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Nelson MR, Black JA. Aspirin: latest evidence and developments. Heart 2024:heartjnl-2024-323948. [PMID: 39074973 DOI: 10.1136/heartjnl-2024-323948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/03/2024] [Indexed: 07/31/2024] Open
Abstract
Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.
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Affiliation(s)
- Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - J Andrew Black
- Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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2
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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3
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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4
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Trujillo-Flores D, García-Mendoza JDJ. Atrial fibrillation de novo in acute coronary syndrome. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2024; 94:181-190. [PMID: 38648718 PMCID: PMC11160543 DOI: 10.24875/acm.23000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 06/15/2023] [Indexed: 04/25/2024] Open
Abstract
One of the complications during an acute coronary syndrome event is the presence of arrhythmias. Among them, those of the supraventricular type, especially atrial fibrillation, carry a poor prognosis both in the short and long term, being the cause of situations such as cerebrovascular event, ventricular arrhythmias, and increased mortality. The arrhythmia tends to appear in a certain population group with particular risk factors during the index event in approximately 10% of cases. Appropriate treatment at the time of its onset, thanks to the use of drugs that modulate heart rate, rhythm, and anticoagulant management in the most vulnerable groups, will lead to a less bleak outcome for these patients.
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Affiliation(s)
- David Trujillo-Flores
- Servicio de Consulta Externa de Cardiología
- Servicio de Hospitalización de Cardiología
- Servicio de Ecocardiografía
| | - José de J. García-Mendoza
- Departamento de Electrocardiografía. Clínica Hospital Instituto de Seguridad y Servicios Sociales de los Trabajadores al Servicios de los Poderes del Estado de Puebla, Tehuacán, Pue., México
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5
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Gragnano F, Capolongo A, Micari A, Costa F, Garcia-Ruiz V, De Sio V, Terracciano F, Cesaro A, Moscarella E, Coletta S, Raucci P, Fimiani F, De Luca L, Gargiulo G, Andò G, Calabrò P. Antithrombotic Therapy Optimization in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2023; 13:98. [PMID: 38202105 PMCID: PMC10780105 DOI: 10.3390/jcm13010098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/12/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
The antithrombotic management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) poses numerous challenges. Triple antithrombotic therapy (TAT), which combines dual antiplatelet therapy (DAPT) with oral anticoagulation (OAC), provides anti-ischemic protection but increases the risk of bleeding. Therefore, TAT is generally limited to a short phase (1 week) after PCI, followed by aspirin withdrawal and continuation of 6-12 months of dual antithrombotic therapy (DAT), comprising OAC plus clopidogrel, followed by OAC alone. This pharmacological approach has been shown to mitigate bleeding risk while preserving adequate anti-ischemic efficacy. However, the decision-making process remains complex in elderly patients and those with co-morbidities, significantly influencing ischemic and bleeding risk. In this review, we discuss the available evidence in this area from randomized clinical trials and meta-analyses for post-procedural antithrombotic therapies in patients with non-valvular AF undergoing PCI.
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Capolongo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98122 Messina, Italy; (A.M.); (F.C.)
| | | | - Vincenzo De Sio
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabrizia Terracciano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Silvio Coletta
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Pasquale Raucci
- Division of Health Technology Assessment, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, Azienda Ospedaliera di Rilievo Nazionale Dei Colli, “Vincenzo Monaldi”, CCMR Regione Campania, 80138 Naples, Italy;
| | - Leonardo De Luca
- Division of Cardiology, Department of Cardiosciences, Azienda Ospedaliera San Camillo-Forlanini, 00152 Roma, Italy;
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy;
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy;
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (F.G.); (A.C.); (V.D.S.); (F.T.); (A.C.); (E.M.)
- Division of Clinical Cardiology, Azienda Ospedaliera di Rilievo Nazionale “Sant’Anna e San Sebastiano”, 81100 Caserta, Italy;
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6
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Wang T, Liu X, Zhu Y, Zhang Y, Zhang Z, Huang G, Xu J. Antithrombotic strategy in cancer patients comorbid with acute coronary syndrome and atrial fibrillation. Front Cardiovasc Med 2023; 10:1325488. [PMID: 38162143 PMCID: PMC10756915 DOI: 10.3389/fcvm.2023.1325488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024] Open
Abstract
It has been shown that patients with cancer have a longer expected life duration, benefiting from advanced medical therapy. Meanwhile, the risk of suffering from cardiovascular disease (CVD) has been increasing with ageing. A growing number of studies have elucidated the association between cancer and CVD. Cancer, atrial fibrillation (AF) and coronary artery disease share some common factors and interact with each other, such as obesity, aging, diabetes, and inflammation, but the potential specific mechanism is still unclear. In addition, cancer-specific and therapy-related factors may increase the risk of embolism and bleeding in patients with cancer than in general population. However, current available embolic and bleeding risk scores applied in patients with CVD may not be applicable for risk assessment in cancer patients, which would be difficult for clinicians to select an appropriate antithrombotic regimen and ensure the balance between bleeding and embolism. Moreover, different types of cancer have distinct risks, which may increase the complexity of antithrombotic therapy. In this review, we review the literature related to cancer, AF, and acute coronary syndrome, focusing on the epidemiological status, physiological mechanism, embolism and bleeding risks, and strategies of antithrombotic therapy.
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Affiliation(s)
- Tianbo Wang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Xiaohan Liu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yuxin Zhu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
| | - Yue Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Zhen Zhang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Gang Huang
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
| | - Junbo Xu
- Department of Cardiology, The Third People’s Hospital of Chengdu, Chengdu, China
- Affiliated Hospital of Southwest Jiaotong University, College of Medicine, Southwest Jiaotong University, Chengdu, China
- Cardiovascular Disease Research Institute of Chengdu, Chengdu, China
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7
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Tsigkas G, Vakka A, Apostolos A, Bousoula E, Vythoulkas-Biotis N, Koufou EE, Vasilagkos G, Tsiafoutis I, Hamilos M, Aminian A, Davlouros P. Dual Antiplatelet Therapy and Cancer; Balancing between Ischemic and Bleeding Risk: A Narrative Review. J Cardiovasc Dev Dis 2023; 10:jcdd10040135. [PMID: 37103014 PMCID: PMC10144375 DOI: 10.3390/jcdd10040135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 04/28/2023] Open
Abstract
Cardiovascular (CV) events in patients with cancer can be caused by concomitant CV risk factors, cancer itself, and anticancer therapy. Since malignancy can dysregulate the hemostatic system, predisposing cancer patients to both thrombosis and hemorrhage, the administration of dual antiplatelet therapy (DAPT) to patients with cancer who suffer from acute coronary syndrome (ACS) or undergo percutaneous coronary intervention (PCI) is a clinical challenge to cardiologists. Apart from PCI and ACS, other structural interventions, such as TAVR, PFO-ASD closure, and LAA occlusion, and non-cardiac diseases, such as PAD and CVAs, may require DAPT. The aim of the present review is to review the current literature on the optimal antiplatelet therapy and duration of DAPT for oncologic patients, in order to reduce both the ischemic and bleeding risk in this high-risk population.
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Affiliation(s)
- Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Angeliki Vakka
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Anastasios Apostolos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
- First Department of Cardiology, Hippocration General Hospital, National and Kapodistrian University of Athens, 157 72 Athens, Greece
| | - Eleni Bousoula
- Department of Cardiology, Tzaneio General Hospital, 185 36 Piraeus, Greece
| | | | | | - Georgios Vasilagkos
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
| | - Ioannis Tsiafoutis
- First Department of Cardiology, Red Cross Hospital, 115 26 Athens, Greece
| | - Michalis Hamilos
- Department of Cardiology, Heraklion University Hospital, 715 00 Heraklion, Crete, Greece
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, 6042 Charleroi, Belgium
| | - Periklis Davlouros
- Department of Cardiology, University Hospital of Patras, 265 04 Patras, Greece
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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9
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He H, Xiao X, Yuan X, Chen J. Therapeutic effect of antithrombotic drug combinations in patients with atrial fibrillation undergoing percutaneous coronary intervention for coronary heart disease: a meta-analysis. Am J Transl Res 2022; 14:8416-8428. [PMID: 36628223 PMCID: PMC9827321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/25/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To explore suitable treatment strategies for patients with coronary heart disease and atrial fibrillation after percutaneous coronary intervention (PCI) via systematically analyzing and comparing the clinical efficacy of dual antithrombotic therapy (DAT) and triple antithrombotic therapy (TAT). METHODS Pubmed, Embase and Cochrane Library databases were searched. The literature from the database establishment to August 2022 was reviewed by 2 researchers separately according to the inclusion and exclusion criteria and the method recommended by the Cochrane Collaboration. The data was extracted for quality assessment. The primary endpoints of the study were safety endpoints and efficacy endpoints, the former includes major bleeding events and the latter includes mortality, myocardial infarction, stent thrombosis and stroke. RevMan5.4 software was used for meta-analysis. RESULTS There were 11 studies were included for the meta-analysis, 5 observational studies and 6 randomized controlled trials. The number of patients included was 2,4032, of which 13818 (57.5%) received DAT and 9483 (39.5%) received TAT. Our analyses indicated that compared with TAT treatment, DAT significantly reduced the incidence of major bleeding (OR=0.71, 95% CI [0.61, 0.83], P<0.0001) and the incidence of minor bleeding (OR=0.61, 95% CI [0.50, 0.75], P<0.00001). Subgroup analysis showed that DAT with novel oral anticoagulants (NOACs) reduced major bleeding (OR=0.64, 95% CI [0.54, 0.76], P<0.00001) and the incidence of minor bleeding (OR=0.56, 95% CI [0.45, 0.69], P<0.00001), but DAT with vitamin K antagonists (VKAs) was not significantly different from TAT in major bleeding (OR=1.20, 95% CI [0.82, 1.75], P=0.35) and minor bleeding (OR=1.15, 95% CI [0.64, 2.05], P=0.64). CONCLUSIONS DAT with NOACs has a higher safety profile against bleeding in patients with atrial fibrillation after PCI. DAT with VKAs was similar to TAT in terms of antithrombotic effect and incidence of bleeding.
