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Bruno F, Wenzl FA, De Filippo O, Kraler S, Giacobbe F, Roffi M, Muller O, Räber L, Templin C, De Ferrari GM, D'Ascenzo F, Lüscher TF. Safety and effectiveness of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: insights from the SPUM-ACS study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:391-402. [PMID: 38604747 DOI: 10.1093/ehjcvp/pvae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/26/2024] [Accepted: 04/10/2024] [Indexed: 04/13/2024]
Abstract
AIMS Data on glycoprotein IIb/IIIa inhibitor (GPI) use in real-world acute coronary syndrome (ACS) patients following the introduction of potent P2Y12 inhibitors and newer-generation stents are scant. Here, we aimed to assess the utilization, effectiveness, and safety of GPI in a large prospective multicentre cohort of contemporary ACS patients. METHODS AND RESULTS SPUM-ACS prospectively recruited patients presenting with ACS between 2009 and 2017. The primary endpoint of the present study was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke at 1 year. Secondary endpoints were defined as any bleeding events, Bleeding Academic Research Consortium (BARC) 3-5 bleeding, and net adverse cardiovascular events (NACE). A total of 4395 ACS patients were included in the analysis. GPI-treated patients had more total coronary artery occlusion (56% vs. 35%, P < 0.001) and thrombus (60% vs. 35%, P < 0.001) at angiography. Among the propensity score-matched (PSM) population (1992 patients equally split into two groups), GPI-treated patients showed lower risk of MACE [PSM adjusted hazard ratio (HR) 0.70, 95% CI 0.49-0.99], but a higher risk of any (PSM adjusted HR 1.46, 95% CI 1.06-1.99) and major bleedings (PSM adjusted HR 1.73, 95% CI 1.09-2.76), resulting in a neutral effect on NACE (PSM adjusted HR 0.87, 95% CI 0.65-1.17). These results remained consistent across all subgroups. CONCLUSIONS In patients with ACS undergoing percutaneous coronary intervention and receiving potent P2Y12 inhibitors, we observed a reduced risk of MACE and an increased risk of major bleedings at 1 year in patients treated with GPI. Although the routine use of GPI is currently not recommended, they might be considered in selected patients following a personalized balancing between ischaemic and bleeding risks.
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Affiliation(s)
- Francesco Bruno
- Royal Brompton & Harefield Hospitals, Imperial College and King's College, Sydney Street, London SW3 6NP, UK
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin 10126, Italy; Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Florian A Wenzl
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin 10126, Italy; Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Simon Kraler
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Federico Giacobbe
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin 10126, Italy; Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Marco Roffi
- Division of Cardiology, Department of Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Olivier Muller
- Department of Cardiology, University Hospital of Lausanne, 1011 Lausanne, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin 10126, Italy; Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin 10126, Italy; Cardiology, Department of Medical Sciences, University of Turin, Italy
| | - Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Imperial College and King's College, Sydney Street, London SW3 6NP, UK
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
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2
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Alenazy FO, Harbi MH, Kavanagh DP, Price J, Brady P, Hargreaves O, Harrison P, Slater A, Tiwari A, Nicolson PLR, Connolly DL, Kirchhof P, Kalia N, Jandrot-Perrus M, Mangin PH, Watson SP, Thomas MR. Amplified inhibition of atherosclerotic plaque-induced platelet activation by glenzocimab with dual antiplatelet therapy. J Thromb Haemost 2023; 21:3236-3251. [PMID: 37541591 DOI: 10.1016/j.jtha.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 06/23/2023] [Accepted: 07/16/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Aspirin and platelet P2Y12 inhibitors, such as ticagrelor, suboptimally inhibit microvascular thrombosis during ST-elevation myocardial infarction. Glycoprotein (GP) IIb/IIIa inhibitors may further inhibit this but cause excessive bleeding. OBJECTIVES We investigated whether combination of glenzocimab, a GPVI inhibitor, with aspirin and ticagrelor provides additional antithrombotic effects, as GPVI has a critical role in atherothrombosis but minimal involvement in hemostasis. METHODS We investigated the effects of glenzocimab (monoclonal antibody Fab fragment) using blood from healthy donors and patients with acute coronary syndrome treated with aspirin and ticagrelor. Platelets were stimulated with multiple agonists, including atherosclerotic plaque, from patients undergoing carotid