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Aggarwal R, Ruff CT, Virdone S, Perreault S, Kakkar AK, Palazzolo MG, Dorais M, Kayani G, Singer DE, Secemsky E, Piccini J, Tahir UA, Shen C, Yeh RW. Development and Validation of the DOAC Score: A Novel Bleeding Risk Prediction Tool for Patients With Atrial Fibrillation on Direct-Acting Oral Anticoagulants. Circulation 2023; 148:936-946. [PMID: 37621213 PMCID: PMC10529708 DOI: 10.1161/circulationaha.123.064556] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/23/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Current clinical decision tools for assessing bleeding risk in individuals with atrial fibrillation (AF) have limited performance and were developed for individuals treated with warfarin. This study develops and validates a clinical risk score to personalize estimates of bleeding risk for individuals with atrial fibrillation taking direct-acting oral anticoagulants (DOACs). METHODS Among individuals taking dabigatran 150 mg twice per day from 44 countries and 951 centers in this secondary analysis of the RE-LY trial (Randomized Evaluation of Long-Term Anticoagulation Therapy), a risk score was developed to determine the comparative risk for bleeding on the basis of covariates derived in a Cox proportional hazards model. The risk prediction model was internally validated with bootstrapping. The model was then further developed in the GARFIELD-AF registry (Global Anticoagulant Registry in the Field-Atrial Fibrillation), with individuals taking dabigatran, edoxaban, rivaroxaban, and apixaban. To determine generalizability in external cohorts and among individuals on different DOACs, the risk prediction model was validated in the COMBINE-AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation) pooled clinical trial cohort and the Quebec Régie de l'Assurance Maladie du Québec and Med-Echo Administrative Databases (RAMQ) administrative database. The primary outcome was major bleeding. The risk score, termed the DOAC Score, was compared with the HAS-BLED score. RESULTS Of the 5684 patients in RE-LY, 386 (6.8%) experienced a major bleeding event, within a median follow-up of 1.74 years. The prediction model had an optimism-corrected C statistic of 0.73 after internal validation with bootstrapping and was well-calibrated based on visual inspection of calibration plots (goodness-of-fit P=0.57). The DOAC Score assigned points for age, creatinine clearance/glomerular filtration rate, underweight status, stroke/transient ischemic attack/embolism history, diabetes, hypertension, antiplatelet use, nonsteroidal anti-inflammatory use, liver disease, and bleeding history, with each additional point scored associated with a 48.7% (95% CI, 38.9%-59.3%; P<0.001) increase in major bleeding in RE-LY. The score had superior performance to the HAS-BLED score in RE-LY (C statistic, 0.73 versus 0.60; P for difference <0.001) and among 12 296 individuals in GARFIELD-AF (C statistic, 0.71 versus 0.66; P for difference = 0.025). The DOAC Score had stronger predictive performance than the HAS-BLED score in both validation cohorts, including 25 586 individuals in COMBINE-AF (C statistic, 0.67 versus 0.63; P for difference <0.001) and 11 945 individuals in RAMQ (C statistic, 0.65 versus 0.58; P for difference <0.001). CONCLUSIONS In individuals with atrial fibrillation potentially eligible for DOAC therapy, the DOAC Score can help stratify patients on the basis of expected bleeding risk.
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Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christian T. Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | | | - Sylvie Perreault
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Ajay K. Kakkar
- Thrombosis Research Institute, London, United Kingdom
- University College London, London, United Kingdom
| | - Michael G. Palazzolo
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Marc Dorais
- StatSciences Inc., Notre-Dame-de-l’Île-Perrot, Quebec, Canada
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Daniel E. Singer
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Piccini
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Usman A. Tahir
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Changyu Shen
- Advanced Analytics, Biogen Digital Health and Worldwide Medical, Cambridge, Massachusetts
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Fischer K, Bodalbhai F, Awudi E, Surani S. Reversing Bleeding Associated With Antiplatelet Use: The Role of Tranexamic Acid. Cureus 2020; 12:e10290. [PMID: 33047080 PMCID: PMC7540200 DOI: 10.7759/cureus.10290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/07/2020] [Indexed: 11/17/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is the mainstay of therapy in patients that have been diagnosed with coronary artery disease. DAPT has known risk factors such as an increased risk of bleeding, and, currently, no specific medication is indicated to reverse bleeding associated with antiplatelet use. One medication that may help reduce blood loss is tranexamic acid (TXA). A retrospective review of the literature regarding TXA in the setting of antiplatelet associated bleeding through a systematic search strategy was conducted. This review of the literature followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines and included seven studies. Multiple studies demonstrated the impact on platelet function resulting from administering TXA through lower volumes of blood loss, lower transfusion requirements, and lower incidence of reoperations. TXA is not widely recommended to reverse antiplatelet medications; however, it is widely available, has a positive track record for use in various types of bleeding, and is relatively inexpensive and safe. Large-scale randomized trials are warranted to make a strong recommendation for TXA in reversing bleeding associated with antiplatelet therapy.
