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Kim JH, Lee SJ, Cha JJ, Park JH, Hong SJ, Ahn TH, Kim BK, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Jeong YH, Kim HS, Kim MH, Shin ES, Lim DS. Prognostic Impact of CYP2C19 Genotypes on Long-Term Clinical Outcomes in Older Patients After Percutaneous Coronary Intervention. J Am Heart Assoc 2024; 13:e032248. [PMID: 38761068 PMCID: PMC11179831 DOI: 10.1161/jaha.123.032248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/17/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Carriers of CYP2C19 loss-of-function alleles have increased adverse events after percutaneous coronary intervention, but limited data are available for older patients. We aimed to evaluate the prognostic impact of CYP2C19 genotypes on clinical outcomes in older patients after percutaneous coronary intervention. METHODS AND RESULTS The study included 1201 older patients (aged ≥75 years) who underwent percutaneous coronary intervention and received clopidogrel-based dual antiplatelet therapy in South Korea. Patients were grouped on the basis of CYP2C19 genotypes. The primary outcome was 3-year major adverse cardiac events, defined as a composite of cardiac death, myocardial infarction, and stent thrombosis. Older patients were grouped into 3 groups: normal metabolizer (36.6%), intermediate metabolizer (48.1%), and poor metabolizer (15.2%). The occurrence of the primary outcome was significantly different among the groups (3.1, 7.0, and 6.2% in the normal metabolizer, intermediate metabolizer, and poor metabolizer groups, respectively; P=0.02). The incidence rate of all-cause death at 3 years was greater in the intermediate metabolizer and poor metabolizer groups (8.1% and 9.2%, respectively) compared with that in the normal metabolizer group (3.5%, P=0.03) without significant differences in major bleeding. In the multivariable analysis, the intermediate metabolizer and poor metabolizer groups were independent predictors of 3-year clinical outcomes. CONCLUSIONS In older patients, the presence of any CYP2C19 loss-of-function allele was found to be predictive of a higher incidence of major adverse cardiac events within 3 years following percutaneous coronary intervention. This finding suggests a need for further investigation into an optimal antiplatelet strategy for older patients. REGISTRATION URL: https://clinicaltrials.gov. Identifier: NCT04734028.
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Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | | | - Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Tae Hoon Ahn
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | | | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine College of Medicine, Catholic University of Korea Seoul South Korea
| | - Yongwhi Park
- Department of Internal Medicine Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital Changwon South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Sung Gyun Ahn
- Department of Cardiology Yonsei University Wonju Severance Christian Hospital Wonju South Korea
| | - Jung-Won Suh
- Department of Cardiology, Department of Internal Medicine Seoul National University Bundang Hospital, Seoul National University College of Medicine Seoul South Korea
| | - Sang Yeub Lee
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine, Kangnam Sacred Heart Hospital Hallym University College of Medicine Seoul South Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine Kangwon National University School of Medicine Chuncheon South Korea
| | - Young-Hoon Jeong
- Department of Cardiology Heart and Brain Institute, Chung-Ang University Gwang-Myeong Hospital, Chung-Ang University College of Medicine Gwangmyeong-si South Korea
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine Seoul National University Hospital Seoul South Korea
| | - Moo Hyun Kim
- Department of Cardiology Dong-A University Hospital Busan South Korea
| | - Eun-Seok Shin
- Division of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
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Shahjahan, Dey JK, Dey SK. Translational bioinformatics approach to combat cardiovascular disease and cancers. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2024; 139:221-261. [PMID: 38448136 DOI: 10.1016/bs.apcsb.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Bioinformatics is an interconnected subject of science dealing with diverse fields including biology, chemistry, physics, statistics, mathematics, and computer science as the key fields to answer complicated physiological problems. Key intention of bioinformatics is to store, analyze, organize, and retrieve essential information about genome, proteome, transcriptome, metabolome, as well as organisms to investigate the biological system along with its dynamics, if any. The outcome of bioinformatics depends on the type, quantity, and quality of the raw data provided and the algorithm employed to analyze the same. Despite several approved medicines available, cardiovascular disorders (CVDs) and cancers comprises of the two leading causes of human deaths. Understanding the unknown facts of both these non-communicable disorders is inevitable to discover new pathways, find new drug targets, and eventually newer drugs to combat them successfully. Since, all these goals involve complex investigation and handling of various types of macro- and small- molecules of the human body, bioinformatics plays a key role in such processes. Results from such investigation has direct human application and thus we call this filed as translational bioinformatics. Current book chapter thus deals with diverse scope and applications of this translational bioinformatics to find cure, diagnosis, and understanding the mechanisms of CVDs and cancers. Developing complex yet small or long algorithms to address such problems is very common in translational bioinformatics. Structure-based drug discovery or AI-guided invention of novel antibodies that too with super-high accuracy, speed, and involvement of considerably low amount of investment are some of the astonishing features of the translational bioinformatics and its applications in the fields of CVDs and cancers.
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Affiliation(s)
- Shahjahan
- Laboratory for Structural Biology of Membrane Proteins, Dr. B.R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi, India
| | - Joy Kumar Dey
- Central Council for Research in Homoeopathy, Ministry of Ayush, Govt. of India, New Delhi, Delhi, India
| | - Sanjay Kumar Dey
- Laboratory for Structural Biology of Membrane Proteins, Dr. B.R. Ambedkar Center for Biomedical Research, University of Delhi, Delhi, India.
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Jordan KP, Rathod-Mistry T, van der Windt DA, Bailey J, Chen Y, Clarson L, Denaxas S, Hayward RA, Hemingway H, Kyriacou T, Mamas MA. Determining cardiovascular risk in patients with unattributed chest pain in UK primary care: an electronic health record study. Eur J Prev Cardiol 2023; 30:1151-1161. [PMID: 36895179 PMCID: PMC10442054 DOI: 10.1093/eurjpc/zwad055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 12/06/2022] [Accepted: 02/21/2023] [Indexed: 03/11/2023]
Abstract
AIMS Most adults presenting in primary care with chest pain symptoms will not receive a diagnosis ('unattributed' chest pain) but are at increased risk of cardiovascular events. To assess within patients with unattributed chest pain, risk factors for cardiovascular events and whether those at greatest risk of cardiovascular disease can be ascertained by an existing general population risk prediction model or by development of a new model. METHODS AND RESULTS The study used UK primary care electronic health records from the Clinical Practice Research Datalink linked to admitted hospitalizations. Study population was patients aged 18 plus with recorded unattributed chest pain 2002-2018. Cardiovascular risk prediction models were developed with external validation and comparison of performance to QRISK3, a general population risk prediction model. There were 374 917 patients with unattributed chest pain in the development data set. The strongest risk factors for cardiovascular disease included diabetes, atrial fibrillation, and hypertension. Risk was increased in males, patients of Asian ethnicity, those in more deprived areas, obese patients, and smokers. The final developed model had good predictive performance (external validation c-statistic 0.81, calibration slope 1.02). A model using a subset of key risk factors for cardiovascular disease gave nearly identical performance. QRISK3 underestimated cardiovascular risk. CONCLUSION Patients presenting with unattributed chest pain are at increased risk of cardiovascular events. It is feasible to accurately estimate individual risk using routinely recorded information in the primary care record, focusing on a small number of risk factors. Patients at highest risk could be targeted for preventative measures.
