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Galli M, Occhipinti G, Ortega-Paz L, Franchi F, Rollini F, Brugaletta S, Capodanno D, Sciarretta S, Angiolillo DJ. Therapeutic Potential of FXI Inhibitors: Hype or Hope? Drugs 2024; 84:1055-1070. [PMID: 39073551 DOI: 10.1007/s40265-024-02049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 07/30/2024]
Abstract
Significant advancements have shaped the landscape of anticoagulant therapy in the past two decades, including the introduction of direct oral anticoagulants (DOACs), characterized by favorable safety and efficacy profiles and reduced drug-to-drug or food interaction resulting in excellent patient compliance. However, residual concerns still exist with standard-of-care anticoagulant therapy, including the inability to use DOACs in several clinical settings and the need to further reduce the risk of bleeding. Recent improvements in the understanding of the mechanisms behind thrombus formation have led to the awareness that the intrinsic pathway of the coagulation cascade may play an important role in pathological thrombosis, but not in hemostasis. This has represented the rationale for targeting this pathway with factor XI (FXI) inhibitors, with the aim of uncoupling hemostasis and thrombosis. Clinical evidence from patients with FXI deficiency further supports this concept. A number of compounds with different mechanisms of action have been developed to target FXI (i.e., asundexian, abelacimab, Ionis-FXIRx, milvexian, osocimab, and Xisomab 3G). To date, the majority of available trials have not gone beyond completion of phase 2 and results are conflictive making it difficult to appraise the clinical benefit of these compounds in the different clinical settings where they have been tested (i.e., atrial fibrillation, acute ischemic stroke, acute myocardial infarction, end-stage renal disease, total knee arthroplasty). Moreover, the largest phase 3 randomized trial designed to test the efficacy of asundexian over apixaban in patients with atrial fibrillation, the OCEANIC-AF, has been prematurely stopped as a result of the inferior efficacy of asundexian. In this review we discuss the pharmacological properties and available evidence generated thus far for factor XI inhibitors, providing a perspective on the current state of these drugs.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giovanni Occhipinti
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- IRCCS NeuroMed, Pozzilli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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Galli M, Occhipinti G, Angiolillo DJ. Aspirin hypersensitivity and intolerance. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:173-174. [PMID: 38268418 DOI: 10.1093/ehjcvp/pvae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 01/26/2024]
Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola 48033, Italy
| | - Giovanni Occhipinti
- Institut Clinic Cardiovascular, Hospital Clínic de Barcelona, University of Barcelona, Barcelona 08036, Spain
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Bucci T, Del Sole F, Menichelli D, Galardo G, Biccirè FG, Farcomeni A, Lip GYH, Pignatelli P, Pastori D. Efficacy and Safety of Combination Therapy with Low-Dose Rivaroxaban in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med 2024; 13:2033. [PMID: 38610798 PMCID: PMC11012887 DOI: 10.3390/jcm13072033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/24/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
Objectives: To review the evidence on the effectiveness and safety of low-dose-rivaroxaban 2.5 mg twice daily (LDR) in patients with coronary artery disease (CAD) and/or peripheral artery disease (PAD) taking antiplatelets. Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Efficacy endpoints were cardiovascular events (CVEs), myocardial infarction, stroke, all-cause, and cardiovascular death. Any, major, fatal bleeding, and intracranial hemorrhage (ICH) were safety endpoints. Numbers needed to treat (NNT), and numbers needed to harm (NNH) were also calculated. Results: Seven RCTs were included with 45,836 patients: 34,276 with CAD and 11,560 with PAD. Overall, 4247 CVEs and 3082 bleedings were registered. LDR in association with either any antiplatelet drug or aspirin (ASA) alone reduced the risk of CVEs (hazard ratio [HR] 0.86, 95% confidence interval [95%CI] 0.78-0.94) and ischemic stroke (HR 0.68, 95%CI 0.55-0.84). LDR + ASA increased the risk of major bleeding (HR 1.71, 95%CI 1.38-2.11) but no excess of fatal bleeding or ICH was found. The NNT to prevent one CVE for LDR + ASA was 63 (43-103) and the NNH to cause major bleeding was 107 (77-193). Conclusions: The combination of LDR with either antiplatelet drugs or low-dose aspirin reduces CVEs and ischemic stroke in patients with CAD/PAD. There was an increased risk of major bleeding but no excess of fatal or ICH was found. LDR seems to have a favorable net clinical benefit compared to ASA treatment alone.
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Affiliation(s)
- Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool and Heart and Chest Hospital, Liverpool L7 8TX, UK (G.Y.H.L.); (D.P.)
- Department of General and Specialized Surgery, Sapienza University of Rome, 00161 Rome, Italy (G.G.); (F.G.B.)
| | - Francesco Del Sole
- Department of Clinical, Internal Medicine, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy;
| | - Danilo Menichelli
- Department of General and Specialized Surgery, Sapienza University of Rome, 00161 Rome, Italy (G.G.); (F.G.B.)
| | - Gioacchino Galardo
- Department of General and Specialized Surgery, Sapienza University of Rome, 00161 Rome, Italy (G.G.); (F.G.B.)
| | - Flavio Giuseppe Biccirè
- Department of General and Specialized Surgery, Sapienza University of Rome, 00161 Rome, Italy (G.G.); (F.G.B.)
| | - Alessio Farcomeni
- Department of Economics and Finance, University of Rome “Tor Vergata,” Via Columbia 2, 00133 Rome, Italy
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool and Heart and Chest Hospital, Liverpool L7 8TX, UK (G.Y.H.L.); (D.P.)
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, 9220 Aalborg, Denmark
| | - Pasquale Pignatelli
- Department of Clinical, Internal Medicine, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy;
| | - Daniele Pastori
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool and Heart and Chest Hospital, Liverpool L7 8TX, UK (G.Y.H.L.); (D.P.)
- Department of Clinical, Internal Medicine, Anaesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy;
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Breitenstein A, Gay A, Vogtländer K, Fox KAA, Steffel J. The Net Clinical Outcome of Dual-Pathway Inhibition in Clinical Practice: The "Xarelto plus Acetylsalicylic Acid: Treatment Patterns and Outcomes in Patients with Atherosclerosis" Registry. J Clin Med 2024; 13:1956. [PMID: 38610724 PMCID: PMC11012443 DOI: 10.3390/jcm13071956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/17/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Background: In the COMPASS trial, the combination of acetylsalicylic acid (ASA) plus 2.5 mg rivaroxaban twice daily (dual-pathway inhibition, DPI) has been shown to be superior to ASA monotherapy for the reduction in ischemic major adverse cardiovascular events (MACEs, i.e., cardiovascular death, stroke, or myocardial infarction). Methods: The international XATOA registry (Xarelto plus Acetylsalicylic acid: Treatment patterns and Outcomes in patients with Atherosclerosis) is a prospective post-approval registry that investigates the cardiovascular outcomes of patients taking ASA plus 2.5 mg rivaroxaban. The aim of this pre-specified analysis was to determine the net clinical outcome (NCO), i.e., a combination of MACEs and bleeding events, of DPI in patients from daily clinical practice. Results: Among the 5615 patients, the presence of multiple risk factors resulted in an increase in the total risk of experiencing an NCO event, e.g., from 1.27% (one risk factor) to 2.18% (two risk factors) and 4.07% (three or more risk factors), respectively, with ischemic MACE representing the primary driver of bleeding complications. Conclusions: In the real-world XATOA registry, the annual rate of NCO events was low and numerically similar to those seen in the treatment group in the randomized COMPASS trial.
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Affiliation(s)
- Alexander Breitenstein
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland;
- University of Zurich, 8006 Zurich, Switzerland
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK;
| | - Jan Steffel
- University of Zurich, 8006 Zurich, Switzerland
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Ortega-Paz L, Franchi F, Rollini F, Galli M, Been L, Ghanem G, Shalhoub A, Ossi T, Rivas A, Zhou X, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Jennings LK, Angiolillo DJ. Switching from Dual Antiplatelet Therapy with Aspirin Plus a P2Y12 Inhibitor to Dual Pathway Inhibition with Aspirin Plus Vascular-Dose Rivaroxaban: The Switching Anti-Platelet and Anti-Coagulant Therapy (SWAP-AC) Study. Thromb Haemost 2024; 124:263-273. [PMID: 37224883 DOI: 10.1055/a-2098-6639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND To date, there are no data on switching to dual pathway inhibition (DPI) patients who have completed a guideline-recommended dual antiplatelet therapy (DAPT) regimen. OBJECTIVES To assess the feasibility of switching from DAPT to DPI and to compare the pharmacodynamic (PD) profiles of these treatments. METHODS This was a prospective, randomized, PD study conducted in 90 patients with chronic coronary syndrome (CCS) on DAPT with aspirin (81 mg/qd) plus a P2Y12 inhibitor (clopidogrel [75 mg/qd; n = 30], ticagrelor [90 mg/bid; n = 30], or prasugrel [10 mg/qd; n = 30]). Patients in each cohort were randomized to maintain DAPT or switch to DPI (aspirin 81 mg/qd plus rivaroxaban 2.5 mg/bid). PD assessments included: VerifyNow P2Y12 reaction units; light transmittance aggregometry following stimuli with adenosine diphosphate (ADP), tissue factor (TF), and a combination of collagen, ADP, and TF (maximum platelet aggregation %); thrombin generation (TG). Assays were performed at baseline and 30 days postrandomization. RESULTS Switching from DAPT to DPI occurred without major side effects. DAPT was associated with enhanced P2Y12 inhibition, while DPI with reduced TG. Platelet-mediated global thrombogenicity (primary endpoint) showed no differences between DAPT and DPI in the ticagrelor (14.5% [0.0-63.0] vs. 20.0% [0.0-70.0]; p = 0.477) and prasugrel (20.0% [0.0-66.0] vs. 4.0% [0.0-70.0]; p = 0.482), but not clopidogrel (27.0% [0.0-68.0] vs. 53.0% [0.0-81.0]; p = 0.011), cohorts. CONCLUSION In patients with CCS, switching from different DAPT regimens to DPI was feasible, showing enhanced P2Y12 inhibition with DAPT and reduced TG with DPI, with no differences in platelet-mediated global thrombogenicity between DPI and ticagrelor- and prasugrel-, but not clopidogrel-, based DAPT. CLINICAL TRIAL REGISTRATION http://www. CLINICALTRIALS gov Unique Identifier: NCT04006288.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
- Departmet of Cardiology, Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Ghussan Ghanem
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Awss Shalhoub
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tiffany Ossi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | | | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Al Said S, Kaier K, Sumaya W, Alsaid D, Duerschmied D, Storey RF, Gibson CM, Westermann D, Alabed S. Non-vitamin-K-antagonist oral anticoagulants (NOACs) after acute myocardial infarction: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD014678. [PMID: 38264795 PMCID: PMC10806408 DOI: 10.1002/14651858.cd014678.pub2] [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] [Indexed: 01/25/2024]
Abstract
BACKGROUND Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited. OBJECTIVES To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI. DATA COLLECTION AND ANALYSIS Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale. MAIN RESULTS We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation. AUTHORS' CONCLUSIONS Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.