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Affiliation(s)
- Kyle Fischer
- Pharmacy, Texas A&M Irma Lerma Rangel College of Pharmacy, Kingsville, USA
| | - Fatema Bodalbhai
- Pharmacy, Texas A&M Irma Lerma Rangel College of Pharmacy, College Station, USA
| | - Elizabeth Awudi
- Pharmacy, Corpus Christi Medical Center, Corpus Christi, USA
| | - Salim Surani
- Internal Medicine, Corpus Christi Medical Center, Corpus Christi, USA
- Internal Medicine, University of North Texas, Dallas, USA
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Pufulete M, Harris J, Sterne JAC, Johnson TW, Lasserson D, Mumford A, Doble B, Wordsworth S, Benedetto U, Rogers CA, Loke Y, Pithara C, Redwood S, Reeves BC. Comprehensive ascertainment of bleeding in patients prescribed different combinations of dual antiplatelet therapy (DAPT) and triple therapy (TT) in the UK: study protocol for three population-based cohort studies emulating 'target trials' (the ADAPTT Study). BMJ Open 2019; 9:e029388. [PMID: 31167875 PMCID: PMC6561407 DOI: 10.1136/bmjopen-2019-029388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/04/2019] [Accepted: 03/12/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION 'Real world' bleeding in patients exposed to different regimens of dual antiplatelet therapy (DAPT) and triple therapy (TT, DAPT plus an anticoagulant) have a clinical and economic impact but have not been previously quantified. METHODS AND ANALYSIS We will use linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data to assemble populations eligible for three 'target trials' in patient groups: percutaneous coronary intervention (PCI); coronary artery bypass grafting (CABG); conservatively managed (medication only) acute coronary syndrome (ACS). Patients ≥18 years old will be eligible if, in CPRD records, they have: ≥1 year of data before the index event; no prescription for DAPT or anticoagulants in the preceding 3 months; a prescription for aspirin or DAPT within 2 months after discharge from the index event. The primary outcome will be any bleeding event (CPRD or HES) up to 12 months after the index event. We will estimate adjusted HR for time to first bleeding event comparing: aspirin and clopidogrel (reference) versus aspirin and prasugrel or aspirin and ticagrelor after PCI; and aspirin (reference) versus aspirin and clopidogrel after CABG and ACS. We will describe rates of bleeding in patients prescribed TT (DAPT plus an anticoagulant). Potential confounders will be identified systematically using literature review, semistructured interviews with clinicians and a short survey of clinicians. We will conduct sensitivity analyses addressing the robustness of results to the study's main limitation-that we will not be able to identify the intervention group for patients whose bleeding event occurs before a DAPT prescription in CPRD. ETHICS AND DISSEMINATION This protocol was approved by the Independent Scientific Advisory Committee for the UK Medicines and Healthcare Products Regulatory Agency Database Research (protocol 16_126R) and the South West Cornwall and Plymouth Research Ethics Committee (17/SW/0092). The findings will be presented in peer-reviewed journals, lay summaries and briefing papers to commissioners/other stakeholders. TRIAL REGISTRATION NUMBER 76607611; Pre-results.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jonathan A C Sterne
- NIHR Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Christalla Pithara
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Sabi Redwood
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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Roberts AB, Gu X, Buffa JA, Hurd AG, Wang Z, Zhu W, Gupta N, Skye SM, Cody DB, Levison BS, Barrington WT, Russell MW, Reed JM, Duzan A, Lang JM, Fu X, Li L, Myers AJ, Rachakonda S, DiDonato JA, Brown JM, Gogonea V, Lusis AJ, Garcia-Garcia JC, Hazen SL. Development of a gut microbe-targeted nonlethal therapeutic to inhibit thrombosis potential. Nat Med 2018; 24:1407-1417. [PMID: 30082863 PMCID: PMC6129214 DOI: 10.1038/s41591-018-0128-1] [Citation(s) in RCA: 351] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/31/2018] [Indexed: 12/15/2022]
Abstract
