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Xu D, Liu Y, Xu C, Liu X, Chen Y, Feng C, Lyu N. Factors Affecting Radial Artery Occlusion After Right Transradial Artery Catheterization for Coronary Intervention and Procedures. Ther Clin Risk Manag 2023; 19:525-533. [PMID: 37388675 PMCID: PMC10305768 DOI: 10.2147/tcrm.s403410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/18/2023] [Indexed: 07/01/2023] Open
Abstract
Objective To determine the factors influencing proximal radial artery occlusion (PRAO) right radial artery after coronary intervention. Methods This is a single-center prospective observational study. A total of 460 patients were selected to undergo coronary angiography (CAG) or percutaneous coronary intervention (PCI) via the proximal transradial approach (PTRA) or distal transradial approach (DTRA). The 6F sheath tube were received by all patients. Radial artery ultrasound was performed 1 day before procedure and 1-4 days after procedure. Patients were divided into the PRAO group (42 cases) and the non-PRAO group (418 cases). General clinical data and preoperative radial artery ultrasound indexes of the two groups were compared to analyze related factors leading to PRAO. Results The total incidence of PRAO was 9.1%, including 3.8% for DTAR and 12.7% for PTRA. The PRAO rate of DTRA was significantly lower than that of PTRA (p < 0.05). Female, low body weight, low body mass index (BMI) and CAG patients were more likely to develop PRAO after procedure (p < 0.05). The internal diameter and cross-sectional area of the distal radial artery and proximal radial artery were smaller in the PRAO group than in the non-PRAO group, and the differences were statistically significant (p < 0.05). Multifactorial model analysis showed that the puncture approach, radial artery diameter and procedure type were predictive factors of PRAO, and the receiver operating characteristic curve showed a good predictive value. Conclusion A larger radial artery diameter and DTRA may reduce the incidence of PRAO. Preoperative radial artery ultrasound can guide the clinical selection of appropriate arterial sheath and puncture approach.
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Affiliation(s)
- Dujuan Xu
- Department of Ultrasound, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Ying Liu
- Department of Ultrasound, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Chao Xu
- Department of Radiology, Xuzhou Children’s Hospital, Xuzhou, People’s Republic of China
| | - Xuekui Liu
- Department of Central Laboratory, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Ye Chen
- Department of Ultrasound, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Chunguang Feng
- Department of Cardiology, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
| | - Nan Lyu
- Department of Ultrasound, Xuzhou Central Hospital, Xuzhou, People’s Republic of China
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Bainey KR, Marquis-Gravel G, Mehta SR, Tanguay JF. The Evolution of Anticoagulation for Percutaneous Coronary Intervention: A 40-Year Journey. Can J Cardiol 2022; 38:S89-S98. [PMID: 35850382 DOI: 10.1016/j.cjca.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 12/30/2022] Open
Abstract
The selection of antithrombotic strategies continue to be of utmost importance during percutaneous coronary intervention (PCI) and have evolved over the past 40 years. Although the backbone of therapy during PCI continues to be a combination of oral antiplatelets and parenteral anticoagulants, a variety of different approaches have been tested over time. In particular, different choices of anticoagulation management have been tested in the stable ischemic heart disease and acute coronary syndrome setting. Evaluation of alternative regimens in the quest to balance ischemic and bleeding risk have undoubtedly improved patient care with PCI. In the current review we highlight the evolution of evidence-based therapeutic options over the past 40 years from the beginning of coronary angioplasty to contemporary PCI. We provide insight into future therapeutic options and provide a contemporary overview of anticoagulation choices for patients who require PCI on the basis of up-to-date evidence balancing ischemic and bleeding risk and according to clinical presentation.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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3
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Capranzano P, Tamburino C, Dangas GD. Parenteral Anticoagulant Agents in PCI. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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4
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Vlachakis PK, Varlamos C, Benetou DR, Kanakakis I, Alexopoulos D. Periprocedural Antithrombotic Treatment in Complex Percutaneous Coronary Intervention. J Cardiovasc Pharmacol 2022; 79:407-419. [PMID: 35385440 DOI: 10.1097/fjc.0000000000001193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/22/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT In recent years, the management of complex lesions in patients undergoing percutaneous coronary intervention (PCI) constitutes a field of high interest and concern for the interventional cardiology. As more and more studies demonstrate the increased hazard of ischemic events in this group of patients, it is of paramount importance for the physicians to choose the optimal periprocedural (pre-PCI, during-PCI and post-PCI) antithrombotic treatment strategies wisely. Evidence regarding the safety and efficacy of current anticoagulation recommendation, the possible beneficial role of the pretreatment with a potent P2Y12 inhibitor in the subgroup of patients with non-ST segment elevation myocardial infarction with complex lesions, and the impact of a more potent P2Y12 inhibitor in individuals with stable coronary artery disease undergoing complex PCI are needed. This will provide and serve as a guide to clinicians to deploy the maximum efficacy of the current choices of antithrombotic therapy, which will lead to an optimal balance between safety and efficacy in this demanding clinical scenario.
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Affiliation(s)
- Panayotis K Vlachakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece; and
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Kanakakis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, Athens, Greece; and
| | - Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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5
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 596] [Impact Index Per Article: 298.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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6
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Affiliation(s)
- Azfar G Zaman
- Cardiology, Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Qaiser Aleem
- Cardiology, James Cook University Hospital, Middlesborough, UK
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Percutaneous Coronary Intervention With an Initial Bolus of Low-Dose Heparin in Biomarker-Negative Patients. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:38-41. [PMID: 32703583 DOI: 10.1016/j.carrev.2020.07.015] [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: 06/07/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The safety and efficacy of an initial intravenous bolus of low-dose heparin (40 IU/kg) was evaluated in biomarker negative patients undergoing percutaneous coronary intervention (PCI). BACKGROUND A bolus of 70-100 IU/kg of heparin is currently recommended for patients undergoing PCI. However, the ideal dose of heparin has not been evaluated in a randomized trial. The higher dose of 100 IU/kg may increase the risk of bleeding. An initial bolus of low-dose heparin may be advantageous to avoid supratherapeutic activating clotting times (ACT) while still allowing for the administration of additional heparin if the ACT is subtherapeutic. METHODS From January 2008 to February 2020, 904 patients undergoing elective transfemoral PCI received an initial bolus of 40 IU/kg of heparin. Patients who underwent transradial PCI were not included. Patients were routinely pretreated with dual antiplatelet therapy. The primary end point was the composite of cardiac death, myocardial infarction (MI), urgent target vessel revascularization (TVR) for ischemia, or major bleeding within 30 days after PCI. RESULTS The initial mean activating clotting time was 235.4 ± 26.6 s. The clinical event rates were low: the primary end point occurred in 5.3%, cardiac death in 1.0%, MI in 3.1%, urgent TVR in 0.7% and major bleeding in 1.9%. Stent thrombosis was uncommon (0.2%). No patients developed profound thrombocytopenia. Three patients (0.3%) had acute limb ischemia that required revascularization. CONCLUSION An initial strategy of low-dose heparin is associated with low ischemic and bleeding complications in biomarker negative patients who undergo transfemoral PCI.
