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Antúnez-Rodríguez A, García-Rodríguez S, Pozo-Agundo A, Sánchez-Ramos JG, Moreno-Escobar E, Triviño-Juárez JM, Martínez-González LJ, Dávila-Fajardo CL. Targeted next-generation sequencing panel to investigate antiplatelet adverse reactions in acute coronary syndrome patients undergoing percutaneous coronary intervention with stenting. Thromb Res 2024; 240:109060. [PMID: 38875847 DOI: 10.1016/j.thromres.2024.109060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/02/2024] [Accepted: 06/04/2024] [Indexed: 06/16/2024]
Abstract
Antiplatelet therapy, the gold standard of care for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), is one of the therapeutic approaches most associated with the development of adverse drug reactions (ADRs). Although numerous studies have shown that pharmacological intervention based on a limited number of high-evidence variants (primarily CYP2C19*2 and *3) can reduce the incidence of major adverse cardiovascular events (MACEs), ADRs still occur at variable rates (10.1 % in our case) despite personalized therapy. This study aimed to identify novel genetic variants associated with the endpoint of MACEs 12 months after PCI by designing and analyzing a targeted gene panel. We sequenced 244 ACS-PCI-stent patients (109 with event and 135 without event) and 99 controls without structural cardiovascular disease and performed an association analysis to search for unexpected genetic variants. No single nucleotide polymorphisms reached genomic significance after correction, but three novel variants, including ABCA1 (rs2472434), KLB (rs17618244), and ZNF335 (rs3827066), may play a role in MACEs in ACS patients. These genetic variants are involved in regulating high-density lipoprotein levels and cholesterol deposition, and as they are regulatory variants, they may affect the expression of nearby lipid metabolism-related genes. Our findings suggest new targets (both at the gene and pathway levels) that may increase susceptibility to MACEs, but further research is needed to clarify the role and impact of the identified variants before these findings can be incorporated into the therapeutic decision-making process.
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Affiliation(s)
- Alba Antúnez-Rodríguez
- GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Junta de Andalucía - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Ilustración 114, 18016 Granada, Spain.
| | - Sonia García-Rodríguez
- GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Junta de Andalucía - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Ilustración 114, 18016 Granada, Spain.
| | - Ana Pozo-Agundo
- GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Junta de Andalucía - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Ilustración 114, 18016 Granada, Spain.
| | - Jesús Gabriel Sánchez-Ramos
- Cardiology Department, Hospital Universitario Clínico San Cecilio - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Innovación s/n, 18016 Granada, Spain
| | - Eduardo Moreno-Escobar
- Cardiology Department, Hospital Universitario Clínico San Cecilio - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Innovación s/n, 18016 Granada, Spain
| | - José Matías Triviño-Juárez
- Department of Radiology and Physical Medicine, Faculty of Medicine, University of Granada, Avenida de la Investigación 11, 18071 Granada, Spain.
| | - Luis Javier Martínez-González
- GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Junta de Andalucía - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Ilustración 114, 18016 Granada, Spain; Department of Biochemistry and Molecular Biology III and Inmunology, Faculty of Medicine, University of Granada, Avenida de la Investigación 11, 18071 Granada, Spain.
| | - Cristina Lucía Dávila-Fajardo
- GENYO, Centre for Genomics and Oncological Research, Pfizer-University of Granada-Junta de Andalucía - Instituto de investigación biosanitaria (ibs.Granada), Avenida de la Ilustración 114, 18016 Granada, Spain; Pharmacy Department, Hospital Universitario Virgen de las Nieves - Instituto de investigación biosanitaria (ibs.Granada), Avenida de las Fuerzas Armadas 2, 18014 Granada, Spain.
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2
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Paul TK. Double Trouble: Dual Antiplatelet Therapy Duration Dilemma in Chronic Kidney Disease Patients With High Bleeding Risk. Am J Cardiol 2024:S0002-9149(24)00509-5. [PMID: 38996896 DOI: 10.1016/j.amjcard.2024.07.003] [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: 06/23/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Timir K Paul
- Department of Cardiovascular Sciences, University of Tennessee Health Sciences Center at Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee.