Trimethylamine N-oxide (TMAO) is a gut microbiota-derived metabolite that enhances both platelet responsiveness and in vivo thrombosis potential in animal models, and TMAO plasma levels predict incident atherothrombotic event risks in human clinical studies. TMAO is formed by gut microbe-dependent metabolism of trimethylamine (TMA) moiety-containing nutrients, which are abundant in a Western diet. Here, using a mechanism-based inhibitor approach targeting a major microbial TMA-generating enzyme pair, CutC and CutD (CutC/D), we developed inhibitors that are potent, time-dependent, and irreversible and that do not affect commensal viability. In animal models, a single oral dose of a CutC/D inhibitor significantly reduced plasma TMAO levels for up to 3 d and rescued diet-induced enhanced platelet responsiveness and thrombus formation, without observable toxicity or increased bleeding risk. The inhibitor selectively accumulated within intestinal microbes to millimolar levels, a concentration over 1-million-fold higher than needed for a therapeutic effect. These studies reveal that mechanism-based inhibition of gut microbial TMA and TMAO production reduces thrombosis potential, a critical adverse complication in heart disease. They also offer a generalizable approach for the selective nonlethal targeting of gut microbial enzymes linked to host disease limiting systemic exposure of the inhibitor in the host.
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Affiliation(s)
- Adam B Roberts
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaodong Gu
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer A Buffa
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Alex G Hurd
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Zeneng Wang
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Weifei Zhu
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Nilaksh Gupta
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Sarah M Skye
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - David B Cody
- Life Sciences Transformative Platform Technologies, Procter & Gamble, Cincinnati, OH, USA
| | - Bruce S Levison
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - William T Barrington
- Departments of Human Genetics and Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Matthew W Russell
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Jodie M Reed
- Life Sciences Transformative Platform Technologies, Procter & Gamble, Cincinnati, OH, USA
| | - Ashraf Duzan
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
- Department of Chemistry, Cleveland State University, Cleveland, OH, USA
| | - Jennifer M Lang
- Departments of Human Genetics and Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Xiaoming Fu
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Lin Li
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Alex J Myers
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - Suguna Rachakonda
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph A DiDonato
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - J Mark Brown
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
| | - Valentin Gogonea
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA
- Department of Chemistry, Cleveland State University, Cleveland, OH, USA
| | - Aldons J Lusis
- Departments of Human Genetics and Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA.
- Center for Microbiome & Human Health, Cleveland Clinic, Cleveland, OH, USA.
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA.
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Uncertain Associations of Major Bleeding and Concurrent Use of Antiplatelet Agents and Chinese Medications: A Nested Case-Crossover Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:9417186. [PMID: 28831288 PMCID: PMC5558644 DOI: 10.1155/2017/9417186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/23/2017] [Accepted: 06/22/2017] [Indexed: 11/17/2022]
Abstract
Despite the evidence that some commonly used Chinese medications (CMs) have antiplatelet/anticoagulant effects, many patients still used antiplatelets combined with CMs. We conducted a nested case-crossover study to examine the associations between the concomitant use of antiplatelets and CMs and major bleeding using population-based health database in Taiwan. Among the cohort of 79,463 outpatients prescribed antiplatelets (e.g., aspirin and clopidogrel) continuously, 1,209 patients hospitalized with new occurring bleeding in 2012 and 2013 were included. Those recruited patients served as their own controls to compare different times of exposure to prespecified CMs (e.g., Asian ginseng and dong quai) and antiplatelet agents. The periods of case, control 1, and control 2 were defined as 1–4 weeks, 6–9 weeks, and 13–16 weeks before hospitalization, respectively. Conditional logistic regression analyses found that concurrent use of antiplatelet drugs with any of the prespecified CMs in the case period might not significantly increase the risks of bleeding over that in the control periods (OR = 1.00, 95% CI 0.51 to 1.95 and OR = 1.13, 95% CI 0.65 to 1.97). The study showed no strong relationships between hospitalization for major bleeding events and concurrent use of antiplatelet drugs with the prespecified CMs.
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