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Affiliation(s)
- Kelvin P Jordan
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
| | - Trishna Rathod-Mistry
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Windmill Road, Oxford OX3 7LD, UK
| | - Danielle A van der Windt
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
| | - James Bailey
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
| | - Ying Chen
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
- Wisdom Lake Academy of Pharmacy, Xi'an Jiaotong-Liverpool University, Suzhou 215123, Jiangsu, China
| | - Lorna Clarson
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
- Health Data Research UK, University College London, 222 Euston Road, London NW1 2DA, UK
| | - Richard A Hayward
- School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
| | - Harry Hemingway
- Institute of Health Informatics, University College London, 222 Euston Road, London NW1 2DA, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, Maple House 1st floor, 149 Tottenham Court Road, London W1T 7DN, UK
| | - Theocharis Kyriacou
- School of Computing and Mathematics, Keele University, Staffordshire ST5 5AA, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, School of Medicine, David Weatherall Building, University Road, Keele University, Staffordshire ST5 5BG, UK
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Sethi Y, Patel N, Kaka N, Kaiwan O, Kar J, Moinuddin A, Goel A, Chopra H, Cavalu S. Precision Medicine and the future of Cardiovascular Diseases: A Clinically Oriented Comprehensive Review. J Clin Med 2023; 12:1799. [PMID: 36902588 PMCID: PMC10003116 DOI: 10.3390/jcm12051799] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Cardiac diseases form the lion's share of the global disease burden, owing to the paradigm shift to non-infectious diseases from infectious ones. The prevalence of CVDs has nearly doubled, increasing from 271 million in 1990 to 523 million in 2019. Additionally, the global trend for the years lived with disability has doubled, increasing from 17.7 million to 34.4 million over the same period. The advent of precision medicine in cardiology has ignited new possibilities for individually personalized, integrative, and patient-centric approaches to disease prevention and treatment, incorporating the standard clinical data with advanced "omics". These data help with the phenotypically adjudicated individualization of treatment. The major objective of this review was to compile the evolving clinically relevant tools of precision medicine that can help with the evidence-based precise individualized management of cardiac diseases with the highest DALY. The field of cardiology is evolving to provide targeted therapy, which is crafted as per the "omics", involving genomics, transcriptomics, epigenomics, proteomics, metabolomics, and microbiomics, for deep phenotyping. Research for individualizing therapy in heart diseases with the highest DALY has helped identify novel genes, biomarkers, proteins, and technologies to aid early diagnosis and treatment. Precision medicine has helped in targeted management, allowing early diagnosis, timely precise intervention, and exposure to minimal side effects. Despite these great impacts, overcoming the barriers to implementing precision medicine requires addressing the economic, cultural, technical, and socio-political issues. Precision medicine is proposed to be the future of cardiovascular medicine and holds the potential for a more efficient and personalized approach to the management of cardiovascular diseases, contrary to the standardized blanket approach.
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Affiliation(s)
- Yashendra Sethi
- PearResearch, Dehradun 248001, India
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Neil Patel
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Nirja Kaka
- PearResearch, Dehradun 248001, India
- Department of Medicine, GMERS Medical College, Himmatnagar 383001, India
| | - Oroshay Kaiwan
- PearResearch, Dehradun 248001, India
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA
| | - Jill Kar
- PearResearch, Dehradun 248001, India
- Department of Medicine, Lady Hardinge Medical College, New Delhi 110001, India
| | - Arsalan Moinuddin
- Vascular Health Researcher, School of Sports and Exercise, University of Gloucestershire, Cheltenham GL50 4AZ, UK
| | - Ashish Goel
- Department of Medicine, Government Doon Medical College, HNB Uttarakhand Medical Education University, Dehradun 248001, India
| | - Hitesh Chopra
- Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, P-ta 1 Decembrie 10, 410087 Oradea, Romania
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Asiimwe IG, Pirmohamed M. Drug-Drug-Gene Interactions in Cardiovascular Medicine. Pharmgenomics Pers Med 2022; 15:879-911. [PMID: 36353710 PMCID: PMC9639705 DOI: 10.2147/pgpm.s338601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022] Open
Abstract
Cardiovascular disease remains a leading cause of both morbidity and mortality worldwide. It is widely accepted that both concomitant medications (drug-drug interactions, DDIs) and genomic factors (drug-gene interactions, DGIs) can influence cardiovascular drug-related efficacy and safety outcomes. Although thousands of DDI and DGI (aka pharmacogenomic) studies have been published to date, the literature on drug-drug-gene interactions (DDGIs, cumulative effects of DDIs and DGIs) remains scarce. Moreover, multimorbidity is common in cardiovascular disease patients and is often associated with polypharmacy, which increases the likelihood of clinically relevant drug-related interactions. These, in turn, can lead to reduced drug efficacy, medication-related harm (adverse drug reactions, longer hospitalizations, mortality) and increased healthcare costs. To examine the extent to which DDGIs and other interactions influence efficacy and safety outcomes in the field of cardiovascular medicine, we review current evidence in the field. We describe the different categories of DDIs and DGIs before illustrating how these two interact to produce DDGIs and other complex interactions. We provide examples of studies that have reported the prevalence of clinically relevant interactions and the most implicated cardiovascular medicines before outlining the challenges associated with dealing with these interactions in clinical practice. Finally, we provide recommendations on how to manage the challenges including but not limited to expanding the scope of drug information compendia, interaction databases and clinical implementation guidelines (to include clinically relevant DDGIs and other complex interactions) and work towards their harmonization; better use of electronic decision support tools; using big data and novel computational techniques; using clinically relevant endpoints, preemptive genotyping; ensuring ethnic diversity; and upskilling of clinicians in pharmacogenomics and personalized medicine.
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Affiliation(s)
- Innocent G Asiimwe
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Munir Pirmohamed
- The Wolfson Centre for Personalized Medicine, MRC Centre for Drug Safety Science, Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
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6
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Naito R, Miyauchi K, Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Nakamura M, Hagiwara N, Kimura K, Hirayama A, Matsui K, Ogawa H. Rivaroxaban Monotherapy vs Combination Therapy With Antiplatelets on Total Thrombotic and Bleeding Events in Atrial Fibrillation With Stable Coronary Artery Disease: A Post Hoc Secondary Analysis of the AFIRE Trial. JAMA Cardiol 2022; 7:787-794. [PMID: 35704345 DOI: 10.1001/jamacardio.2022.1561] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Importance Appropriate regimens of antithrombotic therapy for patients with atrial fibrillation (AF) and coronary artery disease (CAD) have not yet been established. Objective To compare the total number of thrombotic and/or bleeding events between rivaroxaban monotherapy and combined rivaroxaban and antiplatelet therapy in such patients. Design, Setting, and Participants This was a post hoc secondary analysis of the Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease (AFIRE) open-label, randomized clinical trial. This multicenter analysis was conducted from February 23, 2015, to July 31, 2018. Patients with AF and stable CAD who had undergone percutaneous coronary intervention or coronary artery bypass grafting 1 or more years earlier or who had angiographically confirmed CAD not requiring revascularization were enrolled. Data were analyzed from September 1, 2020, to March 26, 2021. Interventions Rivaroxaban monotherapy or combined rivaroxaban and antiplatelet therapy. Main Outcomes and Measures The total incidence of thrombotic, bleeding, and fatal events was compared between the groups. Cox regression analyses were used to estimate the risk of subsequent events in the 2 groups, with the status of thrombotic or bleeding events that had occurred by the time of death used as a time-dependent variable. Results A total of 2215 patients (mean [SD] age, 74 [8.2] years; 1751 men [79.1%]) were included in the modified intention-to-treat analysis. The total event rates for the rivaroxaban monotherapy group (1107 [50.0%]) and the combination-therapy group (1108 [50.0%]) were 12.2% (135 of 1107) and 19.2% (213 of 1108), respectively, during a median follow-up of 24.1 (IQR, 17.3-31.5) months. The mortality rate was 3.7% (41 of 1107) in the monotherapy group and 6.6% (73 of 1108) in the combination-therapy group. Rivaroxaban monotherapy was associated with a lower risk of total events compared with combination therapy (hazard ratio, 0.62; 95% CI, 0.48-0.80; P < .001). Monotherapy was an independent factor associated with a lower risk of subsequent events compared with combination therapy. The mortality risk after a bleeding event (monotherapy, 75% [6 of 8]; combination therapy, 62.1% [18 of 29]) was higher than that after a thrombotic event (monotherapy, 25% [2 of 8]; combination therapy, 37.9% [11 of 29]). Conclusions and Relevance Rivaroxaban monotherapy was associated with lower risks of total thrombotic and/or bleeding events than combination therapy in patients with AF and stable CAD. Tapered antithrombotic therapy with a sole anticoagulant should be considered in these patients. Trial Registration ClinicalTrials.gov Identifier: NCT02642419.
