes (ACS). Despite significant reductions in cardiovascular morbidity and mortality over the last half century, residual vascular risk remains disproportionately high in these populations. In large part, this is attributable to pre-existing vascular morbidity and substantial enrichment of traditional risk factors among those with either CKD or DM. Other factors, such as less aggressive therapeutic intervention and a unique atherothrombotic phenotype, are also contributory. The introduction of novel antiplatelet and antithrombotic agents over the last several years provides fresh opportunities to improve the adverse prognosis among patients with CKD or DM and concomitant ACS.
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Affiliation(s)
- Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA.
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Capranzano P, Dangas G. Bivalirudin for primary percutaneous coronary intervention in acute myocardial infarction: the HORIZONS-AMI trial. Expert Rev Cardiovasc Ther 2014; 10:411-22. [DOI: 10.1586/erc.12.24] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
This review aims to describe new developments in coronary revascularization strategies for patients with pre-existing Type 2 diabetes mellitus (DM). Recommended strategies for revascularization have been an active area of study with recent important developments. In patients with Type 2 DM and multivessel coronary artery disease (CAD), coronary artery bypass graft (CABG) surgery is the preferred method for revascularization. Patients with DM are at increased risk for diffuse cardiovascular disease due to the proinflammatory, prothrombotic effects of chronic hyperglycemia. In patients undergoing percutaneous coronary intervention, drug-eluting stents and more potent antiplatelet agents especially in those presenting with acute coronary syndromes should be employed.
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Affiliation(s)
- Sharon S Choi
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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18
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A Review of JACC Journal Articles on the Topic of Interventional Cardiology: 2011–2012. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Sergie Z, Gukathasan N, Yu JJ, Mehran R. The Use of Bivalirudin in ST-Segment Elevation Myocardial Infarction: Advantages and Limitations. Interv Cardiol Clin 2012; 1:441-451. [PMID: 28581962 DOI: 10.1016/j.iccl.2012.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The incidence of ST-segment elevation myocardial infarction (STEMI) is a common, albeit declining, manifestation of coronary heart disease. Significant improvements in cardiovascular outcomes and mortality in STEMI patients have occurred in recent years, reflecting evolution in the understanding of the pathophysiological mechanisms and therapeutic targets of this disease. Nonetheless, the risks of recurrent ischemia and bleeding complications in this population remain substantial. This review focuses on the adjunctive anticoagulant agents used in the management of STEMI. Major insights from the HORIZONS-AMI trial regarding the impact of bivalirudin on both hemorrhagic and ischemic outcomes in STEMI patients are discussed.
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Affiliation(s)
- Ziad Sergie
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Nilusha Gukathasan
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Jennifer J Yu
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA; Cardiovascular Research Foundation, 111 East 59th Street, New York, NY 10022, USA.
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Dziewierz A, Mielecki W, Siudak Z, Rakowski T, Janzon M, Birkemeyer R, Zasada W, Dubiel JS, Dudek D. Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in diabetic patients with ST-segment elevation myocardial infarction (EUROTRANSFER Registry). Atherosclerosis 2012; 223:212-8. [DOI: 10.1016/j.atherosclerosis.2012.04.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 03/29/2012] [Accepted: 04/12/2012] [Indexed: 12/21/2022]
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Sethi SS, Akl EG, Farkouh ME. Diabetes mellitus and acute coronary syndrome: lessons from randomized clinical trials. Curr Diab Rep 2012; 12:294-304. [PMID: 22528594 DOI: 10.1007/s11892-012-0272-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus is a major independent risk factor for acute coronary syndrome (ACS). In addition, diabetic patients with ACS suffer from increased mortality compared to their nondiabetic peers. Driven by multiple pathophysiological disturbances, such patients are predisposed to a proinflammatory, prothrombotic state, which may lead to plaque rupture. To counteract this more complex biology, several therapies and strategies have emerged, with some having unique preferential benefits in this population. Antiplatelet agents such as aspirin and clopidogrel have long been standard of care. Dose adjustment of these therapies remains the subject of continued research. Along with medical therapy, ACS diabetic patients preferentially benefit from primary percutaneous intervention compared to fibrinolysis. However, with advances in reperfusion techniques, the optimal strategy has yet to be determined. With these differences in ACS treatment responses, diabetic individuals may not just be a high-risk group, but may actually constitute a fundamentally different population, requiring dedicated clinical trials and individualized treatment regimens.