endarterectomy. RESULTS Aspirin and ticagrelor partially inhibited atherosclerotic plaque-induced platelet aggregation by 48% compared with control (34 ± 3 vs 65 ± 4 U; P < .001). Plaque-induced platelet aggregation, adhesion, secretion, and activation were critically dependent on GPVI activation. Glenzocimab alone reduced plaque-induced aggregation by 75% compared with control (16 ± 4 vs 65 ± 4 U; P < .001) and by >95% when combined with aspirin and ticagrelor (3 ± 1 vs 65 ± 4 U; P < .001). Glenzocimab reduced platelet aggregation, adhesion, and thrombin generation when added to blood of aspirin- and ticagrelor-treated patients with acute coronary syndrome. Glenzocimab shared several antithrombotic effects with the GPIIb/IIIa inhibitor eptifibatide with less effect on general hemostasis assessed by rotational thromboelastometry. In a murine intravital model of ST-elevation myocardial infarction, genetic depletion of GPVI reduced microvascular thrombosis. CONCLUSION Addition of glenzocimab to aspirin and ticagrelor enhances platelet inhibition via multiple mechanisms of atherothrombosis. Compared with a GPIIb/IIIa inhibitor, glenzocimab shares multiple antithrombotic effects, with less inhibition of mechanisms involved in general hemostasis.
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Affiliation(s)
- Fawaz O Alenazy
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Jouf University, Sakaka, Saudi Arabia
| | - Maan H Harbi
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Pharmacology and Toxicology Department, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Dean P Kavanagh
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Joshua Price
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul Brady
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, United Kingdom
| | - Oscar Hargreaves
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Alexandre Slater
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Alok Tiwari
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Phillip L R Nicolson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Derek L Connolly
- Department of Cardiology, Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, United Kingdom
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, University Heart and Vascular Center (UKE) Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Neena Kalia
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Pierre H Mangin
- UMR_S1255, INSERM, Etablissement Francais du Sang-Alsace, Strasbourg, France
| | - Steve P Watson
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Centre of Membrane Proteins and Receptors (COMPARE), The Universities of Birmingham and Nottingham, The Midlands, United Kingdom
| | - Mark R Thomas
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom; Department of Cardiology, Sandwell and West Birmingham Hospitals National Health Service (NHS) Trust, Birmingham, United Kingdom; Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
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3
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Saleiro C, de Campos D, Ribeiro JM, Lopes J, Puga L, Sousa JP, Gomes ARM, Siserman A, Lourenço C, Gonçalves L. Glycoprotein IIb/IIIa inhibitor use in cardiogenic shock complicating myocardial infarction: The Portuguese Registry of Acute Coronary Syndromes. Rev Port Cardiol 2023; 42:113-120. [PMID: 36163139 DOI: 10.1016/j.repc.2021.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/23/2021] [Accepted: 09/27/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Cardiogenic shock (CS) complicates 5-10% of cases of myocardial infarction (MI). Whether glycoprotein IIb/IIIa inhibitors (GPIs) are beneficial in these patients is controversial. Our aim is to assess the prognostic impact of GPI use on in-hospital mortality and outcomes in patients with MI and CS undergoing percutaneous coronary intervention (PCI). METHODS Between October 2010 and December 2019, 27578 acute coronary syndrome (ACS) patients were included in the multicenter Portuguese Registry of Acute Coronary Syndromes. Of these, 357 with an MI complicated by CS were included in the analysis and grouped based on whether they received GPI therapy (with GPI, n=107 and without GPI, n=250). The primary endpoint was in-hospital mortality. Secondary endpoints included successful PCI and in-hospital reinfarction and major bleeding. RESULTS Demographics and cardiovascular risk factors did not differ between groups. ST-elevation MI patients were more likely to receive GPIs (95% vs. 83%, p=0.002). In-hospital mortality was similar between groups (OR 1.80, 95% CI 0.96-3.37). Only age and the use of inotropes or intra-aortic balloon pump were predictors of mortality. Also, no differences between groups were noted for successful PCI (OR 0.33, 95% CI 0.62-4.06), reinfarction (OR 0.77, 95% CI 0.15-3.90), or major bleeding (OR 1.68, 95% CI 0.75-3.74). CONCLUSION The use of GPIs in the context of MI with CS did not significantly impact in-hospital outcomes.