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J 2020; 40:87-165. [PMID: 30165437 DOI: 10.1093/eurheartj/ehy394] [Citation(s) in RCA: 4033] [Impact Index Per Article: 1008.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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10
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Integrin ß1 polymorphisms and bleeding risk after coronary artery stenting. Mol Biol Rep 2019; 46:5695-5702. [PMID: 31359383 DOI: 10.1007/s11033-019-05003-2] [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: 05/12/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
Abstract
Bleeding complications following percutaneous coronary intervention associate with increased mortality. However, the underlying molecular mechanisms are insufficiently understood. Platelet recruitment and activation at sites of vascular injury depends on the function of integrin adhesion receptors. Besides GPIIbIIIa as the most abundant integrin receptor, platelets relevantly express ß1 integrins. Experimental evidence from in vivo studies suggests a significant role of ß1 integrins in primary haemostasis. However, little is known about the clinical impact of genetic alterations of the β1 subunit, which might contribute to bleeding complications in patients. In this study, we performed DNA sequencing of patients suffering from bleeding complications after coronary artery stenting according to TIMI or BARC classification. We isolated DNA samples from 741 patients out of a cohort from 14,160 patients recruited in seven randomized clinical trials between June 2000 and May 2011. Subsequently, Sanger sequencing was performed covering the β1 integrin cytoplasmic activation domain (exon16) and its non-coding upstream region. Out of 764 patients suffering from bleeding complications, 741 DNA samples were successfully sequenced. Genotype variation was detected for SNP rs2153875 located within the non-coding upstream region with following allele frequency in study population: CC (7.3%), CA (35%) and AA (57.8%), which is similar to a general population cohort. Further, genotype variation in SNP rs2153875 do not associate with the frequency of TIMI or BARC classified access or non-access site bleedings. Genotype variations of the β1 integrin activation domain do not associate with bleeding risk after PCI.
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11
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Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferović PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. EUROINTERVENTION 2019; 14:1435-1534. [PMID: 30667361 DOI: 10.4244/eijy19m01_01] [Citation(s) in RCA: 332] [Impact Index Per Article: 66.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Franz-Josef Neumann
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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Sousa-Uva M, Neumann FJ, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg 2018; 55:4-90. [PMID: 30165632 DOI: 10.1093/ejcts/ezy289] [Citation(s) in RCA: 347] [Impact Index Per Article: 57.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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13
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Collet JP, Berti S, Cequier A, Van Belle E, Lefevre T, Leprince P, Neumann FJ, Vicaut E, Montalescot G. Oral anti-Xa anticoagulation after trans-aortic valve implantation for aortic stenosis: The randomized ATLANTIS trial. Am Heart J 2018; 200:44-50. [PMID: 29898848 DOI: 10.1016/j.ahj.2018.03.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 03/03/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antithrombotic treatment regimen following transcatheter aortic valve replacement (TAVR) is not evidence-based. Apixaban, a non-vitamin K direct anticoagulant (NOAC) was shown to be superior to VKA and superior to aspirin to prevent cardioembolic stroke in non-valvular atrial fibrillation. It may have the potential to reduce TAVR-related thrombotic complications including subclinical valve thrombosis along with a better safety than the standard of care. DESIGN ATLANTIS is a multicenter, randomized, phase IIIb, prospective, open-label, superiority study comparing standard of care (SOC Group) versus an apixaban-based strategy (Anti-Xa Group) after successful TAVR (ClinicalTrials.gov NCT 02664649). Randomization is stratified according to the need for chronic anticoagulation therapy for a reason other than the TAVR procedure. In the experimental arm, patients receive 5 mg bid of apixaban or a reduced dose of 2.5 mg bid according to the drug label or when apixaban is combined with antiplatelet therapy. In the control arm, patients receive VKA therapy if there is an indication for oral anticoagulation or antiplatelet therapy alone (single or dual) or the combination of both if needed. The primary study end point is the composite of all-cause death, TIA/stroke, myocardial infarction, symptomatic valve thrombosis, pulmonary embolism, deep venous thrombosis, systemic embolism, life-threatening, disabling or major bleeding, according to the Valve Academic Research Consortium definitions. CONCLUSIONS ATLANTIS tests the superiority of an apixaban-based strategy versus the recommended standard of care strategy to reduce the risk of post-TAVR thromboembolic and bleeding complications in an all comer population.
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Kikkert WJ, van Nes SH, Lieve KVV, Dangas GD, van Straalen J, Vis MM, Baan J, Koch KT, de Winter RJ, Piek JJ, Tijssen JGP, Henriques JP. Prognostic value of post-procedural aPTT in patients with ST-elevation myocardial infarction treated with primary PCI. Thromb Haemost 2017; 109:961-70. [DOI: 10.1160/th12-10-0726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/25/2013] [Indexed: 11/05/2022]
Abstract
SummaryUnfractionated heparin is the most commonly used anticoagulant in ST-elevation myocardial infarction (STEMI) and its effect can be monitored with activated partial thromboplastin time (aPTT). However, the optimal aPTT range during heparin therapy after primary percutaneous coronary intervention (PCI) is yet to be defined. A mean aPTT was calculated of all aPTT measurements in the first 24 hours after pPCI in a total of 1,876 STEMI patients. Mean aPTT measurements were stratified into four categories; < 1.5 times the upper limit of normal (ULN), 1.5 – 2.0 times ULN (the therapeutic group), 2.01 – 3.99 times ULN, and ≥ 4 times ULN. Compared to patients with a therapeutic aPTT, patients with aPTTs < 1.5 times ULN had no increase in recurrent ischaemic events and had similar rates of bleeding complications. Patients with a mean aPTT ≥ 4 times ULN had higher rates recurrent ischaemic and haemorrhagic complications. After multivariable analyses, aPTT ratios ≥ 4 times ULN were no longer associated with recurrent ischaemic events, but remained a strong predictor of severe and moderate bleeding (hazard ratio [HR] 4.64, p = 0.016 and HR 2.27, p = 0.052). In conclusion, in 1,876 STEMI patients treated with pPCI, low aPTTs in the first 24 hours after PCI were not associated with an increase in ischaemic events, whereas high aPTT values were associated with more frequent bleeding complications. These results indicate no clear benefit as well as a safety concern with heparin treatment after primary PCI.
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. Parenteral anticoagulants in heart disease: Current status and perspectives (Section II). Thromb Haemost 2017; 109:769-86. [DOI: 10.1160/th12-06-0403] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/25/2012] [Indexed: 11/05/2022]
Abstract
SummaryAnticoagulants are a mainstay of cardiovascular therapy, and parenteral anticoagulants have widespread use in cardiology, especially in acute situations. Parenteral anticoagulants include unfractionated heparin, low-molecular-weight heparins, the synthetic pentasaccharides fondaparinux, idraparinux and idrabiotaparinux, and parenteral direct thrombin inhibitors. The several shortcomings of unfractionated heparin and of low-molecular-weight heparins have prompted the development of the other newer agents. Here we review the mechanisms of action, pharmacological properties and side effects of parenteral anticoagulants used in the management of coronary heart disease treated with or without percutaneous coronary interventions, cardioversion for atrial fibrillation, and prosthetic heart valves and valve repair. Using an evidence-based approach, we describe the results of completed clinical trials, highlight ongoing research with currently available agents, and recommend therapeutic options for specific heart diseases.
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Chaudry HI, Curran TB, Andrus BW, Conley SM, DeVries JT. Bivalirudin versus heparin, without glycoprotein inhibition, in percutaneous coronary intervention: A comparison of ischemic and hemorrhagic outcomes over 10years. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 19:338-342. [PMID: 29055661 DOI: 10.1016/j.carrev.2017.09.003] [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: 06/20/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The choice of antithrombotic agent used during percutaneous coronary intervention (PCI) is controversial. While earlier studies suggested a reduction in bleeding events with bivalirudin, these studies were confounded by the concomitant use of glycoprotein IIbIIIa inhibitors (GPI) in the heparin group. More recent studies have challenged the superiority of bivalirudin, pointing to an increased risk of stent thrombosis. Real-world data remains limited. METHODS We queried our institutional catheterization laboratory database for all PCI cases performed between January 2003 and December 2012 using only heparin or only bivalirudin (no use of GPI). We collected data on relevant patient and procedural characteristics and compared both efficacy and safety outcomes. We adjusted for baseline differences using coarsened exacting matching. RESULTS 8061 cases met our inclusion criteria. Of these, 34.9% were performed with heparin alone and 65.1% with bivalirudin. After adjusting for baseline differences, we found that those patients receiving heparin had a slightly lower risk of post-procedural abrupt vessel closure (0.1% vs 0.5%). All other outcomes favored bivalirudin including procedural success (97.2% vs 95.5%), transfusion within 72h (2.2% vs 4.8%), retroperitoneal bleeding (0.1% vs 0.8%), and all-cause mortality (0.9% vs 1.9%). Subgroup analysis suggested that outcomes were different only in non-elective cases and non STEMI cases. CONCLUSION Heparin appears to offer the advantage of slightly reduced risk of abrupt vessel closure post-procedure but at the cost of increased hemorrhagic complications and all-cause mortality. This difference in outcomes may be limited to non-elective and non STEMI cases with femoral access.