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Mankerious N, Toelg R, Vogel B, Sartori S, Angiolillo DJ, Vranckx P, Feng Y, de la Torre Hernandez JM, Krucoff MW, Bhatt DL, Spirito A, Cao D, Chehab BM, Kunadian V, Maksoud A, Picon H, Sardella G, Thiele H, Varenne O, Windecker S, Richardt G, Valgimigli M, Mehran R. One-Month Versus Three-Month Dual-Antiplatelet Therapy in High Bleeding Risk Patients With Chronic Kidney Disease. Am J Cardiol 2024; 225:25-34. [PMID: 38871156 DOI: 10.1016/j.amjcard.2024.06.003] [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: 03/05/2024] [Revised: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/15/2024]
Abstract
Shortening the duration of dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) was shown to be effective and safe in patients at high bleeding risk (HBR). We aimed to investigate the effect of 1 versus 3-month DAPT on outcomes after drug-eluting stent in HBR patients with or without chronic kidney disease (CKD). Data from 3 prospective single-arm studies (XIENCE Short DAPT Program) enrolling HBR patients after successful coronary implantation of cobalt-chromium everolimus-eluting stent (XIENCE, Abbott) were analyzed. Subjects were eligible for DAPT discontinuation at 1 or 3 months if free from ischemic events. The primary end point was all-cause death or any myocardial infarction. The key secondary end point was Bleeding Academic Research Consortium Type 2 to 5 bleeding. Outcomes were assessed from 1 to 12 months after PCI. CKD was defined as baseline creatinine clearance <60 ml/min. Of 3,286 patients, 1,432 (43.6%) had CKD. One-month versus 3-month DAPT was associated with a similar 12-month risk of the primary outcome irrespective of CKD status (CKD: 9.5% vs 10.9%, adjusted hazard ratio 0.86, 95% confidence interval 0.60 to 1.22; no-CKD: 6.6% vs 5.6%, adjusted hazard ratio 1.15, 95% confidence interval 0.77 to 1.73; p interaction 0.299). Bleeding Academic Research Consortium 2 to 5 bleeding rates were numerically but not significantly lower with 1-month versus 3-month DAPT in both CKD (9.9% vs 12%) and no-CKD (6.4% vs 9.0%) patients. In conclusion, in HBR patients, 1-month versus 3-month DAPT was associated with a similar risk of ischemic complications and a trend toward fewer bleeding events at 12 months after PCI, irrespective of CKD status.
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Affiliation(s)
- Nader Mankerious
- Department for Cardiology and Angiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany; Cardiology Department, Zagazig University, Sharkia, Egypt
| | - Ralph Toelg
- Department for Cardiology and Angiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany; Medical Faculty of the Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Birgit Vogel
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Pascal Vranckx
- Department of Cardiology, Heart Centre Hasselt and University of Hasselt, Hasselt, Belgium
| | - Yihan Feng
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Mitchell W Krucoff
- Division of Cardiology, Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alessandro Spirito
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Davide Cao
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Bassem M Chehab
- Heart Center, Ascension Via Christi Hospital, Wichita, Kansas
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Aziz Maksoud
- Kansas Heart Hospital and University of Kansas School of Medicine, Wichita, Kasnas
| | | | - Gennaro Sardella
- Department of Cardiovascular and Respiratory Sciences, Policlinico Umberto I di Roma, Rome, Italy
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | | | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gert Richardt
- Department for Cardiology and Angiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Roxana Mehran
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York.
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Benefit and risk of prolonged dual antiplatelet therapy after drug-eluting stent implantation in patients with chronic kidney disease: A nationwide cohort study. Atherosclerosis 2022; 352:69-75. [PMID: 35714431 DOI: 10.1016/j.atherosclerosis.2022.05.019] [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: 03/30/2022] [Revised: 05/06/2022] [Accepted: 05/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent in patients with chronic kidney disease (CKD) is not clearly established. This study purposed to compare clinical outcomes of patients with 6-12 (standard) versus 12-24 months (prolonged) DAPT according to CKD. METHODS Using a nationwide, claim-based database, we retrospectively evaluated association between DAPT duration and clinical outcomes including death, composite ischemic event, and composite bleeding event between 1 and 3 years after PCI. CKD was defined as estimated glomerular filtration rate <60 mL/min/1.73 m2. Of 73,941 eligible patients, 13,425 (18.2%) had CKD and 49,019 (66%) were prescribed prolonged DAPT. Prolonged DAPT had no significant impact on the risk of clinical outcomes in patients with normal renal function. RESULTS In patients with CKD, prolonged DAPT was associated with a lower risk of all-cause death (HR 0.85, 95% CI 0.76-0.95) and composite ischemic events (HR 0.87, 95% CI 0.78-0.96) and a higher risk of composite bleeding events (HR 1.18, 95% CI 1.02-1.37). Benefit of prolonged DAPT on reducing composite ischemic event increased significantly in patients with worsened renal dysfunction (pinteraction = 0.02) while there was no significant interaction between its bleeding risk and renal dysfunction (pinteraction = 0.22). CONCLUSIONS While standard DAPT would be recommended in patients with normal renal function, tailored decision for DAPT duration would be considered in those with CKD to balance between ischemic and bleeding risks.