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Affiliation(s)
- Ryo Naito
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Katsumi Miyauchi
- Department of Cardiovascular Medicine, Juntendo Tokyo Koto Geriatric Medical Center, Koto-Ku, Tokyo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.,National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Fukakusa, Fushimi-Ku, Kyoto, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Minami-Ku, Sagamihara, Kanagawa, Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Meguro-Ku, Tokyo, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Shinjuku-Ku, Tokyo, Japan
| | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center, Minami-Ku, Yokohama, Kanagawa, Japan
| | - Atsushi Hirayama
- Department of Cardiology Osaka Police Hospital, Osaka City, Osaka, Japan
| | - Kunihiko Matsui
- Department of General and Community Medicine, Kumamoto University Hospital, Kumamoto, Japan
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7
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Chacón-Diaz M, Hernández-Vásquez A, Custodio-Sánchez P. [One-year survival among patients with ST-elevation myocardial infarction in Peru]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:53-59. [PMID: 37351306 PMCID: PMC10284578 DOI: 10.47487/apcyccv.v3i2.218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/30/2022] [Indexed: 06/24/2023]
Abstract
Objectives To determine one-year survival and factors associated with mortality in patients with ST-segment elevation myocardial infarction in Peru. Methods An analysis was made of the cohort of patients included in the PERSTEMI-II registry during the year 2020, in whom survival at one year after the event and its risk factors were evaluated using Kaplan-Meier survival analysis and Cox regression. Results Of 374 patients in the PERSTEMI-II study, 366 (97.9%) completed follow-up up to one year after the event with a survival rate of 85%. Successful reperfusion was related to better survival at 1 year (hazard ratio [HR]=0.30, 95% CI: 0.14-0.62, p=0.001). Age (HR=1.04, 95% CI: 1.01-1.07, p=0.003), chronic kidney disease (HR=2.15, 95% CI: 1.04-4.39, p=0.037) and cardiogenic shock (HR=6.67, 95% CI: 3.72-11.97, p<0.001) were factors of higher mortality at 1-year follow-up. Conclusion The PERSTEMI-II registry is the first Peruvian registry that provides data on survival after ST-segment elevation myocardial infarction, which is 85% at one year. Successful reperfusion improves survival at one-year post infarction.
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Affiliation(s)
- Manuel Chacón-Diaz
- Universidad Científica del Sur. Lima, Perú.Universidad Científica del SurUniversidad Científica del SurLimaPeru
- Instituto Nacional Cardiovascular INCOR. Lima, Perú.Instituto Nacional Cardiovascular INCORLimaPerú
| | - Akram Hernández-Vásquez
- Centro de Excelencia en Investigaciones Económicas y Sociales en Salud, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola. Lima, Perú.Universidad San Ignacio de LoyolaCentro de Excelencia en Investigaciones Económicas y Sociales en SaludVicerrectorado de InvestigaciónUniversidad San Ignacio de LoyolaLimaPeru
| | - Piero Custodio-Sánchez
- Hospital Nacional Almanzor Aguinaga Asenjo, Essalud. Chiclayo, Perú.Hospital Nacional Almanzor Aguinaga Asenjo, EssaludChiclayoPerú
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Alkhalil M, Džavík V, Bhatt DL, Mehran R, Mehta SR. Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention. Curr Cardiol Rep 2022; 24:277-293. [PMID: 35294730 DOI: 10.1007/s11886-022-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation. RECENT FINDINGS Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the P2Y12 inhibitor of choice, while more data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
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9
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Jourdi G, Godier A, Lordkipanidzé M, Marquis-Gravel G, Gaussem P. Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches. Front Cardiovasc Med 2022; 9:805525. [PMID: 35155631 PMCID: PMC8832164 DOI: 10.3389/fcvm.2022.805525] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/06/2022] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet agents, with aspirin and P2Y12 receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.
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Affiliation(s)
- Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- *Correspondence: Georges Jourdi
| | - Anne Godier
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Department of Anesthesiology and Critical Care, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Lordkipanidzé
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Marquis-Gravel
- Research Center, Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Service d'Hématologie Biologique, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
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10
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Tervonen T, Prawitz T, Chua GN, Hyacinthe J, Pinto CA. Net clinical benefit of antiplatelet therapy was affected by patient preferences: A personalized benefit-risk assessment. J Clin Epidemiol 2021; 144:84-92. [PMID: 34856367 DOI: 10.1016/j.jclinepi.2021.11.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/13/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the effect of patient preferences on the net clinical benefit (NCB) of an antiplatelet therapy for the secondary prevention of cardiovascular complications. STUDY DESIGN AND SETTING Risk equations were developed to estimate the individual predicted risk of key outcomes of antiplatelet treatment in patients with a prior myocardial infarction using the Clinical Practice Research Datalink linked to the Hospital Episode Statistics and UK Office of National Statistics databases. Patient preferences for outcomes of antiplatelet therapies were elicited in a separate discrete choice experiment survey. Trial hazard ratios, relative to placebo, were used to calculate the per-patient NCB using equal or preference weighting of outcomes. RESULTS Risk equations were estimated using 31,941 adults in the Clinical Practice Research Datalink population, of which 22,125 were included in the benefit-risk assessment. The mean NCB was lower in the preference-weighted than in the equal-weighted analysis (0.040 vs 0.057; p < 0.0001), but the direction of effect was unchanged by the weighting. In analyses stratified by the presence of bleeding risk factors, including preference weighting altered the ranking of subgroups by NCB. CONCLUSION Patient preference weighting may have a significant effect on NCB and should be included in personalized benefit-risk assessments.
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Affiliation(s)
- Tommi Tervonen
- Evidera, The Ark, 201 Talgarth Rd, London W6 8BJ, UK; Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | | | - Gin Nie Chua
- Evidera, The Ark, 201 Talgarth Rd, London W6 8BJ, UK
| | | | - Cathy Anne Pinto
- Department of Epidemiology, Merck & Co., Inc., Kenilworth, NJ, USA
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11
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Tan JWC, Chew DP, Tsui KL, Tan D, Duplyakov D, Hammoudeh A, Zhang B, Li Y, Xu K, Ong PJ, Firman D, Gamra H, Almahmeed W, Dalal J, Tam LW, Steg G, Nguyen QN, Ako J, Al Suwaidi J, Chan M, Sobhy M, Shehab A, Buddhari W, Wang Z, Fong AYY, Karadag B, Kim BK, Baber U, Chin CT, Han YL. 2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y1 2 Receptor Antagonists in the Asia-Pacific Region: Special Populations. Eur Cardiol 2021; 16:e43. [PMID: 34815751 PMCID: PMC8591619 DOI: 10.15420/ecr.2021.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - Kin Lam Tsui
- Pamela Youde Nethersole Eastern Hospital Hong Kong, China
| | - Doreen Tan
- Department of Pharmacy, Faculty of Science, National University of Singapore Singapore
| | | | | | - Bo Zhang
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University Dalian, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | - Paul J Ong
- Heart Specialist International, Mount Elizabeth Novena Hospital Singapore.,Tan Tock Seng Hospital Singapore
| | - Doni Firman
- Harapan Kita National Cardiovascular Center/Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia Harapan Kita Jakarta, Indonesia
| | - Habib Gamra
- Cardiology Department, Fattouma Bourguiba University Hospital and University of Monastir Monastir, Tunisia
| | | | - Jamshed Dalal
- Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital Mumbai, India
| | | | - Gabriel Steg
- Department of Cardiology, Hôpital Bichat Paris, France
| | - Quang N Nguyen
- Department of Cardiology, Hanoi Medical University Hanoi, Vietnam
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine Sagamihara, Kanagawa, Japan
| | | | - Mark Chan
- National University Heart Centre Singapore
| | | | - Abdulla Shehab
- College of Medicine and Health Sciences, UAE University, Al Ain United Arab Emirates
| | | | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | | | - Bilgehan Karadag
- Istanbul University-Cerrahpasa School of Medicine Istanbul, Turkey
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine Seoul, South Korea
| | - Usman Baber
- University of Oklahoma Health Sciences Center Oklahoma City, OK, US
| | | | - Ya Ling Han
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
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12
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Gao G, Zhao Y, Zhang D, Song C, Song W, Feng L, Zhu C, Xu B, Yin D, Dou K. Validation of the DAPT score in large-scale consecutive and contemporary patients population in the real world. Platelets 2021; 32:1084-1091. [PMID: 33141634 DOI: 10.1080/09537104.2020.1841894] [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: 10/23/2022]
Abstract
Dual antiplatelet therapy (DAPT) score emerged as a tool for quantification of ischemia and bleeding risks. However, there was discrepancy of the prediction ability of DAPT score in previous studies. We aimed to assess the utility of DAPT score in a large-scale cohort of consecutive percutaneous coronary intervention (PCI) patients. This study enrolled 9,114 patients who had undergone PCI at Fuwai Hospital in 2013, adhered to DAPT and were event-free within the first 12 months following PCI. The endpoints included primary ischemic endpoints (major adverse cardiovascular and cerebrovascular events, and myocardial infarction and/or stent thrombosis), and bleeding endpoint from 12 through 24 months after PCI. Patients were classified into low (score <2, n = 3,989) and high (score ≥2, n = 5,125) DAPT score groups. The incidence rates of primary ischemic endpoints and bleeding endpoint were similar between the two groups. Multivariable analysis demonstrated DAPT score not to be an independent predictor of primary ischemic endpoints or bleeding endpoint. Based on receiver operating characteristic curves analysis, the C-statistic of DAPT score for primary ischemic endpoints or bleeding endpoint did not achieve a significant extent. In this large-scale cohort of PCI patients, DAPT score did not discriminate the risks of ischemic and bleeding events.
