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Canonico ME, Hess CN, Secemsky EA, Bonaca MP. Antithrombotic Therapy in Patients Undergoing Peripheral Artery Interventions. Interv Cardiol Clin 2024; 13:553-559. [PMID: 39245554 DOI: 10.1016/j.iccl.2024.07.003] [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: 09/10/2024]
Abstract
Patients with peripheral artery disease (PAD) who undergo lower extremity revascularization (LER) are at high risk for cardiovascular and limb-related ischemic events. The role of antithrombotic therapy is to prevent thrombotic complications, but this requires balancing increased risk of bleeding events. The dual pathway inhibition (DPI) strategy including aspirin and low-dose rivaroxaban after LER has been shown to reduce major adverse cardiovascular and limb-related events without significant differences in major bleeding. There is now a need to implement the broad adoption of DPI therapy in PAD patients who have undergone LER in routine practice.
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Affiliation(s)
- Mario Enrico Canonico
- CPC Clinical Research, Aurora, CO, USA; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Connie N Hess
- CPC Clinical Research, Aurora, CO, USA; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA. https://twitter.com/cpcresearch
| | - Eric A Secemsky
- Richard A. and Susan F.Smith Center for Outcomes Research in Cardiology and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Harvard Medical School, MA, USA. https://twitter.com/EricSecemskyMD
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA. https://twitter.com/MarcBonaca
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Jiao J, Zhao X, Li L, Zhu T, Chen X, Ding Q, Chen Z, Xu P, Shi Y, Shao J. The promotion of vascular reconstruction by hierarchical structures in biodegradable small-diameter vascular scaffolds. BIOMATERIALS ADVANCES 2024; 162:213926. [PMID: 38917650 DOI: 10.1016/j.bioadv.2024.213926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024]
Abstract
Tissue engineering of small-diameter vessels remains challenging due to the inadequate ability to promote endothelialization and infiltration of smooth muscle cells (SMCs). Ideal vascular graft is expected to provide the ability to support endothelial monolayer formation and SMCs infiltration. To achieve this, vascular scaffolds with both orientation and dimension hierarchies were prepared, including hierarchically random vascular scaffold (RVS) and aligned vascular scaffold (AVS), by utilizing degradable poly(ε-caprolactone)-co-poly(ethylene glycol) (PCE) and the blend of PCE/gelatin (PCEG) as raw materials. In addition to the orientation hierarchy, dimension hierarchy with small pores in the inner layer and large pores in the outer layer was also constructed in both RVS and AVS to further investigate the promotion of vascular reconstruction by hierarchical structures in vascular scaffolds. The results show that the AVS with an orientation hierarchy that consists with the natural vascular structure had better mechanical properties and promotion effect on the proliferation of vascular cells than RVS, and also exhibited excellent contact guidance effects on cells. While the dimension hierarchy in both RVS and AVS was favorable to the rapid infiltration of SMCs in a short culture time in vitro. Besides, the results of subcutaneous implantation further demonstrate that AVS achieved a fully infiltrated outer layer with wavy elastic fibers-mimic strips formation by day 14, ascribing to hierarchies of aligned orientation and porous dimension. The results further indicate that the scaffolds with both orientation and dimension hierarchical structures have great potential in the application of promoting the vascular reconstruction.
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Affiliation(s)
- Jingjing Jiao
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
| | - Xin Zhao
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
| | - Long Li
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China.
| | - Tao Zhu
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
| | - Xing Chen
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, China
| | - Qiuyue Ding
- Department of Orthopedics, Guizhou Provincial People's Hospital, Guiyang, Guizhou 550000, China
| | - Zhu Chen
- Guiyang Hospital of Stomatology, Guiyang, Guizhou 550002, China
| | - Peng Xu
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
| | - Yan Shi
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
| | - Jiaojing Shao
- College of Materials and Metallurgy, Guizhou University, Guiyang, Guizhou 550025, China
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Chen J, Liu S, Ruan Z, Wang K, Xi X, Mao J. Thrombotic events associated with immune checkpoint inhibitors and novel antithrombotic strategies to mitigate bleeding risk. Blood Rev 2024; 67:101220. [PMID: 38876840 DOI: 10.1016/j.blre.2024.101220] [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: 04/26/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/16/2024]
Abstract
Although immunotherapy is expanding treatment options for cancer patients, the prognosis of advanced cancer remains poor, and these patients must contend with both cancers and cancer-related thrombotic events. In particular, immune checkpoint inhibitors are associated with an increased risk of atherosclerotic thrombotic events. Given the fundamental role of platelets in atherothrombosis, co-administration of antiplatelet agents is always indicated. Platelets are also involved in all steps of cancer progression. Classical antithrombotic drugs can cause inevitable hemorrhagic side effects due to blocking integrin β3 bidirectional signaling, which regulates simultaneously thrombosis and hemostasis. Meanwhile, many promising new targets are emerging with minimal bleeding risk and desirable anti-tumor effects. This review will focus on the issue of thrombosis during immune checkpoint inhibitor treatment and the role of platelet activation in cancer progression as well as explore the mechanisms by which novel antiplatelet therapies may exert both antithrombotic and antitumor effects without excessive bleeding risk.
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Affiliation(s)
- Jiayi Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Shuang Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Zheng Ruan
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Kankan Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China; Sino-French Research Center for Life Sciences and Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Xiaodong Xi
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
| | - Jianhua Mao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, Collaborative Innovation Center of Hematology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China.
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Espinola-Klein C. [Lower extremity arterial disease (LEAD)]. Herz 2024; 49:313-318. [PMID: 38916707 DOI: 10.1007/s00059-024-05252-3] [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] [Accepted: 05/15/2024] [Indexed: 06/26/2024]
Abstract
Peripheral arterial occlusive disease (PAOD) is a frequent manifestation of atherosclerosis with a high risk of cardiovascular events (myocardial infarction, stroke, amputation, cardiovascular death). A distinction is made between the stable form of intermittent claudication and chronic limb-threatening ischemia (CLTI, pain at rest, wounds). The most frequent risk factors are diabetes mellitus and smoking. As the disease is often asymptomatic early diagnostic necessary. Measurement of the ankle-brachial index (ABI) is suitable for screening. Consistent treatment of cardiovascular risk factors and antithrombotic medication are important. At the stage of intermittent claudication, exercise training should be performed. In CLTI early endovascular or surgical revascularization must be performed to avoid amputation of the extremity.
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Affiliation(s)
- Christine Espinola-Klein
- Kardiologie III - Angiologie, Zentrum für Kardiologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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Debus ES, Aboyans V, Bosch J, Fox KAA, Patel MR, Welsh RC, Zeymer U, Gay A, Vogtländer K, Anand SS. Effect of Peripheral Interventions in Patients with Peripheral Artery Disease Receiving Rivaroxaban and Aspirin: Analyses from the XATOA Registry. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00621-X. [PMID: 39009110 DOI: 10.1016/j.ejvs.2024.07.017] [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: 10/24/2023] [Revised: 04/24/2024] [Accepted: 07/11/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE To assess the characteristics and clinical outcomes of patients with lower extremity peripheral artery disease (PAD) in XATOA receiving dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin according to lower extremity revascularisation (LER) history. METHODS XATOA is an international, multicentre, prospective, single arm registry study. This subanalysis investigated patients with lower extremity PAD according to LER history. Patients with coronary artery disease, PAD, or both, receiving DPI were followed for 12 or more months. Baseline characteristics and clinical outcomes were assessed according to LER history. A time dependency analysis assessed outcomes by time between the most recent LER procedure and the start of DPI. A multivariable analysis assessed the influence of patient characteristics on clinical outcomes. RESULTS In XATOA (n = 5 532), 2 820 (51.0%) patients had lower extremity PAD, of whom 1 736 (61.6%) had prior LER and 1 084 (38.4%) had no prior LER. Baseline characteristics were generally similar between patients with or without prior LER. A higher proportion of patients with prior LER experienced any treatment emergency clinical events compared with those without prior LER (15.0% vs. 9.4%, respectively), with greater differences observed between incidence rates of limb events, including major adverse limb events (9.06 vs. 4.09 events per 100 patient years, respectively). Similar rates of myocardial infarction, stroke, and major bleeding were observed in both subgroups. Clinical event rates were generally higher in patients who had previous LER for six months or less compared with patients who had previous LET for more than six months before starting DPI, regardless of LER type. Multivariable analyses showed that prior LER was predictive of limb events. CONCLUSION This subanalysis of XATOA found that prior LER was associated with increased rates of limb events, consistent with results of COMPASS and VOYAGER PAD. Rates of bleeding were also low regardless of LER history and consistent with the findings from these trials.
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Affiliation(s)
- E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany.
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and EpiMaCT, Inserm U1094/IRD290, Limoges, France
| | - Jackie Bosch
- School of Rehabilitation Science and Chanchlani Research Centre, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Manesh R Patel
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen, Medizinische Klinik B, and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | | | | | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Mahé G, Aboyans V, Cosson E, Mohammedi K, Sarlon-Bartoli G, Lanéelle D, Mirault T, Darmon P. Challenges and opportunities in the management of type 2 diabetes in patients with lower extremity peripheral artery disease: a tailored diagnosis and treatment review. Cardiovasc Diabetol 2024; 23:220. [PMID: 38926722 PMCID: PMC11210102 DOI: 10.1186/s12933-024-02325-9] [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] [Received: 04/22/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
Lower extremity peripheral artery disease (PAD) often results from atherosclerosis, and is highly prevalent in patients with type 2 diabetes mellitus (T2DM). Individuals with T2DM exhibit a more severe manifestation and a more distal distribution of PAD compared to those without diabetes, adding complexity to the therapeutic management of PAD in this particular patient population. Indeed, the management of PAD in patients with T2DM requires a multidisciplinary and individualized approach that addresses both the systemic effects of diabetes and the specific vascular complications of PAD. Hence, cardiovascular prevention is of the utmost importance in patients with T2DM and PAD, and encompasses smoking cessation, a healthy diet, structured exercise, careful foot monitoring, and adherence to routine preventive treatments such as statins, antiplatelet agents, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. It is also recommended to incorporate glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) in the medical management of patients with T2DM and PAD, due to their demonstrated cardiovascular benefits. However, the specific impact of these novel glucose-lowering agents for individuals with PAD remains obscured within the background of cardiovascular outcome trials (CVOTs). In this review article, we distil evidence, through a comprehensive literature search of CVOTs and clinical guidelines, to offer key directions for the optimal medical management of individuals with T2DM and lower extremity PAD in the era of GLP-1RA and SGLT2i.
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Affiliation(s)
- Guillaume Mahé
- Vascular Medicine Unit, University Hospital of Rennes, Rennes, France.
- Clinical Investigation Center, CIC 1414, INSERM, Rennes, France.
- M2S- EA 7470, University of Rennes, Rennes, France.