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Baaten CC, Schröer JR, Floege J, Marx N, Jankowski J, Berger M, Noels H. Platelet Abnormalities in CKD and Their Implications for Antiplatelet Therapy. Clin J Am Soc Nephrol 2022; 17:155-170. [PMID: 34750169 PMCID: PMC8763166 DOI: 10.2215/cjn.04100321] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients with CKD display a significantly higher risk of cardiovascular and thromboembolic complications, with around half of patients with advanced CKD ultimately dying of cardiovascular disease. Paradoxically, these patients also have a higher risk of hemorrhages, greatly complicating patient therapy. Platelets are central to hemostasis, and altered platelet function resulting in either platelet hyper- or hyporeactivity may contribute to thrombotic or hemorrhagic complications. Different molecular changes have been identified that may underlie altered platelet activity and hemostasis in CKD. In this study, we summarize the knowledge on CKD-induced aberrations in hemostasis, with a special focus on platelet abnormalities. We also discuss how prominent alterations in vascular integrity, coagulation, and red blood cell count in CKD may contribute to altered hemostasis in these patients who are high risk. Furthermore, with patients with CKD commonly receiving antiplatelet therapy to prevent secondary atherothrombotic complications, we discuss antiplatelet treatment strategies and their risk versus benefit in terms of thrombosis prevention, bleeding, and clinical outcome depending on CKD stage. This reveals a careful consideration of benefits versus risks of antiplatelet therapy in patients with CKD, balancing thrombotic versus bleeding risk. Nonetheless, despite antiplatelet therapy, patients with CKD remain at high cardiovascular risk. Thus, deep insights into altered platelet activity in CKD and underlying mechanisms are important for the optimization and development of current and novel antiplatelet treatment strategies, specifically tailored to these patients who are high risk. Ultimately, this review underlines the importance of a closer investigation of altered platelet function, hemostasis, and antiplatelet therapy in patients with CKD.
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Affiliation(s)
- Constance C.F.M.J. Baaten
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Jonas R. Schröer
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Joachim Jankowski
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Pathology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Martin Berger
- Department of Internal Medicine I, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
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6
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Coyle M, Flaherty G, Jennings C. A critical review of chronic kidney disease as a risk factor for coronary artery disease. IJC HEART & VASCULATURE 2021; 35:100822. [PMID: 34179334 PMCID: PMC8213912 DOI: 10.1016/j.ijcha.2021.100822] [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: 04/03/2021] [Revised: 05/14/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
Chronic kidney disease (CKD) is a significant risk factor for cardiovascular disease (CVD). In addition to common CVD risk factors, the presence of CKD is independently associated with an elevated cardiovascular (CV) risk. We examined the association between CKD and CVD, focusing on coronary artery disease (CAD) in both primary and secondary CVD. A total of 94 articles were included for this review using search strategies on Pubmed and Google scholar. The main findings of our review included that besides sharing common risk factors, CKD induces several physiological microscopic changes leading to increased CV risk. These microscopic changes manifest macroscopically with evidence of the development of primary CAD in CKD patients, in addition to accelerating CAD in those with pre-established CV pathology, with CKD consequently being a risk factor for both primary and secondary CAD progression. Current CV guideline recommendations do not discriminate between those patients with and without CKD. Future research is needed in this area, examining if there may be a role for tighter modifiable risk factor targets in this high-risk population.
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Affiliation(s)
- Mark Coyle
- Corresponding author at: National Institute for Prevention and Cardiovascular Health, Galway, Ireland.
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Huo Y, Van de Werf F, Han Y, Rossello X, Pocock SJ, Chin CT, Lee SWL, Li Y, Jiang J, Vega AM, Medina J, Bueno H. Long-Term Antithrombotic Therapy and Clinical Outcomes in Patients with Acute Coronary Syndrome and Renal Impairment: Insights from EPICOR and EPICOR Asia. Am J Cardiovasc Drugs 2021; 21:471-482. [PMID: 33537947 PMCID: PMC8263456 DOI: 10.1007/s40256-020-00447-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Information is lacking on long-term management of patients with acute coronary syndrome (ACS) and chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73 m2). OBJECTIVES Our objectives were to describe antithrombotic management patterns and outcomes in patients with ACS with varying renal function from the EPICOR (long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients; NCT01171404) and EPICOR Asia (NCT01361386) studies. METHODS EPICOR and EPICOR Asia were prospective observational studies of patients who survived hospitalization for ACS and were enrolled at discharge in 28 countries across Europe, Latin America, and Asia. The studies were conducted from 2010 to 2013 and from 2011 to 2014, respectively. This analysis evaluated patient characteristics and oral antithrombotic management patterns and outcomes up to 2 years post-discharge according to admission eGFR: ≥ 90, 60-89, 30-59, or < 30 mL/min/1.73 m2. RESULTS Among 22,380 patients with available data, eGFR < 60 mL/min/1.73 m2 was observed in 16.7%. Patients with poorer renal function were older, were at greater cardiovascular risk, and had more prior cardiovascular disease and bleeding. Patients with CKD underwent fewer cardiovascular interventions and had more in-hospital cardiovascular and bleeding events. Dual antiplatelet therapy was less likely at discharge in patients with eGFR < 30 (82.3%) than in those with ≥ 90 (91.3%) mL/min/1.73 m2 and declined more sharply during follow-up in patients with low eGFR (p < 0.0001). An adjusted proportional hazards model showed that patients with lower eGFR levels had a higher risk of cardiovascular events and bleeding. CONCLUSIONS The presence of CKD in patients with ACS was associated with less aggressive cardiovascular management and an increased risk of cardiovascular events.