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Affiliation(s)
- Guofeng Gao
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dong Zhang
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenxi Song
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Weihua Song
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Feng
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenggang Zhu
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Bo Xu
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Dong Yin
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kefei Dou
- From State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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13
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Joshi A, Rienks M, Theofilatos K, Mayr M. Systems biology in cardiovascular disease: a multiomics approach. Nat Rev Cardiol 2021; 18:313-330. [PMID: 33340009 DOI: 10.1038/s41569-020-00477-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 12/13/2022]
Abstract
Omics techniques generate large, multidimensional data that are amenable to analysis by new informatics approaches alongside conventional statistical methods. Systems theories, including network analysis and machine learning, are well placed for analysing these data but must be applied with an understanding of the relevant biological and computational theories. Through applying these techniques to omics data, systems biology addresses the problems posed by the complex organization of biological processes. In this Review, we describe the techniques and sources of omics data, outline network theory, and highlight exemplars of novel approaches that combine gene regulatory and co-expression networks, proteomics, metabolomics, lipidomics and phenomics with informatics techniques to provide new insights into cardiovascular disease. The use of systems approaches will become necessary to integrate data from more than one omic technique. Although understanding the interactions between different omics data requires increasingly complex concepts and methods, we argue that hypothesis-driven investigations and independent validation must still accompany these novel systems biology approaches to realize their full potential.
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Affiliation(s)
- Abhishek Joshi
- King's British Heart Foundation Centre, King's College London, London, UK
- Bart's Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Marieke Rienks
- King's British Heart Foundation Centre, King's College London, London, UK
| | | | - Manuel Mayr
- King's British Heart Foundation Centre, King's College London, London, UK.
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14
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Cha JJ, Park JH, Joo HJ, Hong SJ, Ahn TH, Kim BK, Shin W, Ahn SG, Yoon J, Kim YH, Cho YH, Kang WC, Kim W, Lim YH, Gwon HC, Choi WG, Lim DS. Impact of genetic variants on clinical outcome after percutaneous coronary intervention in elderly patients. Aging (Albany NY) 2021; 13:6506-6524. [PMID: 33707344 PMCID: PMC7993709 DOI: 10.18632/aging.202799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/16/2021] [Indexed: 12/02/2022]
Abstract
Elderly patients treated with percutaneous coronary intervention (PCI) have a higher risk of both ischemic and bleeding complications than younger patients. However, few studies have reported how genetic information of elderly patients treated with PCI affects clinical outcomes. We investigated the impact of genetic variants on clinical outcomes in elderly patients. Correlations between single-nucleotide polymorphisms (CYP2C19 and P2Y12 receptor gene G52T polymorphism) and clinical outcomes were analyzed in 811 elderly patients (≥75 years of age) from a prospective multicenter registry. The primary endpoint was a composite of myocardial infarction and death. Secondary endpoints were an individual event of death, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, stroke, and major bleeding (Bleeding Academic Research Consortium ≥3). Regarding CYP2C19, patients with poor metabolizers had a significantly higher risk for the primary endpoint (hazard ratio [HR] 2.43; 95% confidence interval [95% CI] 1.12–5.24; p=0.024) and secondary endpoints (death and cardiac death). Regarding P2Y12 G52T, the TT group had a significantly higher occurrence of major bleeding than the other groups (HR 3.87; 95% CI 1.41–10.68; p=0.009). In conclusion, poor metabolizers of CYP2C19 and TT groups of P2Y12 G52T may be significant predictors of poor clinical outcomes in elderly patients.
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Affiliation(s)
- Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Tae Hoon Ahn
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - WonYong Shin
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - JungHan Yoon
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Yun-Hyeong Cho
- Department of Internal Medicine, Hanyang University Myongji Hospital, Goyang, South Korea
| | - Woong Chol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Weon Kim
- Department of Internal Medicine, Division of Cardiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Young-Hyo Lim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woong Gil Choi
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
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15
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Kürzinger ML, Douarin L, Uzun I, El-Haddad C, Hurst W, Juhaeri J, Tcherny-Lessenot S. Structured benefit-risk evaluation for medicinal products: review of quantitative benefit-risk assessment findings in the literature. Ther Adv Drug Saf 2020; 11:2042098620976951. [PMID: 33343857 PMCID: PMC7727082 DOI: 10.1177/2042098620976951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/03/2020] [Indexed: 11/15/2022] Open
Abstract
A favorable benefit–risk profile remains an essential requirement for marketing authorization of medicinal drugs and devices. Furthermore, prior subjective, implicit and inconsistent ad hoc benefit–risk assessment methods have rightly evolved towards more systematic, explicit or “structured” approaches. Contemporary structured benefit–risk evaluation aims at providing an objective assessment of the benefit–risk profile of medicinal products and a higher transparency for decision making purposes. The use of a descriptive framework should be the preferred starting point for a structured benefit–risk assessment. In support of more precise assessments, quantitative and semi-quantitative methodologies have been developed and utilized to complement descriptive or qualitative frameworks in order to facilitate the structured evaluation of the benefit–risk profile of medicinal products. In addition, quantitative structured benefit–risk analysis allows integration of patient preference data. Collecting patient perspectives throughout the medical product development process has become increasingly important and key to the regulatory decision-making process. Both industry and regulatory authorities increasingly rely on descriptive structured benefit–risk evaluation and frameworks in drug, vaccine and device evaluation and comparison. Although varied qualitative methods are more commonplace, quantitative approaches have recently been emphasized. However, it is unclear how frequently these quantitative frameworks have been used by pharmaceutical companies to support submission dossiers for drug approvals or to respond to the health authorities’ requests. The objective of this study has been to identify and review, for the first time, currently available, published, structured, quantitative benefit–risk evaluations which may have informed health care professionals and/or payor as well as contributed to decision making purposes in the regulatory setting for drug, vaccine and/or device approval.
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Affiliation(s)
- Marie-Laure Kürzinger
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, 1, Avenue Pierre Brossolette - 91385 Chilly-Mazarin, 91000, France
| | - Ludivine Douarin
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, Chilly-Mazarin, France
| | - Ievgeniia Uzun
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, Bridgewater, USA
| | - Chantal El-Haddad
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, Chilly-Mazarin, France
| | - William Hurst
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, Bridgewater, USA
| | - Juhaeri Juhaeri
- Global Epidemiology & Benefit-Risk Evaluation, Sanofi, Bridgewater, USA
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16
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Update to Evidence-Based Secondary Prevention Strategies After Acute Coronary Syndrome. CJC Open 2020; 2:402-415. [PMID: 32995726 PMCID: PMC7499366 DOI: 10.1016/j.cjco.2020.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/03/2020] [Indexed: 02/07/2023] Open
Abstract
A recent acute coronary syndrome provides an opportunity to optimise secondary prevention strategies to reduce the risk of future cardiovascular events. This review provides an updated synopsis of current evidence-based approaches. New clinical trial data on the use of antiplatelet and anticoagulants allow choices of the selection and duration of treatment. Lipid lowering after an acute coronary syndrome is now enhanced, with proprotein convertase subtilisin-kexin type 9 inhibitors providing added benefit on top of statin and ezetimibe treatment in high-risk patients. In addition, a recent trial of icosapent ethyl, a highly purified ethyl ester of eicosapentaenoic acid, addresses residual risk in patients with elevated triglycerides already treated with statins. The use of both sodium-glucose co-transporter 2 inhibitors and glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes reduces cardiovascular events independently of glucose lowering.
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17
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Dobesh PP, Finks SW, Trujillo TC. Dual Antiplatelet Therapy for Long-term Secondary Prevention of Atherosclerotic Cardiovascular Events. Clin Ther 2020; 42:2084-2097. [PMID: 32873416 DOI: 10.1016/j.clinthera.2020.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/31/2020] [Accepted: 08/06/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is currently recommended to prevent further ischemic events after percutaneous coronary intervention and acute coronary syndrome (ACS). Guidelines currently recommend a minimum of 6 months after elective drug-eluting stent placement and at least 12 months of DAPT after ACS; however, the benefits of prolonged treatment are unclear. The purpose of this review was to conduct a detailed examination of the data refuting or supporting the use of DAPT beyond 1 year in patients with ACS and in patients receiving percutaneous coronary intervention with stenting. METHODS A search of PubMed was performed to identify articles published in the last 20 years that addressed the role of DAPT beyond 12 months' duration. FINDINGS A number of studies have shown ischemic benefits associated with prolonging DAPT beyond 12 months, but this finding is dependent on the patient population studied and the quality of the study design. Many studies also show that longer duration therapy has been associated with increased bleeding risk. In patients with previous myocardial infarction completing at least 1 year of DAPT, continuing DAPT with a reduced dose of ticagrelor 60 mg BID is a regimen to be considered for these patients; in general ACS patients, a reduced dose of 60 mg BID of ticagrelor after the first year of DAPT should be considered; and in the post-percutaneous coronary intervention patients, DAPT beyond 1 year should be considered after careful evaluation of the patient's thrombotic and bleeding risks. IMPLICATIONS The duration of DAPT, and the choice of P2Y12 inhibitor, should be tailored to the individual patient. To optimize patient outcomes, the benefits and risks associated with prolonging DAPT need to be evaluated, considering comorbidities and the presence of bleeding and ischemic risk factors. Despite some limitations, risk scores, such as the DAPT score, are available to help guide decisions for the best approach for each patient.