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Affiliation(s)
- Samer Al Said
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Wael Sumaya
- Department of Medicine, Faculty of Medicine, Dalhousie University, QE II Health Sciences Centre, Halifax Infirmary, Halifax, Canada
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany, Mannheim, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - C Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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8
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Alharbi A, Mhanna M, Alyosif M, Pena C, Jabr A, Alsughayer A, Alfatlawi H, Safi M, Aldhafeeri A, Patel N, Khuder S, Eltahawy E. Safety and Efficacy of Direct Oral Anticoagulant in Addition to Antiplatelet Therapy After Acute Coronary Syndrome: A Systemic Review and Meta-analysis of 53,869 Patients. Clin Ther 2024; 46:e1-e6. [PMID: 37880055 DOI: 10.1016/j.clinthera.2023.09.027] [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: 01/09/2023] [Revised: 08/17/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Significant progress has been made in the management of patients with acute coronary syndrome (ACS) during the past few decades. However, the role of direct oral anticoagulants (DOACs) in post-ACS prophylactic therapy remains unknown. This study aims to assess the efficacy and safety of DOACs plus antiplatelet treatment (APT) after ACS. METHODS A systematic literature search was conducted to identify randomized clinical trials comparing DOACs plus APT with APT alone after ACS. The primary efficacy end points were cardiovascular mortality, myocardial infarction, all-cause mortality, and stroke and systemic embolization (SSE). The primary safety end point was major bleeding. The random-effects model was used to calculate relative risk (RR) and corresponding 95% CIs. RESULTS Nine trials with a total of 53,869 patients were identified, with 33,011 (61.2%) in the DOACs plus APT group and 20,858 (38.8%) in the APT alone group. The use of DOACs did not decrease the risk of cardiovascular death (RR = 0.87; 95% CI, 0.75-1.01; P = 0.08; I2 = 0%) or myocardial infarction (RR = 0.90; 95% CI, 0.80-1.02; P = 0.10; I2 = 6%). However, the risk of SSE was significantly lower in patients who received DOACs plus APT compared with APT alone (RR = 0.67; 95% CI, 0.50-0.90; P = 0.008). Moreover, all-cause mortality was significantly lower in the DOACs plus APT group (RR = 0.83; 95% CI, 0.71-98; P = 0.03; I2 = 0%). However, the risk of major bleeding was significantly higher in patients treated with DOACs plus APT compared with APT alone (RR = 2.53; 95% CI, 1.96-3.26; P < 0.01; I2 = 0%), as was the risk of nonmajor bleeding (RR = 2.27; 95% CI, 1.51-3.41; P < 0.01). IMPLICATIONS DOACs plus APT for the prevention of left ventricular thrombus in patients with ACS were associated with a lower risk of SSE and all-cause mortality but increased the risk of major and nonmajor bleeding. The benefits and risks of this approach should be weighed based on a patient's individual clinical characteristics.
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Affiliation(s)
- Abdulmajeed Alharbi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio.
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Mohammed Alyosif
- Department of Cardiology, University of Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Clarissa Pena
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abed Jabr
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Anas Alsughayer
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Halah Alfatlawi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Mohammad Safi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abdulaziz Aldhafeeri
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Neha Patel
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Sadik Khuder
- Department of Medicine, Statistics, and Public Health, College of Medicine and Life Sciences, The University of Toledo, Toledo, Ohio
| | - Ehab Eltahawy
- Department of Cardiology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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9
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Bachorski W, Bychowski J, Gruchała M, Jaguszewski M. Two Approaches to Triple Antithrombotic Therapy in Patients with Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Treated with Percutaneous Coronary Intervention: Which Is More Efficient and Safer? Diagnostics (Basel) 2023; 13:3055. [PMID: 37835798 PMCID: PMC10572308 DOI: 10.3390/diagnostics13193055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding and thromboembolic events. Thus, optimal treatment strategies in this challenging subset have been controversial. Herein, we aim to investigate different triple antithrombotic treatment (TAT) strategies in patients with ACS and AF after PCI. METHODS This was a retrospective, single-center study based on all consecutive patients with the diagnosis of ACS and AF treated with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus dual antiplatelet therapy using a P2Y12 inhibitor (clopidogrel) and aspirin (for 1 to 3 months) and observed for 12 months for major adverse cardiac events (MACE) and major or clinically relevant non-major bleeding incidents. RESULTS MACE occurred in 26.6% of patients treated with the VKA and 30.9% with NOAC (p = 0.659). Bleeding occurred in 7.8% of patients treated with VKA and 7.4% with NOAC (ns). CONCLUSIONS Among patients with ACS and AF who had undergone PCI, there was no significant difference in the risk of bleeding and ischemic events among those who received TAT with NOAC and VKA.
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Affiliation(s)
- Witold Bachorski
- Department of Cardiology, Medical University of Gdansk, M. Skłodowskiej-Curie 3a, 80-210 Gdansk, Poland
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10
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Mazzone PM, Capodanno D. Low dose rivaroxaban for the management of atherosclerotic cardiovascular disease. J Thromb Thrombolysis 2023:10.1007/s11239-023-02821-x. [PMID: 37148437 DOI: 10.1007/s11239-023-02821-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/08/2023]
Abstract
Atherosclerotic cardiovascular disease is characterized by some risk of major adverse events despite the availability of effective medical therapies for secondary prevention. There is emerging evidence suggesting that thrombin partly contributes to this residual risk. In fact, thrombin (i.e., activated coagulation factor II) triggers not only the conversion of fibrinogen to fibrin but also platelet activation and various pathways responsible for pro-atherogenic and/or pro-inflammatory effects through interaction with protease activated receptors. To reduce the risk associated with thrombin activation, oral anticoagulants antagonists of vitamin K showed promise, but were associated with unacceptable bleeding rates. Direct oral anticoagulants targeting the activated factors X and II carry a lower risk of bleeding than vitamin K antagonists. Rivaroxaban, a direct inhibitor of activated factor X approved at the dose of 20 mg once daily for the prevention of thromboembolic events, has been also investigated at a reduced dose of 2.5 mg twice daily in several alternative scenarios of atherosclerotic cardiovascular disease, in combination with standard of care. Current guidelines recommend that low-dose rivaroxaban is given in an adjunct to standard therapy to patients with stable atherosclerosis and acute coronary syndromes at low bleeding risk. Several studies are underway to evaluate its putative benefits in other clinical settings.
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Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, Catania, 78 - 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, Catania, 78 - 95123, Italy.
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11
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Zhou T, Gong Y, Li J, Wang Y, Wang X. Efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with coronary atherosclerotic heart disease and gastrointestinal disease undergoing percutaneous coronary intervention: study protocol for a non-inferiority randomized controlled trial. Trials 2023; 24:209. [PMID: 36945020 PMCID: PMC10031942 DOI: 10.1186/s13063-023-07236-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for patients with coronary heart disease (CHD) undergoing percutaneous coronary intervention (PCI) to antithrombosis, meanwhile, increasing the risks of gastrointestinal bleeding. Rivaroxaban, a novel oral anticoagulant, combined with a P2Y12 receptor inhibitor reduces adverse events in patients with CHD and atrial fibrillation who underwent PCI. The effect of rivaroxaban plus P2Y12 inhibitor on reducing bleeding events in patients with CHD and gastrointestinal disease (GID) undergoing PCI remains unclear. METHOD The study is a prospective, single-center, randomized controlled trial. A total of 1020 patients with CHD and GID undergoing PCI will be enrolled. Patients are randomized (1:1) to receive either rivaroxaban 10 mg plus clopidogrel 75 mg daily or aspirin 100 mg plus clopidogrel 75 mg daily; both treatments will last 6 months. The primary endpoint is Bleeding Academic Research Consortium (BARC) type 2-5 bleeding requiring medical intervention. The secondary endpoint is a composite of major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, cardiac death, nonfatal myocardial infarction, stent thrombosis, ischemia-driven target vessel revascularization, and stroke. DISCUSSION The objective of this study is to evaluate the efficacy and safety of rivaroxaban plus clopidogrel versus aspirin plus clopidogrel in patients with CHD and GID undergoing PCI. We aim to explore an optimized antithrombotic strategy, which achieves the same anti-ischemic effect as standard DAPT without increasing the risk of GIB, for patients with CHD and GID undergoing PCI. TRIAL REGISTRATION This protocol is registered at the Chinese Clinical Trial Registry under the number ChiCTR2100044319. And this publication is based on version 1.4 of the trial protocol dated Sep 6, 2021.
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Affiliation(s)
- Tienan Zhou
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yinghui Gong
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Jingyuan Li
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Yasong Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China
| | - Xiaozeng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, No. 83 Wenhua Rd, Shenyang, 110016, Liaoning, China.
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12
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Are Factor Xa Inhibitors Efficacious for Ischemic Stroke Prevention in Patients Without Atrial Fibrillation? Evidence From Randomized Clinical Trials. Can J Cardiol 2023; 39:187-197. [PMID: 36179950 DOI: 10.1016/j.cjca.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/29/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Clinical trials provide conflicting evidence regarding oral factor Xa inhibitors for prevention of ischemic stroke in patients without a history of atrial fibrillation (AF). METHODS We performed a critical appraisal of randomized clinical trials that tested oral factor Xa inhibitors in patients without AF that reported ischemic stroke. RESULTS Considering the 11 trials that reported > 10 ischemic strokes during follow-up (97,578 participants, 1195 ischemic strokes), 1 tested apixaban (57 strokes), 1 betrixaban (52 strokes), and 9 rivaroxaban (1086 strokes). In 7 trials with placebo comparisons, numerically fewer ischemic strokes occurred among those assigned factor Xa inhibitors in 7 of 8 randomized comparisons (range of hazard ratios [HRs], 0.89-0.51), including statistically significant reductions in 2 trials that compared rivaroxaban 2.5 mg twice daily vs placebo on a background of aspirin in patients with cardiovascular disease, COMPASS (HR, 0.51; 95% confidence interval [CI], 0.38-0.68) and COMMANDER-HF (HR, 0.64; 95% CI, 0.43-0.95). Compared with aspirin in 4 trials, oral factor Xa inhibitors were associated with fewer ischemic strokes in 2, with statistically significant reduction in 1 (rivaroxaban 5 mg twice daily in COMPASS; HR, 0.69; 95% CI, 0.53-0.90). Major bleeding was increased by oral factor Xa inhibitors in all 7 placebo-controlled trials (HR range, 1.42-4.08), with statistically significant increases reported in 5 trials, and in all 4 aspirin-controlled trials (all statistically significant increases; HR range, 1.52-2.72). CONCLUSIONS Aggregate evidence on the basis of placebo comparisons from randomized trials supports the potential for oral factor Xa inhibitors to reduce ischemic stroke in patients without AF, but major bleeding is increased.
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13
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Zhou S, Xiao Y, Zhou C, Zheng Z, Jiang W, Shen Q, Zhu C, Pan H, Liu C, Zeng G, Ge L, Zhang Y, Ouyang Z, Fu G, Pan G, Chen F, Huang L, Liu Q. Effect of Rivaroxaban vs Enoxaparin on Major Cardiac Adverse Events and Bleeding Risk in the Acute Phase of Acute Coronary Syndrome: The H-REPLACE Randomized Equivalence and Noninferiority Trial. JAMA Netw Open 2023; 6:e2255709. [PMID: 36763358 PMCID: PMC9918885 DOI: 10.1001/jamanetworkopen.2022.55709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
IMPORTANCE Parenteral enoxaparin is a preferred anticoagulant used in the acute phase for patients with acute coronary syndrome (ACS). The safety and efficacy of short-term low-dose rivaroxaban in this clinical setting remain unknown. OBJECTIVE To compare the safety and efficacy of rivaroxaban vs enoxaparin in the acute phase of ACS. DESIGN, SETTING, AND PARTICIPANTS This multicenter, prospective, open-label, active-controlled, equivalence and noninferiority trial was conducted from January 2017 through May 2021 with a 6-month follow-up at 21 hospitals in China. Participants included patients with ACS missing the primary reperfusion window or before selective revascularization. Data were analyzed from November 2021 to November 2022. INTERVENTIONS Participants were randomized 1:1:1 to oral rivaroxaban 2.5 mg or 5 mg or 1 mg/kg subcutaneous enoxaparin twice daily in addition to dual antiplatelet therapy (DAPT; aspirin 100 mg and clopidogrel 75 mg once daily) for a mean of 3.7 days. MAIN OUTCOMES AND MEASURES The primary safety end point was bleeding events, as defined by the International Society on Thrombosis and Haemostasis, and the primary efficacy end point was major adverse cardiovascular events (MACEs), including cardiac death, myocardial infarction, rerevascularization, or stroke during the 6-month follow-up. RESULTS Of 2055 enrolled patients, 2046 (99.6%) completed the trial (mean [SD] age 65.8 [8.2] years, 1443 [70.5%] male) and were randomized to enoxaparin (680 patients), rivaroxaban 2.5 mg (683 patients), or rivaroxaban 5 mg (683 patients). Bleeding rates were 46 patients (6.8%) in the enoxaparin group, 32 patients (4.7%) in the rivaroxaban 2.5 mg group, and 36 patients (5.3%)in the rivaroxaban 5 mg group (rivaroxaban 2.5 mg vs enoxaparin: noninferiority hazard ratio [HR], 0.68; 95% CI, 0.43 to 1.07; P = .005; rivaroxaban 5 mg vs enoxaparin: noninferiority HR, 0.88; 95% CI, 0.70 to 1.09; P = .001). The incidence of MACEs was similar among groups, and noninferiority was reached in the rivaroxaban 5 mg group (HR, 0.60; 95% CI, 0.31 to 1.16, P = .02) but not in the rivaroxaban 2.5 mg group (HR, 0.68; 95% CI, 0.36 to 1.30; P = .05) compared with the enoxaparin group. CONCLUSIONS AND RELEVANCE In this equivalence and noninferiority trial, oral rivaroxaban 5 mg showed noninferiority to subcutaneous enoxaparin (1 mg/kg) for patients with ACS treated with DAPT during the acute phase. Results of this feasibility study provide useful information for designing future randomized clinical trials with sufficient sample sizes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03363035.