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Emmanuel Cosson
- AP-HP, Avicenne Hospital, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Paris 13 University, Sorbonne Paris Cité, Bobigny, France
- Nutritional Epidemiology Research Unit, UMR U557 INSERM/U11125 INRAE/CNAM, Paris 13 University, Sorbonne Paris Cité, Bobigny, France
| | - Kamel Mohammedi
- Department of Endocrinology, Diabetes, and Nutrition, University Hospital of Bordeaux, Pessac, France
- INSERM, BMC, U1034, University of Bordeaux, Pessac, France
| | - Gabrielle Sarlon-Bartoli
- Vascular Medicine and Hypertension Department, La Timone University Hospital of Marseille, Marseille, France
- Centre for Nutrition and Cardiovascular Disease (C2VN), Faculty of Medicine, Aix-Marseille University, Marseille, France
| | - Damien Lanéelle
- Department of Vascular Medicine, Caen Normandy University Hospital, Caen, France
- COMETE, INSERM, GIP Cyceron, University of Caen Normandy, Caen, France
| | - Tristan Mirault
- Vascular Medicine Department, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Université Paris Cité, Paris, France
- Institut des Sciences Cardiovasculaires, Paris Cardiovascular Research Center, INSERM U970, Université Paris Cité, Paris, France
| | - Patrice Darmon
- Centre for Nutrition and Cardiovascular Disease (C2VN), Faculty of Medicine, Aix-Marseille University, Marseille, France
- Department of Endocrinology, Metabolic Diseases, and Nutrition, Assistance Publique-Hôpitaux de Marseille (AP-HM), University Hospital Conception, Marseille, France
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Canonico ME, Hess CN, Rogers RK, Bonaca MP. Medical Therapy for Peripheral Artery Disease. Curr Cardiol Rep 2024; 26:651-659. [PMID: 38696099 DOI: 10.1007/s11886-024-02065-y] [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] [Accepted: 04/18/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE OF REVIEW Patients with lower extremity peripheral artery disease (PAD) are at high risk for major adverse cardiovascular events (MACE) and major adverse limb events (MALE). This manuscript will review the current evidence for medical therapy in patients with PAD according to different clinical features and the overall cardiovascular (CV) risk. RECENT FINDINGS The management of PAD encompasses non-pharmacologic strategies, including lifestyle modification such as smoking cessation, supervised exercise, Mediterranean diet and weight loss as well as pharmacologic interventions, particularly for high risk patients. Benefits for reduction of CV and limb outcomes have been demonstrated for new therapies, including antithrombotic therapy (i.e., low-dose rivaroxaban plus aspirin), lipid lowering therapy (i.e., proprotein convertase subtilisin/kexin type 9 inhibitors), and glucose lowering therapy (i.e., sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists). However, the adoption of these therapies in PAD remains suboptimal in practice. Implementation science studies have recently shown promising results in PAD patients. Comprehensive medical and non-medical management of PAD patients is crucial to improving patient outcomes, mitigating symptoms, and reducing the risk of MACE and MALE. A personalized approach, considering the patient's overall risk profile and preference, is essential for optimizing medical management of PAD.
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Affiliation(s)
- Mario Enrico Canonico
- CPC Clinical Research, Aurora, CO, USA.
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Connie N Hess
- CPC Clinical Research, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - R Kevin Rogers
- CPC Clinical Research, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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Fan EY, Schanzer A, Beck AW, Eagleton MJ, Farber MA, Gasper WJ, Lee WA, Oderich GS, Parodi FE, Schneider DB, Sweet MP, Timaran CH, Simons JP. Practice patterns of antiplatelet and anticoagulant therapy after fenestrated/branched endovascular aortic repair. J Vasc Surg 2024:S0741-5214(24)01220-5. [PMID: 38796031 DOI: 10.1016/j.jvs.2024.05.041] [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: 12/27/2023] [Revised: 04/02/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Antiplatelet and/or anticoagulant therapy are commonly prescribed after fenestrated/branched endovascular aortic repair (F/BEVAR). However, the optimal regimen remains unknown. We sought to characterize practice patterns and outcomes of antiplatelet and anticoagulant use in patients who underwent F/BEVAR. METHODS Consecutive patients enrolled (2012-2023) as part of the United States Aortic Research Consortium (US-ARC) from 10 independent physician-sponsored investigational device exemption studies were evaluated. The cohort was characterized by medication regimen on discharge from index F/BEVAR: (1) Aspirin alone OR P2Y12 alone (single-antiplatelet therapy [SAPT]); (2) Anticoagulant alone; (3) Aspirin + P2Y12 (dual-antiplatelet therapy [DAPT]); (4) Aspirin + anticoagulant OR P2Y12 + anticoagulant (SAPT + anticoagulant); (5) Aspirin + P2Y12 + anticoagulant (triple therapy [TT]); and (6) No therapy. Kaplan-Meier analysis and Cox proportional hazards modeling were used to compare 1-year outcomes including survival, target artery patency, freedom from bleeding complication, freedom from all reinterventions, and freedom from stent-specific reintervention. RESULTS Of the 1525 patients with complete exposure and outcome data, 49.6% were discharged on DAPT, 28.8% on SAPT, 13.6% on SAPT + anticoagulant, 3.2% on TT, 2.6% on anticoagulant alone, and 2.2% on no therapy. Discharge medication regimen was not associated with differences in 1-year survival, bleeding complications, composite reintervention rate, or stent-specific reintervention rate. However, there was a significant difference in 1-year target artery patency. On multivariable analysis comparing with SAPT, DAPT conferred a lower hazard of loss of target artery patency (hazard ratio [HR], 0.48; 95% confidence interval [CI], 0.27-0.84; P = .01). On sub-analyses of renal stents alone or visceral stents alone, DAPT no longer had a significantly lower hazard of loss of target artery patency (renal: HR, 0.66; 95% CI, 0.35-1.27; P = .22; visceral: HR, 0.31; 95% CI, 0.05-1.9; P = .21). Lastly, duration of DAPT therapy (1 month, 6 months, or 1 year) did not significantly affect target artery patency. CONCLUSIONS Practice patterns for antiplatelet and anticoagulant regimens after F/BEVAR vary widely across the US-ARC. There were no differences in bleeding complications, survival or reintervention rates among different regimens, but higher branch vessel patency was noted in the DAPT cohort. These data suggest there is a benefit in DAPT therapy. However, the generalizability of this finding is limited by the retrospective nature of this data, and the clinical significance of this finding is unclear, as there is no difference in survival, bleeding, or reintervention rates amongst the different regimens. Hence, an "optimal" regimen, including the duration of such regimen, could not be clearly discerned. This suggests equipoise for a randomized trial, nested within this cohort, to identify the most effective antiplatelet/anticoagulant regimen for the growing number of patients being treated globally with F/BEVAR.
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Huang J, Tian H, Chen Z, Teng B, Zhao Y, Li F. Outcomes of thoracic endovascular aortic repair with physician-manufactured partial micropore stent grafts for aortic arch pathologies. J Vasc Surg 2024; 79:1005-1012. [PMID: 38157994 DOI: 10.1016/j.jvs.2023.12.043] [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: 10/19/2023] [Revised: 12/05/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has been used extensively in the management of thoracic aortic diseases. Numerous efforts have been made to enhance clinical outcomes through the use of stent grafts. This study aimed to investigate the effectiveness and safety of physician-manufactured partial micropore stent grafts (PSMGs) in TEVAR. METHODS Between December 2017 and June 2022, data were collected from 56 patients who underwent TEVAR using physician-manufactured PSMGs. The evaluation encompassed technical success, perioperative and follow-up morbidity and mortality, stroke incidence, and branch artery patency. RESULTS In this investigation, 56 patients received treatment with physician-manufactured PSMGs. Of these patients, 46 were male, with a mean age of 62.1 ± 11.2 years. Aortic pathologies comprised aortic dissection (n = 31 [55.4%]), aortic aneurysms (n = 10 [17.9%]), penetrating aortic ulcer (n = 8 [14.3%]), and intramural hematoma (n = 7 [12.5%]). During a median follow-up of 18 months (interquartile range, 13-25 months), the stroke rate, supra-aortic branch patency rate, and endoleak rate were 0%, 100%, and 7.1%, respectively. There were no occurrences of all-cause mortality, stroke, or the necessity for open conversion. CONCLUSIONS TEVAR with physician-manufactured PSMGs is a viable alternative for addressing aortic arch pathologies in proficient medical centers. The approach demonstrates favorable branch patency, a low complication rate, and minimal postoperative mortality.
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Affiliation(s)
- Junpu Huang
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hao Tian
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Biyun Teng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fenghe Li
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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11
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Raffo C, Capodanno D. Factor XI inhibition in patients with acute coronary syndrome. Eur Heart J Suppl 2024; 26:i29-i34. [PMID: 38867863 PMCID: PMC11167979 DOI: 10.1093/eurheartjsupp/suae013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
A hypercoagulable condition is typical of patients with acute coronary syndrome and is a determining factor in the genesis of recurrent ischaemic events. Modern pharmacological therapies consisting of antiplatelets and anticoagulants derive their rationale for use on the pathophysiological mechanisms most commonly associated with myocardial infarction (MI); they have contributed to reducing the ischaemic risk of these patients, but left ample room for improvement. In particular, trials that have studied the association of an anticoagulant with antiplatelet drugs have provided promising results in terms of efficacy, but highlighted a significant bleeding risk. Evidence derived from experimental animal and epidemiological studies has shown how factor XI (FXI) deficiency is associated with a reduction in thrombotic events but with modest bleeding. These data added to the role that FXI plays in the coagulation cascade constituted an incipit for the pharmacological attempt to decouple thrombosis from haemostasis by means of the inhibition of this factor. The theoretical assumption that FXI inhibitor drugs may be able to reduce the ischaemic risk without significantly increasing the haemorrhagic risk makes these compounds a potential therapeutic aid for patients in secondary prevention after acute MI. To date, on these patients, we only have data from a Phase 2 trial, PACIFIC-AMI (Study to Gather Information About the Proper Dosing and Safety of the Oral FXIa Inhibitor BAY 2 433 334 in Patients Following an Acute Heart Attack). In this study, the primary endpoint-represented by the Bleeding Academic Research Consortium (BARC) composite of Type 2, 3, or 5 bleeding-showed no significant differences between the various doses of asundexian tested (10, 20, and 50 mg quoque die), and between these and placebo (asundexian all doses vs. placebo: hazard ratio, 0.98; 90% confidence interval, 0.71-1.35). The data on efficacy, however, showed neutral results, but it should be noted that the study did not have the adequate statistical power to evaluate this outcome. Valuable information could, therefore, derive in the future from the ongoing Phase 3 trial with milvexian, LIBREXIA-ACS (A Study of Milvexian in Participants After a Recent Acute Coronary Syndrome) and from any future studies that could be started by testing different molecules.