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Affiliation(s)
- Hannah I Chaudry
- Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States; Giesel School of Medicine at Dartmouth, Hanover, NH, United States.
| | | | - Bruce W Andrus
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Sheila M Conley
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - James T DeVries
- Giesel School of Medicine at Dartmouth, Hanover, NH, United States; Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
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Mehrzad M, Tuktamyshov R, Mehrzad R. Safety, efficiency and cost effectiveness of Bivalirudin: A systematic review. World J Cardiol 2017; 9:761-772. [PMID: 29081910 PMCID: PMC5633541 DOI: 10.4330/wjc.v9.i9.761] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/31/2017] [Accepted: 08/16/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To review the early and more recent studies of Bivalirudin, to assess the safety, effectiveness, and cost benefits of this drug.
METHODS Literature search of MEDLINE and PubMed databases from 1990 to 2017 using keywords as “bivalirubin” and “angiomax”, combined with the words “safety”, “effectiveness”, “efficiency”, “side effects”, “toxicity”, “adverse effect”, and “adverse drug reaction”.
RESULTS A total of 66 publications were reviewed. The changes in clinical practice and differences in clinical protocols make it difficult to do direct comparisons of studies among each other. However, most trials showed decreased bleeding complications with bivalirudin, although ischemic complications and mortality were mostly comparable, with some favor towards bivalirudin.
CONCLUSION Bivalirudin and heparin are both acceptable options according to current ACA/AHA guidelines. Authors conclude however, that that due to bivalirudin safer bleeding profile, it should be the preferred medication for anticoagulation.
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Affiliation(s)
- Melorin Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Rasikh Tuktamyshov
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
| | - Raman Mehrzad
- Department of Internal Medicine, Yale New Haven Hospital, Yale School of medicine, New Haven, CT 06510, United States
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18
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Li X, Fu Y, Miao J, Li H, Hu B. Video-assisted thoracoscopic lobectomy after percutaneous coronary intervention in lung cancer patients with concomitant coronary heart disease. Thorac Cancer 2017; 8:477-481. [PMID: 28749044 PMCID: PMC5582468 DOI: 10.1111/1759-7714.12471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/07/2017] [Accepted: 06/07/2017] [Indexed: 12/26/2022] Open
Abstract
Background In recent years, based on clinical observations, the number of lung cancer patients with concomitant coronary heart disease (CHD) has gradually increased. However, because of the requirement of long‐term anticoagulant therapy after percutaneous coronary intervention (PCI), some of these patients lose the opportunity for surgical treatment, resulting in tumor progression. The objective of this study was to determine the appropriate timing of video‐assisted thoracic surgery (VATS) lobectomy after PCI without increasing perioperative cardiovascular risk. Methods This study retrospectively analyzed clinical data of patients with a combination of NSCLC and CHD who underwent selective pulmonary lobectomy by VATS in the early postoperative PCI period between 2010 and 2015 at Beijing Chaoyang Hospital, China. Results Fourteen patients received VATS lobectomy after PCI. The disease had progressed to T stage in two patients after PCI. No perioperative death occurred. Two patients suffered postoperative atrial fibrillation: one had a pulmonary infection, and the other had acute coronary syndrome. All patients recovered and were discharged. Conclusion For NSCLC patients with severe CHD, the use of VATS lobectomy in the early postoperative PCI period could not only advance the timing of surgery, but may also control perioperative hemorrhage and CHD event risks within acceptable ranges, which could provide more patients with an opportunity to undergo surgical treatment.
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Affiliation(s)
- Xin Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - YiLi Fu
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - JinBai Miao
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Hui Li
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Bin Hu
- Department of Thoracic Surgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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19
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Caporale R, Geraci G, Gulizia MM, Borzi M, Colivicchi F, Menozzi A, Musumeci G, Scherillo M, Ledda A, Tarantini G, Gerometta P, Casolo G, Formigli D, Romeo F, Di Bartolomeo R. Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Association of Interventional Cardiology (SICI-GISE) and Italian Society of Cardiac Surgery (SICCH): clinical approach to pharmacologic pre-treatment for patients undergoing myocardial revascularization procedures. Eur Heart J Suppl 2017; 19:D151-D162. [PMID: 28751841 PMCID: PMC5520758 DOI: 10.1093/eurheartj/sux010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The wide availability of effective drugs in reducing cardiovascular events together with the use of myocardial revascularization has greatly improved the prognosis of patients with coronary artery disease. The combination of antithrombotic drugs to be administered before the knowledge of the coronary anatomy and before the consequent therapeutic strategies, can allow to anticipate optimal treatment, but can also expose the patients at risk of bleeding that, especially in acute coronary syndromes, can significantly weigh on their prognosis, even more than the expected theoretical benefit. In non ST-elevation acute coronary syndromes patients in particular, we propose a 'selective pre-treatment' with P2Y12 inhibitors, based on the ischaemic risk, on the bleeding risk and on the time scheduled for the execution of coronary angiography. Much of the problems concerning this issue would be resolved by an early access to coronary angiography, particularly for patients at higher ischaemic and bleeding risk.
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Affiliation(s)
- Roberto Caporale
- Interventional Cardiology Department, Ospedale Civile dell'Annunziata, Via Migliori 1, 87100 Cosenza, Italy
| | - Giovanna Geraci
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Mauro Borzi
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
| | | | - A. Menozzi
- Cardiology Unit, Azienda Ospedaliero-Universitaria, Parma, Italy
| | | | | | - Antonietta Ledda
- Cardiology Department, Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Giuseppe Tarantini
- Cardiological Sciences, Thoracic and Vascular Department, Università degli Studi, Padova, Italy
| | | | - Giancarlo Casolo
- Cardiology Department, Nuovo Ospedale Versilia, Lido di Camaiore, Lucca, Italy
| | - Dario Formigli
- Interventional Cardiology, A.O. G. Rummo, Benevento, Italy
| | - Francesco Romeo
- Cardiology and Interventional Cardiology Department, Università di Tor Vergata, Roma, Italy
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20
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Auffret V, Leurent G, Boulmier D, Bedossa M, Zabalawi A, Hacot JP, Coudert I, Filippi E, Castellant P, Rialan A, Rouault G, Druelles P, Boulanger B, Treuil J, Avez B, Le Guellec M, Gilard M, Le Breton H. Efficacy and safety of prehospital administration of unfractionated heparin, enoxaparin or bivalirudin in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: Insights from the ORBI registry. Arch Cardiovasc Dis 2016; 109:696-707. [DOI: 10.1016/j.acvd.2015.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 09/25/2015] [Accepted: 10/13/2015] [Indexed: 11/29/2022]
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21
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Capranzano P, Tamburino C, Dangas GD. Parenteral Anticoagulant Agents in PCI. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Piera Capranzano
- Cardiovascular Department, Ferrarotto Hospital; University of Catania; Catania Italy
| | - Corrado Tamburino
- Cardiovascular Department, Ferrarotto Hospital; University of Catania; Catania Italy
| | - George D. Dangas
- Department of Cardiology; Mount Sinai Medical Center; New York NY USA
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22
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Barria Perez AE, Rao SV, Jolly SJ, Pancholy SB, Plourde G, Rimac G, Poirier Y, Costerousse O, Bertrand OF. Meta-Analysis of Effects of Bivalirudin Versus Heparin on Myocardial Ischemic and Bleeding Outcomes After Percutaneous Coronary Intervention. Am J Cardiol 2016; 117:1256-66. [PMID: 26899489 DOI: 10.1016/j.amjcard.2016.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/15/2022]
Abstract
Bivalirudin is an alternative to unfractionated heparin (UFH) anticoagulation during percutaneous coronary intervention. Previously, we have reported clinical benefit on major bleeding in favor of bivalirudin compared with UFH monotherapy but inconclusive results on mortality. Controversial data have been reported in the last 2 years. We conducted an updated meta-analysis including randomized trials and observational studies, which evaluated ischemic and bleeding outcomes for bivalirudin compared with UFH-only during percutaneous coronary intervention. We included 18 observational studies and 12 randomized trials published from 2003 to 2015. Primary outcomes were major adverse cardiovascular events within 30 days including death, myocardial infarction, and urgent revascularization and stent thrombosis, major bleeding, and transfusion. Overall, we found a significant risk reduction with bivalirudin for major bleeding (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.49 to 0.71, p <0.0001) and for transfusion (OR 0.79, 95% CI 0.66 to 0.95, p = 0.01) and similar risk for major adverse cardiovascular events (OR 0.98, 95% CI 0.86 to 1.12, p = 0.80). However, there was a substantial increased risk of stent thrombosis associated with bivalirudin (OR 1.52, 95% CI 1.11 to 2.08, p = 0.009). No impact on mortality was found. Meta-regression analyses on major bleeding suggested that bivalirudin was more effective than UFH at doses >60 IU/kg and independent of radial access. In conclusion, compared with UFH monotherapy, bivalirudin remains associated with less bleeding risk but higher stent thrombosis risk. Further study remains required to define its role in current antithrombotic armamentarium.