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Affiliation(s)
- Shenghua Zhou
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Yichao Xiao
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Chonglun Zhou
- Department of Cardiology, Xiangxiang People’s Hospital, Xiangxiang, People’s Republic of China
| | - Zhaofen Zheng
- Department of Cardiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, People’s Republic of China
| | - Weihong Jiang
- Department of Cardiology, Third Xiangya Hospital of Central South University, Changsha, People’s Republic of China
| | - Qiang Shen
- Department of Cardiology, First People’s Hospital of Huaihua, Huaihua, People’s Republic of China
| | - Can Zhu
- Department of Cardiology, First Affiliated Hospital of Jishou University, Jishou, People’s Republic of China
| | - Hongwei Pan
- Department of Cardiology, Hunan Provincial People’s Hospital, First Affiliated Hospital of Hunan Normal University, Changsha, People’s Republic of China
| | - Changhui Liu
- Department of Cardiology, First Affiliated Hospital of University of South China, Hengyang, People’s Republic of China
| | - Gaofeng Zeng
- Department of Cardiology, Second Affiliated Hospital of University of South China, Hengyang, People’s Republic of China
| | - Liangqing Ge
- Department of Cardiology, First People’s Hospital of Changde City, Changde, People’s Republic of China
| | - Yumin Zhang
- Department of Cardiology, Third Hospital of Changsha, Changsha, People’s Republic of China
| | - Zewei Ouyang
- Department of Cardiology, Central Hospital of Shaoyang, Shaoyang, People’s Republic of China
| | - Guang Fu
- Department of Cardiology, First Hospital of Changsha, Changsha, People’s Republic of China
| | - Gang Pan
- Department of Cardiology, First People’s Hospital of Yueyang, Yueyang, People’s Republic of China
| | - Feng Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, People’s Republic of China
| | - Lihong Huang
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, People’s Republic of China
| | - Qiming Liu
- Department of Cardiology, Second Xiangya Hospital of Central South University, Changsha, People’s Republic of China
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Wu H, Xu L, Zhao X, Zhang H, Cheng K, Wang X, Chen M, Li G, Huang J, Lan J, Wei G, Zhang C, Wang Y, Qian J, Ge J. Indobufen or Aspirin on Top of Clopidogrel After Coronary Drug-Eluting Stent Implantation (OPTION): A Randomized, Open-Label, End Point-Blinded, Noninferiority Trial. Circulation 2023; 147:212-222. [PMID: 36335890 DOI: 10.1161/circulationaha.122.062762] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin as a background therapy has become the standard care after percutaneous coronary intervention. However, some adverse noncardiac effects limited the use of aspirin in clinical practice. Thus, evaluation of pharmacological alternatives to aspirin is attractive. Previous data indicated that indobufen could lessen the unwanted side effects of aspirin while retaining the antithrombotic efficacy, but its combination with a P2Y12 inhibitor still lacks randomized clinical trial evidence. METHODS In this randomized, open-label, noninferiority trial, patients with negative cardiac troponin undergoing coronary drug-eluting stent implantation were randomly assigned in a 1:1 ratio to receive either indobufen-based DAPT (indobufen 100 mg twice a day plus clopidogrel 75 mg/d for 12 months) or conventional DAPT (aspirin 100 mg/d plus clopidogrel 75 mg/d for 12 months). The primary end point was a 1-year composite of cardiovascular death, nonfatal myocardial infarction, ischemic stroke, definite or probable stent thrombosis, or Bleeding Academic Research Consortium criteria type 2, 3, or 5 bleeding. The end points were adjudicated by an independent Clinical Event Committee. RESULTS Between January 11, 2018, and October 12, 2020, 4551 patients were randomized in 103 cardiovascular centers: 2258 patients to the indobufen-based DAPT group and 2293 to the conventional DAPT group. The primary end point occurred in 101 patients (4.47%) in the indobufen-based DAPT group and 140 patients (6.11%) in the conventional DAPT group (absolute difference, -1.63%; Pnoninferiority<0.001; hazard ratio, 0.73 [95% CI, 0.56-0.94]; P=0.015). Cardiovascular death, nonfatal myocardial infarction, ischemic stroke, and stent thrombosis were observed in 0.13%, 0.40%, 0.80%, and 0.22% of patients in the indobufen-based DAPT group and 0.17%, 0.44%, 0.83%, and 0.17% of patients in the conventional DAPT group (all P>0.05). The occurrence of Bleeding Academic Research Consortium criteria type 2, 3, or 5 bleeding events was lower in the indobufen-based DAPT group compared with the conventional DAPT group (2.97% versus 4.71%; hazard ratio, 0.63 [95% CI, 0.46-0.85]; P=0.002), with the main decrease in type 2 bleeding (1.68% versus 3.49%; hazard ratio, 0.48 [95% CI, 0.33-0.70]; P<0.001). CONCLUSIONS In Chinese patients with negative cardiac troponin undergoing drug-eluting stent implantation, indobufen plus clopidogrel DAPT compared with aspirin plus clopidogrel DAPT significantly reduced the risk of 1-year net clinical outcomes, which was driven mainly by a reduction in bleeding events without an increase in ischemic events. REGISTRATION URL: https://www.chictr.org.cn; Unique identifier: ChiCTR-IIR-17013505.
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Affiliation(s)
- Hongyi Wu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Lili Xu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Xin Zhao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Huanyi Zhang
- Department of Cardiology, Taian City Central Hospital, Shandong, China (H.Y.Z.)
| | - Kang Cheng
- Department of Cardiology, Xi'an No. 3 Hospital, Affiliated Hospital of Northwest University, Xi'an, Shanxi, China (K.C.)
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.Y.W.)
| | - Manhua Chen
- Department of Cardiology, Central Hospital of Wuhan, Hubei, China (M.H.C.)
| | - Guangping Li
- Department of Cardiology, Second Hospital of Tianjin Medical University, China (G.P.L.)
| | - Jiangnan Huang
- Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, Nanning, China (J.N.H.)
| | - Jun Lan
- Department of Cardiology, Dongguan Third People's Hospital, Guangdong, China (J.L.)
| | - Guanghe Wei
- Department of Cardiology, Affiliated Hospital of Jining Medical University, Shandong, China (G.H.W.)
| | - Chi Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Yinman Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, China (H.Y.W., L.L.X., X.Z., C.Z., Y.M.W., J.Y.Q., J.B.G.)
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15
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Sagris M, Theofilis P, Papanikolaou A, Antonopoulos AS, Tsioufis C, Tousoulis D. Direct Oral Anticoagulants use in Patients with Stable Coronary Artery Disease, Acute Coronary Syndrome or Undergoing Percutaneous Coronary Intervention. Curr Pharm Des 2023; 29:2787-2794. [PMID: 38038010 DOI: 10.2174/0113816128259508231118141831] [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: 05/22/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
The investigation for the optimal anticoagulation strategy for patients with stable coronary artery disease, acute coronary syndromes, and undergoing percutaneous coronary intervention constitutes a great challenge for physicians and is a field of extensive research. Although aspirin is commonly recommended as a protective measure for all patients with coronary artery disease and dual antiplatelet therapy for those undergoing procedures, such as percutaneous coronary intervention or coronary artery bypass graft surgery, the risk of recurrent cardiovascular events remains significant. In this context, the shortcomings associated with the use of vitamin K antagonists have led to the assessment of direct oral anticoagulants as promising alternatives. This review will explore and provide a comprehensive analysis of the existing data regarding the use of direct oral anticoagulants in patients with stable coronary artery disease or acute coronary syndrome, as well as their effectiveness in those undergoing percutaneous coronary intervention or coronary artery bypass graft surgery.
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Affiliation(s)
- Marios Sagris
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Angelos Papanikolaou
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Constantinos Tsioufis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
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16
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Galli M, Franchi F, Rollini F, Ortega-Paz L, D'Amario D, De Caterina R, Mehran R, Gibson CM, Angiolillo DJ. Dual pathway inhibition in patients with atherosclerotic disease: pharmacodynamic considerations and clinical implications. Expert Rev Clin Pharmacol 2023; 16:27-38. [PMID: 36455906 DOI: 10.1080/17512433.2023.2154651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The persistence of elevated rates of ischemic recurrences despite the use of antiplatelet therapy among patients with atherosclerotic disease together with the understanding of the pivotal role of coagulation in the thrombo-inflammatory processes involved in the pathogenesis of atherosclerosis and its complications has fostered the development of treatments targeting both platelets and coagulation, a strategy known as dual-pathway inhibition (DPI). AREAS COVERED In this review we discuss the recent advancements in the understanding of the interplay between coagulation, platelets and inflammation involved in the pathophysiology of atherosclerosis and atherothrombosis, as the rationale for the implementation of a DPI strategy. We also discuss the available pharmacodynamic (PD) evidence and clinical implications with the use of DPI in patients with atherosclerotic disease. EXPERT OPINION The implementation of a DPI by adding the so-called 'vascular dose of rivaroxaban' (i.e. 2.5 mg bis in die), on top of antiplatelet therapy has consistently been associated with reduced levels of thrombin generation in PD studies and with reduced ischemic event rates at the cost of increased bleeding compared to antiplatelet therapy alone. Further research is warranted to best define patients in whom a DPI regimen has the best safety and efficacy profile.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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17
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Szapáry L, Tornyos D, Kupó P, Lukács R, El Alaoui El Abdallaoui O, Komócsi A. Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:1036609. [PMID: 36568540 PMCID: PMC9773199 DOI: 10.3389/fcvm.2022.1036609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Background Despite numerous randomized clinical trials (RCT), data regarding the efficacy of antiplatelet and anticoagulant combinations are still conflicting. We aimed to analyze treatment options tested in various fields of cardiovascular prevention, regarding their efficacy and bleeding risk. Methods Systematic searches of electronic databases were conducted until June 2022. A component network meta-analysis was performed in R. Risk estimates across trials were pooled using random-effects model selecting risk ratio (RR) with 95% confidence intervals (95% CIs) as summary statistics. The primary endpoint of interest was the rate of major cardiac adverse events (MACE). Major bleeding events were assessed as main safety endpoint. Secondary outcomes included cardiovascular- and overall mortality, myocardial infarction (MI), stent thrombosis, and stroke. Results Fifteen studies randomizing 73,536 patients were identified. The MACE risk reflected heterogeneity among the anticoagulants with dabigatran and apixaban significantly reducing the risk of MACE (RR 0.56; 95% CI 0.39-0.80 and RR 0.75; 95% CI 0.58-0.98, respectively). Vitamin K antagonist (VKA), rivaroxaban, or edoxaban did not reduced of MACE while it was associated with a significant increase of bleeding risk (RR 1.66; 3.66, and 5.47, respectively). The direct anticoagulant (DOAC) dose reduction resulted in tendencies of fewer bleeding but higher MACE risk, while combination with aspirin was followed with increased risk for bleeding, however, remained non-significant in these cases. Conclusion Our meta-analysis supports that the ischemic-bleeding balance is different among direct-acting oral anticoagulants (DOACs) while this is not significantly affected by the dose reduction approaches. Long-term aspirin treatment as part of the anticoagulant and dual antiplatelet regimen provides no ischemic benefit but may increase bleeding risk. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [259703].
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Spirito A, Cangialosi P, Cao D, Nicolas J, Mehran R. Recent Advances in Antiplatelet Therapy in Complex Percutaneous Coronary Intervention. Interv Cardiol Clin 2022; 11:419-428. [PMID: 36243487 DOI: 10.1016/j.iccl.2022.02.003] [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] [Indexed: 06/16/2023]
Abstract
Antithrombotic therapy is the cornerstone of secondary cardiovascular prevention after percutaneous coronary intervention (PCI). Improvements in drug-eluting stent (DES) design and materials over the last 2 decades have prompted the development of new antithrombotic strategies. Current guidelines recommend to tailor dual antiplatelet therapy (DAPT) according to clinical presentation and individual ischemic and bleeding risk. Given the growing number of complex PCI procedures performed nowadays, it is a priority to define the optimal antithrombotic treatment in this challenging patient subset. In this review article, we sought to summarize and discuss the current evidence on antiplatelet therapy in patients undergoing complex PCI.