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Affiliation(s)
- Carmelo Raffo
- Cardiovascular Department, A.O.U. Polyclinic ‘G. Rodolico—San Marco’, University of Catania, Catania
| | - Davide Capodanno
- Cardiovascular Department, A.O.U. Polyclinic ‘G. Rodolico—San Marco’, University of Catania, Catania
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Mühlberg KS. [Conservative Treatment and Secondary Prevention of PAD (Peripheral Artery Disease)]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:114-121. [PMID: 38354731 DOI: 10.1055/a-2250-8816] [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: 02/16/2024]
Abstract
The immediate and long-term success of endovascular and surgical revascularization crucially depends on the conservative treatment of the PAD. The "gentle, preserving" treatment should be understood as he absolutely basic therapy for every PAD patient, because conservative treatment adresses the "big five" of atherosclerotic risk factors. This article presents both the full spectrum of pharmacological and non-pharmacological strategies.
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13
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Lee JH, Jeon HS, Lee JW, Youn YJ, Ahn SG, Kim H, Bae Y, Kim U, Ahn CM, Ko YG. Impact of guideline-directed medical therapy on 5-year mortality in patients with newly diagnosed peripheral artery disease. J Vasc Surg 2023; 78:1471-1478.e3. [PMID: 37597591 DOI: 10.1016/j.jvs.2023.08.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Current guidelines recommend that patients with peripheral artery disease (PAD) should be treated with antithrombotic agents, renin-angiotensin-system blockers, and statins. However, the clinical impact of guideline-directed medical therapy (GDMT) on long-term mortality in patients with newly diagnosed PAD remains unclear. We aimed to investigate the prevalence of GDMT and evaluate 5-year mortality according to GDMT after PAD diagnosis. METHODS This retrospective cohort study, using nationwide health insurance claims data in Korea, included patients newly diagnosed with PAD between 2006 and 2015. GDMT was defined as the use of all drugs, including antithrombotic agents, renin-angiotensin-system blockers, and statins, within 3 months of PAD diagnosis. The primary endpoint was all-cause mortality. RESULTS We investigated 19,561 newly diagnosed patients with PAD without proven cardiovascular disease. Among the study population, 4378 patients (22.4%) were categorized in the GDMT and 15,183 (77.6%) in the non-GDMT groups. During the 5-year follow-up, GDMT showed a lower incidence of all-cause mortality than that of non-GDMT (2.8% vs 4.8%; adjusted hazard ratio, 0.329; 95% confidence interval, 0.257-0.421; P < .001). Even in the propensity-matched population, GDMT showed a lower mortality rate than non-GDMT (hazard ratio, 0.283; 95% confidence interval, 0.217-0.370; P < .001). As the number of guideline-recommended drugs increased, the mortality rate decreased proportionately. CONCLUSIONS After PAD diagnosis, GDMT was associated with a lower incidence of mortality regardless of proven cardiovascular disease. This retrospective analysis showed an insufficient prevalence of GDMT among patients with PAD in real-world practice.
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Affiliation(s)
- Jung-Hee Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Ho Sung Jeon
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Yoonjong Bae
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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14
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Kaski JC, Niessner A, Dobrev D, Rocca B. The European Society of Cardiology working group on cardiovascular pharmacotherapy. Eur Heart J 2023; 44:4400-4402. [PMID: 37796825 DOI: 10.1093/eurheartj/ehad651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Affiliation(s)
- Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - Alexander Niessner
- Dept. Int. Med. II, Division of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, AT-1090 Vienna, Austria
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Centre, University Duisburg-Essen, Hufelandstrasse 55, DE-45122 Essen, Germany
- Department of Medicine, Montreal Heart Institute and Université de Montréal, Montréal, Canada
- Department of Molecular Physiology & Biophysics, Baylor College of Medicine, Houston, TX, USA
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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15
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Oliva A, Cao D, Spirito A, Nicolas J, Pileggi B, Kamaleldin K, Vogel B, Mehran R. Personalized Approaches to Antiplatelet Treatment for Cardiovascular Diseases: An Umbrella Review. Pharmgenomics Pers Med 2023; 16:973-990. [PMID: 37941790 PMCID: PMC10629404 DOI: 10.2147/pgpm.s391400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023] Open
Abstract
Antiplatelet therapy is the cornerstone of antithrombotic prevention in patients with established atherosclerosis, since it has been proven to reduce coronary, cerebrovascular, and peripheral thrombotic events. However, the protective effect of antiplatelet agents is counterbalanced by an increase of bleeding events that impacts on patients' mortality and morbidity. Over the last years, great efforts have been made toward personalized antithrombotic strategies according to the individual bleeding and ischemic risk profile, aiming to maximizing the net clinical benefit. The development of risk scores, consensus definitions, and the new promising artificial intelligence tools, as well as the assessment of platelet responsiveness using platelet function and genetic testing, are now part of an integrated approach to tailored antithrombotic management. Moreover, novel strategies are available including dual antiplatelet therapy intensity and length modulation in patients undergoing myocardial revascularization, the use of P2Y12 inhibitor monotherapy for long-term secondary prevention, the implementation of parenteral antiplatelet agents in high-ischemic risk clinical settings, and combination of antiplatelet agents with low-dose factor Xa inhibitors (dual pathway inhibition) in patients suffering from polyvascular disease. This review summarizes the currently available evidence and provides an overview of the principal risk-stratification tools and antiplatelet strategies to inform treatment decisions in patients with cardiovascular disease.
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Affiliation(s)
- Angelo Oliva
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Cardio Center, Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brunna Pileggi
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Cardiopneumonology, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Karim Kamaleldin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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16
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Nicolajsen CW, Søgaard M, Jensen M, Eldrup N, Larsen TB, Goldhaber SZ, Behrendt CA, Nielsen PB. Antiplatelet Therapy in Patients With Abdominal Aortic Aneurysm Without Symptomatic Atherosclerotic Disease. JAMA Netw Open 2023; 6:e2339715. [PMID: 37878310 PMCID: PMC10600585 DOI: 10.1001/jamanetworkopen.2023.39715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/13/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Patients with abdominal aortic aneurysm have a high risk of ischemic events associated with concomitant atherosclerotic cardiovascular disease, and current clinical practice guidelines recommend antiplatelet therapy to mitigate this risk. However, in patients with aneurysms without symptomatic atherosclerosis, the benefit of antiplatelet therapy has been sparsely investigated. Objective To estimate the effect of antiplatelets on the risk of ischemic events and bleeding in individuals with abdominal aneurysms with no symptomatic atherosclerotic vascular disease. Design, Setting, and Participants A comparative effectiveness research study using a target trial emulation framework was performed. Population-based, cross-linked observational data from Danish national health registries containing comprehensive, individual-level information on all Danish citizens were used to evaluate patients who were antiplatelet-naive and diagnosed with abdominal aortic aneurysms, with no record of symptomatic atherosclerotic vascular disease, from January 1, 2010, through August 21, 2021. Exposure Prescription filled for aspirin or clopidogrel. Main Outcomes and Measures Risk of ischemic events (myocardial infarction and/or ischemic stroke) and risk of major bleeding. For target trial emulation, trials were emulated as sequential, contingent on patient eligibility at the time of inclusion, and were evaluated by means of pooled logistic regression models to estimate the intention-to-treat and as-treated effects, expressed as hazard ratio (HR) and event-free survival. Results A total of 6344 patients (65.2% men; age, 72 [IQR, 64-78] years) provided 131 047 trial cases; 3363 of these cases involved initiation of antiplatelet therapy and 127 684 did not. A total of 182 ischemic events occurred among initiators and 5602 ischemic events occurred among noninitiators, corresponding to an intention-to-treat HR of 0.91 (95% CI, 0.73-1.17) and an estimated absolute event-free survival difference of -0.6% (95% CI, -1.7% to 0.5%). After censoring nonadherent person-time, the treatment HR was 0.90 (95% CI, 0.68-1.20), with similar risk difference. For bleeding, the intention-to-treat HR was 1.26 (95% CI, 0.97-1.58) and the event-free survival difference was 1.0%. The treatment HR was 1.21 (95% CI, 0.82-1.72); the risk difference was similar. Conclusions and Relevance In this study, no evidence of effectiveness of antiplatelet therapy to lower the risk of ischemic events and a trend toward higher bleeding risk was noted. The observed differences between the treatment groups were minimal, suggesting limited clinical relevance of antiplatelet treatment.
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Affiliation(s)
- Chalotte W. Nicolajsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Torben B. Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Samuel Z. Goldhaber
- Thrombosis Research Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Medical School, Asklepios Clinic Wandsbek, Hamburg, Germany
- Division of Cardiovascular Medicine, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Peter B. Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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17
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Mühlberg KS. [Conservative therapy and secondary prevention of PAD]. Dtsch Med Wochenschr 2023; 148:1293-1300. [PMID: 37757889 DOI: 10.1055/a-2017-7742] [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: 09/29/2023]
Abstract
Today, peripheral artery disease (PAD) is treated with the most modern endovascular and open surgical revascularisation procedures. But the short and long-term success of these interventions is decisively determined by the conservative therapy of PAD, which therefore represents the absolute basic therapy of every PAD. Conservative treatment addresses the "Big Five" of atherosclerosis risk factors: smoking, lack of exercise and overweight, diabetes, hypertension, and hyperlipidemia. Despite the knowledge that PAD as a peripheral manifestation of the systemic atherosclerosis needs the same risk factor management as e.g., coronary heart disease, not even every second PAD patient in Germany receives the required therapy. This paper presents the spectrum of both drug and non-drug strategies and focuses on aspects such as platelet inhibition and anticoagulation regimes, lipid-lowering options as well as the benefits and necessity of exercise programs to promote collaterals and improve quality of life by extending the pain-free walking distance. Proven strategies to overcome smoking addiction, use and purpose of vasoactive substances are highlighted as well as the potential risks of diabetic foot syndrome for limb salvage and prevention of wounds.