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Affiliation(s)
- Huabin He
- Department of Cardiology, Jiujiang First People’s HospitalJiujiang 332000, Jiangxi, China
| | - Xifeng Xiao
- Department of Gastroenterology, Jiujiang First People’s HospitalJiujiang 332000, Jiangxi, China
| | - Xiangyang Yuan
- Department of Cardiology, Jiujiang First People’s HospitalJiujiang 332000, Jiangxi, China
| | - Jianhai Chen
- Department of Cardiology, Jiujiang First People’s HospitalJiujiang 332000, Jiangxi, China
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Szapáry L, Tornyos D, Kupó P, Lukács R, El Alaoui El Abdallaoui O, Komócsi A. Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:1036609. [PMID: 36568540 PMCID: PMC9773199 DOI: 10.3389/fcvm.2022.1036609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Background Despite numerous randomized clinical trials (RCT), data regarding the efficacy of antiplatelet and anticoagulant combinations are still conflicting. We aimed to analyze treatment options tested in various fields of cardiovascular prevention, regarding their efficacy and bleeding risk. Methods Systematic searches of electronic databases were conducted until June 2022. A component network meta-analysis was performed in R. Risk estimates across trials were pooled using random-effects model selecting risk ratio (RR) with 95% confidence intervals (95% CIs) as summary statistics. The primary endpoint of interest was the rate of major cardiac adverse events (MACE). Major bleeding events were assessed as main safety endpoint. Secondary outcomes included cardiovascular- and overall mortality, myocardial infarction (MI), stent thrombosis, and stroke. Results Fifteen studies randomizing 73,536 patients were identified. The MACE risk reflected heterogeneity among the anticoagulants with dabigatran and apixaban significantly reducing the risk of MACE (RR 0.56; 95% CI 0.39-0.80 and RR 0.75; 95% CI 0.58-0.98, respectively). Vitamin K antagonist (VKA), rivaroxaban, or edoxaban did not reduced of MACE while it was associated with a significant increase of bleeding risk (RR 1.66; 3.66, and 5.47, respectively). The direct anticoagulant (DOAC) dose reduction resulted in tendencies of fewer bleeding but higher MACE risk, while combination with aspirin was followed with increased risk for bleeding, however, remained non-significant in these cases. Conclusion Our meta-analysis supports that the ischemic-bleeding balance is different among direct-acting oral anticoagulants (DOACs) while this is not significantly affected by the dose reduction approaches. Long-term aspirin treatment as part of the anticoagulant and dual antiplatelet regimen provides no ischemic benefit but may increase bleeding risk. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [259703].
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11
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The Association of Sex with Unplanned Cardiac Readmissions following Percutaneous Coronary Intervention in Australia: Results from a Multicentre Outcomes Registry (GenesisCare Cardiovascular Outcomes Registry). J Clin Med 2022; 11:jcm11226866. [PMID: 36431346 PMCID: PMC9692358 DOI: 10.3390/jcm11226866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022] Open
Abstract
Background and aim: Unplanned cardiac readmissions in patients with percutaneous intervention (PCI) is very common and is seen as a quality indicator of in-hospital care. Most studies have reported on the 30-day cardiac readmission rates, with very limited information being available on 1-year readmission rates and their association with mortality. The aim of this study was to investigate the impact of biological sex at 1-year post-PCI on unplanned cardiac readmissions. Methods and results: Patients enrolled into the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from December 2008 to December 2020 were included in the study. A total of 13,996 patients completed 12 months of follow-up and were assessed for unplanned cardiac readmissions. All patients with unplanned cardiac readmissions in the first year of post-PCI were followed in year 2 (post-PCI) for survival status. The rate of unplanned cardiac readmissions was 10.1%. Women had a 29% higher risk of unplanned cardiac readmission (HR 1.29, 95% CI 1.11 to 1.48; p = 0.001), and female sex was identified as an independent predictor of unplanned cardiac readmissions. Any unplanned cardiac readmission in the first year was associated with a 2.5-fold higher risk of mortality (HR 2.50, 95% CI 1.67 to 3.75; p < 0.001), which was similar for men and women. Conclusion: Unplanned cardiac readmissions in the first year post-PCI was strongly associated with increased all-cause mortality. Whilst the incidence of all-cause mortality was similar between women and men, a higher incidence of unplanned cardiac readmissions was observed for women, suggesting distinct predictors of unplanned cardiac readmissions exist between women and men.
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12
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Parfrey S, Abdelrahman A, Blackman D, Blaxill JM, Cunnington MS, Greenwood JP, Malkin CJ, Mozid AM, Rossington JA, Veerasamy M, Wassef N, Wheatcroft SB, Bulluck H. Safety and efficacy of interrupting dual antiplatelet therapy one month following percutaneous coronary intervention: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2022; 22:450. [PMID: 36307769 PMCID: PMC9615356 DOI: 10.1186/s12872-022-02900-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
Very short duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) has recently attracted a lot of attention with the introduction of newer generations stents. This is appealing, especially in patients at high bleeding risk. However, none of the trials were powered for the individual ischemic and bleeding endpoints. All randomised controlled trials (RCTs) investigating one-month versus routine duration of DAPT in patients undergoing PCI and reporting outcomes from the time of cessation of DAPT (1 month) to 1 year were eligible for inclusion in the meta-analysis. The pooled risk ratios (RR) with their 95% confidence interval (CI) were calculated with the random-effects model using the Mantel-Haenszel method. Four RCTs involving 26,576 patients were included in this meta-analysis. Cessation of DAPT after 1 month was associated with significantly less major bleeding [RR 0.70, 95%CI (0.51–0.95), P = 0.02, heterogeneity (I2) = 42%]. There was no statistically significant difference in all-cause mortality [RR 0.84 (95%CI 0.69–1.03), P = 0.10, I2 = 0%] and stroke [RR 0.71 (95%CI 0.45–1.13), P = 0.15, I2 = 42%] when compared to routine duration of DAPT. There was also no difference in myocardial infarction (MI) [RR 1.12 (95%CI 0.91–1.39), P = 0.28, I2 = 0%], and definite or probable stent thrombosis [RR 1.49 (95%CI 0.92–2.41), P = 0.11, I2 = 0%] with cessation of DAPT after 1 month. Cessation of DAPT 1 month after PCI was associated with significantly less major bleeding, but there was no difference in the rate of all-cause mortality, stroke, MI and stent thrombosis.
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Martens KL, Dekker SE, Crowe M, DeLoughery TG, Shatzel JJ. Challenging clinical scenarios for therapeutic anticoagulation: A practical approach. Thromb Res 2022; 218:72-82. [PMID: 36027629 PMCID: PMC9481720 DOI: 10.1016/j.thromres.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/20/2022] [Accepted: 08/15/2022] [Indexed: 01/03/2023]
Abstract
Therapeutic anticoagulation remains a fundamental backbone in the treatment and prevention of venous thromboembolism. However, while modern therapies are increasingly safe, anticoagulation is not without risks, particularly in those at high risk for or with recent bleeding. When weighing concurrent risks and benefits in each challenging clinical scenario, an individualized assessment of the risk and acuity of bleeding should be balanced by the indication for anticoagulation. Addressing modifiable risk factors and routine re-evaluation of any changes in this balance is critical. This review outlines available data and current guidelines for the management of anticoagulation in high-risk populations, including those with thrombocytopenia, elderly and high-fall risk, inherited bleeding disorders, and in acute coronary syndrome. We also examine management after clinically significant bleeding episodes, including intracranial hemorrhage, gastrointestinal bleeding, hemoptysis, retroperitoneal bleeding, hematuria, and abnormal uterine bleeding. The aim is to provide a comprehensive review of available literature to guide clinicians in providing optimal, safe, and individualized care for patients in these challenging scenarios.
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Affiliation(s)
- Kylee L. Martens
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America,Corresponding author at: OHSU Knight Cancer Institute, 3181 SW Sam Jackson Park Road, Mail Code: OC14HO, Portland, OR 97239, United States of America. (K.L. Martens)
| | - Simone E. Dekker
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Megan Crowe
- Division of Internal Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Thomas G. DeLoughery
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
| | - Joseph J. Shatzel
- Division of Hematology-Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, United States of America
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14
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Zwart B, Bor WL, de Veer AJWM, Mahmoodi BK, Kelder JC, Lip GY, Bhatt DL, Cannon CP, ten Berg JM. A novel risk score to identify the need for triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a post hoc analysis of the RE-DUAL PCI trial. EUROINTERVENTION 2022; 18:e292-e302. [PMID: 35105533 PMCID: PMC9912964 DOI: 10.4244/eij-d-21-00165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines recommend treating atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) with triple antithrombotic therapy (TAT) for up to one month in patients at high thrombotic risk. It is unclear how to select these high-risk patients. AIMS The aim of this study was to identify patients at high thrombotic risk who might benefit from TAT over double antithrombotic therapy (DAT). METHODS This study was a post hoc subanalysis of the RE-DUAL PCI trial. A Cox proportional hazards model was built by stepwise selection of plausible predictor variables for a composite ischaemic endpoint, defined as cardiovascular death, myocardial infarction (MI), stent thrombosis (ST) or ischaemic stroke. The effect of TAT versus DAT was calculated for those patients with the highest proportion of predicted thrombotic risk. A simplified risk score was constructed based on beta-coefficients. RESULTS For 209 patients (7.7%) the composite ischaemic endpoint occurred during the first year. The simplified risk score contained six variables. In patients with a score ≥5 (n=154, 5.7%), a significant reduction in the composite of MI and ST was observed with TAT versus DAT (6.3% vs 21.0%, p=0.041), without a penalty in terms of bleeding. In patients at low thrombotic risk, a significant increase in bleeding was observed without a reduction of ischaemic events. CONCLUSIONS Our findings support the use of DAT in the majority of patients. A small subgroup of patients might benefit from TAT and we propose a novel clinical risk score to select these patients.