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Affiliation(s)
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sanjit J Jolly
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Samir B Pancholy
- The Wright Center for Graduate Medical Education, The Common Wealth Medical College, Scranton, Pennsylvania
| | | | - Goran Rimac
- Quebec Heart-Lung Institute, Quebec, Quebec, Canada
| | - Yann Poirier
- Quebec Heart-Lung Institute, Quebec, Quebec, Canada
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Zeymer U, Rao SV, Montalescot G. Anticoagulation in coronary intervention. Eur Heart J 2016; 37:3376-3385. [DOI: 10.1093/eurheartj/ehw061] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 01/16/2023] Open
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Gargiulo G, Moschovitis A, Windecker S, Valgimigli M. Developing drugs for use before, during and soon after percutaneous coronary intervention. Expert Opin Pharmacother 2016; 17:803-18. [DOI: 10.1517/14656566.2016.1145666] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Ali-Hassan-Sayegh S, Mirhosseini SJ, Shahidzadeh A, Mahdavi P, Tahernejad M, Haddad F, Lotfaliani MR, Sabashnikov A, Popov AF. Administration of low molecular weight and unfractionated heparin during percutaneous coronary intervention. Indian Heart J 2016; 68:213-24. [PMID: 27133344 DOI: 10.1016/j.ihj.2016.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 01/08/2016] [Accepted: 01/11/2016] [Indexed: 01/08/2023] Open
Abstract
This systematic review with meta-analysis sought to determine the efficacy and safety of unfractionated heparin (UFH) and low molecular weight heparin (LMWH) on clinical outcomes following percutaneous coronary intervention. Medline, Embase, Elsevier, and web of knowledge as well as Google scholar literature were used for selecting appropriate studies with randomized controlled design. After screening 445 studies, a total of 23 trials (including a total of 43,912 patients) were identified that reported outcomes. Pooled analysis revealed that LMWH compared to UFH could significantly increase thrombolysis in myocardial infarction grade 3 flow (p<0.001), which was associated with similar target vessel revascularization (p=0.6), similar incidence of stroke (p=0.7), and significantly lower incidence of re-myocardial infarction (p<0.001), major bleeding (p=0.02) and mortality (p<0.001). Overall, LMWH was shown to be a useful type of heparin for patients with MI undergoing PCI, due to its higher efficacy and lower rate of complication compared to UFH. It is also associated with increased myocardial perfusion, decreased major hemorrhage, and mortality.
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Affiliation(s)
| | | | - Azadeh Shahidzadeh
- Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Parisa Mahdavi
- Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mahbube Tahernejad
- Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Haddad
- Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | | | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS guidelines on myocardial revascularization. EUROINTERVENTION 2015; 10:1024-94. [PMID: 25187201 DOI: 10.4244/eijy14m09_01] [Citation(s) in RCA: 211] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Stephan Windecker
- Cardiology, Bern University Hospital, Freiburgstrasse 4, CH-3010 Bern, Switzerland
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Mahmoud A, Saad M, Elgendy AY, Abuzaid A, Elgendy IY. Bivalirudin in Percutaneous Coronary Intervention, is it the Anticoagulant of Choice? Cardiovasc Ther 2015; 33:227-35. [PMID: 25879426 DOI: 10.1111/1755-5922.12124] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ahmed Mahmoud
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Marwan Saad
- Department of Medicine; Seton Hall University School of Health and Medical Sciences; Trinitas Regional Medical Center; Elizabeth NJ USA
| | - Akram Y. Elgendy
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Ahmed Abuzaid
- Department of Medicine; Creighton University; Omaha NE USA
| | - Islam Y. Elgendy
- Department of Medicine; University of Florida; Gainesville FL USA
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28
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Cassese S, Byrne RA, Laugwitz KL, Schunkert H, Berger PB, Kastrati A. Bivalirudin versus heparin in patients treated with percutaneous coronary intervention: a meta-analysis of randomised trials. EUROINTERVENTION 2015; 11:196-203. [DOI: 10.4244/eijy14m08_01] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bavry AA, Elgendy IY, Mahmoud A, Jadhav MP, Huo T. Critical Appraisal of Bivalirudin versus Heparin for Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Trials. PLoS One 2015; 10:e0127832. [PMID: 26010682 PMCID: PMC4444249 DOI: 10.1371/journal.pone.0127832] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 04/20/2015] [Indexed: 12/28/2022] Open
Abstract
Percutaneous coronary intervention with bivalirudin plus bail-out glycoprotein IIb/IIIa inhibitors has been shown to be as effective as unfractionated heparin plus routine glycoprotein IIb/IIIa inhibitors in preventing cardiac ischemic events, but with a lower bleeding risk. It is unknown whether bivalirudin would have the same beneficial effects if compared with heparin when the use of glycoprotein IIb/IIIa inhibitors was similar between treatment arms. We searched the MEDLINE, Web of Science, and Cochrane databases from inception until March 2015 for randomized trials that compared bivalirudin to heparin in patients undergoing percutaneous coronary intervention. We required that the intended use of glycoprotein IIb/IIIa inhibitors was similar between the study groups. Summary estimates were principally constructed by the Peto method. Fifteen trials met our inclusion criteria, which yielded 25,824 patients. Bivalirudin versus heparin was associated with an increased hazard of stent thrombosis (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.15-1.92, P = .002, I2 = 16.9%), with a similar hazard of myocardial infarction (OR 1.09, 95% CI 0.98-1.22, P = .11, I2 = 35.8%), all-cause mortality (OR 0.88, 95% CI 0.72-1.08, P = .21, I2 = 31.5%) and major adverse cardiac events (OR 1.04, 95% CI 0.94-1.14, P = .46, I2 = 53.9%). Bivalirudin was associated with a reduced hazard of major bleeding (OR 0.80, 95% CI 0.70-0.92, P = .001, I2 = 63.5%). The dose of heparin in the control arm modified this association; when the dose of unfractionated heparin in the control arm was ≥ 100 units/kg, bivalirudin was associated with a reduction in major bleeding (OR 0.55, 95% CI 0.45-0.68, P < .0001), but when the dose of unfractionated heparin was ≤ 75 units/kg, bivalirudin was not associated with reduction in bleeding (OR 1.09, 95% CI 0.91-1.31, P = .36). Among patients undergoing PCI, bivalirudin was associated with an increased hazard of stent thrombosis. Bivalirudin may be associated with a reduced hazard of major bleeding; however, this benefit was no longer apparent when compared with a dose of unfractionated heparin ≤ 75 units/kg.