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18
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Crea F. Antithrombotic treatment: personalized antiplatelet therapies and lessons from the gut microbiota. Eur Heart J 2023; 44:3023-3026. [PMID: 37607038 DOI: 10.1093/eurheartj/ehad521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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19
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Aboyans V, Chastaingt L. What LEADs to the under-treatment of patients with lower-extremity artery disease? Eur J Prev Cardiol 2023; 30:1090-1091. [PMID: 36929828 DOI: 10.1093/eurjpc/zwad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 03/08/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Victor Aboyans
- EpiMaCT, Inserm 1094/IRD270, Limoges University, 2, Rue du docteur Marcland, 87025 Limoges, France
- Department of Cardiology, Dupuytren-2 University Hospital, 2, Martin Luther King Ave., 87042 Limoges, France
| | - Lucie Chastaingt
- EpiMaCT, Inserm 1094/IRD270, Limoges University, 2, Rue du docteur Marcland, 87025 Limoges, France
- Department of Vascular Surgery & Medicine, Dupuytren-2 University Hospital, 2, Martin Luther King Ave., 87042 Limoges, France
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20
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Poledniczek M, Neumayer C, Kopp CW, Schlager O, Gremmel T, Jozkowicz A, Gschwandtner ME, Koppensteiner R, Wadowski PP. Micro- and Macrovascular Effects of Inflammation in Peripheral Artery Disease-Pathophysiology and Translational Therapeutic Approaches. Biomedicines 2023; 11:2284. [PMID: 37626780 PMCID: PMC10452462 DOI: 10.3390/biomedicines11082284] [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: 06/25/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Inflammation has a critical role in the development and progression of atherosclerosis. On the molecular level, inflammatory pathways negatively impact endothelial barrier properties and thus, tissue homeostasis. Conformational changes and destruction of the glycocalyx further promote pro-inflammatory pathways also contributing to pro-coagulability and a prothrombotic state. In addition, changes in the extracellular matrix composition lead to (peri-)vascular remodelling and alterations of the vessel wall, e.g., aneurysm formation. Moreover, progressive fibrosis leads to reduced tissue perfusion due to loss of functional capillaries. The present review aims at discussing the molecular and clinical effects of inflammatory processes on the micro- and macrovasculature with a focus on peripheral artery disease.
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Affiliation(s)
- Michael Poledniczek
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Neumayer
- Division of Vascular Surgery, Department of General Surgery, Medical University of Vienna, 1090 Vienna, Austria;
| | - Christoph W. Kopp
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
| | - Oliver Schlager
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
| | - Thomas Gremmel
- Department of Internal Medicine I, Cardiology and Intensive Care Medicine, Landesklinikum Mistelbach-Gänserndorf, 2130 Mistelbach, Austria;
- Institute of Cardiovascular Pharmacotherapy and Interventional Cardiology, Karl Landsteiner Society, 3100 St. Pölten, Austria
| | - Alicja Jozkowicz
- Department of Medical Biotechnology, Faculty of Biophysics, Biochemistry and Biotechnology, Jagiellonian University, 31-007 Krakow, Poland;
| | - Michael E. Gschwandtner
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
| | - Renate Koppensteiner
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
| | - Patricia P. Wadowski
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (M.P.); (C.W.K.); (O.S.); (M.E.G.); (R.K.)
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21
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Lee K, Chang M. Intraoperative use of fibrin glue in blepharoplasty: a possible solution to reduce postoperative complication. Sci Rep 2023; 13:12982. [PMID: 37563229 PMCID: PMC10415304 DOI: 10.1038/s41598-023-40183-9] [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: 09/29/2022] [Accepted: 08/06/2023] [Indexed: 08/12/2023] Open
Abstract
The purpose of this study was to investigate the effects of intraoperative fibrin glue use on surgery for blepharoptosis. This retrospective study included patients with acquired blepharoptosis who underwent surgical correction and were followed for at least one month. Patients were classified into two groups depending on whether treated with antithrombotic agents or otherwise. All patients taking antithrombotic agents discontinued with the treatment one week prior to surgery in accordance with our clinical guidelines. Preoperative and postoperative marginal reflex distance 1(MRD1) and ecchymosis grade were evaluated and compared. The subjects were 56 patients (111 eyes) who discontinued antithrombotic agents before surgery and 59 patients (117 eyes) who had never taken antithrombotic agents. Fibrin glue was used in 13 patients (26 eyes, 23.4%) in the antithrombotic group, and 11 patients (21 eyes, 17.9%) in the non-antithrombotic group. The rate of severe ecchymosis was significantly lower in patients who used fibrin glue in the antithrombotic group at 1 week (11.5 vs 40.0%, p = 0.008). However, in non-antithrombotic group, there was no difference in the rate of severe ecchymosis according to the use of fibrin glue at 1 week (14.3 vs 30.2%, p = 0.181). In patients with a history of taking antithrombotic agents, the intraoperative use of fibrin glue is thought to be helpful as it could significantly reduce significant ecchymosis.
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Affiliation(s)
- Kangmin Lee
- Department of Ophthalmology, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea
| | - Minwook Chang
- Department of Ophthalmology, Dongguk University Ilsan Hospital, 27, Dongguk-ro, Ilsandong-gu, Goyang-si, Gyeonggi-do, Republic of Korea.
- Shiley Eye Clinic, Hwa Sung, Republic of Korea.
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22
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Wittig T, Pflug T, Schmidt A, Scheinert D, Steiner S. Impact of Optimal Medical Therapy on Reintervention and Survival Rates after Endovascular Infrapopliteal Revascularization. J Clin Med 2023; 12:5146. [PMID: 37568548 PMCID: PMC10419982 DOI: 10.3390/jcm12155146] [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: 07/14/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Within this single-center cohort study, we investigated the impact of optimal medical therapy on all-cause mortality, major amputation-free survival and clinically driven target lesion revascularization (CD TLR) in 552 patients with peripheral arterial disease (PAD) undergoing endovascular infrapopliteal revascularization. From the overall cohort, 145 patients were treated for intermittent claudication (IC) and 407 were treated for critical limb ischemia (CLI). Optimal medical therapy (OMT) was defined as the presence of at least one antiplatelet agent, statin and ACE inhibitor or AT-2 antagonist based on guideline recommendations. About half (55.5%) of all patients were prescribed OMT at discharge, with a higher proportion in claudicants (62.1%) versus CLI patients (53.2%). Over three years of follow-up, survival was significantly better in patients with IC (80.6 ± 3.8% vs. 59.9 ± 2.9%; p < 0.001). There was a signal towards better survival in those patients receiving OMT (log-rank p = 0.09). Similarly, amputation-free survival (AFS) was significantly better in patients with IC (p = 0.004) and also in patients receiving OMT (78.8 ± 3.6%) compared to that in those without OMT (71.5 ± 4.2%; p = 0.046). Freedom from CD TLR within three years was significantly better in the IC group (p = 0.002), but there were no statistically significant differences for CD TLR dependent on the presence of OMT (p = 0.79). In conclusion, there is still an important underuse of OMT in patients undergoing infrapopliteal interventions, which is even more pronounced in CLI despite a signal for its benefit regarding all-cause mortality and major amputation-free survival.
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Affiliation(s)
- Tim Wittig
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany; (T.W.); (A.S.); (D.S.)
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich, University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
| | - Toni Pflug
- Department of Vascular Surgery, Sana Klinikum Borna, 04552 Borna, Germany;
| | - Andrej Schmidt
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany; (T.W.); (A.S.); (D.S.)
| | - Dierk Scheinert
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany; (T.W.); (A.S.); (D.S.)
| | - Sabine Steiner
- Department of Angiology, University Hospital Leipzig, 04103 Leipzig, Germany; (T.W.); (A.S.); (D.S.)
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Center Munich, University of Leipzig and University Hospital Leipzig, 04103 Leipzig, Germany
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23
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Steiger K, Fuentes A, Erben Y. Medical Management of Cardiovascular Disease. Surg Clin North Am 2023; 103:565-575. [PMID: 37455025 DOI: 10.1016/j.suc.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
We offer an overview of lipid lowering, antiplatelet, antihypertensive, and glucose-lowering therapies for vascular surgeons and their respective medical teams. Further reviews should offer additional guidance on smoking cessation, exercise therapy, and nutritional optimization.
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Affiliation(s)
- Kyle Steiger
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana Fuentes
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA.
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24
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Martelli E, Enea I, Zamboni M, Federici M, Bracale UM, Sangiorgi G, Martelli AR, Messina T, Settembrini AM. Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications. Diagnostics (Basel) 2023; 13:2356. [PMID: 37510100 PMCID: PMC10377859 DOI: 10.3390/diagnostics13142356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.
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Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 Via di Sant'Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 Viale Europa, 32100 Belluno, Italy
| | - Massimo Federici
- Department of Systems Medicine, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Umberto M Bracale
- Division of Vascular Surgery, Federico II Polyclinic, Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, 5 Via S. Pansini, 80131 Naples, Italy
| | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Allegra R Martelli
- Faculty-Medicine & Surgery, Campus Bio-Medico University of Rome, 21 Via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Alberto M Settembrini
- Division of Vascular Surgery, Maggiore Polyclinic Hospital Ca' Granda IRCCS and Foundation, 35 Via Francesco Sforza, 20122 Milan, Italy
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Linnemann B, Espinola-Klein C. [Thromboembolic disease - the angiologist's point of view]. Dtsch Med Wochenschr 2023; 148:890-898. [PMID: 37493950 DOI: 10.1055/a-1825-7033] [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: 07/27/2023]
Abstract
Thrombosis and embolism are among the most common causes of death worldwide and, in addition to venous thromboembolism with the two main manifestations of deep venous thrombosis and pulmonary embolism, also include arterial thrombotic disease such as myocardial infarction, stroke and systemic arterial embolism. It is often the interaction of several predisposing factors that leads to the formation of an intravascular thrombus. Changes in the vascular wall, the blood flow and the composition of the blood (Virchow's triad) play a decisive role in both the arterial and venous vascular systems. The management of thromboembolic diseases requires a dedicated clarification of the cause and classification of the disease process in order to minimize the risk of recurrence and embolic complications through differentiated antithrombotic therapy. For this purpose, a risk-benefit analysis based on the individual case and regular reassessment are of particular importance. In this article, the pathophysiological concepts of venous and arterial thrombosis and the main therapeutic implications resulting from this are reviewed.
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Fioretti V, Gerardi D, Giugliano G, Di Fazio A, Stabile E. Focus on Prevention: Peripheral Arterial Disease and the Central Role of the Cardiologist. J Clin Med 2023; 12:4338. [PMID: 37445373 PMCID: PMC10342387 DOI: 10.3390/jcm12134338] [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: 05/17/2023] [Revised: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral artery disease (PAD) is a manifestation of systemic atherosclerotic disease. PAD patients have a poor prognosis with an increased risk of cardiovascular (CV) events, including myocardial infarction (MI), stroke, limb ischemia and CV death; therefore, it is important to detect and treat PAD early. PAD and coronary artery disease (CAD) share a common pathogenesis and risk factors for development; therefore, cardiologists are in a unique position to screen, diagnosis and treat PAD. Moreover, PAD and CAD also share some treatment goals, including an aggressive modification of risk factors to reduce the risk of CV events. However, PAD remains an underdiagnosed and undertreated disease with medico-legal implications. As the role of cardiologists is expanding, the purpose of this review was to awaken the clinicians to the significance of PAD.