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Affiliation(s)
- Paul P Dobesh
- University of Nebraska Medical Center, College of Pharmacy, Omaha, NE, USA.
| | - Shannon W Finks
- University of Tennessee College of Pharmacy, Memphis, TN, USA
| | - Toby C Trujillo
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Pharmacy & Pharmaceutical Sciences, Aurora, CO, USA
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18
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Marquis-Gravel G, Mehta SR, Valgimigli M, Levine GN, Neumann FJ, Granger CB, Costa F, Lordkipanidzé M, Roffi M, Robinson SD, Cantor WJ, Tanguay JF. A Critical Comparison of Canadian and International Guidelines Recommendations for Antiplatelet Therapy in Coronary Artery Disease. Can J Cardiol 2020; 36:1298-1307. [DOI: 10.1016/j.cjca.2019.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 11/22/2019] [Accepted: 12/07/2019] [Indexed: 12/15/2022] Open
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19
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Abstract
Compared with the general population, myocardial infarction (MI) survivors have a higher risk of mortality in the first year after the index event.The aim of this study was to determine the associations between variables obtained during the index admission and 1-year all-cause mortality on follow-up.A cohort of 296 patients was enrolled in the study, with a median age of 63.8 ± 12.68 years. All patients received a coronary angiography and stent implantation by percutaneous coronary intervention. Each variable was tested for association with all-cause mortality, using chi-square tests for categorical and binary variables and t tests for continuous variables. The relative prognostic power of each significant variable was further evaluated by logistic regression before and after adjustment for differences in baseline characteristics.Patients who were deceased after 1-year of MI had significantly higher mean age, increased prevalence of diabetes, and elevated heart rate as compared to those who were surviving. Univariate analysis indicated that patient mortality within 1-year of MI was strongly correlated with higher rates of pump failure on admission (P < .0001), bleeding complications (P = .02), the severity of coronary artery disease measured by Gensini score (P = .04), and decreased left ventricular ejection fraction (LVEF) (P < .0001). After adjustment of baseline variables, only pump failure (P = .006) and reduced LVEF (P < .0001) were independently associated with 1-year mortality.Our study shows that LVEF dysfunction and pump failure are independent predictors of 1-year all-cause post-MI mortality, while the severity of coronary artery disease and bleeding did not qualify as independent predictors. Also, age, history of diabetes, and elevated heart rate may be used as markers for increased mortality rates.
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20
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Abstract
Dual antiplatelet therapy (DAPT) duration in patients undergoing percutaneous coronary intervention (PCI) has long been considered a matter of controversy. Complex-PCI (C-PCI) is considered to be associated with an increased ischemic risk that tends to be greater with progressively higher procedural complexity. Thus, with a view to balance ischemic versus bleeding risks, high complexity of PCI intuitively represents an advocate of prolonged DAPT duration. However, the optimal DAPT strategy in this high ischemic risk subset of patients remains unclear, a fact that is exacerbated by the absence of a universal definition of C-PCI, resulting in a significant between-study heterogeneity. The aim of this review is to highlight the increased risks associated with C-PCI, compare long- versus short-term DAPT regimens regarding safety and efficacy endpoints as well as investigate outcomes in special C-PCI cohorts, such as patients with bifurcation, left main or chronic total occlusion lesions. Furthermore, controversial issues, such as antithrombotic regimens in C-PCI patients with atrial fibrillation, and future perspectives are addressed.
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21
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Abstract
PURPOSE OF REVIEW Perioperative management of antiplatelet agents (APAs) in the setting of noncardiac surgery is a controversial topic of balancing bleeding versus thrombotic risks. RECENT FINDINGS Recent data do not support a clear association between continuation or discontinuation of APAs and rates of ischemic events, bleeding complications, and mortality up to 6 months after surgery. Clinical factors, such as indication and urgency of the operation, time since stent placement, invasiveness of the procedure, preoperative cardiac optimization, underlying functional status, as well as perioperative control of supply-demand mismatch and bleeding may be more responsible for adverse outcome than antiplatelet management. SUMMARY Perioperative management of antiplatelet therapy (APT) should be individually tailored based on consensus among the anesthesiologist, cardiologist, surgeon, and patient to minimize both ischemic/thrombotic and bleeding risks. Where possible, surgery should be delayed for a minimum of 1 month but ideally for 3-6 months from the index cardiac event. If bleeding risk is acceptable, dual APT (DAPT) should be continued perioperatively; otherwise P2Y12 inhibitor therapy should be discontinued for the minimum amount of time possible and aspirin monotherapy continued. If bleeding risk is prohibitive, both aspirin and P2Y12 inhibitor therapy should be interrupted and bridging therapy may be considered in patients with high thrombotic risk.
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22
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Pasea L, Chung SC, Pujades-Rodriguez M, Shah AD, Alvarez-Madrazo S, Allan V, Teo JT, Bean D, Sofat R, Dobson R, Banerjee A, Patel RS, Timmis A, Denaxas S, Hemingway H. Bleeding in cardiac patients prescribed antithrombotic drugs: electronic health record phenotyping algorithms, incidence, trends and prognosis. BMC Med 2019; 17:206. [PMID: 31744503 PMCID: PMC6864929 DOI: 10.1186/s12916-019-1438-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Clinical guidelines and public health authorities lack recommendations on scalable approaches to defining and monitoring the occurrence and severity of bleeding in populations prescribed antithrombotic therapy. METHODS We examined linked primary care, hospital admission and death registry electronic health records (CALIBER 1998-2010, England) of patients with newly diagnosed atrial fibrillation, acute myocardial infarction, unstable angina or stable angina with the aim to develop algorithms for bleeding events. Using the developed bleeding phenotypes, Kaplan-Meier plots were used to estimate the incidence of bleeding events and we used Cox regression models to assess the prognosis for all-cause mortality, atherothrombotic events and further bleeding. RESULTS We present electronic health record phenotyping algorithms for bleeding based on bleeding diagnosis in primary or hospital care, symptoms, transfusion, surgical procedures and haemoglobin values. In validation of the phenotype, we estimated a positive predictive value of 0.88 (95% CI 0.64, 0.99) for hospitalised bleeding. Amongst 128,815 patients, 27,259 (21.2%) had at least 1 bleeding event, with 5-year risks of bleeding of 29.1%, 21.9%, 25.3% and 23.4% following diagnoses of atrial fibrillation, acute myocardial infarction, unstable angina and stable angina, respectively. Rates of hospitalised bleeding per 1000 patients more than doubled from 1.02 (95% CI 0.83, 1.22) in January 1998 to 2.68 (95% CI 2.49, 2.88) in December 2009 coinciding with the increased rates of antiplatelet and vitamin K antagonist prescribing. Patients with hospitalised bleeding and primary care bleeding, with or without markers of severity, were at increased risk of all-cause mortality and atherothrombotic events compared to those with no bleeding. For example, the hazard ratio for all-cause mortality was 1.98 (95% CI 1.86, 2.11) for primary care bleeding with markers of severity and 1.99 (95% CI 1.92, 2.05) for hospitalised bleeding without markers of severity, compared to patients with no bleeding. CONCLUSIONS Electronic health record bleeding phenotyping algorithms offer a scalable approach to monitoring bleeding in the population. Incidence of bleeding has doubled in incidence since 1998, affects one in four cardiovascular disease patients, and is associated with poor prognosis. Efforts are required to tackle this iatrogenic epidemic.
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Affiliation(s)
- Laura Pasea
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Sheng-Chia Chung
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | | | - Anoop D Shah
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Samantha Alvarez-Madrazo
- Health Data Research UK Scotland, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Victoria Allan
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - James T Teo
- Department of Stroke and Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Reecha Sofat
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Richard Dobson
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Amitava Banerjee
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Riyaz S Patel
- Institute of Health Informatics, University College London, London, UK
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Adam Timmis
- Bart's Heart Centre, Queen Mary University London, London, UK
| | - Spiros Denaxas
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Harry Hemingway
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK.