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Affiliation(s)
- Sanjum S Sethi
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Abstract
PURPOSE OF REVIEW Major bleeding in the setting of acute coronary syndromes and percutaneous coronary intervention has been associated with increased short-term and long-term risk for adverse cardiac events and mortality. Recent studies on antithrombotic agents in this setting have highlighted their differential impact on ischemic and hemorrhagic complications. RECENT FINDINGS To measure bleeding events consistently, an updated standardized definition has been developed by the Bleeding Academic Research Consortium (BARC) representatives. Additionally, the antithrombin agent bivalirudin has emerged as a frontrunner in the invasive management of acute coronary syndromes because of fewer bleeding complications, lower long-term mortality, and similar efficacy compared with heparin plus a glycoprotein IIb/IIIa inhibitor. The mortality benefit with bivalirudin is most likely correlated with reductions in major bleeding, including in-hospital, access-site, and nonaccess site bleeding, and despite the use of preprocedural unfractionated heparin. SUMMARY The BARC definition is an improved version of prior bleeding classifications, and will likely play a significant role in comparing different anticoagulation strategies in future clinical trials and registry analyses. Bivalirudin has been shown to reduce bleeding events in a multitude of diverse clinical settings and bleeding definitions, and has become the preferred antithrombotic agent in the setting of acute coronary syndromes.
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Abstract
Limitations of commonly used anticoagulants, unfractionated heparin, low-molecular-weight heparin, and oral vitamin K antagonists have prompted the development of alternative therapies. Direct thrombin inhibitors are a new class of anticoagulants that bind directly to thrombin and inhibit its interaction with substrates. In this Review, we critically examine the evidence from randomized controlled trials for the efficacy and safety of the parenteral direct thrombin inhibitors bivalirudin and argatroban, and the novel oral direct thrombin inhibitor dabigatran etexilate, in cardiovascular and thrombotic disease.
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Kristensen SD, Würtz M, Grove EL, De Caterina R, Huber K, Moliterno DJ, Neumann FJ. Contemporary use of glycoprotein IIb/IIIa inhibitors. Thromb Haemost 2012; 107:215-24. [PMID: 22234385 DOI: 10.1160/th11-07-0468] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 11/12/2011] [Indexed: 11/05/2022]
Abstract
Platelet glycoprotein IIb/IIIa inhibitors (GPI) are antithrombotic agents preventing the binding of fibrinogen to GP IIb/IIIa receptors. Thus, GPI interfere with interplatelet bridging mediated by fibrinogen. Currently, three generic GPI with different antithrombotic properties are available for intravenous administration: abciximab, eptifibatide, and tirofiban. The development of oral GPI was abandoned, whereas intravenous GPI were introduced in various clinical settings during the 1990s, yielding substantial benefit in the treatment of acute coronary syndromes, particularly during percutaneous coronary interventions. Results of the many randomised trials evidenced the efficacy of this drug class, though these trials were conducted prior to the emergence of modern oral antiplatelet therapy with efficient P2Y(12) inhibitors. Subsequent trials failed to consolidate the strongly favourable impression of GPI, and indications for their use have been more restricted in recent years. Nonetheless, GPI may still be beneficial during coronary interventions among high-risk patients including acute ST-elevation and non-ST-elevation myocardial infarctions, particularly in the absence of adequate pretreatment with oral antiplatelet drugs or when direct thrombin inhibitors are not utilised. Intracoronary GPI administration has been suggested as adjunctive therapy during primary percutaneous coronary intervention, and the results of larger ongoing trials are expected to elucidate its clinical potential. The present review outlines the key milestones of GPI development and provides an up-to-date overview of the clinical applicability of these drugs in the era of refined coronary stenting, potent antithrombotic drugs, and novel thrombin inhibiting agents.
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