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Affiliation(s)
- Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", 85100 Potenza, Italy
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy
| | - Donato Gerardi
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", 85100 Potenza, Italy
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy
| | - Aldo Di Fazio
- Regional Complex Intercompany Institute of Legal Medicine, Azienda Ospedaliera Regionale "San Carlo", 85100 Potenza, Italy
| | - Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale "San Carlo", 85100 Potenza, Italy
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27
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Castelijns MC, Hageman SHJ, Teraa M, van der Meer MG, Westerink J, Costa F, Ten Berg JM, Visseren FLJ. External validation of bleeding risk models for the prediction of long-term bleeding risk in patients with established cardiovascular disease. Am Heart J 2023; 260:72-81. [PMID: 36841319 DOI: 10.1016/j.ahj.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/14/2023] [Accepted: 02/18/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE The long-term predictive performance of existing bleeding risk models in patients with various manifestations of cardiovascular disease (CVD) is not well known. This study aims to assess and compare the performance of relevant existing bleeding risk models in estimating the long-term risk of major bleeding in a cohort of patients with established CVD. METHODS Seven existing bleeding risk models (PRECISE-DAPT, DAPT, Ducrocq et al, de Vries et al, S2TOP-BLEED, Intracranial B2LEED3S and HAS-BLED) were identified and externally validated in 7,249 patients with established CVD included in the Utrecht Cardiovascular Cohort-second manifestations of arterial disease study. Predictive performance was assessed in terms of discrimination and calibration, both at 10 years and the original prediction horizon of the models. Major bleeding was defined as Bleeding Academic Research Consortium type 3 or 5. RESULTS After a median follow-up of 8.4 years (interquartile range 4.5-12.5), a total of 233 (3.2%) major bleeding events occurred. C-statistics for discrimination at 10 years ranged from 0.53 (95%CI 0.49-0.57) to 0.64 (95%CI 0.60-0.68). Calibration plots after recalibration to 10 years showed best agreement between predicted and observed bleeding risk for De Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. CONCLUSIONS The performance of existing bleeding risk models to predict long-term bleeding in patients with CVD varied. Discrimination and calibration were best for the models of de Vries et al, S2TOP-BLEED, DAPT and PRECISE-DAPT. Of these, recalibrated models requiring the least predictors may be preferred for use to personalize prevention with antithrombotic therapy.
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Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon G van der Meer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Internal Medicine, Isala Clinics Zwolle, Zwolle, The Netherlands
| | - Francesco Costa
- Department of Cardiology, G. Martino University Hospital Messina, Messina, Italy
| | - Jurriën M Ten Berg
- Department of Cardiology and Platelet Function Research, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
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Crea F. Thrombotic and bleeding complications during antithrombotic treatment: the need for new therapeutic targets. Eur Heart J 2023; 44:1767-1770. [PMID: 37210634 DOI: 10.1093/eurheartj/ehad285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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29
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Achim A, Péter OÁ, Cocoi M, Serban A, Mot S, Dadarlat-Pop A, Nemes A, Ruzsa Z. Correlation between Coronary Artery Disease with Other Arterial Systems: Similar, Albeit Separate, Underlying Pathophysiologic Mechanisms. J Cardiovasc Dev Dis 2023; 10:jcdd10050210. [PMID: 37233177 DOI: 10.3390/jcdd10050210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
Atherosclerosis is a multifactorial systemic disease that affects the entire arterial tree, although some areas are more prone to lipid deposits than others. Moreover, the histopathological composition of the plaques differs, and the clinical manifestations are also different, depending on the location and structure of the atherosclerotic plaque. Some arterial systems are correlated with each other more than in that they simply share a common atherosclerotic risk. The aim of this perspective review is to discuss this heterogeneity of atherosclerotic impairment in different arterial districts and to investigate the current evidence that resulted from studies of the topographical interrelations of atherosclerosis.
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Affiliation(s)
- Alexandru Achim
- Department of Cardiology, "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001 Cluj-Napoca, Romania
- Department of Cardiology, Medizinische Universitätsklinik, Kantonsspital Baselland, Rheinstrasse 26, 4410 Liestal, Switzerland
- Department of Internal Medicine, Invasive Cardiology Division, University of Szeged, Semmelweis u. 8, 6725 Szeged, Hungary
| | | | - Mihai Cocoi
- Department of Cardiology, "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Adela Serban
- Department of Cardiology, "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Stefan Mot
- Department of Cardiology, "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Alexandra Dadarlat-Pop
- Department of Cardiology, "Niculae Stancioiu" Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Motilor 19-21, 400001 Cluj-Napoca, Romania
| | - Attila Nemes
- Department of Internal Medicine, Invasive Cardiology Division, University of Szeged, Semmelweis u. 8, 6725 Szeged, Hungary
| | - Zoltan Ruzsa
- Department of Internal Medicine, Invasive Cardiology Division, University of Szeged, Semmelweis u. 8, 6725 Szeged, Hungary
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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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Li M, Wang P, Zou Y, Wang W, Zhao Y, Liu M, Wu J, Zhang Y, Zhang N, Sun Y. Spleen tyrosine kinase (SYK) signals are implicated in cardio-cerebrovascular diseases. Heliyon 2023; 9:e15625. [PMID: 37180910 PMCID: PMC10172877 DOI: 10.1016/j.heliyon.2023.e15625] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/16/2023] Open
Abstract
Post-translational modifications regulate numerous biochemical reactions and functions through covalent attachment to proteins. Phosphorylation, acetylation and ubiquitination account for over 90% of all reported post-translational modifications. As one of the tyrosine protein kinases, spleen tyrosine kinase (SYK) plays crucial roles in many pathophysiological processes and affects the pathogenesis and progression of various diseases. SYK is expressed in tissues outside the hematopoietic system, especially the heart, and is involved in the progression of various cardio-cerebrovascular diseases, such as atherosclerosis, heart failure, diabetic cardiomyopathy, stroke and others. Knowledge on the role of SYK in the progress of cardio-cerebrovascular diseases is accumulating, and many related mechanisms have been discovered and validated. This review summarizes the role of SYK in the progression of various cardio-cerebrovascular diseases, and aims to provide a theoretical basis for future experimental and clinical research targeting SYK as a therapeutic option for these diseases.
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Affiliation(s)
- Mohan Li
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Pengbo Wang
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Yuanming Zou
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Wenbin Wang
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Yuanhui Zhao
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Mengke Liu
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Jianlong Wu
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
| | - Ying Zhang
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Institute of Health Sciences, China Medical University, 77 Puhe Road, Shenbei New District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Corresponding author. Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China.
| | - Naijin Zhang
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Institute of Health Sciences, China Medical University, 77 Puhe Road, Shenbei New District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Key Laboratory of Reproductive and Genetic Medicine (China Medical University), National Health Commission, 77 Puhe Road, Shenbei New District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Corresponding author. Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China.
| | - Yingxian Sun
- Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Institute of Health Sciences, China Medical University, 77 Puhe Road, Shenbei New District, Shenyang, 110001, Liaoning Province, People's Republic of China
- Corresponding author. Department of Cardiology, First Hospital of China Medical University, 155 Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, People's Republic of China.
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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Meuli L, Stadlbauer T, Stähli BE, Espinola-Klein C, Zimmermann A. Preventing Lower Limb Graft Thrombosis after Infrainguinal Arterial Bypass Surgery with Antithrombotic Agents (PATENT Study): An International Expert Based Delphi Consensus. J Clin Med 2023; 12:jcm12093223. [PMID: 37176663 PMCID: PMC10178874 DOI: 10.3390/jcm12093223] [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: 03/05/2023] [Revised: 04/22/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
(1) Background: High-level evidence on antithrombotic therapy after infrainguinal arterial bypass surgery in specific clinical scenarios is lacking. (2) Methods: A modified Delphi procedure was used to develop consensus statements. Experts voted on antithrombotic treatment regimens for three types of infrainguinal arterial bypass procedures: above-the-knee popliteal artery; below-the-knee popliteal artery; and distal, using vein, prosthetic, or biological grafts. The treatment regimens for these nine procedures were then voted on in three clinical scenarios: isolated PAOD, atrial fibrillation, and recent coronary intervention. (3) Results: The survey was conducted with 28 experts from 15 European countries, resulting in consensus statements on 25/27 scenarios. Experts recommended single antiplatelet therapy after above-the-knee popliteal artery bypasses regardless of the graft material used. For below-the-knee popliteal artery bypasses, experts suggested combining single antiplatelet therapy with low-dose rivaroxaban if the graft material used was autologous or biological. They did not recommend switching to triple therapy for patients on oral anticoagulants for atrial fibrillation or dual antiplatelet therapy in any scenario. (4) Conclusions: Great inconsistency in the antithrombotic therapy administered was found in this study. This consensus offers guidance for scenarios that are not covered in the current ESVS guidelines but must be interpreted within its limitations.
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Affiliation(s)
- Lorenz Meuli
- Department of Vascular Surgery, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
| | - Thomas Stadlbauer
- Department of Vascular Surgery, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
| | - Barbara E Stähli
- Department of Cardiology, University Heart Centre, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
| | - Christine Espinola-Klein
- Centre for Cardiology, Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg University of Mainz, 55131 Mainz, Germany
| | - Alexander Zimmermann
- Department of Vascular Surgery, University Hospital Zürich, University of Zürich, 8091 Zürich, Switzerland
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Bontekoe J, Matsumura J, Liu B. Thrombosis in the pathogenesis of abdominal aortic aneurysm. JVS Vasc Sci 2023; 4:100106. [PMID: 37564632 PMCID: PMC10410173 DOI: 10.1016/j.jvssci.2023.100106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/23/2023] [Indexed: 08/12/2023] Open
Abstract
Background Abdominal aortic aneurysms (AAAs) are a relatively common vascular pathology of the elderly with high morbidity potential. Irreversible degeneration of the aortic wall leads to lethal rupture if left untreated. Nearly all AAAs contain intraluminal thrombus (ILT) to a varying degree, yet the mechanisms explaining how thrombosis is disturbed in AAA are relatively unknown. This review examined the thrombotic complications associated with AAA, the impact of thrombosis on AAA surgical outcomes and AAA pathogenesis, and the use of antithrombotic therapy in the management of this disease. Methods A literature search of the PubMed database was conducted using relevant keywords related to thrombosis and AAAs. Results Thrombotic complications are relatively infrequent in AAA yet carry significant morbidity risks. The ILT can impact endovascular aneurysm repair by limiting anatomic suitability and influence the risk of endoleaks. Many of the pathologic mechanisms involved in AAA development, including hemodynamics, inflammation, oxidative stress, and aortic wall remodeling, contain pathways that interact with thrombosis. Conversely, the ILT can also be a source of biochemical stress and exacerbate these aneurysmal processes. In animal AAA models, antithrombotic therapies have shown favorable results in preventing and stabilizing AAA. Antiplatelet agents may be beneficial for reducing risks of major adverse cardiovascular events in AAA patients; however, neither antiplatelet nor anticoagulation is currently used solely for the management of AAA. Conclusions Thrombosis and ILT may have detrimental effects on AAA growth, rupture risk, and patient outcomes, yet there is limited understanding of the pathologic thrombotic mechanisms in aneurysmal disease at the molecular level. Preventing ILT using platelet and coagulation inhibitors may be a reasonable theoretical target for aneurysm progression and stability; however, the practical benefits of current antithrombotic therapies in AAA are unclear. Further research is needed to demonstrate the extent to which thrombosis impacts AAA pathogenesis and to develop novel pharmacologic strategies for the medical management of this disease.