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Affiliation(s)
- Yong Huo
- Department of Cardiology, Peking University First Hospital, 8 Xishiku St., Xicheng District, Beijing, 100034, China.
| | | | - Yaling Han
- General Hospital of Shenyang Military Region, Shenyang, China
| | - Xavier Rossello
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Yi Li
- Department of Cardiology, Shenyang Northern Hospital, Shenyang, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, 8 Xishiku St., Xicheng District, Beijing, 100034, China
| | | | | | - Héctor Bueno
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
- Instituto de investigación i+12 and Cardiology Department, Hospital Universitario, 12 de Octubre, Madrid, Spain
- Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Xiong J, He T, Yu Z, Yang K, Chen F, Cheng J, Shi Y, Huang Y, Qiao Y, Li H, Shen Y, Zhao J. Antiplatelet therapy for the prevention of atherosclerosis in chronic kidney disease (ALTAS-CKD) patients: study protocol for a randomized clinical trial. Trials 2021; 22:37. [PMID: 33413594 PMCID: PMC7792066 DOI: 10.1186/s13063-020-04992-x] [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: 03/01/2020] [Accepted: 12/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the most common complication and the leading cause of death in patients with chronic kidney disease (CKD). Accelerated atherosclerosis is a pathophysiological process that is vital to the occurrence of cardiovascular complications associated with CKD. Abnormal platelet activation is not only the leading cause of atherosclerosis but also plays a critical role in the occurrence of thrombotic events. Currently, antiplatelet drugs are commonly used as a secondary prevention strategy for high blood pressure, obesity, diabetes, and ischemic heart disease and can reduce the risk of CVD in the susceptible population. However, the benefits and evidence of using antiplatelet agents in patients with CKD remain controversial. This study aimed to determine whether antiplatelet therapy can safely prevent atherosclerosis in patients with CKD in the primary care setting. METHODS/DESIGN The ALTAS-CKD study is a multicenter, prospective, randomized, double-blind, placebo-controlled trial of 554 adult patients with stage 3-5 non-dialysis-dependent CKD recruited from 10 territory medical centers in China. A secured web-based computer randomization system will be used to administer aspirin 100 mg once daily or a matching inactive placebo for 36 months. The primary endpoint will be the occurrence of atherosclerosis, as measured by carotid ultrasonography. The secondary endpoints will be combined cardiovascular events, all-cause mortality, and 50% decrease in the estimated glomerular filtration rate. TRIAL REGISTRATION {2A}: Current controlled trials number: ChiCTR1900021393 . Registered on 18 February 2019.
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Affiliation(s)
- Jiachuan Xiong
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Ting He
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Zhikai Yu
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Ke Yang
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Feng Chen
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Jingbo Cheng
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Yu Shi
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Yinghui Huang
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Yu Qiao
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Haiyang Li
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Yunzhu Shen
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China
| | - Jinghong Zhao
- Department of Nephrology, the Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, 400037, People's Republic of China.
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Park S, Kim Y, Jo HA, Lee S, Kim MS, Yang BR, Lee J, Han SS, Lee H, Lee JP, Joo KW, Lim CS, Kim YS, Kim DK. Clinical outcomes of prolonged dual antiplatelet therapy after coronary drug-eluting stent implantation in dialysis patients. Clin Kidney J 2020; 13:803-812. [PMID: 33125004 PMCID: PMC7577762 DOI: 10.1093/ckj/sfaa037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 02/25/2020] [Indexed: 11/12/2022] Open
Abstract
Background End-stage renal disease yields susceptibility to both ischemia and bleeding. The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is not established in dialysis patients, who are usually excluded from randomized studies. Since recent studies implied the benefits of prolonged DAPT >12 months in chronic kidney disease, we investigated the effectiveness and safety of prolonged DAPT in dialysis patients with higher cardiovascular risks. Methods In this nationwide population-based study, we analyzed dialysis patients who underwent DES implantation from 2008 to 2015. Continued DAPT was compared with discontinued DAPT using landmark analyses, including free-of-event participants at 12 (n = 2246), 15 (n = 1925) and 18 months (n = 1692) after DES implantation. The primary outcome was major adverse cardiovascular events (MACEs): a composite of mortality, nonfatal myocardial infarction, coronary revascularization and stroke. Major bleeding was a safety outcome. Inverse probability of treatment weighting Cox regression was performed. Results Mean follow-up periods were 278.3-292.4 days, depending on landmarks. Overall, incidences of major bleeding were far lower than those of MACE. Continued DAPT groups showed lower incidences of MACE and higher incidences of major bleeding, compared with discontinued DAPT groups. In Cox analyses, continued DAPT reduced the hazards of MACE at the 12- [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.61-0.90; P = 0.003], 15- (HR = 0.78, 95% CI 0.64-0.96; P = 0.019) and 18-month landmarks (HR = 0.79, 95% CI 0.63-0.99; P = 0.041), but without a significant increase in major bleeding at 12 (HR = 1.39, 95% CI 0.90-2.16; P = 0.14), 15 (HR = 1.13, 95% CI 0.75-1.70; P = 0.55) or 18 months (HR = 1.27, 95% CI 0.83-1.95; P = 0.27). Conclusions Prolonged DAPT reduced MACE without significantly increasing major bleeding in patients who were event-free at 12 months after DES implantation. In deciding on DAPT duration, prolonged DAPT should be considered in dialysis patients.