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Affiliation(s)
- Carolina Saleiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.
| | - Diana de Campos
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana M Ribeiro
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Serviço de Cardiologia, Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - João Lopes
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Luís Puga
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - José P Sousa
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Ana Rita M Gomes
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Alexandrina Siserman
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Carolina Lourenço
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Lino Gonçalves
- Serviço de Cardiologia, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, Coimbra, Portugal; Coimbra Institute for Biomedical Research (ICBR), Coimbra, Portugal
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Shen M, Liao Y, Wang J, Zhou X, Guo Y, Nong Y, Guo Y, Lu H, Jin R, Wang J, Fu Z, Li D, Zhao S, Tian J. Intracoronary artery retrograde thrombolysis combined with percutaneous coronary interventions for ST-segment elevation myocardial infarction complicated with diabetes mellitus: A case report and literature review. Front Cardiovasc Med 2022; 9:962127. [PMID: 35935661 PMCID: PMC9354457 DOI: 10.3389/fcvm.2022.962127] [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: 06/05/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background The management of a large thrombus burden in patients with acute myocardial infarction and diabetes is still a worldwide problem. Case presentation A 74-year-old Chinese woman presented with ST-segment elevation myocardial infarction (STEMI) complicated with diabetes mellitus and hypertension. Angiography revealed massive thrombus formation in the mid-segment of the right coronary artery leading to vascular occlusion. The sheared balloon was placed far from the occlusion segment and urokinase (100,000 u) was administered for intracoronary artery retrograde thrombolysis, and thrombolysis in myocardial infarction (TIMI) grade 3 blood flow was restored within 7 min. At last, one stent was accurately implanted into the culprit’s vessel. No-reflow, coronary slow flow, and reperfusion arrhythmia were not observed during this process. Conclusion Intracoronary artery retrograde thrombolysis (ICART) can be effectively and safely used in patients with STEMI along with diabetes mellitus and hypertension, even if the myocardial infarction exceeds 12 h (REST or named ICART ClinicalTrials.gov number, ChiCTR1900023849).
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Affiliation(s)
- Mingzhi Shen
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yichao Liao
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Jian Wang
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Xinger Zhou
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yuting Guo
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yingqiao Nong
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yi Guo
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Haihui Lu
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Rongjie Jin
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Jihang Wang
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
| | - Zhenhong Fu
- Department of Cardiology, Sixth Medical Center, PLA General Hospital, Beijing, China
| | - Dongyun Li
- The First Department of Health Care, Second Medical Center of PLA General Hospital, Beijing, China
- *Correspondence: Dongyun Li,
| | - Shihao Zhao
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- Shihao Zhao,
| | - Jinwen Tian
- Department of Cardiology, Hainan Geriatric Disease Clinical Medical Research Center, Hainan Branch of China Geriatric Disease Clinical Research Center, Hainan Hospital of Chinese PLA General Hospital, Sanya, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Jinwen Tian,
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5
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Radu RI, Ben Gal T, Abdelhamid M, Antohi E, Adamo M, Ambrosy AP, Geavlete O, Lopatin Y, Lyon A, Miro O, Metra M, Parissis J, Collins SP, Anker SD, Chioncel O. Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature. ESC Heart Fail 2021; 8:4717-4736. [PMID: 34664409 PMCID: PMC8712803 DOI: 10.1002/ehf2.13643] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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Affiliation(s)
- Razvan I. Radu
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityCairoEgypt
| | - Elena‐Laura Antohi
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Marianna Adamo
- Cardiothoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Research, Kaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Oliviana Geavlete
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Yuri Lopatin
- Cardiology CentreVolgograd Medical UniversityVolgogradRussian Federation
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Marco Metra
- Cardiology, Cardiothoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - John Parissis