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Affiliation(s)
- Bastiaan Zwart
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deepak L. Bhatt
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Cannon
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jurriën Maria ten Berg
- Dept. of Cardiology, St Antonius Hospital Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
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15
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Tarlovskaya EI, Dorofeeva JA. [Adherence of patients with atrial fibrillation after acute coronary syndrome to antithrombotic therapy at stage III of cardiac rehabilitation: data from the local register of the Kirov region]. KARDIOLOGIIA 2022; 62:27-32. [PMID: 35692171 DOI: 10.18087/cardio.2022.5.n1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/07/2021] [Indexed: 06/15/2023]
Abstract
Aim To evaluate the quality of antithrombotic therapy (ATT) in patients with atrial fibrillation (AF) after acute coronary syndrome (ACS) at stage 3 of rehabilitation.Material and methods The registry included 163 patients with AF (mean age, 65.0 [59.0; 72.0] years; 55.8 % men) undergoing rehabilitation after ACS (ACS <1 month ago) in the hospital of the Kirov State Medical University.Results Recommendations for 73.6 % of patients on ATT provided upon discharge from the hospital after stage 2 of rehabilitation were consistent with clinical guidelines (CG). During the entire stage 3, 25.8% of patients had acute cardiovascular complications (CVC) or urgent interventions (8.0% died). Furthermore, the ATT was actually consistent with CG only in 9.2 % of patients; in 21.5 %, errors in changing the ATT timing were detected; and in 84.1 %, various mistakes in the control of international normalized ratio were observed. On the whole, 3.6% of patients incorrectly adjusted their ATT independently, and for 15.3%, the attending physician made incorrect APT adjustments.Conclusion In AF patients after ACS who were undergoing stage 3 of rehabilitation, the quality of the ATT was low despite the recommendations at discharge from the hospital, which depended not only on the patient but also on the attending physician.
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16
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Batchelor RJ, Dinh D, Noaman S, Brennan A, Clark D, Ajani A, Freeman M, Stub D, Reid CM, Oqueli E, Yip T, Shaw J, Walton A, Duffy SJ, Chan W. Adverse 30-Day Clinical Outcomes and Long-Term Mortality Among Patients With Preprocedural Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Heart Lung Circ 2022; 31:638-646. [PMID: 35125322 DOI: 10.1016/j.hlc.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 11/16/2021] [Accepted: 12/09/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Approximately 5-10% of patients presenting for percutaneous coronary intervention (PCI) have concurrent atrial fibrillation (AF). To what extent AF portends adverse long-term outcomes in these patients remains to be defined. METHODS We analysed data from the multicentre Melbourne Interventional Group Registry from 2014-2018. Patients were identified as being in AF or sinus rhythm (SR) at the commencement of PCI. The primary endpoint was long-term mortality, obtained via linkage with the National Death Index. RESULTS 13,286 procedures were included, with 800 (6.0%) patients in AF and 12,486 (94.0%) in SR. Compared to SR, patients with AF were older (72.9±10.9 vs 64.1±12.0 p<0.001) and more likely to have comorbidities including diabetes mellitus (31.3% vs 25.0% p<0.001), hypertension (74.4% vs 65.1% p<0.001) and moderate to severe left ventricular systolic dysfunction (36.6% vs 19.5% p<0.001). Atrial fibrillation was associated with an increased risk of in-hospital mortality (11.0% vs 2.5% p<0.001) and MACE (composite of all-cause mortality, myocardial infarction, or target vessel revascularisation) (11.9% vs 4.2% p<0.001). In-hospital major bleeding was more common in the AF group (3.1% vs 1.0% p<0.001). On Cox proportional hazards modelling, AF was an independent predictor of long-term mortality (adjusted HR 1.38 95% CI 1.11-1.72 p<0.004) at a mean follow-up of 2.3±1.5 years. CONCLUSIONS Preprocedural AF is common among patients presenting for PCI. Preprocedural AF is associated with high-rates of comorbid illnesses and portends higher risk of short- and long-term outcomes including mortality underscoring the need for careful evaluation of its risks prior to PCI.
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Affiliation(s)
- Riley J Batchelor
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - Diem Dinh
- Monash University, Melbourne, Vic, Australia
| | - Samer Noaman
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | | | - David Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Melbourne, Vic, Australia
| | - Dion Stub
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia
| | - Christopher M Reid
- Monash University, Melbourne, Vic, Australia; Curtin University, Perth, WA, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Health Services, Ballarat, Vic, Australia
| | - Thomas Yip
- Deakin University, Geelong, Vic, Australia; Department of Cardiology, Barwon Health, Geelong, Vic, Australia
| | - James Shaw
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Antony Walton
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
| | - Stephen J Duffy
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia
| | - William Chan
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia; Monash University, Melbourne, Vic, Australia; Department of Cardiology, Western Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia.
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17
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Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11030512. [PMID: 35159964 PMCID: PMC8836736 DOI: 10.3390/jcm11030512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.
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18
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Lee CC, Chang CH, Hung Y, Lin CS, Yang SP, Cheng SM, Yu FH, Lin WS, Lin WY. Changes of antithrombotic prescription in atrial fibrillation patients with acute coronary syndrome or percutaneous coronary intervention and the subsequent impact on long-term outcomes: a longitudinal cohort study. Thromb J 2021; 19:100. [PMID: 34906162 PMCID: PMC8670061 DOI: 10.1186/s12959-021-00353-z] [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: 05/14/2021] [Accepted: 11/28/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives The choice of optimal antithrombotic therapy in atrial fibrillation (AF) patients with acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI) remains controversial. The aim of this longitudinal cohort study is to investigate the prescribing pattern of antithrombotic regimen in different cohorts and its subsequent impact. Setting and design Longitudinal data from the Tri-Service General Hospital-Coronary Heart Disease (TSGH-CHD) registry, between January 2016 and August 2018 was screened. Participants and method Patients with prior history of nonvalvular AF, who had ACS presentation or underwent PCI were selected, and these patients were divided into cohort 1 and cohort 2, according to the index date of antithrombotic prescription before and after the PIONEER AF-PCI study. Primary and secondary outcomes The primary safety endpoints were composites of major bleeding and/or clinically relevant non-major bleeding. The secondary efficacy endpoints included the occurrence of all-cause mortality, stroke/systemic embolization, nonfatal myocardial infarction (MI), and >30-days coronary revascularization. Results A total of 121 patients were included into analysis (cohort 1=35; cohort 2=86). Comparing with cohort 1, the prescription rate of triple antithrombotic therapy (TAT) increased from 17.1 to 38.4%, especially the regimen with dual antiplatelet therapy (DAPT) plus low-dose non-vitamin-K dependent oral anticoagulation (NOAC). However, the prescription rate of dual antithrombotic therapy (DAT) decreased (14.3–10.5%), as well as the prescription rate of DAPT (68.6–51.2%). These changes of antithrombotic prescription across different cohorts were not associated with risk of adverse safety (HR= 0.87; 95% CI, 0.42-1.80, p=0.710) and efficacy outcomes (HR=0.96; 95% CI, 0.40-2.32, p=0.930). Conclusions Entering the NOAC era, the prescription of TAT increased alongside the decrease in DAT. As the prescription rate of DAPT without anticoagulation remained high, future efforts are mandatory to improve the implementation of guidelines and clinical practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00353-z.
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Affiliation(s)
- Chiao-Chin Lee
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chiao-Hsiang Chang
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan Hung
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Sheng Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Ping Yang
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shu-Meng Cheng
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Fan-Han Yu
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Yu Lin
- Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. .,Division of Cardiology, Department of Internal Medicine Tri-Service General Hospital, National Defense Medical Center, No. 325, Cheng-Gong Road, Section 2, Neihu 114, Taipei, Taiwan.
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19
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Shao QY, Wang ZJ, Ma XT, Lin XZ, Pan L, Zhou YJ. Stroke of antiplatelet and anticoagulant therapy in patients with coronary artery disease: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2021; 21:574. [PMID: 34852763 PMCID: PMC8638430 DOI: 10.1186/s12872-021-02384-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We performed a meta-analysis sought to investigate the risk of stroke with antiplatelet and anticoagulant therapies among patients with coronary artery disease (CAD). METHODS We searched PubMed, EMBASE, and Cochrane Library for randomized controlled trials from January 1995 to March 2020. Studies were retrieved if they reported data of stroke for patients with CAD and were randomized to receive intensive versus conservative antithrombotic therapies, including antiplatelet and oral anticoagulant (OAC). Analyses were pooled by random-effects modeling. A total of 42 studies with 301,547subjects were enrolled in this analysis. RESULTS Intensive antithrombotic therapy significantly reduced risk of all stroke (RR 0.86, 95% CI 0.80-0.94) and ischemic stroke (RR 0.80, 95% CI 0.71-0.91), but increased risk of hemorrhagic stroke (RR 1.36, 95% CI 1.00-1.86) and intracranial hemorrhage (RR 1.46, 95% CI 1.17-1.81). Subgroup analyses indicated that OAC yields more benefit to all stroke than antiplatelet therapy (OAC: RR 0.73, 95% CI 0.58-0.92; Antiplatelet: RR 0.90, 95% CI 0.83-0.97; Between-group heterogeneity P value = 0.030). The benefit of antiplatelet therapy on all stroke and ischemic stroke were mainly driven by the studies comparing longer versus shorter duration of dual antiplatelet therapy (All stroke: RR 0.86, 95% CI 0.78-0.95; ischemic stroke: RR 0.84, 95% CI 0.75-0.94). CONCLUSIONS Among CAD patients who have already received antiplatelet therapy, either strengthening antiplatelet or anticoagulant treatments significantly reduced all stroke, mainly due to the reduction of ischemic stroke, although it increased the risk of hemorrhagic stroke and intracranial hemorrhage. OAC yields more benefit to all stroke than antiplatelet therapy.