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Affiliation(s)
- Seokwoo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yaerim Kim
- Division of Nephrology, Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Hyung Ah Jo
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Ilsan, Korea
| | - Soojin Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Mi-Sook Kim
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University Hospital, Seoul, Korea
| | - Bo Ram Yang
- Division of Clinical Epidemiology, Medical Research Collaborating Center, Biomedical Research Institution, Seoul National University Hospital, Seoul, Korea
| | - Joongyub Lee
- Department of Prevention and Management, Inha University Hospital, Incheon, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Chun Soo Lim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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10
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Burlacu A, Covic A. Longer or shorter dual antiplatelet therapy in dialysis patients receiving a coronary drug-eluting stent? A rope game still ongoing. Clin Kidney J 2020; 13:749-752. [PMID: 33125001 PMCID: PMC7577774 DOI: 10.1093/ckj/sfaa040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/05/2020] [Indexed: 12/25/2022] Open
Abstract
In this issue of Clinical Kidney Journal, Park et al. presents the results of a nationwide population-based trial that included >5000 dialysis patients receiving a drug-eluting stent (DES). The main objective was to evaluate the effectiveness and the safety of prolonged dual antiplatelet therapy (DAPT). The primary outcome was a composite of mortality, non-fatal myocardial infarction, coronary revascularization and stroke, significantly lowered by a longer DAPT regimen at 12, 15 and 18 months, respectively. Longer DAPT tended to be correlated with higher bleeding events at all landmarks, with no statistical significance. An important element was that almost 75% of the index events were acute coronary syndromes. This study presents the first solid evidence for a significant benefit of prolonged DAPT in dialysis patients receiving a DES. We believe that end-stage renal disease is still in the middle of a rope game, being pulled to one side or another by other features, inclining towards a higher bleeding risk or towards higher ischaemic risk. The acute versus elective presentation seems to weigh in choosing the antiplatelet regimen. The 'one-size-fits-all strategy' is not suitable for this particular group. Probably in the future, practitioners will be provided with decision pathways generated by artificial intelligence algorithms yielding 'truly individualized' DAPT protocols for every single patient.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, Iasi, Romania
- “Grigore T. Popa” University of Medicine, Iasi, Romania
| | - Adrian Covic
- “Grigore T. Popa” University of Medicine, Iasi, Romania
- Nephrology Clinic, Dialysis and Renal Transplant Center, ‘C.I. Parhon’ University Hospital, Iasi, Romania
- Academy of Romanian Scientists (AOSR), Iasi, Romania
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11
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Burlacu A, Genovesi S, Basile C, Ortiz A, Mitra S, Kirmizis D, Kanbay M, Davenport A, van der Sande F, Covic A. Coronary artery disease in dialysis patients: evidence synthesis, controversies and proposed management strategies. J Nephrol 2020; 34:39-51. [PMID: 32472526 DOI: 10.1007/s40620-020-00758-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/23/2020] [Indexed: 12/31/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality among patients with end-stage renal disease (ESRD). Clustering of traditional atherosclerotic and non-traditional risk factors drive the excess rates of coronary and non-coronary CVD in this population. The incidence, severity and mortality of coronary artery disease (CAD) as well as the number of complications of its therapy is higher in dialysis patients than in non-chronic kidney disease patients. Given the lack of randomized clinical trial evidence in this population, current practice is informed by observational data with a significant potential for bias. Furthermore, guidelines lack any recommendation for these patients or extrapolate them from trials performed in non-dialysis patients. Patients with ESRD are more likely to be asymptomatic, posing a challenge to the correct identification of CAD, which is essential for appropriate risk stratification and management. This may lead to "therapeutic nihilism", which has been associated with worse outcomes. Here, the ERA-EDTA EUDIAL Working Group reviews the diagnostic work-up and therapy of chronic coronary syndromes, unstable angina/non-ST elevation and ST-elevation myocardial infarction in dialysis patients, outlining unclear issues and controversies, discussing recent evidence, and proposing management strategies. Indications of antiplatelet and anticoagulant therapies, percutaneous coronary intervention and coronary artery bypass grafting are discussed. The issue of the interaction between dialysis session and myocardial damage is also addressed.