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Affiliation(s)
- Jack Bontekoe
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Jon Matsumura
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Bo Liu
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
- Department of Cellular and Regenerative Biology, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
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Canonico ME, Piccolo R, Avvedimento M, Leone A, Esposito S, Franzone A, Giugliano G, Gargiulo G, Hess CN, Berkowitz SD, Hsia J, Cirillo P, Esposito G, Bonaca MP. Antithrombotic Therapy in Peripheral Artery Disease: Current Evidence and Future Directions. J Cardiovasc Dev Dis 2023; 10:164. [PMID: 37103043 PMCID: PMC10144744 DOI: 10.3390/jcdd10040164] [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] [Received: 03/10/2023] [Revised: 04/07/2023] [Accepted: 04/08/2023] [Indexed: 04/28/2023] Open
Abstract
Patients with peripheral artery disease (PAD) are at an increased risk of major adverse cardiovascular events, and those with disease in the lower extremities are at risk of major adverse limb events primarily driven by atherothrombosis. Traditionally, PAD refers to diseases of the arteries outside of the coronary circulation, including carotid, visceral and lower extremity peripheral artery disease, and the heterogeneity of PAD patients is represented by different atherothrombotic pathophysiology, clinical features and related antithrombotic strategies. The risk in this diverse population includes systemic risk of cardiovascular events as well as risk related to the diseased territory (e.g., artery to artery embolic stroke for patients with carotid disease, lower extremity artery to artery embolism and atherothrombosis in patients with lower extremity disease). Moreover, until the last decade, clinical data on antithrombotic management of PAD patients have been drawn from subanalyses of randomized clinical trials addressing patients affected by coronary artery disease. The high prevalence and related poor prognosis in PAD patients highlight the pivotal role of tailored antithrombotic therapy in patients affected by cerebrovascular, aortic and lower extremity peripheral artery disease. Thus, the proper assessment of thrombotic and hemorrhagic risk in patients with PAD represents a key clinical challenge that must be met to permit the optimal antithrombotic prescription for the various clinical settings in daily practice. The aim of this updated review is to analyze different features of atherothrombotic disease as well as current evidence of antithrombotic management in asymptomatic and secondary prevention in PAD patients according to each arterial bed.
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Affiliation(s)
- Mario Enrico Canonico
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC G1V0A6, Canada
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Salvatore Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Connie N. Hess
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Scott D. Berkowitz
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Judith Hsia
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marc P. Bonaca
- CPC Clinical Research, Department of Medicine, University of Colorado, Aurora, CO 80045, USA
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Patient Characteristics in the Recording Courses of Vascular Diseases (Reccord) Registry: Comparison with the Voyager Pad Endovascular Cohort. J Cardiovasc Dev Dis 2023; 10:jcdd10030115. [PMID: 36975879 PMCID: PMC10054422 DOI: 10.3390/jcdd10030115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Background: To compare the characteristics of a “real world” population included in a prospective registry to patients enrolled in a randomized, controlled trial (RCT) after endovascular revascularization (EVR) for symptomatic peripheral artery disease (PAD). Methods: The RECcording COurses of vasculaR Diseases (RECCORD) registry is an observational registry prospectively recruiting patients undergoing EVR for symptomatic PAD in Germany. VOYAGER PAD was an RCT which demonstrated the superiority of rivaroxaban and aspirin versus aspirin to reduce major cardiac and ischemic limb events following infrainguinal revascularization for symptomatic PAD. For this exploratory analysis, the clinical characteristics of 2.498 patients enrolled in RECCORD and of 4.293 patients from VOYAGER PAD who underwent EVR were compared. Results: The rate of patients aged ≥ 75 years was considerably higher in the registry (37.7 vs. 22.5%). More patients in the registry had undergone previous EVR (50.7 vs. 38.7%) or suffered from critical limb threatening ischemia (24.3 vs. 19.5%). Registry patients were more commonly active smokers (51.8 vs. 33.6%), but less frequently suffered from diabetes mellitus (36.4 vs. 44.7%). While statins (70.5 vs. 81.7%) were less frequently used, antiproliferative catheter technologies (45.6 vs. 31.4%) and postinterventional dual antiplatelet therapy (64.5 vs. 53.6%) were more commonly applied in the registry. Conclusions: There were many similarities but some clinically meaningful differences in clinical characteristics between PAD patients who underwent EVR and were included in a nationwide registry and PAD patients from the VOYAGER PAD trial.
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Chen Z, Liu Z, Cai J, Liu C, Li Z, Liu H, Mamateli S, Lv X, Liu C, Ran F, Wang W, Zhang M, Li X, Qiao T. Risk factors for target vessel endoleaks after physician-modified fenestrated or branched endovascular aortic repair for postdissection thoracoabdominal aortic aneurysms. J Vasc Surg 2023; 77:685-693.e2. [PMID: 36270559 DOI: 10.1016/j.jvs.2022.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Patients with postdissection thoracoabdominal aortic aneurysms (TAAAs) have been more likely to develop endoleaks than those with degenerative TAAAs after fenestrated or branched endovascular aortic repair (F/BEVAR). In the present study, we aimed to determine the risk factors for target vessel (TV)-related endoleaks after visceral segment F/BEVAR for postdissection TAAAs. METHODS We performed a retrospective analysis of all patients with degenerative and postdissection TAAAs treated with F/BEVAR between 2017 and 2021. All the patients had undergone computed tomography angiography before and 3 months, 6 months, and annually after discharge. Two experienced vascular surgeons had used data from computed tomography angiography and vascular angiography to judge the presence of endoleaks. The study end points were mortality, aneurysm rupture, and the emergence of and reintervention for TV-related endoleaks. RESULTS A total of 195 patients (mean age, 66 ± 10 years; 69% men) had undergone F/BEVAR for 99 postdissection TAAAs and 96 degenerative TAAAs. During a mean follow-up of 16 ± 12 months, we found that the patients with postdissection TAAAs were younger (age, 64 ± 10 years vs 69 ± 9 years; P = .001), had required more prior aortic repairs (58% vs 40%; P = .012), and had had a higher body mass index (26.1 ± 3.4 kg/m2 vs 24.8 ± 3 kg/m2; P = .008), a larger visceral segment aortic diameter (47.1 ± 7.5 mm vs 44.5 ± 7.5 mm; P = .016), and more TV-related endoleaks (18% vs 7%; P = .023) compared with those with degenerative TAAAs. Of the 99 patients with postdissection TAAAs, 327 renal-mesenteric arteries were revascularized using 12 scallops, 141 fenestrations, and 174 inner or outer branch stents. A total of 25 TV-related endoleaks were identified among 18 patients during follow-up, including 6 type Ic (retrograde from the distal end of the branch), 3 type IIIb (bridging stent fabric tear), and 16 type IIIc endoleaks (detachment or loose connection of the bridging stent). The patients with an endoleak had had a larger visceral aortic diameter (52.7 ± 6.4 mm vs 45.8 ± 7.2 mm; P < .001) and had undergone revascularization of more TVs (3.7 ± 0.7 vs 3.2 ± 0.9; P = .032). In contrast, true lumen compression did not seem to affect the occurrence of TV endoleaks (39% vs 27%; P = .323). The use of presewn branch stents in the fenestration position was associated with a lower risk of TV-related endoleaks (5% vs 11%; P = .025). In addition, TVs derived entirely or partially from the false lumen were more prone to the development of endoleaks after reconstruction (19% vs 4% [P < .001]; and 15% vs 4% [P = .047], respectively). CONCLUSIONS We found that patients with postdissection TAAAs were more likely to have TV-related endoleaks after F/BEVAR in the visceral region than those with degenerative TAAAs. Additionally, patients with a larger aortic diameter and a greater number of fenestrations in the visceral region were more likely to have experienced TV-related endoleaks. Branch vessels deriving from the false lumen were also more likely to develop endoleaks after reconstruction, and prefabricated branch stents were related to a lower possibility of TV-related endoleaks.
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Affiliation(s)
- Zhipeng Chen
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhao Liu
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Cai
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cheng Liu
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhigao Li
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Heqian Liu
- Nanjing Drum Tower Hospital, Clinical College of Xuzhou Medical University, Nanjing, China
| | - Subinur Mamateli
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaochen Lv
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chen Liu
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Ran
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wei Wang
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ming Zhang
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Tong Qiao
- Department of Vascular Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.
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Nicolajsen CW, Nielsen PB, Jensen M, Eldrup N, Larsen TB, Lip GYH, Goldhaber SZ, Søgaard M. Stroke and Myocardial Infarction in Patients with Abdominal Aortic Aneurysm and New-Onset Atrial Fibrillation. Thromb Haemost 2023; 123:555-564. [PMID: 36626930 DOI: 10.1055/a-2009-8954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease. METHODS Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy. RESULTS A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA2DS2-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%. CONCLUSION Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.