- Second Department of Cardiology, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University Medical CentreNashvilleTNUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
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Blanchart K, Heudel T, Ardouin P, Lemaitre A, Briet C, Bignon M, Sabatier R, Legallois D, Roule V, Beygui F. Glycoprotein IIb/IIIa inhibitors use in the setting of primary percutaneous coronary intervention for ST elevation myocardial infarction in patients pre-treated with newer P2Y12 inhibitors. Clin Cardiol 2021; 44:1080-1088. [PMID: 34114653 PMCID: PMC8364724 DOI: 10.1002/clc.23654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/07/2021] [Accepted: 05/18/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES We sought to investigate the safety and potential benefit of administrating glycoprotein IIb-IIIa inhibitors (GPIs) on top of more potent P2Y12 inhibitors. BACKGROUND A number of clinical trials, performed at a time when pretreatment and potent platelet inhibition was not part of routine clinical practice, have documented clinical benefits of GPI in ST-segment elevation myocardial infarction (STEMI) patients at the cost of a higher risk of bleeding. METHODS We used the data of a prospective, ongoing registry of patients admitted for STEMI in our center. For the purpose of this study only patients presenting for primary percutaneous coronary intervention and pretreated with new P2Y12 inhibitors (prasugrel or ticagrelor) were included. We compared patients who received GPI with those who did not. RESULTS Eight hundred twenty-four STEMI patients were included in our registry; GPIs were used in 338 patients (41%). GPI patients presented more often with cardiogenic shock and Thrombolysis in myocardial infarction (TIMI) flow grade <3. GPI use was not associated with an increase in in-hospital or 3-month mortality. Bleeding endpoints were similar in both groups. CONCLUSIONS Our study suggests that GPI may be used safely in combination with recent P2Y12 inhibitors in STEMI patients in association with modern primary percutaneous coronary intervention strategies (radial access and anticoagulation with enoxaparin) with similar bleeding and mortality rates at hospital discharge and 3-month follow-up.
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Affiliation(s)
| | | | | | | | - Clément Briet
- CHU de Caen Normandie, Service de CardiologieCaenFrance
| | | | - Rémi Sabatier
- CHU de Caen Normandie, Service de CardiologieCaenFrance
| | - Damien Legallois
- CHU de Caen Normandie, Service de CardiologieCaenFrance
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie‐reperfusion myocardiqueCaenFrance
| | - Vincent Roule
- CHU de Caen Normandie, Service de CardiologieCaenFrance
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie‐reperfusion myocardiqueCaenFrance
| | - Farzin Beygui
- CHU de Caen Normandie, Service de CardiologieCaenFrance
- Normandie Univ, UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie‐reperfusion myocardiqueCaenFrance
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7
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Tavenier AH, Claassens DMF, Hermanides RS, Vos GJA, Bergmeijer TO, Kelder JC, Deneer VHM, van 't Hof AWJ, Ten Berg JM. Efficacy and safety of glycoprotein IIb/IIIa inhibitors in addition to P2Y 12 inhibitors in ST-segment elevation myocardial infarction: A subanalysis of the POPular Genetics trial. Catheter Cardiovasc Interv 2021; 99:676-685. [PMID: 34233065 DOI: 10.1002/ccd.29861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Glycoprotein IIb/IIIa inhibitors (GPI) are still used in patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), although discussion about its clinical benefit is ongoing. METHODS GPI use was analyzed in this subanalysis of the POPular Genetics trial, which randomized STEMI patients to CYP2C19 genotype-guided treatment (clopidogrel or ticagrelor) or standard treatment with ticagrelor/prasugrel. The composite thrombotic endpoint consisted of cardiovascular death, myocardial infarction (MI), definite stent thrombosis, and stroke at 30 days. The combined bleeding endpoint consisted of Platelet Inhibition and Patient Outcomes (PLATO) major and minor bleeding at 30 days. Univariable and multivariable analyses in addition to a propensity score-matched (PSM) analysis were conducted. RESULTS In total, 2378 patients, of whom 1033 received GPI and 1345 did not, were included. In multivariable analysis, GPI administration was associated with fewer thrombotic events (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.09-0.55) and MIs (HR 0.24, 95% CI 0.08-0.73). Furthermore, GPI administration was associated with an increase in bleedings (HR 2.02, 95% CI 1.27-3.19), driven by minor bleedings (HR 2.32, 95% CI 1.43-3.76), without a significant difference in major bleedings (HR 0.69, 95% CI 0.19-2.57). In the PSM analysis, no significant association was found. CONCLUSION In STEMI patients undergoing primary PCI, GPI administration was associated with a reduction in thrombotic events at a cost of an increase in (mostly minor) bleedings in multivariable analysis, while propensity score analysis did not show significant associations.