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Affiliation(s)
- Alexandru Burlacu
- Department of Interventional Cardiology, Cardiovascular Diseases Institute, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Simonetta Genovesi
- Nephrology Unit, San Gerardo Hospital, Monza, Italy, University of Milan-Bicocca, Milan, Italy
| | - Carlo Basile
- Division of Nephrology, Miulli General Hospital, Via Battisti 192, Acquaviva delle Fonti, 74121, Taranto, Italy. .,Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy.
| | - Alberto Ortiz
- FRIAT and REDINREN, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | - Sandip Mitra
- Manchester Academy of Health Sciences Centre, Manchester University Hospitals Foundation Trust and University of Manchester, Oxford Road, Manchester, UK
| | | | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Andrew Davenport
- Division of Medicine, UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
| | - Frank van der Sande
- Division of Nephrology, Department of Internal Medicine, University Hospital Maastricht, Maastricht, The Netherlands
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center-'C.I. Parhon' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania.,The Academy of Romanian Scientists (AOSR), Bucharest, Romania
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12
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Epidemiology research to foster improvement in chronic kidney disease care. Kidney Int 2020; 97:477-486. [DOI: 10.1016/j.kint.2019.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/12/2019] [Accepted: 11/15/2019] [Indexed: 11/24/2022]
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13
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Wu Y, Song Y, Pan Y, Gong Y, Zhou Y. Long-term and short-term duration of thienopyridine therapy after coronary stenting in patients with chronic kidney disease a meta-analysis of literature studies. Platelets 2019; 31:483-489. [PMID: 31357901 DOI: 10.1080/09537104.2019.1647528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Yu Wu
- Department of Nephrology, Beijing Tiantan hospital, Capital Medical University, Beijing, China
| | - Yimiao Song
- School of Economics, Central University of Finance and Economics, Beijing, China
| | - Yuesong Pan
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases (NCRC-ND), Beijing, China
| | - Yong Gong
- Department of Nephrology, Beijing Tiantan hospital, Capital Medical University, Beijing, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan hospital, Capital Medical University, Beijing, China
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14
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Mavrakanas TA, Chatzizisis YS, Gariani K, Kereiakes DJ, Gargiulo G, Helft G, Gilard M, Feres F, Costa RA, Morice MC, Georges JL, Valgimigli M, Bhatt DL, Mauri L, Charytan DM. Duration of Dual Antiplatelet Therapy in Patients with CKD and Drug-Eluting Stents: A Meta-Analysis. Clin J Am Soc Nephrol 2019; 14:810-822. [PMID: 31010936 PMCID: PMC6556713 DOI: 10.2215/cjn.12901018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 03/27/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Whether prolonged dual antiplatelet therapy (DAPT) is more protective in patients with CKD and drug-eluting stents compared with shorter DAPT is uncertain. The purpose of this meta-analysis was to examine whether shorter DAPT in patients with drug-eluting stents and CKD is associated with lower mortality or major adverse cardiovascular event rates compared with longer DAPT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A Medline literature research was conducted to identify randomized trials in patients with drug-eluting stents comparing different DAPT duration strategies. Inclusion of patients with CKD was also required. The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, or stent thrombosis (definite or probable). Major bleeding was the secondary outcome. The risk ratio (RR) was estimated using a random-effects model. RESULTS Five randomized trials were included (1902 patients with CKD). Short DAPT (≤6 months) was associated with a similar incidence of the primary outcome, compared with 12-month DAPT among patients with CKD (48 versus 50 events; RR, 0.93; 95% confidence interval [95% CI], 0.64 to 1.36; P=0.72). Twelve-month DAPT was also associated with a similar incidence of the primary outcome compared with extended DAPT (≥30 months) in the CKD subgroup (35 versus 35 events; RR, 1.04; 95% CI, 0.67 to 1.62; P=0.87). Numerically lower major bleeding event rates were detected with shorter versus 12-month DAPT (9 versus 13 events; RR, 0.69; 95% CI, 0.30 to 1.60; P=0.39) and 12-month versus extended DAPT (9 versus 12 events; RR, 0.83; 95% CI, 0.35 to 1.93; P=0.66) in patients with CKD. CONCLUSIONS Short DAPT does not appear to be inferior to longer DAPT in patients with CKD and drug-eluting stents. Because of imprecision in estimates (few events and wide confidence intervals), no definite conclusions can be drawn with respect to stent thrombosis.