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Affiliation(s)
- Qiao Yu Shao
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Zhi Jian Wang
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China. .,Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Anzhen Avenue #2, Chaoyang District, Beijing, 100029, China.
| | - Xiao Teng Ma
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Xu Ze Lin
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Liu Pan
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
| | - Yu Jie Zhou
- Anzhen Hospital, Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Disease, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing, China
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20
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Cohen JE, Gomori JM, Honig A, Leker RR. Carotid Artery Stenting in Patients with Atrial Fibrillation: Direct Oral Anticoagulants, Brief Double Antiplatelets, and Testing Strategy. J Clin Med 2021; 10:jcm10225242. [PMID: 34830524 PMCID: PMC8620833 DOI: 10.3390/jcm10225242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 12/03/2022] Open
Abstract
Carotid endarterectomy is usually preferred over carotid artery stenting (CAS) for patients with atrial fibrillation (AF). We present our experience with short-course periprocedural triple antithrombotic therapy in 32 patients aged >18 years with nonvalvular AF undergoing CAS. There were no deaths, cardiac events, embolic strokes, hyperperfusion syndrome, intracranial hemorrhage, or stent thrombosis within 30 days. Transient intraprocedural hemodynamic instability in 15/32 (47%) and prolonged instability in 4/32 (13%) was managed conservatively. At a mean 16-month follow-up, there were no new neurological events or deterioration. Mean stenosis was reduced from 78.0% ± 9.7% to 17.3% ± 12.2%. This retrospective study included patients AF who were symptomatic (minor stroke (NIHSS ≤ 5)/TIA) with ICA stenosis >50%, or asymptomatic under DOAC therapy with carotid stenosis >80%, who underwent CAS from 6/2014–10/2020. Patients received double antiplatelets and statins. Antiplatelet therapy effectiveness was monitored. Stenting was performed when P2Y12 reaction units (PRU) were <150. DOACs were discontinued 48 h before angioplasty; one 60 mg dose of subcutaneous enoxaparin was administered in lieu. DOAC was restarted 12–24 h after intervention. Patients were discharged under DOAC and one nonaspirin antiplatelet. 32 patients on DOAC were included (26 male, mean age 71). 19 (59.4%) presented with stroke (ICA stenosis-related in 14); 13 (40.6%) were asymptomatic. Stents were deployed under filter protection following pre-angioplasty; post-angioplasty was performed at least once in 12 patients (37.5%). Our experience suggests that CAS can be safely performed in selected patients with CAS and AF requiring DOAC. The role of CAS in AF patients under DOAC warrants study in rigorous trials.
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Affiliation(s)
- José E. Cohen
- Departments of Neurosurgery and Radiology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
- Correspondence:
| | - John Moshe Gomori
- Department of Radiology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel;
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (R.R.L.)
| | - Ronen R. Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (R.R.L.)
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21
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Grajek S, Kałużna-Oleksy M, Siller-Matula JM, Grajek M, Michalak M. Non-Vitamin K Antagonist Oral Anticoagulants and Risk of Myocardial Infarction in Patients with Atrial Fibrillation with or without Percutaneous Coronary Interventions: A Meta-Analysis. J Pers Med 2021; 11:jpm11101013. [PMID: 34683155 PMCID: PMC8539187 DOI: 10.3390/jpm11101013] [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: 08/16/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022] Open
Abstract
The study aimed to assess the risk of myocardial infarction (MI) and major adverse cardiac events during non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin therapy in patients with atrial fibrillation (AF), both treated and not treated with percutaneous coronary interventions (PCI). In a systematic search, we selected eight randomized clinical trials with a total of 81,943 patients. Dabigatran, compared to warfarin, significantly increased the risk of MI (relative risk [RR] 1.38, 95% CI 1.14–1.67), while the FXa inhibitors’ effect did not differ significantly from warfarin (RR 0.96, 95% CI 0.86–1.09). The RR comparison between analyzed subgroups (dabigatran vs. FXa inhibitors) showed a significant difference (Chi2 = 9.51, df = 1, p = 0.002). In a network meta-analysis, dabigatran 110 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, edoxaban, and rivaroxaban. Also, dabigatran 150 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, and rivaroxaban. Moreover, we tried to estimate the treatment ranking of the best therapy for MI prevention in patients with AF treated with PCI. Rivaroxaban had a 90% probability of being ranked the best therapy for MI prevention, whereas dabigatran 110 mg had an 8.2% probability. Dabigatran 150 mg was the most effective in stroke prevention (94% probability). Each NOAC is associated with a different risk of MI. Furthermore, we should consider FXa inhibitors as the first line NOACs in AF and coronary artery disease patients. PROSPERO ID CRD42020179808.
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Affiliation(s)
- Stefan Grajek
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-848 Poznan, Poland;
- Correspondence: mail: ; Tel.: +502-896-932
| | - Jolanta M. Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
- Center for Preclinical Research and Technology (CEPT), Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, 02-097 Warsaw, Poland
| | | | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 60-806 Poznan, Poland;
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22
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Gupta R, Malik AH, Gupta R, Ranchal P, Yandrapalli S, Patel B, Frishman WH, Aronow WS, Garg J. Dual Versus Triple Therapy in Patients with Acute Coronary Syndrome and an Anticoagulation Indication: A Systematic Review with Meta-Analysis and Trial-Sequential Analysis. Cardiol Rev 2021; 29:245-252. [PMID: 34001690 DOI: 10.1097/crd.0000000000000320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Choosing an antithrombotic regime in patients with acute coronary syndrome (ACS) and a concomitant indication for anticoagulation is a challenge commonly encountered by clinicians. Our aim in this article is to evaluate the safety and efficacy of triple antithrombotic therapy (TT, anticoagulant plus dual antiplatelet) versus dual antithrombotic therapy [dual therapy (DT), anticoagulant plus single antiplatelet] in patients with ACS. We included all randomized trials comparing the outcomes of single versus dual antiplatelet therapy in patients with ACS on anticoagulants. The primary outcome was major adverse cardiac events (MACE). Other outcomes studied were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, stent thrombosis (ST), and major bleeding. The Mantel-Haenszel risk ratio (RR) random-effects model was used to summarize data. Six studies, with a total of 11,437 patients, met our selection criteria. With a follow-up duration of 9-14 months, there was no significant difference between DT and TT in terms of MACE [RR 0.96; 95% confidence interval (CI), 0.79-1.17], all-cause mortality (RR 1.00; 95% CI, 0.77-1.29), cardiovascular mortality (RR 1.03; 95% CI, 0.79-1.34), MI (RR 1.14; 95% CI, 0.90-1.45), stroke (RR 0.83; 95% CI, 0.56-1.23), and ST (RR 1.32; 95% CI, 0.87-2.01). Compared with TT, DT was associated with significant reductions in major bleeding 4.1% versus 6.5% (RR 0.61; 95% CI, 0.45-0.81; number needed to treat = 42), clinically significant bleeding 10.5% versus 16.4% (RR 0.62; 95% CI, 0.48-0.80) and intracranial hemorrhage 0.4% versus 0.8% (RR 0.43; 95% CI, 0.24-0.77). In patients on anticoagulant therapy, the strategy of single antiplatelet therapy (DT) confers a benefit of less major bleeding with no difference in MACE, all-cause mortality, cardiovascular mortality, MI, stroke, and ST.
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Affiliation(s)
- Rahul Gupta
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Aaqib H Malik
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Rajiv Gupta
- Department of Surgery, Adesh Medical College and Hospital, Kurukshetra, India
| | - Purva Ranchal
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Srikanth Yandrapalli
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Brijesh Patel
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
- Division of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Jalaj Garg
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, WI
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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24
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Khan AA, Murtaza G, Khalid M, Finniss M, Helton T. Efficacy of Cangrelor as Bridging Therapy Post PCI. Cardiovasc Hematol Disord Drug Targets 2021; 20:227-231. [PMID: 32108005 PMCID: PMC8226151 DOI: 10.2174/1871529x20666200228114925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 11/22/2022]
Abstract
Background Dual antiplatelet therapy (DAPT) remains the cornerstone management for the prevention of acute stent thrombosis after percutaneous intervention (PCI). Situations mandating early interruption of DAPT carry a high risk of ischemic complications. Perioperative bridge therapy using Cangrelor, an intravenous P2Y2 inhibitor, may offer a potential solution. Unfortunately, evidence for its use in non-cardiac procedures is limited. Methods Our protocol demonstrates successful off-label use of IV Cangrelor bridge therapy in a non-cardiac surgery patient. We describe a case of a 77-year old male; triple therapy with Aspirin, Apixaban, and Ticagrelor for recent drug-eluting stent placement required immediate surgical resection of stage I colonic adenocarcinoma. Results Cangrelor bridge therapy was utilized both preoperatively and postoperatively without ischemic or bleeding complications. The patient tolerated exploratory laparoscopic colectomy with minimal bleeding and good post-op recovery. Conclusion Minimizing the interruption of DAPT therapy in high-risk patients is achievable. However, careful planning with a team-based approach involving surgeons, cardiologists and pharmacists, along with close clinical follow-up and vigilant management of anti-platelet therapy is recommended.