- Institute of Health Informatics, University College London, London, UK.
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK.
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23
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Urban P, Mehran R, Colleran R, Angiolillo DJ, Byrne RA, Capodanno D, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Laschinger J, Leon MB, Magee PFA, Mitsutake Y, Mylotte D, Pocock S, Price MJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhoevel U, Yeh RW, Krucoff MW, Morice MC. Defining high bleeding risk in patients undergoing percutaneous coronary intervention: a consensus document from the Academic Research Consortium for High Bleeding Risk. Eur Heart J 2019; 40:2632-2653. [PMID: 31116395 PMCID: PMC6736433 DOI: 10.1093/eurheartj/ehz372] [Citation(s) in RCA: 320] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention-related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Philip Urban
- La Tour Hospital, Geneva, Switzerland
- Cardiovascular European Research Center, Massy, France
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Roisin Colleran
- Deutsches Herzzentrum München, Technische Universität München,
Germany
| | | | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München,
Germany
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti,
Catania, Italy
- Azienda Ospedaliero Universitario “Vittorio Emanuele-Policlinico,”
University of Catania, Italy
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and
Inserm, Inra, Centre de recherche en cardiovasculaire et nutrition, Faculté de Médecine,
Aix-Marseille Université, Marseille, France
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA
| | | | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD
| | - C Michael Gibson
- Harvard Medical School, Boston, MA
- Baim Institute for Clinical Research, Brookline, MA
| | - John Gregson
- London School of Hygiene and Tropical Medicine, UK
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center,
Uppsala University, Sweden
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Korea
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School
of Medicine, Japan
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices
Agency, Tokyo, Japan
| | | | - Martin B Leon
- Columbia University Medical Center, New York, NY
- Cardiovascular Research Foundation, New York, NY
| | | | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices
Agency, Tokyo, Japan
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway
| | | | | | - Sunil V Rao
- Duke Clinical Research Institute, Durham, NC
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the
Netherlands
- Cardialysis, Clinical Trial Management and Core Laboratories,
Rotterdam, the Netherlands
| | | | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern,
Switzerland
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance publique - hôpitaux
de Paris, Paris, France
- Université Paris Descartes, Sorbonne Paris-Cité, France
| | | | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, MA
| | - Mitchell W Krucoff
- Duke Clinical Research Institute, Durham, NC
- Duke University Medical Center, Durham, NC
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24
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Urban P, Mehran R, Colleran R, Angiolillo DJ, Byrne RA, Capodanno D, Cuisset T, Cutlip D, Eerdmans P, Eikelboom J, Farb A, Gibson CM, Gregson J, Haude M, James SK, Kim HS, Kimura T, Konishi A, Laschinger J, Leon MB, Magee PA, Mitsutake Y, Mylotte D, Pocock S, Price MJ, Rao SV, Spitzer E, Stockbridge N, Valgimigli M, Varenne O, Windhoevel U, Yeh RW, Krucoff MW, Morice MC. Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention. Circulation 2019; 140:240-261. [PMID: 31116032 PMCID: PMC6636810 DOI: 10.1161/circulationaha.119.040167] [Citation(s) in RCA: 433] [Impact Index Per Article: 86.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Identification and management of patients at high bleeding risk undergoing percutaneous coronary intervention are of major importance, but a lack of standardization in defining this population limits trial design, data interpretation, and clinical decision-making. The Academic Research Consortium for High Bleeding Risk (ARC-HBR) is a collaboration among leading research organizations, regulatory authorities, and physician-scientists from the United States, Asia, and Europe focusing on percutaneous coronary intervention-related bleeding. Two meetings of the 31-member consortium were held in Washington, DC, in April 2018 and in Paris, France, in October 2018. These meetings were organized by the Cardiovascular European Research Center on behalf of the ARC-HBR group and included representatives of the US Food and Drug Administration and the Japanese Pharmaceuticals and Medical Devices Agency, as well as observers from the pharmaceutical and medical device industries. A consensus definition of patients at high bleeding risk was developed that was based on review of the available evidence. The definition is intended to provide consistency in defining this population for clinical trials and to complement clinical decision-making and regulatory review. The proposed ARC-HBR consensus document represents the first pragmatic approach to a consistent definition of high bleeding risk in clinical trials evaluating the safety and effectiveness of devices and drug regimens for patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Philip Urban
- La Tour Hospital, Geneva, Switzerland (P.U.)
- Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Roisin Colleran
- Deutsches Herzzentrum München, Technische Universität München, Germany (R.C., R.A.B.)
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Robert A. Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany (R.A.B.)
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti (D. Capodanno), Catania, Italy
- Azienda Ospedaliero Universitario “Vittorio Emanuele-Policlinico,” University of Catania, Italy (D. Capodanno)
| | - Thomas Cuisset
- Département de Cardiologie, Centre Hospitalier Universitaire Timone and Inserm, Inra, Centre de recherche en cardiovasculaire et nutrition, Faculté de Médecine, Aix-Marseille Université, Marseille, France (T.C.)
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (D. Cutlip)
| | - Pedro Eerdmans
- Head of the Notified Body, DEKRA Certification B.V. (P.E.)
| | - John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada (J.E.)
| | - Andrew Farb
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - C. Michael Gibson
- Baim Institute for Clinical Research, Brookline, MA (C.M.G.)
- Harvard Medical School, Boston, MA (C.M.G.)
| | - John Gregson
- London School of Hygiene and Tropical Medicine, UK (J.G., S.P.)
| | - Michael Haude
- Städtische Kliniken Neuss, Lukaskrankenhaus GmbH, Germany (M.H.)
| | - Stefan K. James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Sweden (S.K.J.)
| | - Hyo-Soo Kim
- Cardiovascular Center, Seoul National University Hospital, Korea (H.-S.K.)
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (T.K.)
| | - Akihide Konishi
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (A.K., Y.M.)
| | - John Laschinger
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Martin B. Leon
- Columbia University Medical Center, New York, NY (M.B.L.)
- Cardiovascular Research Foundation, New York, NY (M.B.L.)
| | - P.F. Adrian Magee
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Yoshiaki Mitsutake
- Office of Medical Devices 1, Pharmaceuticals and Medical Devices Agency, Tokyo, Japan (A.K., Y.M.)
| | - Darren Mylotte
- University Hospital and National University of Ireland, Galway (D.M.)
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, UK (J.G., S.P.)
| | | | - Sunil V. Rao
- Duke Clinical Research Institute, Durham, NC (S.V.R., M.W.K.)
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands (E.S.)
- Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands (E.S.)
| | - Norman Stockbridge
- US Food and Drug Administration, Silver Spring, MD (A.F., J.L., P.F.A.M., N.S.)
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, University of Bern, Switzerland (M.V.)
| | - Olivier Varenne
- Service de Cardiologie, Hôpital Cochin, Assistance publique - hôpitaux de Paris, Paris, France (O.V.)
- Université Paris Descartes, Sorbonne Paris-Cité, France (O.V.)
| | - Ute Windhoevel
- Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
| | - Robert W. Yeh
- Beth Israel Deaconess Medical Center, Boston, MA (R.W.Y.)
| | - Mitchell W. Krucoff
- Duke Clinical Research Institute, Durham, NC (S.V.R., M.W.K.)
- Duke University Medical Center, Durham, NC (M.W.K.)
| | - Marie-Claude Morice
- Cardiovascular European Research Center, Massy, France (P.U., U.W., M.-C.M.)
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25
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Chew DP, Bhatt DL. Predicting Risk in ACS: Taking the Long-Term View. J Am Coll Cardiol 2019; 70:1858-1860. [PMID: 28982498 DOI: 10.1016/j.jacc.2017.08.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Derek P Chew
- School of Medicine, Flinders University of South Australia, Adelaide, South Australia, Australia.
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
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26
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Tervonen T, Angelis A, Hockley K, Pignatti F, Phillips LD. Quantifying Preferences in Drug Benefit-Risk Decisions. Clin Pharmacol Ther 2019; 106:955-959. [PMID: 30929257 DOI: 10.1002/cpt.1447] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/21/2019] [Indexed: 01/13/2023]
Abstract
Benefit-risk assessment is used in various phases along the drug lifecycle, such as marketing authorization and surveillance, health technology assessment (HTA), and clinical decisions, to understand whether, and for which patients, a drug has a favorable or more valuable profile with reference to one or more comparators. Such assessments are inherently preference-based as several clinical and nonclinical outcomes of varying importance might act as evaluation criteria, and decision makers must establish acceptable trade-offs between these outcomes. Different healthcare stakeholder perspectives, such as those from patients and healthcare professionals, are key for informing benefit-risk trade-offs. However, the degree to which such preferences inform the decision is often unclear as formal preference-based evaluation frameworks are generally not used for regulatory decisions, and, if used, rarely communicated in HTA decisions. We argue that for better decisions, as well as for reasons of transparency, preferences in benefit-risk decisions should more often be quantified and communicated explicitly.