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Affiliation(s)
- Chalotte W Nicolajsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Peter B Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Copenhagen University, Copenhagen, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Thrombosis Research Group, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Crea F. Ischaemic heart disease: antithrombotic treatment and new therapeutic targets. Eur Heart J 2023; 44:239-242. [PMID: 36680421 DOI: 10.1093/eurheartj/ehac816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Zink N. Basistherapie bei PAVK häufig vernachlässigt. MMW Fortschr Med 2023; 165:14-17. [PMID: 36648646 DOI: 10.1007/s15006-023-2265-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Nicola Zink
- Springer Medizin Verlag GmbH, Aschauer Str. 30, 81549, München, Germany
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41
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Chen Z, Fu D, Liu C, Jin Y, Pan C, Mamateli S, Lv X, Qiao T, Liu Z. Risk factors for target vessel endoleaks after physician-modified fenestrated or branched endovascular aortic arch repair: A retrospective study. Front Cardiovasc Med 2023; 10:1058440. [PMID: 37025680 PMCID: PMC10070968 DOI: 10.3389/fcvm.2023.1058440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/28/2023] [Indexed: 04/08/2023] Open
Abstract
Objective Fenestrated or branched endovascular aortic arch repair (fb-arch repair) is an effective option for treating complex aortic arch lesions, including thoracic aortic aneurysms and aortic dissections. However, the relatively high rate of re-intervention due to target vessel (TV)-related endoleaks have raised concerns. This study aimed to determine risk factors for TV-related endoleaks after fb-arch repair. Methods This was a retrospective analysis of all patients undergoing fb-arch repair between 2017 and 2021in nanjing drum tower hospital of China. All the patients underwent computed tomography angiography (CTA) before surgery; at discharge; and at 3 months, 6 months, and yearly post-discharge. All procedures are performed with physician modified grafts. Two experienced vascular surgeons used CTA and vascular angiography data to assess endoleaks. The study endpoints were mortality, aneurysm rupture, and emergence of and re-intervention for TV-related endoleaks. Results During the follow-up period, 218 patients underwent fb-arch repair. There were seven perioperative deaths and four deaths during follow-up (two myocardial infarctions and two malignancies). There were nine additional patients who were excluded from the study (two strokes, three with abnormal aortic arch anatomy, and four with insufficient clinical data). Among the 198 patients considered (mean age, 59 ± 13.3 years; 85% male), 309 branch arteries were revascularized. A total of 35 TV-related endoleaks were identified in 28 patients during a mean follow-up of 23 ± 14 months (median 23, IQR 26.3): six type Ic, 4 type IIIb, and 20 type IIIc endoleaks. Patients in the endoleak group had greater aortic arch segment diameters (43.1 ± 5.1 vs. 40.3 ± 4.7; P = 0.004) and a greater number of TVs revascularized (2.0 ± 0.8 vs. 1.5 ± 0.8; P = 0.004) than those in the non-endoleak group. However, the morphological classification of the aortic arch did not seem to affect the occurrence of TV endoleaks (13%, 14%, and 15% for type І, II, and III aortic arches, respectively; P = 0.957). Pre-sewing branch stents in the fenestration position reduced the risk of TV endoleaks (5% vs. 14%; P = 0.037). Additionally, in TVs affected by aortic aneurysm or dissection, the risk of endoleaks increased after reconstruction (17% vs. 8%; P = 0.018). The incidence of secondary TV-related endoleaks after fb-arch repair was 14.1%. Conclusion The data from this study showed that the incidence of secondary target vessel related endoleaks after fb-arch repair is approximately 14.1%. Additionally, patients with a larger aortic arch diameter or more revascularized arteries during surgery were at increased risk TV-related endoleaks. The target vessels originating from the false lumen or aneurysm sac are more prone to endoleaks after reconstruction. Finally, prefabricated branch stents reduced risk of TV-related endoleaks.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Zhao Liu
- Correspondence: Tong Qiao Zhao Liu
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42
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Bleeding Risk in Patients with Peripheral Arterial Disease. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010047. [PMID: 36675996 PMCID: PMC9861549 DOI: 10.3390/life13010047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022]
Abstract
Patients with peripheral arterial disease (PAD) are at high risk of major adverse cardiac events (MACE) and major adverse limb events (MALE). Recently, antithrombotic therapies employing antiplatelet and anticoagulant drugs have proven to be valid in reducing MACE in patients with PAD and polyvascular disease and MALE, particularly in patients who have already been revascularized and remain at increased risk of MALE. However, more aggressive antithrombotic therapies lead to an increased risk of bleeding. Antithrombotic therapy and revascularization procedures entail an increased hemorrhagic risk that is also linked to having received more vigorous antithrombotic therapies. Therefore, it appears crucial to have specifically targeted scores for a PAD patient to assess bleeding and thrombotic risks. The correct utilization of a risk score will determine the variable risk factors for bleeding that can be corrected or modified, as well as identify patients at high risk that require regular reexamination and follow-up. Clinical risk scores do not represent the absolute reality, and inter-score variability must be taken into account. Moreover, several risk scores have been created to be basic and to facilitate and improve clinical decisions in daily practice. Many risk scores based on points vary according to the configuration of the studies, population type, and ethnic group, and many of the risk factor elements in a specific score are unlikely to sustain same weight for that risk. The best approach continues to be devising an uncomplicated, functional, validated, and precise score that can be adjusted to different clinical contexts and populations, while considering the mutable composition of clinical risk.
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Fox KAA, Aboyans V, Debus ES, Zeymer U, Cowie MR, Patel M, Welsh RC, Bosch J, Gay A, Vogtländer K, Anand SS. Patients selected for dual pathway inhibition in clinical practice have similar characteristics and outcomes to those included in the COMPASS randomized trial: The XATOA Registry. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:825-836. [PMID: 35594542 DOI: 10.1093/ehjcvp/pvac028] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/24/2022] [Indexed: 12/29/2022]
Abstract
AIMS To determine the characteristics of patients with coronary artery disease (CAD), peripheral artery disease (PAD), or both, initiating dual pathway inhibition (DPI) using rivaroxaban 2.5 mg twice daily plus aspirin, and to report their clinical outcomes and bleeding rates in clinical practice compared to the COMPASS randomized trial, which provided the basis for using DPI in this patient population. METHODS AND RESULTS XATOA is a prospective registry of 5532 patients: of which, 72.7% had CAD, 58.9% had PAD, and 31.6% had both. The mean age of patients was 68 years and 25.5% were women. The mean follow-up period was 15 months. The most frequently reported reason for initiating DPI was the presence of existing, worsening or newly diagnosed risk characteristics (n = 4753, 85.9%). Before initiating DPI, 75.3% received a single antiplatelet and 18.3% received various antiplatelet combinations. The incidence of major adverse cardiovascular events (MACE), major adverse limb events (MALE) and acute or severe limb ischaemia was 2.26, 3.57, and 1.54 per 100 patient-years, respectively, among the 5532 patients in XATOA. Corresponding rates in COMPASS were 2.18, 0.19, and 0.12 per 100 patient-years, respectively. Major bleeding rates were 0.95 and 1.67 per 100 patient-years in XATOA and COMPASS, respectively. CONCLUSION High-risk vascular patients are prioritized for DPI in clinical practice, and rates of MACE are similar to COMPASS, but MALE rates are higher in XATOA, consistent with the greater proportion of PAD patients. Major bleeding rates were lower in XATOA. The findings provide support for favourable net clinical benefit of DPI in high-risk vascular patients. ONE-SENTENCE SUMMARY The characteristics of patients initiated on dual pathway inhibition (DPI: rivaroxaban 2.5 mg twice daily plus aspirin) have not previously been defined in clinical practice and the XATOA registry findings demonstrate patient outcomes are consistent with those of the COMPASS trial, despite geographic differences in recruitment and the higher proportion of PAD patients.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and Inserm U1094, Limoges, France
| | - E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery, Angiology, Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Uwe Zeymer
- Klinikum der Stadt Ludwigshafen, Medizinische Klinik B, and Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Martin R Cowie
- Royal Brompton Hospital and King's College London, London, UK
| | - Manesh Patel
- Division of Cardiology, Duke Clinical Research Institute, Duke University, Durham NC
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Jackie Bosch
- School of Rehabilitation Science, Chanchlani Research Centre and the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sonia S Anand
- School of Rehabilitation Science, Chanchlani Research Centre and the Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Espinola-Klein C. Antithrombotische Therapie bei pAVK und Aortenerkrankungen. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1954-8578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ZusammenfassungPatienten mit peripherer arterieller Verschlusskrankheit (pAVK) oder Aortenerkrankungen haben ein hohes Risiko für kardiovaskuläre Ereignisse. Gerinnungshemmende Medikamente verbessern die
Prognose und haben daher einen hohen Stellenwert. Bei jeder gerinnungshemmenden Therapie sollte das individuelle Blutungsrisiko berücksichtigt werden und eine individuelle
Nutzen-Risiko-Abwägung durchgeführt werden. Patienten mit symptomatischer pAVK sollten einen Thrombozytenaggregationshemmer (TZAH) erhalten. Bei hohem Risiko für kardiovaskuläre Ereignisse
und niedrigem Blutungsrisiko wird die Kombination von Acetylsalicylsäure (ASS) 100 mg und Rivaroxaban 2 × 2,5 mg empfohlen. Liegt ein hohes Blutungsrisiko vor, ist Clopidogrel ASS
vorzuziehen. Bei Patienten mit Aortenerkrankungen (z. B. komplexe Plaques, Aortenaneurysma) ist die Gabe eines TZAH indiziert. Patienten mit einer atherosklerotischen Gefäßerkrankung und
Indikation für eine orale Antikoagulation wegen Vorhofflimmern oder venöser Thromboembolie sollten keinen zusätzlichen TZAH erhalten. Denn dieser erhöht das Blutungsrisiko, ohne die Prognose
zu verbessern.
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Affiliation(s)
- Christine Espinola-Klein
- Kardiologie III – Angiologie, Zentrum für Kardiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
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Kamaltdinov RR, Akhmetzianov RV, Bredikhin RA, Dzhordzhikiya RK. Outpatient management of patients after surgical operations for acute aortic dissection of type A. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-44-49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.
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Affiliation(s)
- R. R. Kamaltdinov
- Kazan State Medical University; Interregional Clinical Diagnostic Center
| | - R. V. Akhmetzianov
- Kazan State Medical University; Interregional Clinical Diagnostic Center
| | - R. A. Bredikhin
- Kazan State Medical University; Interregional Clinical Diagnostic Center
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Wong KHF, Zlatanovic P, Bosanquet DC, Saratzis A, Kakkos SK, Aboyans V, Twine CP. Antithrombotic Therapy for Aortic Aneurysms: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2022; 64:544-556. [PMID: 35853579 DOI: 10.1016/j.ejvs.2022.07.008] [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: 02/05/2022] [Revised: 06/25/2022] [Accepted: 07/10/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVES The role of antithrombotic therapy in the management of aortic and peripheral aneurysms is unclear. This systematic review and meta-analysis aimed to assess the impact of antithrombotics on clinical outcomes for aortic and peripheral aneurysms. METHODS Medline, Embase, and CENTRAL databases were searched. Randomised controlled trials and observational studies investigating the effect of antithrombotic therapy on clinical outcomes for patients with any aortic or peripheral artery aneurysm were included. RESULTS Fifty-nine studies (28 with antiplatelet agents, 12 anticoagulants, two intra-operative heparin, and 16 any antithrombotic agent) involving 122 102 patients were included. Abdominal aortic aneurysm (AAA) growth rate was not significantly associated with the use of antiplatelet therapy (SMD -0.36 mm/year; 95% CI -0.75 - 0.02; p = .060; GRADE certainty: very low). Antithrombotics were associated with increased 30 day mortality for patients with AAAs undergoing intervention (OR 2.30; 95% CI 1.51 - 3.51; p < .001; GRADE certainty: low). Following intervention, antiplatelet therapy was associated with reduced long term all cause mortality (HR 0.84; 95% CI 0.76 - 0.92; p < .001; GRADE certainty: moderate), whilst anticoagulants were associated with increased all cause mortality (HR 1.64; 95% CI 1.14 - 2.37; p = .008; GRADE certainty: very low), endoleak within three years (OR 1.99; 95% CI 1.10 - 3.60; p = .020; I2 = 60%; GRADE certainty: very low), and an increased re-intervention rate at one year (OR 3.25; 95% CI 1.82 - 5.82; p < .001; I2 = 35%; GRADE certainty: moderate). Five studies examined antithrombotic therapy for popliteal aneurysms. Meta-analysis was not possible due to heterogeneity. CONCLUSIONS There was a lack of high quality data examining antithrombotic therapy for patients with aneurysms. Antiplatelet therapy was associated with a reduction in post-intervention all cause mortality for AAA, whilst anticoagulants were associated with an increased risk of all cause mortality, endoleak, and re-intervention. Large, well designed trials are still required to determine the therapeutic benefits of antithrombotic agents in this setting.