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Affiliation(s)
- Abdul A Khan
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Ghulam Murtaza
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Muhammad Khalid
- Division of Cardiovascular Medicine, East Tennessee State University, TN, United States
| | - Mathew Finniss
- Department of Internal Medicine, East Tennessee State University, TN, United States
| | - Thomas Helton
- Division of Cardiovascular Medicine, Mountain Home VA Medical Center, TN, United States
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25
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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26
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Evaluation of Dual Versus Triple Therapy by Landmark Analysis in the RE-DUAL PCI Trial. JACC Cardiovasc Interv 2021; 14:768-780. [PMID: 33826497 DOI: 10.1016/j.jcin.2021.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 02/11/2021] [Accepted: 02/11/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The aim of this study was to explore the early versus late benefits and risks of dabigatran dual therapy versus warfarin triple therapy in the RE-DUAL PCI (Randomized Evaluation of Dual Antithrombotic Therapy With Dabigatran Versus Triple Therapy With Warfarin in Patients With Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) trial. BACKGROUND Patients with atrial fibrillation who undergo percutaneous coronary intervention are at increased risk for both bleeding and thrombotic events. METHODS A total of 2,725 patients with atrial fibrillation underwent percutaneous coronary intervention and were randomized to receive dabigatran 110 mg, or dabigatran 150 mg plus a P2Y12 inhibitor (and no aspirin), or warfarin plus a P2Y12 inhibitor plus aspirin. Landmark analysis was performed at 30 and 90 days. RESULTS There was a consistent and large reduction in major or clinically relevant nonmajor bleeding in patients randomized to dual therapy during the first 30 days (110 mg: hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.31 to 0.66; p < 0.0001; 150 mg: HR: 0.46; 95% CI: 0.30 to 0.72; p = 0.0006) compared with warfarin triple therapy. There was early net clinical benefit in both dabigatran groups versus warfarin (110 mg: HR: 0.65; 95% CI: 0.47 to 0.88; p = 0.0062; 150 mg: HR: 0.54; 95% CI: 0.37 to 0.79; p = 0.0015), due to larger reductions in bleeding than increased thrombotic events for dabigatran 110 mg and bleeding reduction without increased thrombotic risk for dabigatran 150 mg dual therapy versus warfarin triple therapy. After the removal of aspirin in the warfarin group, bleeding remained lower with dabigatran 110 mg and was similar with dabigatran 150 mg versus warfarin. CONCLUSIONS In RE-DUAL PCI, in which patients in the dual-therapy arms were treated with aspirin for an average of only 1.6 days, there was early net clinical benefit with both doses of dabigatran dual therapy, without an increase in thrombotic events with dabigatran 150 mg. This could be helpful in the subset of patients with elevated risk for both bleeding and thrombotic events.
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27
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Santos-Gallego CG, Badimon J. Overview of Aspirin and Platelet Biology. Am J Cardiol 2021; 144 Suppl 1:S2-S9. [PMID: 33706986 DOI: 10.1016/j.amjcard.2020.12.018] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/11/2020] [Indexed: 12/31/2022]
Abstract
Aspirin (ASA) has historically been one of the most important drugs in cardiology and has long been the cornerstone of antiplatelet therapy. Although its role in acute coronary syndrome remains undisputed, emerging data suggest that reappraisal of the efficacy of long-term ASA in some primary and secondary prevention may be warranted. The aim of this review is to place these new results in the context of previous evidence on aspirin by appraising the current body of evidence on its use of for cardiovascular diseases. This overview first summarizes the history of the discovery of aspirin, as well as its pharmacology and the concept of ASA resistance. We subsequently recapitulate the evidence of ASA on primary prevention and secondary prevention starting from the classical studies in order to serve as an introductory background to the examination of the most recent clinical trials that will be performed in the rest of the articles of this Supplement. Although the benefit of ASA in acute coronary syndrome remains incontrovertible, emerging evidence challenge the universal need for primary prevention, or for lifelong treatment in secondary prevention or all adults with stable coronary disease who are at highest risk for ASA-induced bleeding. The role of aspirin is quickly changing in recent times and this review provides a review for the clinician about the current role of this drug in cardiovascular care.
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28
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Holm A, Henriksson M, Alfredsson J, Janzon M, Johansson T, Swahn E, Vial D, Sederholm Lawesson S. Long term risk and costs of bleeding in men and women treated with triple antithrombotic therapy-An observational study. PLoS One 2021; 16:e0248359. [PMID: 33764988 PMCID: PMC7993563 DOI: 10.1371/journal.pone.0248359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 02/24/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Bleeding is the most common non-ischemic complication in patients with coronary revascularisation procedures, associated with prolonged hospitalisation and increased mortality. Many factors predispose for bleeds in these patients, among those sex. Anyhow, few studies have characterised the population receiving triple antithrombotic therapy (TAT) as well as long term bleeds from a sex perspective. We investigated the one year rate of bleeds in patients receiving TAT, potential sex disparities and premature discontinuation of TAT. We also assessed health care costs in bleeders vs non-bleeders. SETTING Three hospitals in the County of Östergötland, Sweden during 2009-2015. PARTICIPANTS All patients discharged with TAT registered in the SWEDEHEART registry. PRIMARY AND SECONDARY OUTCOME MEASURES All bleeds receiving medical attention during one-year follow-up were collected by retrieving relevant information about each patient from medical records. Resource use associated with bleeds was assigned unit cost to estimate the health care costs associated with bleeding episodes. RESULTS Among 272 patients, 156 bleeds occurred post-discharge, of which 28.8% were gastrointestinal. In total 54.4% had at least one bleed during or after the index event and 40.1% bled post discharge of whom 28.7% experienced a TIMI major or minor bleeding. Women discontinued TAT prematurely more often than men (52.9 vs 36.1%, p = 0.01) and bled more (48.6 vs. 37.1%, p = 0.09). One-year mean health care costs were EUR 575 and EUR 5787 in non-bleeding and bleeding patients, respectively. CONCLUSION The high bleeding incidence in patients with TAT, especially in women, is a cause of concern. There is a need for an adequately sized randomised, controlled trial to determine a safe but still effective treatment for these patients.
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Affiliation(s)
- Anna Holm
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Martin Henriksson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Therese Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
| | - Dominique Vial
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping University Hospital, Linköping, Sweden
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29
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de Veer AJWM, Bennaghmouch N, Dewilde WJM, Ten Berg JM. How cardiologists manage antithrombotic treatment of patients with atrial fibrillation undergoing percutaneous coronary stenting: the WOEST survey 2018. Neth Heart J 2021; 29:135-141. [PMID: 33052578 PMCID: PMC7904986 DOI: 10.1007/s12471-020-01500-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Antithrombotic treatment choices are complicated when patients have both atrial fibrillation (AF) and acute coronary syndrome and/or undergo percutaneous coronary intervention (PCI). In this study, we aimed to gain insight into antithrombotic management strategies in daily clinical practice. METHODS We invited interventional cardiologists to complete the WOEST (What is the Optimal antiplatElet & Anticoagulant Therapy in Patients With Oral Anticoagulation and Coronary StenTing) survey 2018. In this questionnaire, we presented a patient with a non-ST-elevation myocardial infarction (NSTEMI) and an elective PCI case. RESULTS The results were based on 118 completed questionnaires (response rate 69.4%). In the case of the AF patient with NSTEMI, most cardiologists indicated they would initiate dual antiplatelet therapy (acetylsalicylic acid and clopidogrel) and continue non-vitamin K antagonist oral anticoagulant (NOAC) therapy at admission and during coronary angiography/PCI. At discharge, 70.3% would prescribe triple antithrombotic therapy (oral anticoagulation, acetylsalicylic acid and clopidogrel), mostly for 1 month. One year after NSTEMI, 83.1% would cancel the antiplatelet therapy and prescribe NOAC monotherapy. For the AF patient undergoing elective PCI, 51.7% would start dual antiplatelet therapy prior to the procedure and 52.5% would discontinue NOAC therapy prior to the PCI. At discharge, 55.1% would start triple antithrombotic therapy. Furthermore, 25.4% responded they routinely prescribe a reduced dose of NOAC after discharge. One year after PCI, 89.0% would continue NOAC monotherapy. CONCLUSION The WOEST survey demonstrated heterogeneity in antithrombotic management strategies among interventional cardiologists. This observed variety mirrors the heterogeneity of the many guidelines and consensus documents. Further research is needed to guide patient-tailored medicine for AF patients undergoing PCI.
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Affiliation(s)
- A J W M de Veer
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - N Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - W J M Dewilde
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
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30
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Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, Granger CB, Holmes DR, Lopes RD, Mehran R, Moliterno DJ, Price MJ, Saw J, Tanguay JF, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update. Circulation 2021; 143:583-596. [PMID: 33555916 DOI: 10.1161/circulationaha.120.050438] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - John W Eikelboom
- Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada (J.W.E.)
| | - C Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Canada (S.G.G.).,The Canadian Heart Research Centre, Toronto, Canada (S.G.G.).,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
| | | | - David R Holmes
- Division of Cardiology, Mayo Clinic, Rochester, MN (D.R.H.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - David J Moliterno
- Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.)
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (J.S.)
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada (J.-F.T.)