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Affiliation(s)
- Anthony A. Bavry
- North Florida/South Georgia Veterans Health System, Gainesville, Florida, United States of America
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
| | - Islam Y. Elgendy
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Ahmed Mahmoud
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Manoj P. Jadhav
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
| | - Tianyao Huo
- Department of Medicine, University of Florida, Gainesville, Florida, United States of America
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Dauerman HL. Anticoagulation Strategies for Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2015; 8:CIRCINTERVENTIONS.115.001947. [DOI: 10.1161/circinterventions.115.001947] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Harold L. Dauerman
- From the Department of Medicine and the Cardiovascular Research Institute, University of Vermont College of Medicine, Burlington
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31
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Kerl JJ, Spexarth FC, Pedersen R, Stone M, Allaqaband SQ, Schulgit JL, Bajwa TK, Gupta AN, DeFranco AC. Beneficial effects of a point-of-care bleeding risk calculator on anticoagulant selection in the coronary catheterization laboratory. Pharmacotherapy 2015; 35:388-95. [PMID: 25884527 DOI: 10.1002/phar.1565] [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: 11/09/2022]
Abstract
STUDY OBJECTIVES To estimate periprocedural bleeding risk before elective percutaneous coronary intervention (PCI) by using a point-of-care bleeding risk calculator and to document changes in anticoagulant use and bleeding complications after implementation of use of this calculator. DESIGN Prospective observational pilot study with a historical control cohort. SETTING Tertiary care medical center. PATIENTS The pilot cohort consisted of 100 patients undergoing ad hoc PCI during elective cardiac catheterization procedures between January and May 2013, whose bleeding risk and accompanying PCI anticoagulant recommendations were determined by the use of a pre-PCI point-of-care bleeding risk calculator. The historical control cohort consisted of all patients who underwent elective PCI at the same facility between April 1, 2011, and March 31, 2012, before implementation of use of the bleeding risk calculator. MEASUREMENTS AND MAIN RESULTS The pre-PCI bleeding risk calculator distinguished patients in the pilot cohort as high risk (score 12 or higher) or low risk (lower than 12) for bleeding after a PCI procedure. The primary outcome was bivalirudin use in the pilot cohort compared with its use in the historical control cohort. Implementation of the bleeding risk calculator significantly decreased bivalirudin use compared with bivalirudin use in the historical control cohort (87% in the control cohort vs 60% in the pilot cohort, p<0.01). Bivalirudin use remained high in patients at high bleeding risk (82.2% in the pilot cohort vs 87.4% in the control cohort, p=0.3) and its use was decreased in patients at low bleeding risk (41.8% in the pilot cohort vs 87.1% in the control cohort, p<0.01). The incidence of bleeding complications in the pilot cohort was comparable with that in the control cohort (1% vs. 0.4%, p=0.37), although this pilot study was underpowered to potentially detect a significant change in the incidence of bleeding complications. CONCLUSION A simple bleeding risk calculator can substantially reduce overall bivalirudin use by specifically decreasing its use among patients at low bleeding risk while maintaining its use among patients at high bleeding risk. The incidence of bleeding complications remained unchanged despite decreasing bivalirudin use among patients undergoing elective coronary catheterization who were at low risk for bleeding.
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Affiliation(s)
- Jocelyn J Kerl
- Department of Pharmacy Services, Meriter Unity-Point Health, Madison, Wisconsin
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Abtahian F, Waldo S, Jang IK. Comparison of heparin and bivalirudin in patients undergoing percutaneous coronary intervention without use of glycoprotein IIb/IIIa inhibitors. Catheter Cardiovasc Interv 2015; 86:390-6. [PMID: 25753749 DOI: 10.1002/ccd.25911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 02/28/2015] [Indexed: 11/10/2022]
Abstract
OBJECTIVES The primary objective of this study is the compare the association between bleeding and the use unfractionated heparin (UFH) versus bivalirudin during percutaneous coronary intervention (PCI). BACKGROUND In patients undergoing PCI, the risk of bleeding with use of bivalirudin compared with UFH in the absence of glycoprotein IIb/IIIa inhibitors is not well defined. METHODS Patients undergoing PCI with either UFH or bivalirudin monotherapy at a single institution between 2007 and 2014 were included (n = 6,143). Propensity score matching was used to adjust for baseline characteristics yielding 2,984 well matched patients (1,492 in each group). The primary endpoint was major non-coronary artery bypass graft (non-CABG) related bleeding as defined by a Bleeding Academic Consortium type 3 or 5. Secondary outcomes included combined major and minor bleeding, in-hospital death, periprocedural myocardial infarction, and recurrent ischemia requiring urgent revascularization (repeat PCI). RESULTS In the propensity matched cohort, there was no difference in major bleeding between UFH and bivalirudin monotherapy (1.8% versus 2.4%, P = 0.305). Combined major and minor bleeding was also similar between the two groups (4.3% versus 4.3%, P = 1.0). Likewise, no differences were observed between the bivalirudin and UFH groups in terms of in-hospital death (0.4% versus 0.5%, P = 0.592), periprocedural myocardial infarction (1.5% versus 2.0%, P = 0.332) and repeat PCI (0.7% versus 0.8%, P = 0.669). CONCLUSION Among patients undergoing PCI, there was no significant difference in rate of bleeding between bivalirudin and heparin monotherapy in a real-world setting.
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Affiliation(s)
- Farhad Abtahian
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Stephen Waldo
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
| | - Ik-Kyung Jang
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, Massachuttes
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Shanmugam VB, Harper R, Meredith I, Malaiapan Y, Psaltis PJ. An overview of PCI in the very elderly. J Geriatr Cardiol 2015; 12:174-84. [PMID: 25870621 PMCID: PMC4394333 DOI: 10.11909/j.issn.1671-5411.2015.02.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/04/2015] [Accepted: 01/16/2015] [Indexed: 12/18/2022] Open
Abstract
Cardiovascular disease, and in particular ischemic heart disease (IHD), is a major cause of morbidity and mortality in the very elderly (> 80 years) worldwide. These patients represent a rapidly growing cohort presenting for percutaneous coronary intervention (PCI), now constituting more than one in five patients treated with PCI in real-world practice. Furthermore, they often have greater ischemic burden than their younger counterparts, suggesting that they have greater scope of benefit from coronary revascularization therapy. Despite this, the very elderly are frequently under-represented in clinical revascularization trials and historically there has been a degree of physician reluctance in referring them for PCI procedures, with perceptions of disappointing outcomes, low success and high complication rates. Several issues have contributed to this, including the tendency for older patients with IHD to present late, with atypical symptoms or non-diagnostic ECGs, and reservations regarding their procedural risk-to-benefit ratio, due to shorter life expectancy, presence of comorbidities and increased bleeding risk from antiplatelet and anticoagulation medications. However, advances in PCI technology and techniques over the past decade have led to better outcomes and lower risk of complications and the existing body of evidence now indicates that the very elderly actually derive more relative benefit from PCI than younger populations. Importantly, this applies to all PCI settings: elective, urgent and emergency. This review discusses the role of PCI in the very elderly presenting with chronic stable IHD, non ST-elevation acute coronary syndrome, and ST-elevation myocardial infarction. It also addresses the clinical challenges met when considering PCI in this cohort and the ongoing need for research and development to further improve outcomes in these challenging patients.