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Affiliation(s)
- Thomas A Mavrakanas
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; .,Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Karim Gariani
- Division of Diabetes and Endocrinology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dean J Kereiakes
- The Christ Hospital Heart and Vascular Center and The Lindner Center for Research and Education, Cincinnati, Ohio
| | - Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy
| | - Gérard Helft
- Institute of Cardiology, University Hospitals Pitié-Salpêtrière- Charles Foix (Public Assistance- Hospitals of Paris), Sorbonne University, Paris, France
| | - Martine Gilard
- Division of Cardiology, Regional University Hospital La Cavale Blanche, Brest, France
| | - Fausto Feres
- Institute Dante Pazzanese de Cardiologia, Sao Paulo, Sao Paulo, Brazil
| | - Ricardo A Costa
- Institute Dante Pazzanese de Cardiologia, Sao Paulo, Sao Paulo, Brazil
| | | | | | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Laura Mauri
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - David M Charytan
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Baim Institute for Clinical Research, Boston, Massachusetts; and.,Division of Nephrology, New York University Langone Medical Center, New York, New York
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15
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Ismail N, Jordan KP, Rao S, Kinnaird T, Potts J, Kadam UT, Mamas MA. Incidence and prognostic impact of post discharge bleeding post acute coronary syndrome within an outpatient setting: a systematic review. BMJ Open 2019; 9:e023337. [PMID: 30787079 PMCID: PMC6398751 DOI: 10.1136/bmjopen-2018-023337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 11/19/2018] [Accepted: 01/23/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE The primary objective was to determine the incidence of bleeding events post acute coronary syndrome (ACS) following hospital discharge. The secondary objective was to determine the prognostic impact of bleeding on mortality, major adverse cardiovascular events (MACE), myocardial re-infarction and rehospitalisation in the postdischarge setting. DESIGN A narrative systematic review. DATA SOURCE Medline, Embase, Amed and Central (Cochrane) were searched up to August 2018. STUDY SELECTION For the primary objective, randomised controlled trials (RCT) and observational studies reporting on the incidence of bleeding post hospital discharge were included. For the secondary objective, RCTs and observational studies that compared patients with bleeding versus those without bleeding post hospital discharge vis-à-vis mortality, MACE, myocardial re-infarction and rehospitalisation were included. RESULTS 53 studies (36 observational studies and 17 RCTs) with a combined cohort of 714 458 participants for the primary objectives and 187 317 for the secondary objectives were included. Follow-up ranged from 1 month to just over 4 years. The incidence of bleeding within 12 months post hospital discharge ranged from 0.20% to 37.5% in observational studies and between 0.96% and 39.4% in RCTs. The majority of bleeds occurred in the initial 3 months after hospital discharge with bruising the most commonly reported event. Major bleeding increased the risk of mortality by nearly threefold in two studies. One study showed an increased risk of MACE (HR 3.00,95% CI 2.75 to 3.27; p<0.0001) with bleeding and another study showed a non-significant association with rehospitalisation (HR 1.20,95% CI 0.95 to 1.52; p=0.13). CONCLUSION Bleeding complications following ACS management are common and continue to occur in the long term after hospital discharge. These bleeding complications may increase the risk of mortality and MACE, but greater evidence is needed to assess their long-term effects. PROSPERO REGISTRATION NUMBER CRD42017062378.
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Affiliation(s)
- Nafiu Ismail
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Kelvin P Jordan
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Sunil Rao
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Jessica Potts
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
| | - Umesh T Kadam
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mamas A Mamas
- Research Institute for Primary Care and Health Sciences, Keele University, Newcastle, UK
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16
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Abstract
Patients surviving an acute coronary syndrome (ACS) remain at increased risk of ischemic events long term. This paper reviews current evidence and guidelines for oral antiplatelet therapy for secondary prevention following ACS, with respect to decreased risk of ischemic events versus bleeding risk according to individual patient characteristics and risk factors. Specifically, data are reviewed from clinical studies of clopidogrel, prasugrel, ticagrelor and vorapaxar, as well as the results of systematic reviews and meta-analyses looking at the benefits and risks of oral antiplatelet therapy, and the relative merits of shorter versus longer duration of dual antiplatelet therapy, in different patient groups.
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Affiliation(s)
- Jeffrey S Berger
- Division of Cardiology, New York University Langone Medical Center, New York, NY, USA.
- Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY, 10016, USA.