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Affiliation(s)
- Anne H Tavenier
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Daniel M F Claassens
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Gerrit J A Vos
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Thomas O Bergmeijer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Vera H M Deneer
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arnoud W J van 't Hof
- Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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Capranzano P, Angiolillo DJ. Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:519-535. [PMID: 33881367 DOI: 10.1080/14779072.2021.1920925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Oral P2Y12 inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y12 inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y12 inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y12 inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y12 inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Revilla-Martí P, Linares-Vicente JA, Martínez Labuena A, Jiménez Melo O, Morlanes Gracia P, Meseguer González D, Lukic A, Simó Sánchez B, Ruiz Arroyo JR. Efficacy and safety of abciximab versus tirofiban in addition to ticagrelor in STEMI patients undergoing primary percutaneous intervention. Platelets 2021; 33:265-272. [PMID: 33560898 DOI: 10.1080/09537104.2021.1881953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Platelet glycoprotein IIb/IIIa inhibitors (GPIs) have been part of the adjuvant treatment of acute coronary syndrome for years. However, real-life data regarding the efficacy and safety of GPIs under the current indications are lacking in the setting of potent platelet inhibition. The objectives were to assess the efficacy and safety of abciximab versus tirofiban in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) and pretreated with ticagrelor, and to identify independent predictor factors of efficacy, bleeding and platelet drop. Three hundred sixty-two patients were divided by GPI administered. Clinical, laboratory, angiographic and outcome characteristics were compared. The primary objective was a composite efficacy endpoint (death from any cause, nonfatal myocardial infarction and nonfatal stroke) at 30 days. The secondary objectives were its individual components, safety (bleeding) and the impact on platelet count during hospital stay. The composite efficacy endpoint was similar in the abciximab and tirofiban groups (6.1% vs 7.3%; p = .632). There were also no differences in cardiovascular death (2.5% vs 2.4%; p = .958), nonfatal myocardial infarction (3% vs 4.3%; p = .521) and nonfatal stroke (0.5% vs 1.8%; p = .332). Tirofiban administration was associated with a higher incidence of bleeding (11.6% vs 22%; p = .008) with no differences in BARC ≥ 3b bleeding (3.6 vs 2.5%; p = .760). In STEMI patients undergoing PPCI with ticagrelor, abciximab and tirofiban had similar rates in the composite efficacy endpoint at 30 days. The 30-day bleeding rate was significantly higher in the tirofiban group. Tirofiban administration was an independent predictor of both bleeding and platelet count drop.