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Affiliation(s)
- Vimalraj Bogana Shanmugam
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Richard Harper
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Ian Meredith
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Yuvaraj Malaiapan
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
| | - Peter J Psaltis
- Cardiovascular Research Centre, Monash University, 246, Clayton Road, Clayton, Victoria 3168, Australia
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Gaglia MA. Glycoprotein IIb/IIIa inhibitors increase bleeding: the elephant in the cardiac catheterization laboratory. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2014; 15:313-4. [PMID: 25440504 DOI: 10.1016/j.carrev.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Michael A Gaglia
- University of Southern California Keck School of Medicine, Division of Cardiovascular Medicine.
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Affiliation(s)
- Peter B Berger
- Department of Cardiology, Geisinger Health System, Danville, PA 17822-2775, USA.
| | - James C Blankenship
- Department of Cardiology, Geisinger Health System, Danville, PA 17822-2775, USA
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Windecker S, Kolh P, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 2014; 35:2541-619. [PMID: 25173339 DOI: 10.1093/eurheartj/ehu278] [Citation(s) in RCA: 3323] [Impact Index Per Article: 332.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V, Filippatos G, Hamm C, Head SJ, Jüni P, Kappetein AP, Kastrati A, Knuuti J, Landmesser U, Laufer G, Neumann FJ, Richter DJ, Schauerte P, Sousa Uva M, Stefanini GG, Taggart DP, Torracca L, Valgimigli M, Wijns W, Witkowski A, Zamorano JL, Achenbach S, Baumgartner H, Bax JJ, Bueno H, Dean V, Deaton C, Erol Ç, Fagard R, Ferrari R, Hasdai D, Hoes AW, Kirchhof P, Knuuti J, Kolh P, Lancellotti P, Linhart A, Nihoyannopoulos P, Piepoli MF, Ponikowski P, Sirnes PA, Tamargo JL, Tendera M, Torbicki A, Wijns W, Windecker S, Sousa Uva M, Achenbach S, Pepper J, Anyanwu A, Badimon L, Bauersachs J, Baumbach A, Beygui F, Bonaros N, De Carlo M, Deaton C, Dobrev D, Dunning J, Eeckhout E, Gielen S, Hasdai D, Kirchhof P, Luckraz H, Mahrholdt H, Montalescot G, Paparella D, Rastan AJ, Sanmartin M, Sergeant P, Silber S, Tamargo J, ten Berg J, Thiele H, van Geuns RJ, Wagner HO, Wassmann S, Wendler O, Zamorano JL. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2014; 46:517-92. [PMID: 25173601 DOI: 10.1093/ejcts/ezu366] [Citation(s) in RCA: 574] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Dobies DR, Barber KR, Cohoon AL. The effect of bivalirudin and closure device on bleeding outcomes after percutaneous coronary interventions. Open Heart 2014; 1:e000087. [PMID: 25332807 PMCID: PMC4189288 DOI: 10.1136/openhrt-2014-000087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/20/2014] [Accepted: 07/15/2014] [Indexed: 01/25/2023] Open
Abstract
Introduction Studies have demonstrated bivalirudin efficacy in some patients at increased risk of bleeding. The aim of this study was to determine the extent to which bleeding reduction is achieved among all patients using bivalirudin as compared with a heparin with or without 2B3A inhibitor strategy. Methods This is a real-world, large-scale retrospective study utilising the American College of Cardiology (ACC) data from a 37-hospital Ascension Health System. The registry represents routine clinical practice between 1 June 2009 and 30 June 2012. End points included major bleeding, major adverse cardiac events and death. Multivariate regression analysis modelled on predictors of end points. Results This study included 58 862 PCI procedures. Major bleeding rates were lowest for bivalirudin plus closure device overall (OR=0.53, CI 0.21 to 0.84, p=0.001). The use of a device for access closure contributed to the greatest declines in major bleeding. Compared with heparin with device, bivalirudin with device had a significantly lower rate of bleeding (OR=0.37, CI 0.18 to 0.74, p=0.005). The use of device had a greater effect on decreasing bleeding among patients receiving bivalirudin compared with heparin, especially among women (p=0.001). After adjustment for 2B3A use, this advantage was no longer significant in ST segment elevation myocardial infarction patients (OR=1.8, CI 0.5 to 6.0, p=0.34). Conclusions All risk groups in this real world database representing current clinical practice benefited from the use of bivalirudin and device closure with lower risk groups benefiting the most. This robust analysis of real-world clinical data supports a combined treatment strategy of bivalirudin and closure device.
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Affiliation(s)
- David R Dobies
- Department of Cardiology , Regional Cardiology Associates , Grand Blanc, Michigan , USA
| | - Kimberly R Barber
- Clinical Research, Genesys Regional Medical Center, Office of Research , Grand Blanc, Michigan , USA
| | - Amanda L Cohoon
- Cardiac Catheterization Laboratory , Genesys Regional Medical Center , Grand Blanc, Michigan , USA
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Collet JP, Montalescot G. Antithrombotic and antiplatelet therapy in TAVI patients: a fallow field? EUROINTERVENTION 2014; 9 Suppl:S43-7. [PMID: 24025957 DOI: 10.4244/eijv9ssa9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Guidelines on antithrombotic therapy after TAVI are scarce and no randomised evaluation has been performed to demonstrate what the best strategy is. Extrapolation from what we know on surgical heart valve replacement is also hazardous as the level of evidence is not very high and the situation, the valves and the patients are different. Patients undergoing TAVI are fragile and at high risk for both bleeding and stroke complications. In addition, the procedure itself may contribute to the occurrence of these complications rendering risk stratification a key step. Improvement in both periprocedural and post-procedural outcome is a major challenge of antithrombotic therapy. The recent release of more potent but also safer antithrombotic therapies is a unique opportunity to sort out what is the best combination for which patient. Our goal is to review the evidence and analyse what are the perspectives in this challenging area.
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Affiliation(s)
- Jean-Philippe Collet
- Institut de Cardiologie - INSERM U 937 - Groupe A.C.T.I.O.N., Groupe Hospitalier Pitié-Salpêtrière and Université Pierre et Marie Curie, Paris, France
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Ndrepepa G, Schulz S, Neumann FJ, Laugwitz KL, Richardt G, Byrne RA, Pöhler A, Kastrati A, Pache J. Prognostic value of bleeding after percutaneous coronary intervention in patients with diabetes. EUROINTERVENTION 2014; 10:83-9. [DOI: 10.4244/eijv10i1a14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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LEE MICHAELS, OYAMA JARED, IQBAL ZAHID, TARANTINI GIUSEPPE. Low-Dose Heparin for Elective Percutaneous Coronary Intervention. J Interv Cardiol 2013; 27:58-62. [DOI: 10.1111/joic.12081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ndrepepa G, Neumann FJ, Schulz S, Fusaro M, Cassese S, Byrne RA, Richardt G, Laugwitz KL, Kastrati A. Incidence and prognostic value of bleeding after percutaneous coronary intervention in patients older than 75 years of age. Catheter Cardiovasc Interv 2013; 83:182-9. [PMID: 24030753 DOI: 10.1002/ccd.25189] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 08/06/2013] [Accepted: 09/02/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVES We aimed to assess the impact of bleeding after percutaneous coronary intervention (PCI) on the outcome of patients >75 years of age. BACKGROUND Limited information exists on the impact of post-PCI bleeding on the outcome in elderly patients. METHODS This study included 3,255 patients >75 years of age. Bleeding events were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality. RESULTS Within 30 days after PCI, bleeding occurred in 501 patients (15.4%). Bleeding according to BARC was: class 1 (170 patients; 33.9%), class 2 (81 patients; 16.2%), class 3a (177 patients; 35.3%), class 3b (65 patients; 13.0%), class 3c (four patients; 0.8%), and class 4 (four patients; 0.8%). There were 201 deaths within the first year after PCI: 61 deaths (12.3%) among bleeders and 140 deaths (5.1%) among nonbleeders (adjusted hazard ratio = 2.03, 95% confidence interval [CI] 1.42-2.91, P < 0.001). Bleeding improved the discriminatory power of multivariable model for mortality prediction (P = 0.001). Female sex (adjusted odds ratio [OR] = 1.49 [1.17-1.88], P = 0.001) and reduced renal function (adjusted OR = 1.30 [1.04-1.63], P = 0.019 for each 30 ml/min decrease in the creatinine clearance) were independent associates of increased bleeding risk. Bivalirudin reduced the bleeding risk by 24% compared with unfractionated heparin and 33% compared with abciximab plus unfractionated heparin. CONCLUSIONS Post-PCI bleeding is an important prognostic factor in patients >75 years of age. The risk for bleeding in this age category is increased in women and patients with impaired renal function. Bleeding risk is reduced by bivalirudin.