| | - David P Faxon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
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31
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Nicolau JC, Bhatt DL, Hohnloser SH, Kimura T, Lip GYH, Miede C, Nordaby M, Oldgren J, Steg PG, Ten Berg JM, Godoy LC, Cannon CP. Dabigatran Dual Therapy vs Warfarin Triple Therapy Post-Percutaneous Coronary Intervention in Patients with Atrial Fibrillation With/Without a Proton Pump Inhibitor: A Pre-Specified Analysis of the RE-DUAL PCI Trial. Drugs 2021; 80:995-1005. [PMID: 32562206 PMCID: PMC7320045 DOI: 10.1007/s40265-020-01323-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Objective In patients with atrial fibrillation following percutaneous coronary intervention, if a proton pump inhibitor is used, could that allow the use of warfarin triple therapy, or is there additional reduction in bleeding while using it with dual therapy? Methods The RE-DUAL PCI trial randomized 2725 patients with atrial fibrillation post-percutaneous coronary intervention to dabigatran dual therapy (110 or 150 mg twice daily, with clopidogrel or ticagrelor) or warfarin triple therapy (with clopidogrel or ticagrelor, and aspirin for 1–3 months). This prespecified subgroup analysis evaluated risks of a first major bleeding event or clinically relevant non-major bleeding event, all gastrointestinal bleeding, and a composite efficacy endpoint of all-cause mortality/thromboembolic event or unplanned revascularization according to baseline use of a proton pump inhibitor. Results Of 2678 analyzed patients, 1641 (61.3%) were receiving a proton pump inhibitor at baseline. Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy regardless of proton pump inhibitor use, with comparable risk of the composite efficacy endpoint (all interaction p values > 0.05). For gastrointestinal bleeding, no interaction was observed between study treatment and proton pump inhibitor use (interaction p values 0.84 and 0.62 for dabigatran 110 and 150 mg dual therapy, respectively, vs warfarin triple therapy). Conclusions Dabigatran 110 and 150 mg dual therapy reduced the risk of major bleeding events or clinically relevant non-major bleeding events vs warfarin triple therapy, regardless of proton pump inhibitor use at baseline, in patients with atrial fibrillation who underwent percutaneous coronary intervention. Risk of the composite efficacy endpoint appeared to be similar for dabigatran dual therapy vs warfarin triple therapy in patients receiving/not receiving a proton pump inhibitor. ClinicalTrials.gov unique identifier NCT02164864. Video abstract
Electronic supplementary material The online version of this article (10.1007/s40265-020-01323-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
| | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- Université de Paris, FACT, INSERM U_1148, Paris, France.,Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Lucas C Godoy
- Instituto do Coracao (InCor), Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Enéas Carvalho Aguiar, 44, Sao Paulo, SP, 05403-000, Brazil.,Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Christopher P Cannon
- Brigham and Women's Hospital and Heart and Vascular Center, and Harvard Medical School, Boston, MA, USA
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2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease. J Am Coll Cardiol 2021; 77:629-658. [DOI: 10.1016/j.jacc.2020.09.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Qian J, Zan J, Kuang L, Che L, Yu Y, Shen T, Tang J, Chen F, Liu X. A predictive nomogram of bleeding risk in patients with atrial fibrillation after drug-eluting stent implantation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:193. [PMID: 33708820 PMCID: PMC7940957 DOI: 10.21037/atm-20-3971] [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: 05/15/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND The use of anticoagulants and antiplatelet therapies is associated with a higher risk of bleeding in atrial fibrillation (AF) patients after percutaneous coronary intervention, especially after stent implantation. However, no accurate bleeding risk prediction tool has been developed for these patients. The aim of this study was thus to establish a bleeding risk prediction model (predictive nomogram) for patients with AF after stent implantation. METHODS Construction of the predictive nomogram was based on a retrospective study, which enrolled 943 AF patients who underwent drug-eluting stent implantation between May 2012 and September 2016. A range of factors, including demographics, comorbidities, medication strategies, arterial access, and laboratory tests, were collected as baseline data. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to identify the key clinical features for construction of the predictive nomogram. The concordance index (C-index) and internal validation were used to evaluate the efficacy of the nomogram. RESULTS Of the 943 AF patients that underwent stent implantation, the occurrence of bleeding events was 8.2% (77 out of 943). Key predictors included the number of antiplatelet drugs, peptic ulcer, cerebral infarction, type 2 diabetes, thrombocytopenia, anemia, prior myocardial infarction, sex (male), use of anticoagulant drugs, liver dysfunction, hypertension, and acute myocardial infarction. These predictors were used to construct the nomogram. The C-index for the prediction of bleeding risk by the nomogram was 0.841 (95% CI: 0.79-0.89), which indicated good discrimination and calibration. The C-index of internal validation was 0.795, which demonstrated good efficacy of the model. CONCLUSIONS This study suggests that our novel nomogram can accurately predict bleeding risk in AF patients after stent implantation during hospitalization, thereby helping to avoid complications. The nomogram may also be helpful for the creation of individualized post-discharge medication strategies.
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Affiliation(s)
- Jun Qian
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiyong Zan
- Department of Gastroenterology, Huazhong University of Science and Technology Union Shenzhen Hospital (Nanshan Hospital), Shenzhen, China
| | - Lijun Kuang
- Department of Ultrasound, Luwan Branch, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Che
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunan Yu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ting Shen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiani Tang
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Chen
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuebo Liu
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 5172] [Impact Index Per Article: 1724.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Gargiulo G, Cannon CP, Gibson CM, Lopes RD, Vranckx P, Valgimigli M. The multiplication of loaves and fishes approach: a critic to double anti-thrombotics or to double number of ischaemic events? EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:e29-e30. [PMID: 33340322 PMCID: PMC8141292 DOI: 10.1093/ehjcvp/pvaa141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.,Baim Institute for Clinical Research, 930-W Commonwealth Avenue, Boston, MA 02215, USA
| | - Charles Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 200 Morris Street, Durham, NC 27701, USA
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium
| | - Marco Valgimigli
- CardioCentro Ticino, Via Tesserete 48, Lugano, 6900, Switzerland.,University of Bern, Freiburgstrasse 10, Bern, 3010, Switzerland
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Volpe M, Gallo G. Atrial fibrillation and ischaemic heart disease: should we use acetylsalicylic acid beside anticoagulants? Eur Heart J Suppl 2020; 22:L166-L169. [PMID: 33239994 PMCID: PMC7673601 DOI: 10.1093/eurheartj/suaa159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Coexistence of atrial fibrillation and ischaemic heart disease is very common and patients affected by these conditions are exposed to both a high ischaemic and haemorrhagic risk. The choice of an appropriate combination of anticoagulant therapy with single or dual antiplatelet treatment is indeed one of the most relevant and contemporary challenges in clinical practice. Several studies and meta-analyses pointed out that 1 year after an acute coronary syndrome or percutaneous revascularization, the use of the sole anticoagulant therapy is not associated with increased risk of major cardiovascular events, whereas there is a substantial reduction of clinical significant bleeding events, as compared to patients treated also with antiplatelet medications. However, there are no clear-cut data regarding the possibility to implement this strategy in each patient, regardless the cardiovascular risk class. Furthermore, for patients requiring a combined anticoagulant and antiplatelet treatment, the available data seem to favour an association of direct anticoagulant and inhibitors of P2Y12, rather than regimens including aspirin. These data are derived mainly from observational studies, with all their limitations. The use of aspirin could be beneficial in patients with significant comorbidities, such as diabetes mellitus, or with severe peripheral atherosclerotic disease, involving the carotids and other large arteries.
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Affiliation(s)
- Massimo Volpe
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy.,IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Giovanna Gallo
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
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Rondano E, Bertolazzi M, Galluzzo A, Maltese L, Caccianotti P, Macciò S, Mazza S, Ruocco MVD, Favretto S, Occhetta E, Rametta F. Effectiveness and safety of antithrombotic strategies in elderly patients with acute myocardial infarction. World J Cardiol 2020; 12:513-525. [PMID: 33312437 PMCID: PMC7701903 DOI: 10.4330/wjc.v12.i11.513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/28/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Elderly patients represent a rapidly growing part of the population more susceptible to acute coronary syndromes and their complications. However, literature evidence is lacking in this clinical setting.
AIM To describe the clinical features, in-hospital management and outcomes of “elderly” patients with myocardial infarction treated with antiplatelet and/or anticoagulation therapy.
METHODS This study was a retrospective analysis of all consecutive patients older than 80 years admitted to the Division of Cardiology of St. Andrea Hospital of Vercelli from January 2018 to December 2018 due to ST-elevation myocardial infarction (STEMI) or non-ST elevation myocardial infarction (NSTEMI). Clinical and laboratory data were collected for each patient, as well as the prevalence of previous or in-hospital atrial fibrillation (AF). In-hospital management, consisting of an invasive or conservative strategy, and the anti-thrombotic therapy used are described. Outcomes evaluated at 1 year follow-up included an efficacy ischemic endpoint and a safety bleeding endpoint.
RESULTS Of the 105 patients enrolled (mean age 83.9 ± 3.6 years, 52.3% males), 68 (64.8%) were admitted due to NSTEMI and 37 (35.2%) due to STEMI. Among the STEMI patients, 34 (91.9%) underwent coronary angiography and all of them were treated with percutaneous coronary intervention (PCI); among the NSTEMI patients, 42 (61.8%) were assigned to an invasive strategy and 16 (38.1%) of them underwent a PCI. No significant difference between the groups was found concerning the prevalence of previous or in-hospital de-novo AF. 10.5% of the whole population received triple antithrombotic therapy and 9.5% single antiplatelet therapy plus oral anticoagulation (OAC), with no significant difference between the subgroups, although a higher number of STEMI patients received dual antiplatelet therapy without OAC as compared with NSTEMI patients. A low rate of in-hospital death (5.7%) and 1-year cardiovascular death (3.3%) was registered. Seven (7.8%) patients experienced major adverse cardiovascular events, while the rate of minor and major bleeding at 1-year follow-up was 10% and 2.2%, respectively, with no difference between NSTEMI and STEMI patients.
CONCLUSION In this real-world study, a tailored evaluation of an invasive strategy and antithrombotic therapy resulted in a low rate of adverse events in elderly patients hospitalized with acute myocardial infarction.
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Affiliation(s)
- Elisa Rondano
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | | | - Ludovica Maltese
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | - Sergio Macciò
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | - Stefano Mazza
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | | | - Serena Favretto
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
| | - Eraldo Occhetta
- Cardiology Department, St. Andrea Hospital, Vercelli 13100, Italy
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Sun X, Ze B, Zhang LJ, BaiMa YZ, Zuo W, Zhao B, GeSang LB. Hemorrhage Risk Profiles among Different Antithrombotic Regimens: Evidence from a Real-World Analysis of Postmarketing Surveillance Data. Cardiovasc Drugs Ther 2020; 36:103-112. [PMID: 33226545 DOI: 10.1007/s10557-020-07110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of direct oral anticoagulants (DOACs) has been reported in patients with atrial fibrillation (AF), there is currently no consensus on the occurrence or characteristics of the hemorrhage risk in different antithrombotic regimens. METHODS Disproportionality and Bayesian analyses were performed in mining data of suspected hemorrhagic events after antithrombotic drug use from the FDA Adverse Event Reporting System (FAERS) from January 2004 to September 2019. The time to onset and fatality rate of hemorrhage following different antithrombotic regimens were also compared. RESULTS A total of 84,998 reports of hemorrhage-related adverse events with the use of antithrombotic drugs were identified. The patients included were mostly from the Americas (80.87%) and Europe (13.22%), with most data submitted by nonhealthcare professionals. Among the seven antithrombotic drug monotherapies, betrixaban had the highest association with hemorrhage based on the highest reporting odds ratio (ROR, 829.95; 95% CI = 113.61-6063.15), proportional reporting ratio (PRR, 24.68, χ2 = 804.24), and multi-item gamma Poisson shrinker (MGPS, 24.68, 95% one-sided CI = 4.67). The combination therapies of clopidogrel plus new oral anticoagulants had higher RORs, PRRs, and empirical Bayesian geometric means (EBGMs) than the antithrombotic drug monotherapies. Hemorrhage associated with rivaroxaban plus clopidogrel appeared to have an earlier onset (171 days vs 219 days, 95% two-sided CI =68.68-27.34, p < 0.0001) and a lower fatality rate (15.30% vs 17.74%, p<0.05) than that associated with rivaroxaban monotherapy. CONCLUSION This study provides a relevant overview of the hemorrhagic complications/fatalities associated with different antithrombotic regimens in their real-world use. Among the combination therapies, clopidogrel plus DOACs were found to have stronger associations with hemorrhage than traditional dual antithrombotic therapies. Rivaroxaban showed a stronger association with hemorrhage than other antithrombotic drug monotherapies, and apixaban monotherapy appeared to have weaker associations with hemorrhage than others.