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17
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Edfors R, Sahlén A, Szummer K, Renlund H, Evans M, Carrero JJ, Spaak J, James SK, Lagerqvist B, Varenhorst C, Jernberg T. Outcomes in patients treated with ticagrelor versus clopidogrel after acute myocardial infarction stratified by renal function. Heart 2018; 104:1575-1582. [PMID: 29574413 DOI: 10.1136/heartjnl-2017-312436] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/15/2018] [Accepted: 02/03/2018] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES We aimed to analyse outcomes of ticagrelor and clopidogrel stratified by estimated glomerular filtration rate (eGFR) in a large unselected cohort of patients with acute myocardial infarction (MI). METHODS We used follow-up data in MI survivors discharged on ticagrelor or clopidogrel enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. The association between ticagrelor versus clopidogrel and the primary composite outcome of death, MI or stroke and the secondary outcome rehospitalisation with bleeding diagnosis at 1 year, was studied using adjusted Cox proportional hazards models, stratifying after eGFR levels. RESULTS In total, 45 206 patients with MI discharged on clopidogrel (n=33 472) or ticagrelor (n=11 734) were included. The unadjusted 1-year event rate for the composite endpoint of death, MI or stroke was 7.0%, 18.0% and 48.0% for ticagrelor treatment and 11.0%, 33.0% and 64.0% for clopidogrel treatment in patients with eGFR>60 (n=33 668), eGFR30-60 (n=9803) and eGFR<30 (n=1735), respectively. After adjustment, ticagrelor as compared with clopidogrel was associated with a lower 1-year risk of the composite outcome (eGFR>60: HR 0.87, 95% CI 0.76 to 99, eGFR30-60: 0.82 (0.70 to 0.97), eGFR<30: 0.95 (0.69 to 1.29), P for interaction=0.55) and a higher risk of bleeding (eGFR>60: HR 1.10, 95% CI 0.90 to 1.35, eGFR30-60: 1.13 (0.84 to 1.51), eGFR<30: 1.79 (1.00 to 3.21), P for interaction=0.30) across the eGFR strata. CONCLUSIONS Treatment with ticagrelor as compared with clopidogrel in patients with MI was associated with lower risk for the composite of death, MI or stroke and a higher bleeding risk across all strata of eGFR. Of caution, bleeding events were more abundant in patients with eGFR<30.
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Affiliation(s)
- Robert Edfors
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sahlén
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.,National Heart Centre, Singapore, Singapore
| | - Karolina Szummer
- Department of Medicine, Huddinge, Karolinska Institute, Stockholm, Sweden.,Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Renlund
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Marie Evans
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden.,Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Stefan K James
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
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18
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Evans M, Methven S, Gasparini A, Barany P, Birnie K, MacNeill S, May MT, Caskey FJ, Carrero JJ. Cinacalcet use and the risk of cardiovascular events, fractures and mortality in chronic kidney disease patients with secondary hyperparathyroidism. Sci Rep 2018; 8:2103. [PMID: 29391567 PMCID: PMC5794851 DOI: 10.1038/s41598-018-20552-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 01/08/2018] [Indexed: 01/31/2023] Open
Abstract
With the aim to expand the randomized controlled trial evidence of cinacalcet treatment to the unselected, general chronic kidney disease (CKD) population we analysed a large inception cohort of CKD patients in the region of Stockholm, Sweden 2006-2012 (both non-dialysis, dialysis and transplanted) with evidence of secondary hyperparathyroidism (SHPT). We used marginal structural models to account for both confounding by indication and time-dependent confounding. Over 37 months, 435/3,526 (12%) initiated cinacalcet de novo. Before cinacalcet initiation, parathyroid hormone (PTH) had increased progressively to a median of 636ng/L. After cinacalcet initiation, PTH declined, as did serum calcium and phosphate. In total, 42% of patients experienced a fatal/non-fatal cardiovascular event, 32% died and 9% had a new fracture. The unadjusted cardiovascular odds ratio (OR) associated with cinacalcet treatment was 1.01 (95% confidence interval: 0.83, 1.22). In the fully weighted model, the cardiovascular odds was lower in cinacalcet treated patients (OR 0.67: 0.48, 0.93). The adjusted ORs for all-cause mortality and for fractures were 0.79 (0.56, 1.11) and 1.08 (0.59, 1.98) respectively. Our study suggests cinacalcet treatment improves biochemical abnormalities in the wider CKD population, and adds real-world support that treating SHPT with cinacalcet may have beneficial effects on cardiovascular outcomes.
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Affiliation(s)
- Marie Evans
- United Kingdom Renal Registry (UKRR), Southmead Hospital, Bristol, BS10 5NB, UK.
- Division of Renal Medicine, Department CLINTEC, Karolinska Institutet, Stockholm, Sweden.
| | - Shona Methven
- United Kingdom Renal Registry (UKRR), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Alessandro Gasparini
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Peter Barany
- United Kingdom Renal Registry (UKRR), Southmead Hospital, Bristol, BS10 5NB, UK
| | - Kate Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Stephanie MacNeill
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Margaret T May
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Fergus J Caskey
- United Kingdom Renal Registry (UKRR), Southmead Hospital, Bristol, BS10 5NB, UK
- School of Social and Community Medicine, University of Bristol, Bristol, BS8 2PS, United Kingdom
| | - Juan-Jesus Carrero
- Department of medical epidemiology and biostatistics, Karolinska Institutet, Stockholm, Sweden
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19
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Drug eluting stents are superior to bare metal stents to reduce clinical outcome and stent-related complications in CKD patients, a systematic review, meta-analysis and network meta-analysis. J Interv Cardiol 2017; 31:319-329. [DOI: 10.1111/joic.12473] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 10/30/2017] [Accepted: 11/07/2017] [Indexed: 12/29/2022] Open
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