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Ndrepepa G, Neumann FJ, Cassese S, Fusaro M, Ott I, Schulz S, Hoppmann P, Richardt G, Laugwitz KL, Schunkert H, Kastrati A. Incidence and impact on prognosis of bleeding during percutaneous coronary interventions in patients with chronic kidney disease. Clin Res Cardiol 2013; 103:49-56. [PMID: 24092474 DOI: 10.1007/s00392-013-0622-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 09/18/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Limited information exists on the prognostic impact of bleeding after percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD). We investigated the impact of bleeding after PCI on the outcome of these patients. METHODS The study included 2,934 patients with estimated creatinine clearance <60 ml/min. Bleeding events within 30 days after PCI were assessed using the Bleeding Academic Research Consortium (BARC) criteria. The primary outcome was 1-year mortality. RESULTS Bleeding events occurred in 485 patients (16.5 %). BARC classes were: class 1 (n = 155), class 2 (n = 73), class 3a (n = 182), class 3b (n = 68), class 3c (n = 6) and class 4 (n = 1). There were 212 deaths over the first year after PCI: 60 deaths in patients who bled and 152 deaths in patients who did not bleed (Kaplan-Meier [KM] estimates, 12.5 and 6.3 %; odds ratio [OR] = 2.11, 95 % confidence interval [CI] 1.57-2.83, P < 0.001). Nonfatal myocardial infarction occurred in 71 patients who bled and in 141 patients who did not bleed (KM estimates, 14.8 and 5.8 %; OR = 2.70 [2.05-3.55], P < 0.001). After adjustment, bleeding was independently associated with increased risk of 1-year mortality (adjusted hazard ratio [HR] = 1.90 [1.33-2.72], P < 0.001) and myocardial infarction (adjusted HR = 2.74 [1.99-3.78], P < 0.001). Bleeding improved the discriminatory power of the multivariable model for prediction of mortality (absolute and relative integrated discrimination improvement [IDI], 0.011 and 15.4 %; P = 0.004) or myocardial infarction (absolute and relative IDI, 0.017 and 70.8 %; P < 0.001). CONCLUSIONS Peri-PCI bleeding in patients with CKD is independently associated with the increased risk of 1-year mortality and nonfatal myocardial infarction.
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Affiliation(s)
- Gjin Ndrepepa
- Deutsches Herzzentrum, Lazarettstrasse 36, 80636, Munich, Germany,
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Song Y, Song JW, Shim JK, Kwak YL. Optimal anticoagulation during off pump coronary artery bypass in patients recently exposed to clopidogrel. Yonsei Med J 2013; 54:1119-26. [PMID: 23918560 PMCID: PMC3743205 DOI: 10.3349/ymj.2013.54.5.1119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The aim of this study was to find an optimal range of activated clotting time (ACT) during off-pump coronary artery bypass surgery (OPCAB) yielding ischemic protection without the risk of hemorrhagic complications in patients with recent exposure to dual antiplatelet therapy. MATERIALS AND METHODS Three hundred and five patients who received aspirin and clopidogrel within 7 days of isolated multi-vessel OPCAB were retrospectively studied. Combined hemorrhagic and ischemic outcome was defined as the occurrence of 1 of the following: significant perioperative bleeding (>30% of estimated blood volume), transfusion of packed red blood cell (pRBC) ≥ 2 U, or myocardial infarction (MI). This was compared in relation to the tertile distribution of the time-weighted average ACT-212-291 sec (first tertile), 292-334 sec (second tertile), 335-485 sec (third tertile). RESULTS The amount of perioperative blood loss was 937 ± 313 mL, 1014 ± 340 mL, and 1076 ± 383 mL, respectively (p=0.022). Significantly more patients in the third tertile developed MI (4%, 4%, and 12%, respectively, p=0.034). The incidence of significant perioperative blood loss and transfusion of pRBC ≥ 2 U were lower in the first tertile than those of other tertiles without statistical significance. In the multivariate analysis, the first tertile was associated with a 52% risk reduction of combined hemorrhagic and ischemic outcomes (95% confidence interval: 0.25-0.92, p= 0.027). CONCLUSION A lower degree of anticoagulation with a reduced initial heparin loading dose should be carefully considered for patients undergoing OPCAB who have recently been exposed to clopidogrel.
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Affiliation(s)
- Young Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
- Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
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Bleeding after percutaneous coronary intervention in women and men matched for age, body mass index, and type of antithrombotic therapy. Am Heart J 2013; 166:534-40. [PMID: 24016504 DOI: 10.1016/j.ahj.2013.07.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/01/2013] [Indexed: 11/21/2022]
Abstract
BACKGROUND Factors underlying the increased risk of bleeding after percutaneous coronary intervention (PCI) in women compared with men remain incompletely understood. METHODS The study included 3,351 women and 3,351 men matched for age, body mass index, and type of antithrombotic therapy. Bleeding within the 30 days after PCI was defined using the Bleeding Academic Research Consortium criteria. The main outcome was 1-year mortality. RESULTS Bleeding occurred in 518 women and 354 men (15.5% vs 10.6%, odds ratio [OR] 1.55, 95% CI 1.34-1.79, P < .001). Severe (Bleeding Academic Research Consortium class ≥2) bleeds (9.4% vs 6.5%, P < .001) and access site bleeds (10.1% vs 5.4%, P < .001) were more common in women. After adjustment, female sex remained an independent correlate of any bleeding (adjusted OR 1.61 [1.35-1.92], P < .001) and access site (adjusted OR 2.00 [1.59-2.50], P < .001) but not of nonaccess site (adjusted OR 1.18 [0.91-1.54], P = .205) bleeding. There were 248 deaths: 32 deaths among men with bleeding versus 107 deaths among men with no bleeding (9.1% vs 3.6%, OR 2.68 [1.78-4.05], P < .001) and 40 deaths among women with bleeding vs 69 deaths among women with no bleeding (7.8% vs 2.5%, OR 3.35 [2.24-5.01], P < .001). No difference in mortality was observed among women and men who bled (P = .487). Bleeding was independently associated 1-year mortality (adjusted hazard ratio 2.18 [1.68-2.84], P < .001) with no bleeding-by-sex interaction (P = .439). CONCLUSIONS Despite matching for age, body mass index, and type of antithrombotic therapy, bleeding risk after PCI remained significantly higher in women than in men. Bleeding was associated with increased risk of 1-year mortality with no bleeding-by-sex interaction.