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Affiliation(s)
| | - Aris Angelis
- Department of Health Policy and LSE Health, London School of Economics and Political Science, London, UK
| | | | | | - Lawrence D Phillips
- Department of Management, London School of Economics and Political Science, London, UK
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27
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Pinto CA, Tervonen T, Marsh K, Lambrelli D, Schultze A, Tershakovec A, Hyacinthe J, Prawitz T, Hammad TA. Personalized benefit-risk assessments combining clinical trial and real-world data provide further insights into which patients may benefit most from therapy: Demonstration for a new oral antiplatelet therapy. Pharmacoepidemiol Drug Saf 2019; 28:443-451. [PMID: 30848010 DOI: 10.1002/pds.4752] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 11/11/2022]
Abstract
PURPOSE Quantitative benefit-risk (B-R) assessments are used to characterize treatment by combining key benefits and risks into a single metric but have historically been done for the "average" patient. Our aim was to conduct an individualized assessment for the oral antiplatelet vorapaxar by combining trial and real-world data to further personalize the treatment profiles. METHODS Using linked UK health care databases, we developed risk prediction equations for key ischemic and bleeding events using Cox proportional hazards models. Trial hazard ratios, relative to placebo, were applied to baseline risk estimates to compute expected attributable risks, summed to derive a per-patient net clinical benefit (NCB). High risk subgroups were defined a priori, and Gaussian mixture models (GMM) were fit to characterize the NCB distribution and identify subgroups with similar NCBs. RESULTS NCB was consistently positive for all subgroups, likely due to the outcome correlation, and would remain positive with a 12-fold increase in bleeding risk. GMMs identified three distinct NCB subgroups. Compared with the middle/lower NCB subgroups, those with a higher NCB tended to be older, female, and have higher CV disease burden. CONCLUSIONS Personalized B-R assessments are feasible and clinically valuable and can be used to better predict who would benefit most from therapy.
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28
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Affiliation(s)
- Abhishek Joshi
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
- Bart’s Heart Centre, St. Bartholomew’s Hospital, London, United Kingdom
| | - Manuel Mayr
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, United Kingdom
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29
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Antithrombotic Therapy for Atrial Fibrillation and Coronary Disease Demystified. Can J Cardiol 2018; 34:1426-1436. [DOI: 10.1016/j.cjca.2018.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 08/11/2018] [Accepted: 08/12/2018] [Indexed: 11/22/2022] Open
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30
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Brener SJ, Kirtane AJ, Rinaldi MJ, Stuckey TD, Witzenbichler B, Weisz G, Neumann FJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Mazzaferri EL, Gurbel PA, Brodie BR, Mehran R, McAndrew T, Stone GW. Prediction of Ischemic and Bleeding Events Using the Dual Antiplatelet Therapy Score in an Unrestricted Percutaneous Coronary Intervention Population. Circ Cardiovasc Interv 2018; 11:e006853. [DOI: 10.1161/circinterventions.118.006853] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | - Ajay J. Kirtane
- NewYork-Presbyterian Hospital/Columbia University Medical Center (A.J.K., G.W.S.)
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., G.W., R.M., T.M., G.W.S.)
| | - Michael J. Rinaldi
- Sanger Heart and Vascular Institute, Carolinas HealthCare System, Charlotte, NC (M.J.R.)
| | - Thomas D. Stuckey
- LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, NC (T.D.S., B.R.B.)
| | | | - Giora Weisz
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., G.W., R.M., T.M., G.W.S.)
- Montefiore Medical Center, Bronx, NY (G.W.)
| | | | | | - Timothy D. Henry
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, MN (T.D.H.)
- Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.)
| | - David A. Cox
- CVA Brookwood Baptist Hospital, Birmingham, AL (D.A.C.)
| | - Peter L. Duffy
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, NC (P.L.D.)
| | | | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G.)
| | - Bruce R. Brodie
- LeBauer-Brodie Center for Cardiovascular Research and Education/Cone Health, Greensboro, NC (T.D.S., B.R.B.)
| | - Roxana Mehran
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., G.W., R.M., T.M., G.W.S.)
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY (R.M.)
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., G.W., R.M., T.M., G.W.S.)
| | - Gregg W. Stone
- NewYork-Presbyterian Hospital/Columbia University Medical Center (A.J.K., G.W.S.)
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY (A.J.K., G.W., R.M., T.M., G.W.S.)
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31
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Ueda P, Jernberg T, James S, Alfredsson J, Erlinge D, Omerovic E, Persson J, Ravn-Fischer A, Tornvall P, Svennblad B, Varenhorst C. External Validation of the DAPT Score in a Nationwide Population. J Am Coll Cardiol 2018; 72:1069-1078. [DOI: 10.1016/j.jacc.2018.06.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/31/2018] [Accepted: 06/04/2018] [Indexed: 11/16/2022]
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32
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Affiliation(s)
- Thomas F Lüscher
- Consultant and Director of Research, Education & Development, Royal Brompton and Harefield Hospital Trust, London, UK
- Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland
- EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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33
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Hemingway H, Asselbergs FW, Danesh J, Dobson R, Maniadakis N, Maggioni A, van Thiel GJM, Cronin M, Brobert G, Vardas P, Anker SD, Grobbee DE, Denaxas S. Big data from electronic health records for early and late translational cardiovascular research: challenges and potential. Eur Heart J 2018; 39:1481-1495. [PMID: 29370377 PMCID: PMC6019015 DOI: 10.1093/eurheartj/ehx487] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/19/2017] [Accepted: 08/08/2017] [Indexed: 12/13/2022] Open
Abstract
Aims Cohorts of millions of people's health records, whole genome sequencing, imaging, sensor, societal and publicly available data present a rapidly expanding digital trace of health. We aimed to critically review, for the first time, the challenges and potential of big data across early and late stages of translational cardiovascular disease research. Methods and results We sought exemplars based on literature reviews and expertise across the BigData@Heart Consortium. We identified formidable challenges including: data quality, knowing what data exist, the legal and ethical framework for their use, data sharing, building and maintaining public trust, developing standards for defining disease, developing tools for scalable, replicable science and equipping the clinical and scientific work force with new inter-disciplinary skills. Opportunities claimed for big health record data include: richer profiles of health and disease from birth to death and from the molecular to the societal scale; accelerated understanding of disease causation and progression, discovery of new mechanisms and treatment-relevant disease sub-phenotypes, understanding health and diseases in whole populations and whole health systems and returning actionable feedback loops to improve (and potentially disrupt) existing models of research and care, with greater efficiency. In early translational research we identified exemplars including: discovery of fundamental biological processes e.g. linking exome sequences to lifelong electronic health records (EHR) (e.g. human knockout experiments); drug development: genomic approaches to drug target validation; precision medicine: e.g. DNA integrated into hospital EHR for pre-emptive pharmacogenomics. In late translational research we identified exemplars including: learning health systems with outcome trials integrated into clinical care; citizen driven health with 24/7 multi-parameter patient monitoring to improve outcomes and population-based linkages of multiple EHR sources for higher resolution clinical epidemiology and public health. Conclusion High volumes of inherently diverse ('big') EHR data are beginning to disrupt the nature of cardiovascular research and care. Such big data have the potential to improve our understanding of disease causation and classification relevant for early translation and to contribute actionable analytics to improve health and healthcare.