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Affiliation(s)
- Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Peter Cangialosi
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Davide Cao
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Johny Nicolas
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA.
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19
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Dual Antiplatelet Therapy After Drug-Eluting Stents Implantation in East Asians: A Network Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2022; 80:216-225. [PMID: 35561287 DOI: 10.1097/fjc.0000000000001288] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/30/2022] [Indexed: 12/23/2022]
Abstract
ABSTRACT Dual antiplatelet therapy (DAPT) is essential to prevent the risk of ischemia events, but it is difficult to avoid concurrent bleeding events. East Asians are associated with a higher tendency of bleeding than Caucasians, which may affect the DAPT duration. Therefore, this network meta-analysis to explore optimum DAPT duration for East Asians. The related randomized controlled trials that compared the different DAPT duration in East Asian patients were included by searching PubMed, EMBASE, and Cochrane Library database. The outcomes included myocardial infarction, stent thrombosis, all-cause death, stroke, and major bleeding. In addition, net adverse cardiac and cardiovascular events was defined as a composite outcome in this study. We calculated the odds ratio (OR) and 95% confidence intervals for end point events by the fixed effects model in the Bayesian's network frame. We included a total of 12 randomized controlled trials with 30,640 patients. Compared with 12-month DAPT, 1- to 3-month DAPT is effective in myocardial infarction (OR 0.72, 0.46-1.08), stents thrombosis (OR 1.27, 0.59-2.84), all-cause death (OR 0.91, 0.65-1.28), and stroke (OR 0.89, 0.57-1.39). The 1- to 3-month DAPT was associated with a lower risk of major bleeding compared with 12-month DAPT (OR 0.55, 0.4-0.76), 6-month DAPT (OR 0.54, 0.31-0.94), and >12-month DAPT (OR 0.43, 0.28-0.65). In addition, more than 12 months of DAPT did not reduce the incidence of myocardial infarction (OR 0.75, 0.51-1.11) and increased the risk of major bleeding (OR 1.28, 0.88-1.87) compared with 12-month DAPT. The 1- to 3-month DAPT was more secure and effective than the other 3 DAPT strategies. Although East Asians have a higher risk of bleeding, more than 12 months of DAPT does not increase this incidence of major bleeding.
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20
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Saiyitijiang A, Aizezi M, Zhao Y, Gao Y. Efficacy and safety of new oral anticoagulants combined with antiplatelet drugs in the treatment of coronary heart disease: Systematic evaluation and meta-analysis. Ann Noninvasive Electrocardiol 2022; 27:e12977. [PMID: 35715952 PMCID: PMC9484016 DOI: 10.1111/anec.12977] [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: 03/09/2022] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To analyze the efficacy and safety of antiplatelet drugs combined with new oral anticoagulants (noac) in the treatment of coronary atherosclerotic heart disease (CAD). Methods The randomized controlled trials of noac combined with antiplatelet therapy in Cochrane, CNKI, PubMed, EMBASE, Wanfang, Google Scholar, and Baidu library were searched using the literature database. Two researchers independently searched and screened to ensure the consistency of the results, and the literature was summarized and analyzed by Revman 5.3 software. Results Five research results were included. The results showed that the incidence of mace [95% CI 0.75–0.95, or = 0.84,p = .04], the incidence of major and minor bleeding [95% CI 1.25–5.16, or = 2.54,p = .01], the mortality of cardiovascular disease [95% CI 0.78–0.96, or = 0.86, p = .05], the total mortality [95% CI 0.79–0.95, or = 0.87, p = .003], and the incidence of myocardial infarction in patients with CAD treated with noac and antiplatelet drugs [95% CI 0.77–0.95, or = 0.85, p = .004] was lower than that treated with antiplatelet drugs alone, and the difference was statistically significant (p < .05); the incidence of fatal bleeding [95% CI 0.81–2.08, or = 1.30, p = .28], the incidence of stroke [95% CI 0.50–1.03, or = 0.71, p = .07], and the incidence of intracranial hemorrhage [95% CI 1.02–2.56, or = 1.61, p = .06]. There was no significant difference with antiplatelet drugs alone (p > .05). Conclusion Noac combined with antiplatelet drugs can reduce mace, total mortality, the incidence of myocardial infarction, and cardiovascular mortality in patients with CAD, but may increase the risk of bleeding.
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Affiliation(s)
- Alimila Saiyitijiang
- The Heart Center of the First Affiliated Hospital of Xinjiang Medical University, Urumuqi, China
| | - Mayila Aizezi
- The Third Departments of the First People's Hospital of Urumqi, Urumuqi, China
| | - Ying Zhao
- The General Practice Department of the Third People's Hospital of Xinjiang Uygur Autonomous Region, Urumuqi, China
| | - Ying Gao
- The Third Departments of the First Affiliated Hospital of Xinjiang Medical University, Urumuqi, China
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21
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Sia CH, Tan SH, Chan SP, Marchesseau S, Sim HW, Carvalho L, Chen R, Amin NHM, Fong AYY, Richards AM, Yip C, Chan MY. Enhanced Thrombin Generation Is Associated with Worse Left Ventricular Scarring after ST-Segment Elevation Myocardial Infarction: A Cohort Study. Pharmaceuticals (Basel) 2022; 15:718. [PMID: 35745638 PMCID: PMC9231218 DOI: 10.3390/ph15060718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 12/29/2022] Open
Abstract
Acute myocardial infarction (AMI) is associated with heightened thrombin generation. There are limited data relating to thrombin generation and left ventricular (LV) scarring and LV dilatation in post-MI LV remodeling. We studied 113 patients with ST-segment elevation myocardial infarction (STEMI) who had undergone primary percutaneous coronary intervention (PPCI) (n = 76) or pharmaco-invasive management (thrombolysis followed by early PCI, n = 37). Endogenous thrombin potential (ETP) was measured at baseline, 1 month and 6 months. Cardiovascular magnetic resonance imaging was performed at baseline and 6 months post-MI. Outcomes studied were an increase in scar change, which was defined as an increase in left ventricular infarct size of any magnitude detected by late gadolinium enhancement, adverse LV remodeling, defined as dilatation (increase) of left ventricular end-diastolic volume (LVEDV) by more than 20% and an increase in left ventricular ejection fraction (LVEF). The mean age was 55.19 ± 8.25 years and 91.2% were men. The baseline ETP was similar in the PPCI and pharmaco-invasive groups (1400.3 nM.min vs. 1334.1 nM.min, p = 0.473). Each 10-unit increase in baseline ETP was associated with a larger scar size (adjusted OR 1.020, 95% CI 1.002-1.037, p = 0.027). Baseline ETP was not associated with adverse LV remodeling or an increase in LVEF. There was no difference in scar size or adverse LV remodeling among patients undergoing PPCI vs. pharmaco-invasive management or patients receiving ticagrelor vs. clopidogrel. Enhanced thrombin generation after STEMI is associated with a subsequent increase in myocardial scarring but not LV dilatation or an increase in LVEF at 6 months post-MI.
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Affiliation(s)
- Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore; (C.-H.S.); (H.-W.S.); (L.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore 119228, Singapore;
| | - Sock-Hwee Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore 119228, Singapore;
| | - Siew-Pang Chan
- National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore;
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597, Singapore
| | | | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore; (C.-H.S.); (H.-W.S.); (L.C.)
| | - Leonardo Carvalho
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore; (C.-H.S.); (H.-W.S.); (L.C.)
- Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor-HCFMUSP), Sao Paulo 05403-904, Brazil
- Cardiac Department, Ferderal University of Sao Paulo State (UNIFESP), Sao Paulo 05303-000, Brazil
| | - Ruth Chen
- Department of Cardiology, Woodlands Health Campus, Tower E, Level 5, Yishun Community Hospital, 2 Yishun Central 2, Singapore 768024, Singapore;
| | - Nor Hanim Mohd Amin
- Clinical Research Centre, Sarawak General Hospital, Jalan Hospital, Kuching 93586, Malaysia; (N.H.M.A.); (A.Y.-Y.F.)
- Department of Cardiology, Sarawak Heart Centre, Samarahan Expressway, Kota Samarahan 94300, Malaysia
| | - Alan Yean-Yip Fong
- Clinical Research Centre, Sarawak General Hospital, Jalan Hospital, Kuching 93586, Malaysia; (N.H.M.A.); (A.Y.-Y.F.)
- Department of Cardiology, Sarawak Heart Centre, Samarahan Expressway, Kota Samarahan 94300, Malaysia
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore 119228, Singapore;
- Christchurch Heart Institute, Department of Medicine, University of Otago, P.O. Box 4345, Christchurch 8140, New Zealand
| | - Christina Yip
- Department of Laboratory Medicine, Main Building, Level 3, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore;
| | - Mark Y. Chan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore; (C.-H.S.); (H.-W.S.); (L.C.)
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore 119228, Singapore;
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22
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Gurbel PA, Rout A, Tantry US. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Choxi R, Kapoor K, Mackman N, Jovin IS. Direct Oral Anticoagulants and Coronary Artery Disease. Arterioscler Thromb Vasc Biol 2022; 42:553-564. [PMID: 35296151 DOI: 10.1161/atvbaha.121.317171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Coronary artery disease is a leading cause of morbidity and mortality worldwide. Acute coronary syndrome as a first presentation is common and patients with established disease have a high rate of recurrent ischemic events, despite antiplatelet therapy. Over the past several years, direct oral anticoagulants have become available and have been studied in patients with coronary artery disease. These medications directly inhibit either thrombin or factor Xa which contribute to atherothrombosis. This review will summarize the clinical data regarding the use of direct oral anticoagulants in different patient populations with coronary disease and the balance between protection against ischemia and bleeding. Additionally, the review will summarize the available data on the use of direct oral anticoagulants periprocedurally in patients undergoing percutaneous coronary intervention. The future direction of coronary artery disease and the role of direct oral anticoagulants will rely on further studies determining the optimal combination of antiplatelet and oral anticoagulant regimens that derive ischemic benefit without increased rates of bleeding. Additional upstream blockade of the coagulation cascade with factor XIIa and factor XIa inhibitors may also improve treatment in the future.
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Affiliation(s)
- Ravi Choxi
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.)
| | - Kunal Kapoor
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.)
| | - Nigel Mackman
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill (N.M.)
| | - Ion S Jovin
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.).,McGuire Veterans Administration Medical Center Richmond, VA (I.S.J.)
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24
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Gao F, Rahman F. DOACs and Atherosclerotic Cardiovascular Disease Management: Can We Find the Right Balance Between Efficacy and Harm. Curr Atheroscler Rep 2022; 24:457-469. [PMID: 35386093 DOI: 10.1007/s11883-022-01022-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The balance between efficacy and harm remains a challenge in the adoption of non-vitamin K antagonist direct oral anticoagulants (DOACs) for secondary atherosclerotic disease prevention. We provide a comprehensive review of the evidence for and against the addition of DOACs to the current management of atherosclerotic cardiovascular disease, including stable coronary artery disease (CAD), acute coronary syndrome (ACS), peripheral artery disease (PAD), and percutaneous coronary interventions (PCI). RECENT FINDINGS The DOAC class exerts pleiotropic effects on atherosclerotic progression through coagulation and inflammatory pathways. In ACS, low-dose DOAC provides no added efficacy in the setting of dual antiplatelet therapy; however, full-dose DOAC increases bleeding. Efficacy-safety profile favor use of low-dose rivaroxaban in select stable CAD or PAD patients. Atrial fibrillation patients undergoing PCI resort to dual therapy with DOAC due to prohibitory bleeding with triple anti-thrombotic therapy. Evidence favors DOAC use in CAD and PAD; however, careful individual considerations must be undertaken.