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Affiliation(s)
- Pablo Revilla-Martí
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Ana Martínez Labuena
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Octavio Jiménez Melo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Paula Morlanes Gracia
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | | | - Antonela Lukic
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Borja Simó Sánchez
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, Spain
| | - Jose R Ruiz Arroyo
- Cardiology Department, Hospital Clínico Universitario 'Lozano Blesa', Zaragoza, 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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Tavenier AH, Hermanides RS, Fabris E, Angiolillo DJ, van 't Hof AWJ. Bridging the gap: Current and future insights for improving suboptimal platelet inhibition in STEMI. Int J Cardiol 2020; 328:40-45. [PMID: 33242504 DOI: 10.1016/j.ijcard.2020.11.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/31/2020] [Accepted: 11/17/2020] [Indexed: 01/31/2023]
Abstract
Antiplatelet therapy is one of the cornerstones in the acute treatment of patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI). However, hemodynamic changes and delayed intestinal absorption of P2Y12 inhibitors leads to a delay in the onset of antiplatelet effects resulting in a gap of platelet inhibition. Several strategies have been proposed to bridge this gap, such as pre-hospital administration of antiplatelet therapy, higher loading doses of P2Y12 inhibitors, crushing or chewing tablets, subcutaneous or intravenous administration of platelet inhibitors, or use of pain relievers alternative to opioids that do not delay intestinal absorption of oral platelet inhibitors. These strategies may improve platelet inhibition with the goal of optimizing clinical outcomes in the acute phase of STEMI. In this review we present current and future insights for bridging the gap in platelet inhibition in STEMI patients undergoing primary PCI.
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Affiliation(s)
| | | | - Enrico Fabris
- Cardiovascular Department, University of Trieste, Trieste, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Arnoud W J van 't Hof
- Department of Cardiology, Isala, Zwolle, the Netherlands; Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
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12
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Picard F, Sokoloff A, Pham V, Diefenbronn M, Laghlam D, Seret G, Varenne O, Dumas F, Cariou A. Safety and benefit of Glycoprotein IIb/IIIa inhibitors in out of hospital cardiac arrest patients treated with percutaneous coronary intervention. Resuscitation 2020; 157:91-98. [PMID: 33129912 DOI: 10.1016/j.resuscitation.2020.10.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Out of hospital cardiac arrest (OHCA) patients requiring percutaneous coronary intervention (PCI) are at higher risk of both stent thrombosis and bleeding. The use of aggressive antiplatelet therapy could lead to a higher risk of bleeding in these patients. Indeed, data on glycoprotein IIb/IIIa inhibitor (GPi) use in this specific indication is scarce. AIM We sought to evaluate the benefit and safety of GPi use in OHCA patients requiring PCI. METHODS AND RESULTS Between January 2007 and December 2017, we retrospectively included all consecutive patients treated with PCI for an OHCA from cardiac cause. Clinical, procedural data and in-hospital outcomes were collected. Three hundred and eighty-five patients were included. GPi were administrated in 41.3% of cases (159 patients). Patients who received GPi were younger, had less prior PCI, more often a TIMI 0 or 1 flow before PCI and thromboaspiration use. There were no differences regarding in-hospital definite stent thrombosis among the two groups (11.9% in the GPi group vs 7.1% in the non-GPi group, p = 0.10) or in-hospital mortality (48.6% vs 49.3%, p = 0.68). The incidence of any bleeding (33.3% vs. 19.6%; p = 0.002), and major bleeding (BARC 3-5) (21.9% vs. 16.8%; p = 0.007) was significantly higher in patients receiving GPi. Indeed, using multivariate analysis, GPi use was predictor of major bleeding (OR: 1.81; 95% CI: 1.06-3.08; p = 0.03). CONCLUSIONS In patients treated with PCI for OHCA from cardiac cause, GPi use was associated with an increased risk of major bleeding events, without difference on in-hospital stent thrombosis or death.
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Affiliation(s)
- Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France; Université de Paris, Faculté de Médecine, Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, Paris, France.
| | - Anastasia Sokoloff
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Vincent Pham
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Marine Diefenbronn
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Driss Laghlam
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Gabriel Seret
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France; Université de Paris, Faculté de Médecine, Paris, France
| | - Florence Dumas
- Université de Paris, Faculté de Médecine, Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Alain Cariou
- Université de Paris, Faculté de Médecine, Paris, France; INSERM U970, Paris Cardiovascular Research Center (PARCC), European Georges Pompidou Hospital, Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
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