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Affiliation(s)
- Harry Hemingway
- Research Department of Clinical Epidemiology, The Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, UK
- The National Institute for Health Research, Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, 222 Euston Road, London NW1 2DA, UK
| | - Folkert W Asselbergs
- Research Department of Clinical Epidemiology, The Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, UK
- The National Institute for Health Research, Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, 222 Euston Road, London NW1 2DA, UK
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - John Danesh
- MRC/BHF Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Worts Causeway, Cambridge CB1 8RN, UK
| | - Richard Dobson
- Research Department of Clinical Epidemiology, The Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, UK
- The National Institute for Health Research, Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, 222 Euston Road, London NW1 2DA, UK
- NIHR Biomedical Research Centre for Mental Health (IOP), King‘s College London, De Crespigny Park, London SE5 8AF, UK
| | - Nikolaos Maniadakis
- European Society of Cardiology (ESC), 2035 Route des Colles, Les Templiers - CS 80179 Biot, 06903 Sophia Antipolis, France
| | - Aldo Maggioni
- European Society of Cardiology (ESC), 2035 Route des Colles, Les Templiers - CS 80179 Biot, 06903 Sophia Antipolis, France
| | - Ghislaine J M van Thiel
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Maureen Cronin
- Vifor Pharma Ltd, lughofstrasse 61, 8152 Glattbrugg, Zurich, Switzerland
| | - Gunnar Brobert
- Department of Epidemiology, Bayer Pharma AG, Müllerstrasse 178, 13353 Berlin, Germany
| | - Panos Vardas
- European Society of Cardiology (ESC), 2035 Route des Colles, Les Templiers - CS 80179 Biot, 06903 Sophia Antipolis, France
| | - Stefan D Anker
- Division of Cardiology and Metabolism—Heart Failure, Cachexia & Sarcopenia; Department of Cardiology (CVK), Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité University Medicine, Charitépl. 1, 10117 Berlin, Germany
- Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Robert-Koch-Strasse 40, 37099, Göttingen, Germany
| | - Diederick E Grobbee
- Julius Centre for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Spiros Denaxas
- Research Department of Clinical Epidemiology, The Farr Institute of Health Informatics Research, University College London, 222 Euston Road, London NW1 2DA, UK
- The National Institute for Health Research, Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, University College London, 222 Euston Road, London NW1 2DA, UK
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Impact of platelet reactivity on 5-year clinical outcomes following percutaneous coronary intervention: a landmark analysis. J Thromb Thrombolysis 2018; 45:496-503. [DOI: 10.1007/s11239-018-1630-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pujades-Rodriguez M, Guttmann OP, Gonzalez-Izquierdo A, Duyx B, O’Mahony C, Elliott P, Hemingway H. Identifying unmet clinical need in hypertrophic cardiomyopathy using national electronic health records. PLoS One 2018; 13:e0191214. [PMID: 29324812 PMCID: PMC5764451 DOI: 10.1371/journal.pone.0191214] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 12/29/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction To evaluate unmet clinical need in unselected hypertrophic cardiomyopathy (HCM) patients to determine the risk of a wide range of subsequent cardiovascular disease endpoints and safety endpoints relevant for trial design. Methods Population based cohort (CALIBER, linked primary care, hospital and mortality records in England, period 1997–2010), all people diagnosed with HCM were identified and matched by age, sex and general practice with ten randomly selected people without HCM. Random-effects Poisson models were used to assess the associations between HCM and cardiovascular diseases and bleeding. Results Among 3,290,455 eligible people a diagnosis of hypertrophic cardiomyopathy was found in 4 per 10,000. Forty-one percent of the 1,160 individuals with hypertrophic cardiomyopathy were women and the median age was 57 years. The median follow-up was 4.0 years. Compared to general population controls, people with HCM had higher risk of ventricular arrhythmia (incidence rate ratio = 23.53, [95% confidence interval 12.67–43.72]), cardiac arrest or sudden cardiac death (6.33 [3.69–10.85]), heart failure (4.31, [3.30–5.62]), and atrial fibrillation (3.80 [3.04–4.75]). HCM was also associated with a higher incidence of myocardial infarction ([MI] 1.90 [1.27–2.84]) and coronary revascularisation (2.32 [1.46–3.69]).The absolute Kaplan-Meier risks at 3 years were 8.8% for the composite endpoint of cardiovascular death or heart failure, 8.4% for the composite of cardiovascular death, stroke or myocardial infarction, and 1.5% for major bleeding. Conclusions Our study identified major unmet need in HCM and highlighted the importance of implementing improved cardiovascular prevention strategies to increase life-expectancy of the contemporary HCM population. They also show that national electronic health records provide an effective method for identifying outcomes and clinically relevant estimates of composite efficacy and safety endpoints essential for trial design in rare diseases.
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Affiliation(s)
- Mar Pujades-Rodriguez
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom
- Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, United Kingdom
- * E-mail:
| | - Oliver P. Guttmann
- Institute for Cardiovascular Science, University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew’s Hospital, St Bartholomew’s Hospital, London, United Kingdom
| | - Arturo Gonzalez-Izquierdo
- Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, United Kingdom
| | - Bram Duyx
- Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, United Kingdom
- CAPHRI School for Public Health and Primary Care, Maastricht University, Universiteitssingel, Maastricht, the Netherlands
| | - Constantinos O’Mahony
- Institute for Cardiovascular Science, University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew’s Hospital, St Bartholomew’s Hospital, London, United Kingdom
| | - Perry Elliott
- Institute for Cardiovascular Science, University College London Institute for Cardiovascular Science and Barts Heart Centre, St. Bartholomew’s Hospital, St Bartholomew’s Hospital, London, United Kingdom
| | - Harry Hemingway
- Farr Institute of Health Informatics Research, Institute of Health Informatics, University College London, London, United Kingdom
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Crea F, Binder RK, Lüscher TF. The year in cardiology 2017: acute coronary syndromes. Eur Heart J 2018; 39:1054-1064. [DOI: 10.1093/eurheartj/ehx781] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 12/27/2017] [Indexed: 12/17/2022] Open
Affiliation(s)
- Filippo Crea
- Istituto di Cardiologia, Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Thomas F Lüscher
- Royal Brompton & Harefield Hospital and Imperial College, London, UK
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Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M, Marquis-Gravel G, Robinson SD, Sibbald M, So DY, Wong GC, Abunassar JG, Ackman ML, Bell AD, Cartier R, Douketis JD, Lawler PR, McMurtry MS, Udell JA, van Diepen S, Verma S, Mancini GBJ, Cairns JA, Tanguay JF. 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2017; 34:214-233. [PMID: 29475527 DOI: 10.1016/j.cjca.2017.12.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.
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Affiliation(s)
- Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kevin R Bainey
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Warren J Cantor
- University of Toronto and Southlake Regional Health Centre, Toronto, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | | | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Matthew Sibbald
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graham C Wong
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Margaret L Ackman
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Alan D Bell
- University of Toronto, Toronto, Ontario, Canada
| | - Raymond Cartier
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | - James D Douketis
- McMaster University and St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Patrick R Lawler
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael S McMurtry
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jacob A Udell
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean van Diepen
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Subodh Verma
- University of Toronto and St Michael's Hospital, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John A Cairns
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jean-François Tanguay
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada.
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Lüscher TF. Managing acute coronary syndromes: from novel biomarkers to mechanical support devices and DAPT in thrombocytopenia. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Banerjee A. Challenges for learning health systems in the NHS. Case study: electronic health records in cardiology. Future Healthc J 2017; 4:193-197. [PMID: 31098470 PMCID: PMC6502575 DOI: 10.7861/futurehosp.4-3-193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Electronic health records (EHRs) are at the centre of advances in health informatics, but also many other innovations in healthcare. However, there are still obstacles to implementation and realisation of the full potential of EHRs as there are with learning health systems (LHS). Cardiovascular disease, in the UK and globally, carries greater morbidity and mortality than any other disease. Therefore, planning and delivery of health services represent major costs to individuals and populations. Both the scale of disease burden and the growing role of technology in cardiology practice make analysis of experiences with EHRs in cardiology a useful lens through which to view achievements and gaps to date. In this article regarding LHS, EHRs in cardiology are used as a case study of LHS in the NHS.
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Affiliation(s)
- Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, London, UK
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Alfonso F, Jiménez-Borreguero LJ. Optimizing dual antiplatelet therapy duration after myocardial infarction: evidence-based, precision, or personalized medicine? Eur Heart J 2017; 38:1056-1059. [DOI: 10.1093/eurheartj/ehx127] [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] [Indexed: 11/12/2022] Open
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Hemingway H, Feder GS, Fitzpatrick NK, Denaxas S, Shah AD, Timmis AD. Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BackgroundElectronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.ObjectiveTo evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.DesignEpidemiological cohort, health informatics, health economics and ethnographic approaches were used.Setting230 NHS hospitals and 226 general practices in England and Wales.ParticipantsUp to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.Main outcome measuresQuality of care, fatal and non-fatal cardiovascular disease (CVD) events.Data platform and methodsWe created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.ResultsCALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.ConclusionsEmerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.Future workThe vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.Study registrationCALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).
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Affiliation(s)
- Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Gene S Feder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie K Fitzpatrick
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anoop D Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Adam D Timmis
- Farr Institute of Health Informatics Research, University College London, London, UK
- Barts Health NHS Trust, London, UK
- Farr Institute of Health Informatics Research, Queen Mary University of London, London, UK
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