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Affiliation(s)
- Feng Gao
- Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Faisal Rahman
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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25
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Galli M, Franchi F, Rollini F, Been L, Jaoude PA, Rivas A, Zhou X, Jia S, Maaliki N, Lee CH, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Geisler T, Jennings LK, Bass TA, Angiolillo DJ. Platelet P2Y12 inhibiting therapy in adjunct to vascular dose of rivaroxaban or aspirin: A pharmacodynamic study of dual pathway inhibition versus dual antiplatelet therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:728-737. [PMID: 35353154 DOI: 10.1093/ehjcvp/pvac022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 12/25/2022]
Abstract
AIM Dual-pathway inhibition (DPI) by adding a vascular dose of rivaroxaban to a single antiplatelet agent has emerged as a promising antithrombotic strategy. However, in most studies the antiplatelet agent of choice used in adjunct to a vascular dose of rivaroxaban was aspirin, and data with a P2Y12 inhibitor and how this DPI regimen compares with standard dual antiplatelet therapy (DAPT) is limited. METHODS AND RESULTS This investigation was a sub-study analysis conducted in selected cohorts of patients with stable atherosclerotic disease enrolled from a larger prospective, open-label, parallel-group pharmacodynamics (PD) study. We analyzed data from 40 patients treated with either clopidogrel or ticagrelor-based DAPT first, and clopidogrel or ticagrelor-based DPI thereafter. PD measures explored key pathways involved in thrombus formation and included markers of: 1) P2Y12 reactivity, 2) platelet-mediated global thrombogenicity, 3) cyclooxygenase-1 activity, 3) TRAP-induced platelet aggregation; 4) tissue factor (TF)-induced platelet aggregation, and 5) thrombin generation. As compared to DAPT, on a background of the same P2Y12 inhibitor (clopidogrel or ticagrelor), DPI was associated with reduced thrombin generation, increased markers of cyclooxygenase-1 activity and TRAP-induced platelet aggregation and no differences in markers of P2Y12 signaling, platelet-mediated global thrombogenicity and TF-induced platelet aggregation. In an analysis according to P2Y12 inhibitor type, ticagrelor reduced markers of platelet-mediated global thrombogenicity, P2Y12 signaling and rates of high platelet reactivity compared to clopidogrel. CONCLUSIONS Compared to DAPT with aspirin and a P2Y12 inhibitor, the use of a P2Y12 inhibitor in adjunct to a vascular dose of rivaroxaban as part of a DPI strategy is associated with similar effects on platelet-mediated global thrombogenicity but reduced thrombin generation. A DPI strategy with ticagrelor is associated with enhanced antithrombotic efficacy, the clinical implications of which warrant larger scale investigations. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03718429.
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Affiliation(s)
- Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Patrick Abou Jaoude
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Sida Jia
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Naji Maaliki
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Chang Hoon Lee
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tobias Geisler
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Lisa K Jennings
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Theodore A Bass
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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26
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Gragnano F, Calabrò P. Anticoagulation After Primary PCI: The Land of Promises and Uncertainty. JACC Cardiovasc Interv 2022; 15:264-267. [PMID: 35144782 DOI: 10.1016/j.jcin.2021.12.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 01/08/2023]
Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy; Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy.
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy; Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy
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27
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Yu J, Liu Y, Peng W, Liu J, Li Y, Liu J, Jiang Y, Liu D, Xu Z. Analysis of the Guiding Role of CYP2C19 Gene Combined With Platelet Function Detection in Antiplatelet Therapy in Patients With Complex Coronary Artery Disease After PCI. Front Surg 2022; 9:839157. [PMID: 35223980 PMCID: PMC8863874 DOI: 10.3389/fsurg.2022.839157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/06/2022] [Indexed: 12/03/2022] Open
Abstract
Objective To explore the influence of CYP2C19 gene combined with platelet function test on clinical prognosis of patients with complex coronary artery disease receiving antiplatelet therapy after PCI. Methods A total of 200 patients undergoing PCI in our hospital due to complex coronary artery disease from February 2019 to February 2021 were selected and divided into the control group and the observation group according to whether CYP2C19 gene detection was performed. The control group was treated with dual antiplatelet therapy of classical aspirin combined with clopidogrel, and the observation group was treated with individual antiplatelet therapy. The patients in the two groups were followed up for 1 year after PCI, and their quality of life was assessed using the Seattle Angina Questionnaire (SAQ score). The occurrence of major adverse cardiovascular events (MACE) during the follow-up period was also recorded. Results The incidence of total MACE events in the observation group was slightly less than that in the control group, and the difference was statistically significant (P = 0.040). In particular, the observation group was superior to the control group in reducing the readmission rate of recurrent unstable angina pectoris, and the difference was statistically significant (P = 0.023). The location of coronary culprit lesions with recurrent ischemic events was commonly seen in non-interventional target lesions (interventional/non-interventional target sites: 12.9%: 77.1%). The SAQ score in the observation group was larger than that in the control group, and the difference was statistically significant (P = 0.012). There was no statistical difference in the incidence of major bleeding between the two groups (P = 0.352). Conclusion Using CYP2C19 genotype combined with platelet function test to guide individualized antiplatelet therapy after complex coronary artery PCI is beneficial to reducing ischemic events in a short period (1 year), mainly due to reducing the risk of readmission for recurrent unstable angina pectoris, and improving the quality of daily life of patients without increasing the risk of massive hemorrhage, which can improve clinical prognosis.
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Affiliation(s)
- Jiancai Yu
- Department of Cardiology, Teaching Hospital of Cangzhou Central Hospital of Tianjin Medical University, Tianjin Medical University, Tianjin, China
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Yongxing Liu
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Wanzhong Peng
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Juan Liu
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Ya Li
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Junyan Liu
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Yang Jiang
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Demin Liu
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
| | - Zesheng Xu
- Department of Cardiology, Teaching Hospital of Cangzhou Central Hospital of Tianjin Medical University, Tianjin Medical University, Tianjin, China
- Department of Cardiology, Cangzhou Central Hospital, Cangzhou, China
- *Correspondence: Zesheng Xu
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28
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Lander K, Thakeria P, Nayyar S. Prophylactic anticoagulation in sinus rhythm for stroke prevention in cardiovascular disease: contemporary meta-analysis of large randomized trials. Eur J Prev Cardiol 2022; 28:1939-1948. [PMID: 34223629 DOI: 10.1093/eurjpc/zwab113] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/04/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022]
Abstract
AIMS Anticoagulation with non-vitamin K oral anticoagulants (NOACs) to prevent stroke is a mainstay of atrial fibrillation (AF) management. However, multiple cardiovascular diseases (CVDs) are associated with elevated ischaemic stroke risk even in sinus rhythm. In this meta-analysis, we assess efficacy and safety of prophylactic NOAC agents for stroke prevention in patients without AF. METHODS AND RESULTS A search was conducted for randomized controlled trials (RCTs) that evaluated an NOAC and control drug (placebo or antiplatelet) in non-AF patients with mixed CVD. The primary efficacy and safety outcomes were ischaemic stroke and major bleeding, respectively. Results were stratified based on primary- and mini-NOAC doses. Thirteen RCTs were identified with a total of 89 383 patients with CVD in sinus rhythm (53 778 on NOAC, 35 605 on control drug; mean age 65.5 ± 2.7 years). Over a mean follow-up of 18.3 months, 1429 (1.6%) ischaemic strokes occurred. Use of NOAC was associated with 26% reduction in stroke [odds ratio (OR) 0.74, 95% confidence interval (CI) 0.62-0.87; 1.1 vs. 1.8 events per 100 person-years], with numbers needed to treat of 153 patients to prevent one stroke. Major bleeding was increased with NOAC (OR 1.74, 95% CI 1.44-2.09; 2.1 vs. 1.0 events per 100 person-years). The weighted net clinical benefit (wNCB, composite of ischaemic stroke and bleeding) did not suggest a favourable effect with any NOAC dose (wNCB for primary-dose: -0.35; mini-dose: -0.06). CONCLUSION Current evidence does not support use of NOACs for stroke prevention in non-AF CVD population as risk of major bleeding still exceeds ischaemic stroke benefit.
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Affiliation(s)
- Krystle Lander
- Department of Cardiology, Townsville University Hospital, James Cook University, 100, Angus Smith Drive, Townsville, QLD 4814, Australia
| | - Priyanka Thakeria
- Department of Cardiology, Townsville University Hospital, James Cook University, 100, Angus Smith Drive, Townsville, QLD 4814, Australia
| | - Sachin Nayyar
- Department of Cardiology, Townsville University Hospital, James Cook University, 100, Angus Smith Drive, Townsville, QLD 4814, Australia
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Evaluation of definitions for oral anticoagulant-associated major bleeding: A population-based cohort study. Thromb Res 2022; 213:57-64. [DOI: 10.1016/j.thromres.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 02/14/2022] [Accepted: 02/19/2022] [Indexed: 11/23/2022]
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Kitano D, Migita S, Li Y, Takahashi R, Taniguchi Y, Kurosawa T, Sudo M, Haruta H, Hiro T, Takayama T, Mitsumata M, Matsumoto T, Okumura Y, Hirayama A. Effect of Rivaroxaban and Clopidogrel Combination Therapy on In-Stent Responses After Everolimus-Eluting Stent Implantation in a Porcine Coronary Model. J Atheroscler Thromb 2022; 29:69-81. [PMID: 33208566 PMCID: PMC8737068 DOI: 10.5551/jat.56549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 10/05/2020] [Indexed: 12/02/2022] Open
Abstract
AIM According to recent clinical trials, a combination of direct oral anticoagulants with antiplatelet drugs is often recommended for atrial fibrillation patients who receive drug-eluting stents (DESs). Although the optimal combination comprises direct factor Xa inhibitors and a P2Y12 receptor antagonist (or aspirin), their influence on vascular responses to DESs remains unclear. METHODS Pigs were given either aspirin and clopidogrel (dual antiplatelet therapy [DAPT] group), aspirin and rivaroxaban (AR group), or clopidogrel and rivaroxaban (CR group), followed by everolimus-eluting stent (Promus Element) implantation into the coronary artery. Stented coronary arteries were evaluated via intravascular optical coherence tomography (OCT) and histological analysis at 1 and 3 months. RESULTS OCT revealed lower neointimal thickness in the DAPT group and comparable thickness among all groups at 1 and 3 months, respectively. Histological analyses revealed comparable neointimal area among all groups and the smallest neointimal area in the CR group at 1 and 3 months, respectively. In the DAPT and AR groups, the neointima continued to grow from 1 to 3 months. A shortened time course for neointima growth was observed in the CR group, with rapid growth within a month (maintained for 3 months). A higher incidence of in-stent thrombi was observed in the AR group at 1 month; no thrombi were found in either group at 3 months. More smooth muscle cells with contractile features were found in the CR group at both 1 and 3 months. CONCLUSIONS Our results proved the noninferiority of the combination of rivaroxaban with an antiplatelet drug, particularly the dual therapy using rivaroxaban and clopidogrel, compared to DAPT after DES implantation.
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Affiliation(s)
- Daisuke Kitano
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Advanced Cardiovascular Imaging, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Suguru Migita
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yuxin Li
- Division of Advanced Cardiovascular Imaging, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Cell Regeneration and Transplantation, Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Rie Takahashi
- Research Support Center, Research Institute of Medical Science, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshiki Taniguchi
- Research Support Center, Research Institute of Medical Science, Nihon University School of Medicine, Tokyo, Japan
| | - Takafumi Kurosawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Mitsumasa Sudo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Advanced Cardiovascular Imaging, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hironori Haruta
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Takafumi Hiro
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Advanced Cardiovascular Imaging, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tadateru Takayama
- Department of General Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masako Mitsumata
- Division of Pathology, Central Clinical Laboratory, Yamanashi Kosei Hospital, Yamanashi, Japan
| | - Taro Matsumoto
- Division of Cell Regeneration and Transplantation, Department of Functional Morphology, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Cardiovascular Division, Osaka Police Hospital, Osaka, Japan
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Moll MA, Zwerger D, Grassl KJ, Westreicher W, Neururer SB, Moll CW, Wipper SH, Klocker J. Prevalence of VOYAGER PAD trial exclusion criteria in unselected patients undergoing lower limb revascularisation. INT ANGIOL 2021; 41:56-62. [PMID: 34913631 DOI: 10.23736/s0392-9590.21.04816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The VOYAGER PAD trial investigated data on dual pathway inhibition after lower limb revascularisation for peripheral arterial disease (PAD). Multiple exclusion criteria were applied. However, neither data on the prevalence of exclusion criteria nor on the total number of patients screened for inclusion was discussed. METHODS We performed a single-center prospective observational study in unselected PAD patients undergoing lower limb revascularisation. Demographic and disease-specific data was collected. RESULTS 150 patients were included with only 29 patients (19.3%) as potential candidates for the VOYAGER PAD study medication. Poorly controlled diabetes or severe uncontrolled hypertension (33.3%), major tissue loss (18.7%), acute limb ischaemia within prior 2 weeks (17.3%) and a history of intracranial haemorrhage, stroke or TIA (16%) were amongst the exclusion criteria most frequently met. Compared to VOYAGER PAD study patients, significant differences regarding sex (36.7% female vs. 25.8%), renal insufficiency (29.0% vs. 20.1%), previous myocardial infarction (16.7% vs. 11.1%) and known carotid artery disease (18.7% vs. 8.6%) revealed. Patients presented significantly more frequently with critical limb ischemia (56.7% vs. 30.4%) and a history of previous peripheral revascularisation (72.0% vs. 35.9%). Fewer endovascular interventions (52% vs. 65.5%) and more surgeries (58% vs. 34.5%) were performed. CONCLUSIONS In unselected patients undergoing revascularisation for peripheral arterial disease, the majority presents with characteristics that, at present, preclude prescription of rivaroxaban in addition to aspirin. This patient cohort represents a population with higher rates of comorbidities and more complex vascular interventions, but might also benefit from dual pathway inhibition strategy.