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Affiliation(s)
- Xue Sun
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Bi Ze
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Ling-Jun Zhang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| | - Yang-Zhong BaiMa
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Wei Zuo
- Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bin Zhao
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China. .,Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Luo-Bo GeSang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
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Abstract
The population suffering from coronary heart disease (CHD) complicated by atrial fibrillation (AF) is rising rapidly. A strong correlation between the two diseases has been reported, and the many common risk factors they share may play prominent roles in their development. In addition, CHD can directly promote the progression of AF by affecting reentry formation, focal ectopic activity, and neural remodeling. At the same time, AF also affects CHD through three aspects: 1) atherosclerosis, 2) the mismatch of blood supply and oxygen consumption, and 3) thrombosis. In conclusion, CHD and AF can aggravate each other and seem to form a vicious cycle. For patients with CHD complicated by AF, principal studies and guidelines have focused on antithrombotic treatment and rhythm control, which are paramount for these patients. Of note, our review sheds light on the strategies to break the cycle of the two diseases, which may be fundamental to treat these patients and optimize the benefit.
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Affiliation(s)
- Feng Liang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Wang
- Department of Cardiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Affiliation(s)
- Azfar G Zaman
- Cardiology, Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Qaiser Aleem
- Cardiology, James Cook University Hospital, Middlesborough, UK
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Lane DA, Dagres N, Dan GA, García Seara J, Iliodromitis K, Lenarczyk R, Lip GYH, Mansourati J, Marín F, Scherr D, Potpara TS. Antithrombotic treatment in patients with atrial fibrillation and acute coronary syndromes: results of the European Heart Rhythm Association survey. Europace 2020; 21:1116-1125. [PMID: 30874724 DOI: 10.1093/europace/euz033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/11/2019] [Indexed: 12/17/2022] Open
Abstract
The management of an acute coronary syndrome (ACS) in a patient with existing atrial fibrillation (AF) often presents a management dilemma both in the acute phase and post-ACS, since the majority of AF patients will already be receiving oral anticoagulation (OAC) for stroke prevention and will require further antithrombotic treatment to reduce the risk of in-stent thrombosis or recurrent cardiac events. Current practice recommendations are based largely on consensus option as there is limited evidence from randomized controlled trials. Prior to the launch of the new European Heart Rhythm Association (EHRA) consensus document, a survey was undertaken to examine current clinical management of these patients across centres in Europe. Forty-seven centres submitted valid responses, with the majority (70.2%) being university hospitals. This EHRA survey demonstrated overall the management of ACS in AF patients is consistent with the available guidance. Most centres would use triple therapy for a short duration (4 weeks) and predominantly utilize a strategy of OAC (vitamin K antagonist, VKA or non-vitamin K antagonist oral anticoagulant, NOAC) plus aspirin and clopidogrel, followed by dual therapy [(N)OAC plus clopidogrel] until 12 months post-percutaneous coronary intervention, followed by (N)OAC monotherapy indefinitely. Where NOAC was used in combination with antiplatelet(s), the lower dose of the respective NOAC was preferred, in accordance with current recommendations.
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Affiliation(s)
- Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Gheorghe-Andrei Dan
- Cardiology Department, Colentina University Hospital, University of Medicine 'Carol Davila', Bucharest, Romania
| | - Javier García Seara
- Cardiology Department, Clinical University Hospital of Santiago de Compostela, CIBER Cardiovascular, Santiago de Compostela, Spain
| | | | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Curie-Sklodowskiej Str 9, Zabrze, Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jacques Mansourati
- Department of Cardiology, University Hospital of Brest and EA, University of Western Brittany, Brest, France
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Daniel Scherr
- Division of Cardiology, Department of Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz, Austria
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
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Zheng YY, Wu TT, Gao Y, Guo QQ, Ma YY, Zhang JC, Xun YL, Wang DY, Pan Y, Cheng MD, Song FH, Liu ZY, Wang K, Jiang LZ, Fan L, Yue XT, Bai Y, Zhang ZL, Dai XY, Zheng RJ, Chen Y, Ma X, Ma YT, Zhang JY, Xie X. A Novel ABC Score Predicts Mortality in Non-ST-Segment Elevation Acute Coronary Syndrome Patients Who underwent Percutaneous Coronary Intervention. Thromb Haemost 2020; 121:297-308. [PMID: 33129207 DOI: 10.1055/s-0040-1718411] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In the present study, we aimed to establish a novel score to predict long-term mortality of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients who underwent percutaneous coronary intervention (PCI). METHODS A total of 2,174 NSTE-ACS patients from the CORFCHD-ZZ study were enrolled as the derivation cohort. The validation cohort including 1,808 NSTE-ACS patients were from the CORFCHD-PCI study. Receiver operating characteristic analysis and area under the curve (AUC) evaluation were used to select the candidate variables. The model performance was validated internally and externally. The primary outcome was cardiac mortality (CM). We also explored the model performance for all-cause mortality (ACM). RESULTS Initially, 28 risk factors were selected and ranked according to their AUC values. Finally, we selected age, N-terminal pro-B-type natriuretic peptide, and creatinine to develop a novel prediction model named "ABC" model. The ABC model had a high discriminatory ability for both CM (C-index: 0.774, p < 0.001) and ACM (C-index: 0.758, p < 0.001) in the derivation cohort. In the validation cohort, the C-index of CM was 0.802 (p < 0.001) and that of ACM was 0.797 (p < 0.001), which suggested good discrimination. In addition, this model had adequate calibration in both the derivation and validation cohorts. Furthermore, the ABC score outperformed the GRACE score to predict mortality in NSTE-ACS patients who underwent PCI. CONCLUSION In the present study, we developed and validated a novel model to predict mortality in patients with NSTE-ACS who underwent PCI. This model can be used as a credible tool for risk assessment and management of NSTE-ACS after PCI.
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Affiliation(s)
- Ying-Ying Zheng
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Ting-Ting Wu
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ying Gao
- Cadre Ward, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qian-Qian Guo
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Yan-Yan Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jian-Chao Zhang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Yi-Li Xun
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ding-Yu Wang
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Ying Pan
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Meng-Die Cheng
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Feng-Hua Song
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Zhi-Yu Liu
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Kai Wang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Li-Zhu Jiang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Lei Fan
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Xiao-Ting Yue
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Yan Bai
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Zeng-Lei Zhang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Xin-Ya Dai
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Ru-Jie Zheng
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - You Chen
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiang Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yi-Tong Ma
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Jin-Ying Zhang
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Key Laboratory of Cardiac Injury and Repair of Henan Province, Zhengzhou, China
| | - Xiang Xie
- Department of Cardiology, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Gargiulo G, Goette A, Tijssen J, Eckardt L, Lewalter T, Vranckx P, Valgimigli M. Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials. Eur Heart J 2020; 40:3757-3767. [PMID: 31651946 DOI: 10.1093/eurheartj/ehz732] [Citation(s) in RCA: 115] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/04/2019] [Accepted: 10/03/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS To investigate the safety and efficacy of double vs. triple antithrombotic therapy (DAT vs. TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome or who underwent percutaneous coronary intervention (PCI). METHODS AND RESULTS A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials comparing DAT vs. TAT in AF patients undergoing PCI. Four trials encompassing 10 234 patients (DAT = 5496 vs. TAT = 4738) were included. The primary safety endpoint (ISTH major or clinically relevant non-major bleeding) was significantly lower with DAT compared with TAT [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.56-0.78; P < 0.0001; I2 = 69%], which was consistent across all available bleeding definitions. This benefit was counterbalanced by a significant increase of stent thrombosis (RR 1.59, 95% CI 1.01-2.50; P = 0.04; I2 = 0%) and a trend towards higher risk of myocardial infarction with DAT. There were no significant differences in all-cause and cardiovascular death, stroke and major adverse cardiovascular events. The comparison of NOAC-based DAT vs. vitamin K antagonist (VKA)-TAT yielded consistent results and a significant reduction of intracranial haemorrhage (RR 0.33, 95% CI 0.17-0.65; P = 0.001; I2 = 0%). CONCLUSION Double antithrombotic therapy, particularly if consisting of a NOAC instead of VKA and a P2Y12 inhibitor, is associated with a reduction of bleeding, including major and intracranial haemorrhages. This benefit is however counterbalanced by a higher risk of cardiac-mainly stent-related-but not cerebrovascular ischaemic occurrences.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, Bern, Switzerland.,Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, Naples, Italy
| | - Andreas Goette
- St. Vincenz-Hospital, Am Busdorf 2, Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Leipziger Str. 44, Magdeburg, Germany.,Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany
| | - Jan Tijssen
- Department of Cardiology, Amsterdam UMC - University of Amsterdam, Meibergdreef 9, AZ Amsterdam, The Netherlands.,Cardialysis B.V., Westblaak 98, KM Rotterdam, The Netherlands
| | - Lars Eckardt
- Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany.,Department of Cardiology II -Electrophysiology; University of Münster, Albert-Schweitzer-Campus 1, Gebäude A1, D-48149 Münster, Germany
| | - Thorsten Lewalter
- Atrial Fibrillation Network (AFNET), Mendel Str.11, Münster, Germany.,Department of Cardiology and Intensive Care, Peter Osypka Heart Center Munich, Hospital Munich-South, Am Isarkanal 36, Munich/Germany
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care Medicine, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Stadsomvaart 11, Hasselt, Belgium
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, Bern, Switzerland
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45
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Wang MT, Hung CC, Lin KC, Mar GY, Kuo SH, Chiang CH, Cheng CC, Kuo FY, Liang HL, Huang WC. Comparison of effects of triple antithrombotic therapy and dual antiplatelet therapy on long-term outcomes of acute myocardial infarction. Heart Vessels 2020; 36:345-358. [PMID: 33033854 DOI: 10.1007/s00380-020-01708-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 09/25/2020] [Indexed: 12/26/2022]
Abstract
Warfarin is an alternate choice for patients who are not eligible for non-vitamin K oral anticoagulants after acute myocardial infarction (AMI). This study aimed to compare the long-term outcome of triple antithrombotic therapy (TAT) with that of dual antiplatelet therapy (DAPT) after AMI. This was a nationwide, propensity score-matched, case-control study of 186,112 first AMI patients, of whom 2,825 received TAT comprising aspirin, clopidogrel, and warfarin. Propensity score matching in a ratio of 1:4 by age, sex, comorbidities, and treatment was adopted, Finally, 2,813 AMI patients and 11,252 matched controls that were administered TAT and DAPT (aspirin and clopidogrel), respectively, were included in our analysis. The 12-year overall survival rate did not differ between both strategies (P = .3167). TAT was beneficial in old age (hazard ratio [HR] = 0.92), female sex (HR = 0.86), atrial fibrillation (AF) (HR = 0.80), hypertension (HR = 0.92), cerebrovascular accident (HR = 0.90), and in the absence of percutaneous coronary intervention (HR = 0.79). TAT reduced the rate of recurrent myocardial infarction (P = .0108) but did not affect the rate of stroke (P = .4867), gastrointestinal bleeding (P = .3889), or intracranial hemorrhage (ICH) (P = .3449). TAT reduces the incidence of recurrent myocardial infarction and does not increase the risk of major bleeding, while compared to DAPT.