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Affiliation(s)
- Kitty H F Wong
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK; North Bristol NHS Trust, Bristol, UK
| | - Petar Zlatanovic
- Clinic for Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | | | | | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, EpiMaCT, Inserm 1094 & IRD, Limoges University, Limoges, France
| | - Christopher P Twine
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK; North Bristol NHS Trust, Bristol, UK.
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Espinola-Klein C, Weißer G, Schmitt V, Schwaderlapp M, Munzel T. Antithrombotic therapy in peripheral arterial disease. Front Cardiovasc Med 2022; 9:927645. [PMID: 36312276 PMCID: PMC9606411 DOI: 10.3389/fcvm.2022.927645] [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: 04/24/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patients with peripheral arterial disease (PAD) are at increased risk for major adverse cardiovascular events (MACE) such as cardiovascular death, myocardial infarction, and stroke as well as major adverse limb events (MALE) such as amputation and acute limb ischemia. Therefore, prevention of thrombotic events is crucial to improve the prognosis of PAD patients. This review article concludes current evidence and guideline recommendations about antithrombotic therapy in PAD patients.Antithrombotic therapy is highly effective to reduce MACE and MALE events in PAD patients. Recently, the concept of dual pathway inhibition (low-dose rivaroxaban plus acetylic salicylic acid (ASA) has been tested in the COMPASS and VOYAGER-PAD trial. Compared to ASA alone dual pathway inhibition was superior to prevent MACE and MALE. After peripheral revascularization, in particular the risk for acute limb ischemia was reduced. In contrast, the risk for major bleeding is increased. Therefore, current guidelines recommend the combination of low-dose rivaroxaban and ASA in PAD patients with low bleeding risk. In patients with high bleeding risk, a single antiplatelet drug (preferable clopidogrel) is indicated. In patients with atherosclerotic vascular disease and indication for oral anticoagulation, no additional antiplatelet drug is necessary, as this would increase the risk of bleeding without improving the prognosis. Conclusion Antithrombotic treatment reduces MACE and MALE and is recommended in all patients with PAD. Individual bleeding risk should always be considered based on the current data situation and an individual benefit-risk assessment must be carried out.
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Affiliation(s)
- Christine Espinola-Klein
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Gerhard Weißer
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Volker Schmitt
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Melanie Schwaderlapp
- Center for Cardiology, Cardiology III–Angiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Thomas Munzel
- Center for Cardiology, Cardiology I–General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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De Carlo M, Schlager O, Mazzolai L, Brodmann M, Espinola-Klein C, Staub D, Aboyans V, Sillesen H, Debus S, Venermo M, Belch J, Ferrari M, De Caterina R. Antithrombotic therapy following revascularization for chronic limb-threatening ischaemia: a European survey from the ESC Working Group on Aorta and Peripheral Vascular Diseases. EUROPEAN HEART JOURNAL - CARDIOVASCULAR PHARMACOTHERAPY 2022; 9:201-207. [PMID: 36208909 DOI: 10.1093/ehjcvp/pvac055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/22/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
Abstract
Aims
Chronic limb-threatening ischaemia (CLTI) entails dismal outcomes and is an absolute indication to lower extremity revascularization (LER) whenever possible. Antithrombotic therapy is here crucial, but available evidence on best strategies (choice of drugs, combinations, duration) is scarce. We conducted a European internet-based survey on physicians’ use of antithrombotic therapy after revascularization for CLTI, under the aegis of the ESC Working Group on Aorta and Peripheral Vascular Disease in collaboration with other European scientific societies involved in CLTI management and agreeing to send the survey to their affiliates.
Methods and results
225 respondents completed the questionnaire. Antithrombotic therapy following surgical/endovascular LER varies widely across countries and specialties, with dedicated protocols reported only by a minority (36%) of respondents. Dual antiplatelet therapy with aspirin and clopidogrel is the preferred choice for surgical (37%) and endovascular (79%) LER. Dual pathway inhibition (DPI) with aspirin and low-dose rivaroxaban is prescribed by 16% of respondents and is tightly related to the availability of reimbursement (OR 6.88; 95% CI 2.60–18.25) and to the choice of clinicians rather than of physicians performing revascularization (OR 2.69; 95% CI 1.10–6.58). A ≥ 6 months-duration of an intense (two-drug) postprocedural antithrombotic regimen is more common among surgeons than among medical specialists (OR 2.08; 95% CI 1.10–3.94). Bleeding risk assessment is not standardised and likely underestimated.
Conclusion
Current antithrombotic therapy of CLTI patients undergoing LER remains largely discretional, and prescription of DPI is related to reimbursement policies. An individualised assessment of thrombotic and bleeding risks is largely missing.
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Affiliation(s)
- Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana , 56124 Pisa , Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna , 1090 Vienna , Austria
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel department, Lausanne University Hospital (CHUV) , 1011 Lausanne , Switzerland
| | - Marianne Brodmann
- Division of Angiology, Medical University Graz , 8036 Graz , Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz , 55131 Mainz , Germany
| | - Daniel Staub
- Division of Angiology, University Hospital Basel, University of Basel , 4031 Basel , Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD 270, University of Limoges , 87042 Limoges , France
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, and Department of Clinical Medicine, University of Copenhagen , 2100 Copenhagen , Denmark
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre Hamburg-Eppendorf , 20246 Hamburg , Germany
| | - Maarit Venermo
- Department of Vascular Surgery, Helsinki University Hospital and University of Helsinki , 00029 Helsinki , Finland
| | - Jill Belch
- The Institute of Cardiovascular Research, University of Dundee , DD19SY Dundee, Ninewells, Scotland , UK
| | - Mauro Ferrari
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana , 56124 Pisa , Italy
| | - Raffaele De Caterina
- Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana , 56124 Pisa , Italy
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Camm AJ, Sabbour H, Schnell O, Summaria F, Verma A. Managing thrombotic risk in patients with diabetes. Cardiovasc Diabetol 2022; 21:160. [PMID: 35996159 PMCID: PMC9396895 DOI: 10.1186/s12933-022-01581-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/25/2022] [Indexed: 12/24/2022] Open
Abstract
It is well known that diabetes is a prominent risk factor for cardiovascular (CV) events. The level of CV risk depends on the type and duration of diabetes, age and additional co-morbidities. Diabetes is an independent risk factor for atrial fibrillation (AF) and is frequently observed in patients with AF, which further increases their risk of stroke associated with this cardiac arrhythmia. Nearly one third of patients with diabetes globally have CV disease (CVD). Additionally, co-morbid AF and coronary artery disease are more frequently observed in patients with diabetes than the general population, further increasing the already high CV risk of these patients. To protect against thromboembolic events in patients with diabetes and AF or established CVD, guidelines recommend optimal CV risk factor control, including oral anticoagulation treatment. However, patients with diabetes exist in a prothrombotic and inflammatory state. Greater clinical benefit may therefore be seen with the use of stronger antithrombotic agents or innovative drug combinations in high-risk patients with diabetes, such as those who have concomitant AF or established CVD. In this review, we discuss CV risk management strategies in patients with diabetes and concomitant vascular disease, stroke prevention regimens in patients with diabetes and AF and how worsening renal function in these patients may complicate these approaches. Accumulating evidence from clinical trials and real-world evidence show a benefit to the administration of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with diabetes and AF.
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Affiliation(s)
- A John Camm
- Division of Cardiac and Vascular Sciences, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, Cranmer Terrace, SW17 0RE, UK.
| | - Hani Sabbour
- Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Warren Alpert School of Medicine, Brown University, Rhode Island, USA
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Neuherberg, Munich, Germany
| | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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D'Oria M, Bertoglio L, Bignamini AA, Mani K, Kölbel T, Oderich G, Chiesa R, Lepidi S. Editor's Choice - PRINciples of optimal antithrombotiC therapy and coagulation managEment during elective fenestrated and branched EndovaScular aortic repairS (PRINCE 2SS): An International Expert Based Delphi Consensus Study. Eur J Vasc Endovasc Surg 2022; 63:838-850. [PMID: 35568605 DOI: 10.1016/j.ejvs.2022.03.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/17/2022] [Accepted: 03/03/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Management of antithrombotic therapy in patients undergoing elective fenestrated branched endovascular aortic repair (F-BEVAR) is not standardised, nor are there any recommendations from current guidelines. By designing an international expert based Delphi consensus, the study aimed to create recommendations on the pre-, intra-, and post-operative management of antithrombotic therapy in patients scheduled for elective F-BEVAR in high volume centres. METHODS Eight facilitators created appropriate statements regarding the study topic that were voted on, using a four point Likert scale, by a selected panel of international experts using a three round modified Delphi consensus process. Based on the experts' responses, only those statements reaching Grade A (full agreement ≥ 75%) or B (overall agreement ≥ 80% and full disagreement < 5%) were included in the final document. The round answers' consistency was graded using Cohen's k, the intraclass correlation coefficient, and, in case of double re-submission, the Fleiss k. RESULTS Sixty-seven experts were included in the final analysis and voted the initial 43 statements related to pre- (n = 15), intra- (n = 10), and post-operative (n = 18) management of antithrombotic drugs. At the end of the process, six statements (13%) were rejected, 20 statements (44%) received a Grade B consensus, and 18 statements (40%) reached a Grade A consensus. Most statements (27; 71%) exhibited very high or high consistency grades, and 11 (29%) a fair or poor grading. The intra-operative statements mostly concentrated on threshold for and monitoring of proper heparinisation. The pre- and post-operative statements mainly focused on indications for dual antiplatelet therapy and its management, considering the possible need for cerebrospinal fluid drainage. CONCLUSION Based on the elevated strength and high consistency of this international expert based Delphi consensus, most of the statements might guide current clinical management of antithrombotic therapy for elective F-BEVAR. Future studies are needed to clarify the debated issues.
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Affiliation(s)
- Mario D'Oria
- Division of Vascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy.
| | - Luca Bertoglio
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | | | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Centre, University Heart and Vascular Centre, Hamburg, Germany
| | - Gustavo Oderich
- Department of Cardiothoracic and Vascular Surgery, The University of Texas Health Science Centre at Houston, McGovern Medical School, Houston, TX, USA
| | - Roberto Chiesa
- Division of Vascular Surgery, IRCCS San Raffaele Scientific Institute, "Vita-Salute" University, Milan, Italy
| | - Sandro Lepidi
- Division of Vascular Surgery, Cardiovascular Department, University Hospital of Trieste ASUGI, Trieste, Italy
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