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Affiliation(s)
- Maria A Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Zwerger
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kristina J Grassl
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Westreicher
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabrina B Neururer
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Clemens Wi Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine H Wipper
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria -
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Zhao Q, Small DS, Ertefaie A. Selective inference for effect modification via the lasso. J R Stat Soc Series B Stat Methodol 2021; 84:382-413. [DOI: 10.1111/rssb.12483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Qingyuan Zhao
- Department of Pure Mathematics and Mathematical Statistics University of Cambridge Cambridge UK
| | - Dylan S. Small
- Department of Statistics and Data Science University of Pennsylvania Philadelphia Pennsylvania USA
| | - Ashkan Ertefaie
- Department of Biostatistics and Computational Biology University of Rochester Rochester New York USA
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Direct Oral Anticoagulants Combined with Antiplatelet Therapy in the Treatment of Coronary Heart Disease: An Updated Meta-analysis. Drugs 2021; 81:2003-2016. [PMID: 34731462 DOI: 10.1007/s40265-021-01637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) combined with antiplatelet therapy for acute coronary syndrome (ACS) may reduce ischemic events, but there is no consensus on bleeding risk. Moreover, the effect of DOACs on stable coronary artery disease (CAD) needs to be elucidated. We conducted a meta-analysis to summarize the efficacy and safety of DOACs combined with antiplatelet therapy in the treatment of stable CAD and ACS. METHODS We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials, then performed a systematic review of all 17 randomized controlled trials. RESULTS For patients with stable CAD, DOACs combined with antiplatelet therapy significantly reduced the rate of major adverse cardiovascular events (MACE) (risk ratio; 95% confidence interval: 0.88; 0.81-0.95) and ischemic stroke (0.62; 0.50-0.77), with a relatively low risk of major bleeding (1.72; 1.42-2.07). For patients with ACS, the combination of DOACs reduced the risk of MACE (0.91; 0.85-0.97), myocardial infarction (MI) (0.90; 0.83-0.98), and ischemic stroke (0.75; 0.58-0.97), accompanied by increased non-fatal bleeding events and intracranial hemorrhage (3.42; 1.76-6.65). Results were similar when restricting the analysis to phase III studies except for the rate of stroke in patients with ACS. CONCLUSIONS Combination therapy reduced the incidence of MI in ACS patients, but the risk of bleeding from intracranial hemorrhaging outweighs the benefit of MACE driven by MI. That is due to combination therapy having no positive impact on mortality; thus, the benefit-risk balance may be more favorable in patients with stable CAD.
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Lee MT, Mahtta D, Dlouhy L, Shahab H, Al Rifai M, Virani SS. Highlights of Cardiovascular Disease Studies Presented at the 2021 European Society of Cardiology Congress. Curr Atheroscler Rep 2021; 23:76. [PMID: 34648072 DOI: 10.1007/s11883-021-00975-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW This review highlights select studies presented at the virtual 2021 European Society of Cardiology (ESC) Congress. RECENT FINDINGS Reviewed studies assess single photon emission computed tomography, positron emission tomography, magnetic resonance imaging in coronary artery disease (PACIFIC-II); empagliflozin in heart failure with preserved ejection fraction (EMPEROR-Preserved); dapagliflozin in chronic heart failure (DAPA-HF); proprotein convertase subtilisin/kexin type 9 inhibitor and its lipid lowering effects (NATURE-PCSK9); fixed-dose combination therapies with or without aspirin in primary prevention; overview of contrasting results between REDUCE-IT versus STRENGTH trials; Quadruple UltrA-low-dose tReaTment for hypertension (QUARTET); evolocumab and changes in plaque composition on optical coherence tomography (HUYGENS); and low-dose rivaroxaban during the acute phase of acute coronary syndrome (H-REPLACE). Research presented at the 2021 ESC Congress shows promise in reducing burden of cardiovascular disease and reinforces the value of cardiovascular disease prevention.
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Affiliation(s)
- Michelle T Lee
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center, Houston, TX, USA.,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Louis Dlouhy
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Hunaina Shahab
- Advanced Cardiac Imaging, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mahmoud Al Rifai
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center, Houston, TX, USA. .,Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA. .,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA. .,Health Services Research and Development (152), Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd, Houston, TX, 77030, USA.
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35
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Chen X, Huang W, Sun A, Wang L, Mo F, Guo W. Bleeding risks with novel oral anticoagulants especially rivaroxaban versus aspirin: a meta-analysis. Thromb J 2021; 19:69. [PMID: 34600549 PMCID: PMC8487538 DOI: 10.1186/s12959-021-00322-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background This pairwise meta-analysis determines the difference in bleeding risks associated with the use of novel oral anticoagulants (NOACs) and aspirin. Methods PubMed, the Cochrane Library database, clinicaltrial.gov, and related studies were searched for randomized control trials (RCTs) comparing NOAC and aspirin published between January 1, 2000 and May 10, 2021. The primary endpoint was intracranial hemorrhage (ICH). Results Eleven studies involving 57,645 patients were included. Compared to aspirin, rivaroxaban (5 mg/day) had a similar risk of ICH, major bleeding, and fatal bleeding; rivaroxaban (10 mg/day) had higher risks of gastrointestinal hemorrhage (OR: 1.41; 95% CI: 1.03–1.94; P = 0.032; I2 = 0%) and a similar risk of ICH, major bleeding, and fatal bleeding; and rivaroxaban (15–20 mg/day) had higher risks of ICH (OR: 3.21; 95% CI: 1.36–7.60; P = 0.008; I2 = 0%), major bleeding (OR: 2.64; 95% CI: 1.68–4.16; P < 0.001; I2 = 0%), and fatal bleeding (OR: 2.26; 95% CI: 1.25–4.08; P = 0.007; I2 = 0%) and a similar risk of gastrointestinal hemorrhage. Bleeding outcomes between other NOACs (apixaban and dabigatran etexilate) and aspirin were not different. Conclusions The bleeding risks associated with NOACs depend on drug type and dosage. For ≥15 mg/day of rivaroxaban, the risk of ICH was significantly higher than that with aspirin. However, further studies comparing dabigatran etexilate and apixaban versus aspirin are warranted to draw a definite conclusion. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00322-6.
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Affiliation(s)
- Xiehui Chen
- Department of Cardiology, Shenzhen Longhua District Central Hospital, No. 187, Guanlan Road, Longhua District, Shenzhen, China.
| | - Weichao Huang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Aimei Sun
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Fanrui Mo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China
| | - Wenqin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, No. 12, Langshan Road, Nanshan District, Shenzhen, China.
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Efficacy and safety of low dose rivaroxaban in patients with coronary heart disease: a systematic review and meta-analysis. J Thromb Thrombolysis 2021; 50:913-920. [PMID: 32281069 DOI: 10.1007/s11239-020-02114-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The mortality effects and risk-benefit profile of low dose rivaroxaban (2.5 mg twice daily) in patients with coronary heart disease are not completely understood. Five randomized controlled trials (26,110 patients) were selected using PubMed and Cochrane library till April 2019. The background antiplatelet therapy was aspirin in 3 trials, P2Y12 inhibitor in 1 trial, and in 1 trial 65% patients received aspirin and 35% were on dual antiplatelet therapy (DAPT). The outcomes of interest were cardiovascular mortality, all-cause mortality, myocardial infarction (MI), stroke and major bleeding events. Random effects hazard ratios (HR) with 95% confidence intervals (CI) were calculated. Low dose rivaroxaban did not reduce the risk of cardiovascular mortality (HR 0.90, 95% CI 0.73-1.11, P = 0.34) or all-cause mortality (HR 0.91, 95% CI 0.74-1.12, P = 0.38) compared with control. However, low dose rivaroxaban was associated with reduction in MI (HR 0.85, 95% CI 0.73-0.99, P = 0.04), and stroke (HR 0.59, 95%CI 0.48-0.73, P < 0.001) at the expense of major bleeding (HR 1.64, 95% CI 1.39-1.94, P < 0.001) compared with control. These effects did not vary according to acute coronary syndrome or stable coronary heart disease (P-interaction > 0.05). The use of low dose rivaroxaban in patients with coronary heart disease predominantly receiving antiplatelet monotherapy did not reduce cardiovascular or all-cause mortality. The benefits of preventing MI and stroke were balanced by increased risk of major bleeding.
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Rivera-Caravaca JM, Camelo-Castillo A, Ramírez-Macías I, Gil-Pérez P, López-García C, Esteve-Pastor MA, Orenes-Piñero E, Tello-Montoliu A, Marín F. Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation. Int J Mol Sci 2021; 22:7113. [PMID: 34281167 PMCID: PMC8267774 DOI: 10.3390/ijms22137113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 12/24/2022] Open
Abstract
Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate antithrombotic therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about antithrombotic therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Pablo Gil-Pérez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology-A, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain;
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
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Siegal DM, Anand SS. Considerations for use of direct oral anticoagulants in arterial disease. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01372-3. [PMID: 34095731 PMCID: PMC8162231 DOI: 10.1002/rth2.12502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
Cardiovascular diseases including coronary heart disease, stroke, and peripheral arterial disease were responsible for an estimated 18 million deaths in 2017. Despite advances in management over the past several decades, these patients continue to have substantial risk of subsequent cardiovascular events. We provide a narrative review of randomized clinical trials evaluating direct oral anticoagulants (DOACs) for the treatment of acute coronary syndromes, noncardioembolic ischemic stroke, embolic stroke of undetermined source, and peripheral arterial disease. In these conditions, considerations for use of single antiplatelet therapy, dual antiplatelet therapy, or low-dose DOACs used together with antiplatelet therapy are presented.
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Affiliation(s)
- Deborah M Siegal
- Department of Medicine University of Ottawa Ottawa ON Canada.,Ottawa Hospital Research Institute Ottawa ON Canada
| | - Sonia S Anand
- Department of Medicine McMaster University Hamilton ON Canada.,Department of Health Research Methods, Evidence and Impact McMaster University Hamilton ON Canada.,Population Health Research Institute Hamilton Health Sciences Hamilton ON Canada
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Хрыщанович В. Dual Pathway of Inhibition and Vascular Protection in Patients with Atherosclerotic Disease. КАРДИОЛОГИЯ В БЕЛАРУСИ 2021. [DOI: 10.34883/pi.2021.13.2.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Несмотря на широкое внедрение в клиническую практику современной антитромботической стратегии (моно- или двойной антитромбоцитарной терапии), резидуальный риск неблагоприятных сердечно-сосудистых событий у пациентов с ишемической болезнью сердца (ИБС) и заболеваниями периферических артерий (ЗПА) по-прежнему остается высоким. До настоящего времени двойная антитромбоцитарная терапия является «золотым стандартом» вторичной профилактики при остром коронарном синдроме (ОКС), а монотерапия рекомендована пациентам с симптоматическим течением ЗПА, стабильной ИБС и цереброваскулярной болезнью. Вместе с тем разрыв атеросклеротической бляшки приводит не только к активации тромбоцитов, но также, вследствие экспозиции тканевого фактора, потенцирует образование тромбина. Поэтому терапевтическая стратегия, направленная на одновременное подавление генерации тромбина и активации тромбоцитов и называемая «двойной путь ингибирования», представляется более эффективной, чем известные варианты лечения, связанные с торможением только одного из двух путей. Как показали результаты исследования COMPASS, комбинация 2,5 мг ривароксабана дважды в сутки со 100 мг/сутки аспирина оказалась более эффективной по сравнению с монотерапией 100 мг/сутки аспирина в части снижения риска серьезных сердечно-сосудистых событий, незапланированных госпитализаций и летальности без увеличения количества фатальных и интракраниальных геморрагических осложнений. Преимущества режима двойного ингибирования, апробированного в исследовании COMPASS, были продемонстрированы в популяции пациентов с недавним ОКС, стабильной ИБС и ЗПА, а также после реваскуляризации нижних конечностей. На сегодняшний день ривароксабан является единственным антикоагулянтом, подтвердившим безусловные преимущества в сочетании с антитромбоцитарной терапией в указанных группах пациентов. Комбинированная терапия низкими дозами ривароксабана (2,5 мг/дважды/сутки) и аспирином (100 мг/сутки) уже включена в последние международные рекомендации как вариант вторичной профилактики у пациентов с патологией коронарных и периферических артерий.