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Ndrepepa G, Neumann FJ, Richardt G, Schulz S, Tölg R, Stoyanov KM, Gick M, Ibrahim T, Fiedler KA, Berger PB, Laugwitz KL, Kastrati A. Prognostic Value of Access and Non–Access Sites Bleeding After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2013; 6:354-61. [DOI: 10.1161/circinterventions.113.000433] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gjin Ndrepepa
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Franz-Josef Neumann
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Gert Richardt
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Stefanie Schulz
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Ralph Tölg
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Kiril M. Stoyanov
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Michael Gick
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Tareq Ibrahim
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Katrin Anette Fiedler
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Peter B. Berger
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Karl-Ludwig Laugwitz
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
| | - Adnan Kastrati
- From the Deutsches Herzzentrum München, Technische Universität, München, Germany (G.N., S.S., K.M.S., K.A.F., A.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Germany (F.-J.N., M.G.); Herzzentrum der Segeberger Kliniken, Bad Segeberg, Germany (G.R., R.T.); Geisinger Clinic, Danville, PA (P.B.B.); 1. Medizinische Klinik rechts der Isar, Technische Universität, München, Germany (T.I., K.-L.L.); and DZHK (German Centre for Cardiovascular Research) as part of the Munich Heart Alliance, Munich,
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Leonardi S, Armstrong PW, Schulte PJ, Ohman EM, Newby LK. Implementation of standardized assessment and reporting of myocardial infarction in contemporary randomized controlled trials: a systematic review. Eur Heart J 2013; 34:894-902d. [PMID: 23355654 DOI: 10.1093/eurheartj/eht003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Myocardial infarction (MI) is a key endpoint in randomized controlled trials (RCTs), but heterogeneous definitions limit comparisons across RCTs or meta-analyses. The 2000 European Society of Cardiology/American College of Cardiology MI redefinition and the 2007 universal MI definition consensus documents made recommendations to address this issue. In cardiovascular randomized trials, we evaluated the impact of implementation of three key recommendations from these reports-troponin use to define MI; separate reporting of spontaneous and procedure-related MI; and infarct size reporting. We searched ClinicalTrials.gov and MEDLINE databases for cardiovascular RCTs with more than 500 patients in which enrolment began between September 2000 and July 2012 and that listed MI in the primary endpoint. We searched English-language publications with primary results or design papers. Of 3222 studies screened, 96 (3.0%) met our criteria. We extracted enrolment start date, number of patients and MI events, follow-up duration, and coronary revascularization rate. Data extraction quality was assessed by duplicated extractions. Of 96 RCTs, 80 had a primary results publication, comprising 608 091 patients and 43 621 endpoint MIs. Myocardial infarction represented 45.3% (95% confidence interval, 40.2-50.4) of events in the primary composite endpoint. Troponin defined MI in 57% (53/93) of trials with an MI definition available. Of these RCTs, three used troponin only if creatine kinase-MB was unavailable, six used troponin to define peri-procedural MI, seven specified the 99th percentile as the MI decision limit, and three reported spontaneous and procedure-related MI separately. None reported biomarker-based infarct size, but five reported MI as multiples of the assay upper limit of normal. Although MI is a major component of cardiovascular RCT primary endpoints, standardized MI reporting and implementation of consensus document recommendations for MI definition are limited. Developing appropriate strategies for uniform implementation is required.
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Affiliation(s)
- Sergio Leonardi
- Duke University Medical Center, The Duke Clinical Research Institute, P.O. Box 17969, Durham, NC 27715-7969, USA
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Ndrepepa G, Neumann FJ, Deliargyris EN, Mehran R, Mehilli J, Ferenc M, Schulz S, Schömig A, Kastrati A, Stone GW. Bivalirudin Versus Heparin Plus a Glycoprotein IIb/IIIa Inhibitor in Patients With Non–ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention After Clopidogrel Pretreatment. Circ Cardiovasc Interv 2012; 5:705-12. [DOI: 10.1161/circinterventions.112.972869] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background—
The optimal antithrombotic therapy for patients with non–ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention is not well defined. We investigated the efficacy and safety of bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor (GPI) in patients with non–ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention after clopidogrel pretreatment.
Methods and Results—
This study included 3798 clopidogrel-pretreated patients with non–ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention, who were randomly assigned to receive bivalirudin (n=1928) or heparin (unfractionated heparin or enoxaparin; n=1870) plus a GPI in the setting of the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) and Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment (ISAR-REACT) 4 trials. Major end points were a composite of death, recurrent myocardial infarction or urgent target vessel revascularization (efficacy end point), major bleeding (safety end point), and the composite of death, recurrent myocardial infarction, urgent target vessel revascularization, or major bleeding (net adverse clinical events [NACE]) at 30 days. The incidence of the efficacy end point was 10.6% (n=205) in the bivalirudin group versus 10.2% (n=191) in the heparin plus a GPI group (OR, 1.04; 95% CI, 0.85–1.27;
P
=0.69). The incidence of safety end point was 3.4% (n=66) in the bivalirudin group versus 6.3% (n=117) in the heparin plus a GPI group (OR, 0.54 [0.40–0.72];
P
<0.001). NACE occurred in 258 patients (13.4%) in the bivalirudin group versus 275 patients (14.7%) in the heparin plus a GPI group (OR, 0.90 [0.76–1.06];
P
=0.21).
Conclusions—
NACE rates were not significantly different between bivalirudin and heparin plus a GPI in patients with non–ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention after clopidogrel pretreatment. Although no significant difference in efficacy was seen in terms of suppression of adverse ischemic events, bivalirudin was superior to heparin plus a GPI in terms of reducing bleeding events.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique Identifier: NCT00093158 and NCT00373451.
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Affiliation(s)
- Gjin Ndrepepa
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Franz-Josef Neumann
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Efthymios N. Deliargyris
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Roxana Mehran
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Julinda Mehilli
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Miroslaw Ferenc
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Stefanie Schulz
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Albert Schömig
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Adnan Kastrati
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
| | - Gregg W. Stone
- From the Cardiology Department, Deutsches Herzzentrum, Technische Universität München, Munich, Germany (G.N., J.M., S.S., A.S., A.K.); Cardiology Department, Universitäts-Herzzentrums Freiburg Bad Krozingen, Germany (F.J.N., M.F.); Global Medical, The Medicines Company, Parsippany, NJ (E.N.D.); Cardiology Department, Mount Sinai Medical Center, New York, NY (R.M.); Cardiology Department, Klinikum rechts der Isar, Technische Universität München, Munich, Germany (A.S.); and Cardiology Department,
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Iqbal Z, Rana G, Cohen M. Appropriate anti-thrombotic/anti-thrombin therapy for thrombotic lesions. Curr Cardiol Rev 2012; 8:181-91. [PMID: 22920489 PMCID: PMC3465822 DOI: 10.2174/157340312803217175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 03/16/2012] [Accepted: 04/10/2012] [Indexed: 11/22/2022] Open
Abstract
Managing coronary thrombus is a challenging task and requires adequate knowledge of the various antithrombotic
agents available. In this article, we will briefly analyze the risk-benefit profile of antithrombotic agents, with critical
analysis of the scientific evidence available to support their use. Since thrombus consists of platelets and coagulation cofactors,
an effective antithrombotic strategy involves using one anticoagulant with two or more antiplatelet agents.
Unfractionated heparin traditionally has been the most commonly used anticoagulant but is fast being replaced by relatively
newer agents like LMWH, direct thrombin inhibitors, and Factor Xa inhibitors. In recent years, the antiplatelet landscape has changed significantly with the availability of more potent and rapidly acting
agents, like prasugrel and ticagrelor. These agents have demonstrated a sizeable reduction in ischemic outcomes in patients
with ACS, who are treated invasively or otherwise, with some concern for an increased bleeding risk. Glycoprotein
IIb/IIIa inhibitors have an established role in high risk NSTE ACS patients pretreated with dual antiplatelets, but its role in
STEMI patients, treated with invasive approach and dual antiplatelets, has not been supported consistently across the studies.
Additionally, in recent years, its place as a directly injected therapy into coronaries has been looked into with mixed
results. In conclusion, a well-tailored antithrombotic strategy requires taking into account each patient’s individual risk
factors and clinical presentation, with an effort to strike balance between not only preventing ischemic outcomes but also
reducing bleeding complications.
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Affiliation(s)
- Zafar Iqbal
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA
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