Patients with cardiovascular (CV) disease are at high residual risk of CV events (including peripheral ischemic events), even when they receive the current antithrombotic strategies (single/dual antiplatelet therapy). Until now, dual antiplatelet therapy is the standard of care for the secondary prevention in patients with acute coronary syndrome (ACS), whereas the single antiplatelet therapy, generally with aspirin, is the standard of care for the secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. Meanwhile, atherosclerotic plaque disruption not only induces the platelet activation, but also results in thrombin generation because of tissue factor exposure. Therefore, interrupting both pathways by combining antiplatelet therapy with an anticoagulant (dual pathway inhibition [DPI]), has the potential to be more effective than inhibiting either pathway alone. The COMPASS trial showed that in comparison with aspirin 100 mg, rivaroxaban 2.5 mg twice a day plus aspirin 100 mg reduced the risk of major cardiac events, CV hospitalization, and mortality, without the increase of intracranial or fatal bleedings. The benefit of DPI using the COMPASS regimen was demonstrated in patients with the recent ACS, in chronic CAD and PAD patients, and after the lower extremity revascularization. So far, rivaroxaban is the only anticoagulant, which is effective in combination with antiplatelet therapies in the mentioned groups. The combination of low-dose rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) has been included recently into the latest international recommendations for the secondary prevention in patients with coronary or peripheral artery disease.
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Drug-Drug Interactions Leading to Adverse Drug Reactions with Rivaroxaban: A Systematic Review of the Literature and Analysis of VigiBase. J Pers Med 2021; 11:jpm11040250. [PMID: 33808367 PMCID: PMC8066515 DOI: 10.3390/jpm11040250] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/27/2022] Open
Abstract
Rivaroxaban has become an alternative to vitamin K antagonists, which are considered to be at higher risk of drug-drug interactions (DDI) and more difficult to use. However, DDI do occur. We systematically reviewed studies that evaluated them and analysed DDI and subsequent adverse drug reactions (ADR) reported in spontaneous reports and VigiBase. We systematically searched articles that explored DDI with rivaroxaban up to 20 August 2018 via Medline, Embase and Google Scholar. Data from VigiBase came from spontaneous reports recovered up to 2 January 2018, where Omega was used to detect signals and identify potential interactions in terms of triplets with two drugs and one ADR. We identified 31 studies and 28 case reports. Studies showed significant variation in the pharmacokinetic for rivaroxaban, and an increased risk of haemorrhage or thromboembolic events due to DDI was highlighted in case reports. From VigiBase, a total of 21,261 triplets were analysed and the most reported was rivaroxaban–aspirin–gastrointestinal haemorrhage. In VigiBase, only 34.8% of the DDI reported were described or understood, and most were pharmacodynamic DDI. These data suggest that rivaroxaban should be considered to have significant potential for DDI, especially with CYP3A/P-gp modulators or with drugs that impair haemostasis.
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van der Sangen NMR, Rozemeijer R, Chan Pin Yin DRPP, Valgimigli M, Windecker S, James SK, Buccheri S, ten Berg JM, Henriques JPS, Voskuil M, Kikkert WJ. Patient-tailored antithrombotic therapy following percutaneous coronary intervention. Eur Heart J 2021; 42:1038-1046. [PMID: 33515031 PMCID: PMC8244639 DOI: 10.1093/eurheartj/ehaa1097] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/03/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
Dual antiplatelet therapy has long been the standard of care in preventing coronary and cerebrovascular thrombotic events in patients with chronic coronary syndrome and acute coronary syndrome undergoing percutaneous coronary intervention, but choosing the optimal treatment duration and composition has become a major challenge. Numerous studies have shown that certain patients benefit from either shortened or extended treatment duration. Furthermore, trials evaluating novel antithrombotic strategies, such as P2Y12 inhibitor monotherapy, low-dose factor Xa inhibitors on top of antiplatelet therapy, and platelet function- or genotype-guided (de-)escalation of treatment, have shown promising results. Current guidelines recommend risk stratification for tailoring treatment duration and composition. Although several risk stratification methods evaluating ischaemic and bleeding risk are available to clinicians, such as the use of risk scores, platelet function testing , and genotyping, risk stratification has not been broadly adopted in clinical practice. Multiple risk scores have been developed to determine the optimal treatment duration, but external validation studies have yielded conflicting results in terms of calibration and discrimination and there is limited evidence that their adoption improves clinical outcomes. Likewise, platelet function testing and genotyping can provide useful prognostic insights, but trials evaluating treatment strategies guided by these stratification methods have produced mixed results. This review critically appraises the currently available antithrombotic strategies and provides a viewpoint on the use of different risk stratification methods alongside clinical judgement in current clinical practice.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Rik Rozemeijer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Dean R P P Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - Marco Valgimigli
- Department of Cardiology, Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds Väg 38, 751 85 Uppsala, Sweden
| | - Sergio Buccheri
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds Väg 38, 751 85 Uppsala, Sweden
| | - Jurriën M ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Oosterparkstraat 9, 1091 AC Amsterdam, the Netherlands
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Zhu H, Xu X, Fang X, Ying F, Song L, Gao B, Tong G, Zhou L, Chen T, Huang J. Efficacy and Safety of Long-Term Antithrombotic Strategies in Patients With Chronic Coronary Syndrome: A Network Meta-analysis of Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019184. [PMID: 33682435 PMCID: PMC8174196 DOI: 10.1161/jaha.120.019184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Long-term antithrombotic strategies for patients with chronic coronary syndrome with high-risk factors represent an important treatment dilemma in clinical practice. Our aim was to conduct a network meta-analysis to evaluate the efficacy and safety of long-term antithrombotic strategies in patients with chronic coronary syndrome. Methods and Results Four randomized studies were included (n=75167; THEMIS [Ticagrelor on Health Outcomes in Diabetes Mellitus Patients Intervention Study], COMPASS [Cardiovascular Outcomes for People Using Anticoagulation Strategies], PEGASUS-TIMI 54 [Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis in Myocardial Infarction 54], and DAPT [Dual Anti-platelet Therapy]). The odds ratios (ORs) and 95% CIs) were calculated as the measure of effect size. The results of the network meta-analysis showed that, compared with aspirin monotherapy, the ORs for trial-defined major adverse cardiovascular and cerebrovascular events were 0.86; (95% CI, 0.80-0.93) for ticagrelor plus aspirin, 0.89 (95% CI, 0.78-1.02) for rivaroxaban monotherapy, 0.74 (95% CI, 0.64-0.85) for rivaroxaban plus aspirin, and 0.72 (95% CI, 0.60,-0.86) for thienopyridine plus aspirin. Compared with aspirin monotherapy, the ORs for trial-defined major bleeding were 2.15 (95% CI, 1.78-2.59]) for ticagrelor plus aspirin, 1.51 (95% CI, 1.23-1.85) for rivaroxaban monotherapy, and 1.68 (95% CI, 1.37-2.05) for rivaroxaban plus aspirin. For death from any cause, the improvement effect of rivaroxaban plus aspirin was detected versus aspirin monotherapy (OR, 0.76; 95% CI, 0.65-0.90), ticagrelor plus aspirin (OR, 0.79; 95% CI, 0.66-0.95), rivaroxaban monotherapy (OR, 0.82; 95% CI, 0.69-0.97), and thienopyridine plus aspirin (OR, 0.58; 95% CI, 0.41-0.82) regimens. Conclusions All antithrombotic strategies combined with aspirin significantly reduced the incidence of major adverse cardiovascular and cerebrovascular events and increased the risk of major bleeding compared with aspirin monotherapy. Considering the outcomes of all ischemic and bleeding events and all-cause mortality, rivaroxaban plus aspirin appears to be the preferred long-term antithrombotic regimen for patients with chronic coronary syndrome and high-risk factors.
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Affiliation(s)
- Houyong Zhu
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Xiaoqun Xu
- Affiliated Hangzhou Chest Hospital, Zhejiang University School of Medicine Zhejiang China
| | - Xiaojiang Fang
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Fei Ying
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Liuguang Song
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Beibei Gao
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Guoxin Tong
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Liang Zhou
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
| | - Tielong Chen
- Department of Cardiology Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University Hangzhou Zhejiang China
| | - Jinyu Huang
- The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine Hangzhou Zhejiang China
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Chen C, Kan Y, Shi Z, Guo D, Fu W, Li Y, Lv Q, Li X, Si Y. Low Dose Rivaroxaban for Atherosclerotic Cardiovascular Diseases: A Systematic Review and Meta-analysis. Front Pharmacol 2021; 11:608247. [PMID: 33732144 PMCID: PMC7957832 DOI: 10.3389/fphar.2020.608247] [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: 09/22/2020] [Accepted: 12/21/2020] [Indexed: 11/13/2022] Open
Abstract
Background: This study aims to explore the role of low-dose rivaroxaban (≤10 mg daily) for the treatment of atherosclerotic cardiovascular disease (ASCVD). Methods: PubMed, Embase and the Cochrane Library were searched for randomized controlled trials (RCTs) of low-dose rivaroxaban in patients with ASCVD including coronary artery disease (CAD) and peripheral artery disease (PAD). Literature screening, data extraction, and risk of bias assessment were carried out independently by two researchers. Hazard ratio (HR) and 95% confidence interval (CI) were calculated using random-effect models to determine risks of outcomes in ASCVD patients treated with rivaroxaban and comparators, and meta-analysis was conducted via Review Manager 5.3.5 software. Results: 3,768 records were obtained through literature search, and 9 articles representing 6 RCTs ultimately qualified for this study. The meta-analysis indicated that for patients with CAD, the addition of rivaroxaban (5 mg daily) to aspirin could significantly reduce the risk of major adverse cardiovascular events (MACEs) compared with aspirin alone (HR 0.81, 95% CI, 0.72 to 0.91, p = 0.0004, I2 = 60%, 4 studies). For PAD patients receiving rivaroxaban (5 mg daily) plus aspirin, there was no significant reduction in the risk of MACEs (HR 0.84, 95% CI, 0.63 to 1.13, p = 0.25, I2 = 74%, 2 studies); however, there was significant reduction in major adverse limb events (MALEs) (HR 0.54, 95% CI, 0.35 to 0.83, p = 0.005, one studies) and in the composite of MACEs or MALEs (HR 0.78, 95% CI, 0.64 to 0.95, p = 0.02, I2 = 66%, 2 studies) when compared with patients receiving aspirin alone. Meanwhile, rivaroxaban combined with aspirin significantly increased the risk of International Society on Thrombosis and Haemostasis (ISTH) major bleeding compared with aspirin alone in patients with CAD (HR 1.74, 95% CI, 1.43 to 2.13, p < 0.00001, I2 = 0%, 2 studies) and PAD (HR 1.47, 95% CI, 1.19 to 1.83, p = 0.0004, I2 = 0%, 2 studies). Conclusions: Compared with standard antiplatelet therapy, the addition of a 5 mg daily dose of rivaroxaban to standard antiplatelet therapy may improve cardiovascular or limb outcomes of patients with ASCVD, with an increase in major bleeding. Patients who would benefit from the addition of low-dose rivaroxaban to antiplatelet agents and appropriate dual-pathway antithrombotic strategies should be identified in clinical practice to individualize antithrombotic therapy.
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Affiliation(s)
- Can Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuanqing Kan
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhenyu Shi
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daqiao Guo
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Weiguo Fu
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yanli Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Si
- Department of Vascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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González-Juanatey JR, Almendro-Delia M, Cosín-Sales J, Bellmunt-Montoya S, Gómez-Doblas JJ, Riambau V, García-Moll X, García-Alegría J, Hernández JL, Lozano FS, Suarez Fernández C. Residual risk reduction opportunities in patients with chronic coronary syndrome. Role of dual pathway inhibition. Expert Rev Clin Pharmacol 2021; 13:695-706. [PMID: 32434452 DOI: 10.1080/17512433.2020.1772056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In this review, the role of the rivaroxaban-plus-aspirin approach (dual pathway inhibition - DPI) in patients with chronic coronary syndrome (CCS) and to perform practical recommendations about its use was updated. AREAS COVERED The contents of this review were proposed in an expert meeting. To identify relevant articles, a systematic search of Medline/Embase was performed (to July 2019), using the key words 'rivaroxaban', 'vascular dose', 'COMPASS' and 'coronary artery disease' in the search strategy. EXPERT OPINION Despite current antithrombotic strategies (single/dual antiplatelet therapy) have decreased rates of recurrent cardiovascular events among patients with CCS, residual risk remains unacceptably high. The COMPASS trial showed in CCS patients that compared with aspirin 100 mg rivaroxaban 2.5 mg bid plus aspirin 100 mg reduced the risk of major cardiac events, cardiovascular hospitalization and mortality, without an increase of intracranial or fatal bleedings. Importantly, residual risk with the rivaroxaban plus aspirin approach was lower than with different dual antiplatelet therapy regimens. The rivaroxaban plus aspirin strategy is of particular benefit in patients with CCS and high-risk cardiovascular feature (i.e. ≥2 vascular beds, heart failure, renal insufficiency, peripheral artery disease, previous stroke or diabetes) and should be considered in these populations.
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Affiliation(s)
- José R González-Juanatey
- Cardiology and Intensive Cardiac Care Department, CIBERCV, University Hospital Santiago de Compostela , Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital , Seville, Spain
| | - Juan Cosín-Sales
- Cardiology Department, Hospital Arnau de Vilanova, Facultad de Medicina, Universidad CEU-Cardenal Herrena , Valencia, Spain
| | - Sergi Bellmunt-Montoya
- Vascular Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | | | - Vincent Riambau
- Vascular Surgery Division, CardioVascular Institute Hospital Clinic University of Barcelona , Barcelona, Spain
| | | | | | - José Luis Hernández
- Internal Medicine Department, Hospital Marqués de Valdecilla-IDIVAL, Universidad de Cantabria , Santander, Spain
| | - Francisco S Lozano
- Department of Vascular Surgery, Hospital Clínico de Salamanca , Salamanca, Spain
| | - Carmen Suarez Fernández
- Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid , Madrid, Spain
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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Marquis-Gravel G, Roe MT, Robertson HR, Harrington RA, Pencina MJ, Berdan LG, Hammill BG, Faulkner M, Muñoz D, Fonarow GC, Nallamothu BK, Fintel DJ, Ford DE, Zhou L, Daugherty SE, Nauman E, Kraschnewski J, Ahmad FS, Benziger CP, Haynes K, Merritt JG, Metkus T, Kripalani S, Gupta K, Shah RC, McClay JC, Re RN, Geary C, Lampert BC, Bradley SM, Jain SK, Seifein H, Whittle J, Roger VL, Effron MB, Alvarado G, Goldberg YH, VanWormer JL, Girotra S, Farrehi P, McTigue KM, Rothman R, Hernandez AF, Jones WS. Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial. JAMA Cardiol 2021; 5:598-607. [PMID: 32186653 DOI: 10.1001/jamacardio.2020.0116] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question. Objective To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method. Design, Setting, and Participants This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020. Interventions Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily. Main Outcomes and Measures The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment. Conclusions and Relevance As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD. Trial Registration ClinicalTrials.gov Identifier: NCT02697916.
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Affiliation(s)
| | - Matthew T Roe
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | | | | | - Michael J Pencina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Lisa G Berdan
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Madelaine Faulkner
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Daniel Muñoz
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregg C Fonarow
- Department of Medicine, University of California, Los Angeles, Los Angeles.,Associate Editor
| | - Brahmajee K Nallamothu
- Michigan Integrated Center of Health Analytics and Medical Prediction, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Dan J Fintel
- Feinberg School of Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel E Ford
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li Zhou
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | | | - Jennifer Kraschnewski
- Department of Medicine, Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Faraz S Ahmad
- Center for Health Information Partnerships, Feinberg School of Medicine, Institute of Public Health and Medicine, Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois
| | | | | | - J Greg Merritt
- Patient-Centered Network of Learning Health Systems (LHSNet), Ann Arbor, Michigan
| | - Thomas Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sunil Kripalani
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kamal Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Kansas Medical Center, Kansas City
| | - Raj C Shah
- Rush Alzheimer's Disease Center, Department of Family Medicine, Rush University Medical Center, Chicago, Illinois
| | - James C McClay
- Department of Emergency Medicine, University of Nebraska Medical Center College of Medicine, Omaha
| | | | - Carol Geary
- University of Nebraska Medical Center, Omaha
| | - Brent C Lampert
- Wexner Medical Center, Division of Cardiovascular Medicine, The Ohio State University, Columbus
| | - Steven M Bradley
- Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, Minneapolis
| | - Sandeep K Jain
- UPMC Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hani Seifein
- AdventHealth Medical Group Cardiology, Oviedo, Florida
| | - Jeff Whittle
- Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee
| | | | - Mark B Effron
- Ochsner Clinical School, John Ochsner Heart and Vascular Institute, University of Queensland School of Medicine, New Orleans, Louisiana
| | - Giselle Alvarado
- Herbert H. Lehman College, Department of Biological Sciences, City University of New York, Bronx
| | | | | | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | | | | | - Russell Rothman
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina.,Duke University Medical Center, Durham, North Carolina
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47
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Xie C, Hang Y, Zhu J, Li C, Jiang B, Zhang Y, Miao L. Benefit and risk of adding rivaroxaban in patients with coronary artery disease: A systematic review and meta-analysis. Clin Cardiol 2020; 44:20-26. [PMID: 33219708 PMCID: PMC7803358 DOI: 10.1002/clc.23514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 01/25/2023] Open
Abstract
Background Although the European Medicines Agency and the US Food and Drug Administration have, respectively, approved rivaroxaban for the prevention of recurrent major adverse cardiovascular events in patients with myocardial infarction and stable coronary artery disease, its efficacy and safety is unclear. This meta‐analysis aimed to evaluate the benefit and risk of adding rivaroxaban in coronary artery disease (CAD) patients, focusing on treatment effects stratified by different baseline clinical presentations. Hypothesis There are differences in treatment effects of adding rivaroxaban among CAD patients with different baseline clinical presentations. Methods Medline, EMBASE, and Cochrane Databases were systematically searched from inception to 21 July 2020 for randomized controlled trials (RCTs) comparing rivaroxaban in CAD patients. The primary efficacy endpoint and safety endpoint were assessed by using Mantel–Haenszel pooled risk ratios (RRs) and 95% confidence intervals (CIs). Results Five RCTs that included 43 650 patients were identified. Patients receiving rivaroxaban had a significantly lower risk of the primary efficacy endpoint (RR, 0.86; 95% CI, 0.76–0.97, p = .01) accompanied by increased risk of the primary safety endpoint (RR, 1.83; 95% CI, 1.10–3.05, p = .02). Subgroup analyses showed that in males the risk–benefit appears to be more favorable while in patients ≥65 years, in females, in patients with diabetes, those with mild to moderate impaired renal function, and region of Asia/other seems unfavorable. Conclusion Rivaroxaban may provide an additional choice for secondary prevention in CAD patients. However, careful estimation of the risk of ischemic and bleeding events using patient characteristics are critical to achieving net benefit.
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Affiliation(s)
- Cheng Xie
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yongfu Hang
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianguo Zhu
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Caiyun Li
- Department of Pharmacy, the Affiliated Suzhou Science and Technology Town Hospital of Nanjing Medical University, Suzhou, China
| | - Bin Jiang
- Department of Cardiology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuzhen Zhang
- Department of Cardiology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Liyan Miao
- Department of Clinical Pharmacology, the First Affiliated Hospital of Soochow University, Suzhou, China
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48
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Molecular Drivers of Platelet Activation: Unraveling Novel Targets for Anti-Thrombotic and Anti-Thrombo-Inflammatory Therapy. Int J Mol Sci 2020; 21:ijms21217906. [PMID: 33114406 PMCID: PMC7662962 DOI: 10.3390/ijms21217906] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of death globally-partly a consequence of increased population size and ageing-and are major contributors to reduced quality of life. Platelets play a major role in hemostasis and thrombosis. While platelet activation and aggregation are essential for hemostasis at sites of vascular injury, uncontrolled platelet activation leads to pathological thrombus formation and provokes thrombosis leading to myocardial infarction or stroke. Platelet activation and thrombus formation is a multistage process with different signaling pathways involved to trigger platelet shape change, integrin activation, stable platelet adhesion, aggregation, and degranulation. Apart from thrombotic events, thrombo-inflammation contributes to organ damage and dysfunction in CVDs and is mediated by platelets and inflammatory cells. Therefore, in the past, many efforts have been made to investigate specific signaling pathways in platelets to identify innovative and promising approaches for novel antithrombotic and anti-thrombo-inflammatory strategies that do not interfere with hemostasis. In this review, we focus on some of the most recent data reported on different platelet receptors, including GPIb-vWF interactions, GPVI activation, platelet chemokine receptors, regulation of integrin signaling, and channel homeostasis of NMDAR and PANX1.
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49
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Abstract
PURPOSE OF REVIEW Coronary artery bypass graft (CABG) surgery remains the gold-standard treatment for multivessel and left main coronary artery disease. Despite significant improvement in cardiovascular outcomes, patients undergoing CABG remain at risk for recurrent adverse ischemic events and other cardiovascular outcomes (coronary revascularisation, stroke, cardiac death, etc.). The purpose of this review is to summarize the most recent evidence in pharmacological preventive therapies addressing the residual cardiovascular risk in patients who have undergone CABG. RECENT FINDINGS Novel cardiovascular pharmacological preventive strategies targeting inflammatory, metabolic and prothrombotic (antiplatelet and anticoagulation) pathways have been recently assessed, with promising results for secondary prevention after CABG. SUMMARY Secondary prevention is an essential part of postoperative care after CABG. Novel lipid-lowering and glucose-controlling agents suggest a strong and consistent benefit on native coronary artery disease and overall cardiovascular outcomes. The role and the choice of enhanced antiplatelet/anticoagulation/lipid/glucose-modulating therapies following CABG should be better defined and deserves further investigation. Additional studies are required to identify new therapeutic target addressing the specific multifactorial nature of the graft CV disease and identifying the best preventive strategies for long-term graft patency.
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50
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Machine learning versus traditional risk stratification methods in acute coronary syndrome: a pooled randomized clinical trial analysis. J Thromb Thrombolysis 2020; 49:1-9. [PMID: 31535314 DOI: 10.1007/s11239-019-01940-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Traditional statistical models allow population based inferences and comparisons. Machine learning (ML) explores datasets to develop algorithms that do not assume linear relationships between variables and outcomes and that may account for higher order interactions to make individualized outcome predictions. To evaluate the performance of machine learning models compared to traditional risk stratification methods for the prediction of major adverse cardiovascular events (MACE) and bleeding in patients with acute coronary syndrome (ACS) that are treated with antithrombotic therapy. Data on 24,178 ACS patients were pooled from four randomized controlled trials. The super learner ensemble algorithm selected weights for 23 machine learning models and was compared to traditional models. The efficacy endpoint was a composite of cardiovascular death, myocardial infarction, or stroke. The safety endpoint was a composite of TIMI major and minor bleeding or bleeding requiring medical attention. For the MACE outcome, the super learner model produced a higher c-statistic (0.734) than logistic regression (0.714), the TIMI risk score (0.489), and a new cardiovascular risk score developed in the dataset (0.644). For the bleeding outcome, the super learner demonstrated a similar c-statistic as the logistic regression model (0.670 vs. 0.671). The machine learning risk estimates were highly calibrated with observed efficacy and bleeding outcomes (Hosmer-Lemeshow p value = 0.692 and 0.970, respectively). The super learner algorithm was highly calibrated on both efficacy and safety outcomes and produced the highest c-statistic for prediction of MACE compared to traditional risk stratification methods. This analysis demonstrates a contemporary application of machine learning to guide patient-level antithrombotic therapy treatment decisions.Clinical Trial Registration ATLAS ACS-2 TIMI 46: https://clinicaltrials.gov/ct2/show/NCT00402597. Unique Identifier: NCT00402597. ATLAS ACS-2 TIMI 51: https://clinicaltrials.gov/ct2/show/NCT00809965. Unique Identifier: NCT00809965. GEMINI ACS-1: https://clinicaltrials.gov/ct2/show/NCT02293395. Unique Identifier: NCT02293395. PIONEER-AF PCI: https://clinicaltrials.gov/ct2/show/NCT01830543. Unique Identifier: NCT01830543.
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