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Affiliation(s)
- Mei-Tzu Wang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Cheng Chung Hung
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Kun-Chang Lin
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Guang-Yuan Mar
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Shu-Hung Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan
| | - Cheng-Hung Chiang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Feng-You Kuo
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Hsing-Li Liang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan.,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan.
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46
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Pradhan A, Bhandari M, Vishwakarma P, Sethi R. Novel Dual Therapy: A Paradigm Shift in Anticoagulation in Patients of Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. TH OPEN 2020; 4:e332-e343. [PMID: 33163856 PMCID: PMC7609168 DOI: 10.1055/s-0040-1719081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/23/2020] [Indexed: 02/08/2023] Open
Abstract
Patients with atrial fibrillation (AF) on long-term oral anticoagulation (OAC) either have underlying coronary artery disease or suffer from acute coronary syndromes necessitating a percutaneous coronary intervention (PCI). In such a scenario, an amalgamation of antiplatelet and antithrombotic therapy (conventionally called as "triple therapy") is obligatory for preventing coronary ischemia and stroke. But such ischemic benefits are accrued at the cost of increased bleeding. We also now know that bleeding events following PCI are related to increased mortality. Balancing the bleeding and ischemic risks is often a clinical dilemma. With the advent of novel oral anticoagulants (NOAC's) with preserved efficacy and attenuated bleeding rates, anticoagulation in AF is undergoing paradigm shift. The spotlight is now shifting from conventional triple therapy (vitamin-K antagonist + dual antiplatelet therapy [VKA + DAPT]) to novel dual therapy (NOAC + single antiplatelet therapy [SAPT]) in situation of anticoagulated AF patients undergoing PCI. Such a strategy aims to ameliorate the higher bleeding risk with conventional VKA's while retaining the ischemic benefits. In this review, we briefly discuss the need for combination therapy, trials of novel dual therapy, strategies for mitigating bleeding, the current guidelines, and the future perspectives in AF undergoing PCI with stent(s).
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Affiliation(s)
- Akshyaya Pradhan
- Department of Cardiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Monika Bhandari
- Department of Cardiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Pravesh Vishwakarma
- Department of Cardiology, King George Medical University, Lucknow, Uttar Pradesh, India
| | - Rishi Sethi
- Department of Cardiology, King George Medical University, Lucknow, Uttar Pradesh, India
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47
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Moustafa A, Khan MS, Marei A, Alsamman MA, Baig M, Saad M. Safety and efficacy of dual versus triple antithrombotic therapy in Patients with atrial fibrillation undergoing percutaneous coronary intervention: A meta-analysis. Avicenna J Med 2020; 10:232-240. [PMID: 33437696 PMCID: PMC7791287 DOI: 10.4103/ajm.ajm_40_20] [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] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients with atrial fibrillation undergoing percutaneous coronary intervention have indications for oral anticoagulation and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor. The concurrent use of all three agents, termed triple oral antithrombotic therapy (TAT), increases the risk of bleeding. A number of prospective trials showed that the omission of aspirin mitigates the risk of bleeding without affecting major adverse cardiovascular event (MACE). MATERIALS AND METHODS The databases of PubMed, Embase, and Cochrane Central databases were searched from inception to October 2019. Relevant randomized control trials comparing dual antithrombotic therapy (DAT) versus TAT were identified and a metanalysis was performed using random-effect model. The safety endpoints of interest were thrombolysis in myocardial infarction criteria (TIMI) major and minor bleeding, TIMI major bleeding, and intracranial bleeding. The efficacy endpoints of interest were MACE and individual components of MACE. RESULTS Six trials with 11,722 patients were included. For safety endpoint, DAT was associated with significantly lower incidence of TIMI major and minor bleeding [RR: 0.58, 95% CI 0.44-0.77, P = 0.0001], TIMI major bleeding [RR: 0.55, 95% CI 0.42-0.73, P < 0.0001] as well as intracranial bleeding [RR: 0.35, 95% CI 0.16-0.73, P = 0.006] compared with TAT. No significant difference was observed for MACE [RR: 0.96 (0.79-1.17) P = 0.71] or any of the individual components of MACE between the two groups. CONCLUSION Omission of aspirin from TAT in patients with Atrial Fibrillation (AF) after percutaneous coronary intervention is associated with lower risk of bleeding without compromising the efficacy in terms of mortality and cardiovascular thrombotic events.
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Affiliation(s)
- Abdelmoniem Moustafa
- Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Mohammad Saud Khan
- Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Abdalla Marei
- Department of Cardiac Surgery, Duesseldorf University Hospital, Düsseldorf, Germany
| | - Mohd Amer Alsamman
- Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Muhammad Baig
- Department of Internal Medicine, The Miriam Hospital, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
| | - Marwan Saad
- Department of Cardiology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
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48
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Jacobsen AP, Raber I, McCarthy CP, Blumenthal RS, Bhatt DL, Cusack RW, Serruys PWJC, Wijns W, McEvoy JW. Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or Is Reappraisal Warranted? Circulation 2020; 142:1579-1590. [PMID: 32886529 DOI: 10.1161/circulationaha.120.045695] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Four decades have passed since the first trial suggesting the efficacy of aspirin in the secondary prevention of myocardial infarction. Further trials, collectively summarized by the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase after a myocardial infarction remains incontrovertible, a number of emerging lines of evidence, discussed in this narrative review, raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios, including early discontinuation of the aspirin component of dual antiplatelet therapy after percutaneous coronary intervention and the withholding of aspirin among patients with both CCS and atrial fibrillation who require anticoagulation. Recent primary prevention trials have also failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. The totality of recent evidence supports further study of the universal need for lifelong aspirin in secondary prevention for all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.
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Affiliation(s)
- Alan P Jacobsen
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD(A.P.J., R.S.B., J.W.M.)
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (I.R.)
| | - Cian P McCarthy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston(C.P.M.)
| | - Roger S Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD(A.P.J., R.S.B., J.W.M.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA(D.L.B.)
| | - Ronan W Cusack
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - Patrick W J C Serruys
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - William Wijns
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
| | - John W McEvoy
- School of Medicine, National University of Ireland Galway, Ireland(R.W.C., P.W.J.C.S., W.W., J.W.M.)
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49
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Vitolo M, Javed S, Capodanno D, Rubboli A, Boriani G, Lip GYH. Antithrombotic treatment in atrial fibrillation patients undergoing percutaneous coronary interventions: focus on stent thrombosis. Expert Rev Cardiovasc Ther 2020; 18:587-600. [DOI: 10.1080/14779072.2020.1808463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Saad Javed
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Andrea Rubboli
- Deparment of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, S. Maria Delle Croci Hospital, Ravenna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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50
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Capodanno D, Di Maio M, Greco A, Bhatt DL, Gibson CM, Goette A, Lopes RD, Mehran R, Vranckx P, Angiolillo DJ. Safety and Efficacy of Double Antithrombotic Therapy With Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017212. [PMID: 32805186 PMCID: PMC7660808 DOI: 10.1161/jaha.120.017212] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/18/2020] [Indexed: 02/06/2023]
Abstract
Background The optimal antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is a topic of debate. We aimed at defining the efficacy and safety of double antithrombotic therapy with single antiplatelet therapy (SAPT) plus a non-vitamin K antagonist oral anticoagulant (NOAC) against triple antithrombotic therapy with dual antiplatelet therapy (DAPT) added to a vitamin K antagonist (VKA), illustrating the pooled cumulative distribution of events, the ranking of different NOACs tested in NOAC+SAPT combination strategies, and the state of the current evidence in the field. Methods and Results Randomized controlled trials meeting the inclusion criteria were identified. The primary efficacy end point was the composite of trial-defined major adverse cardiac events. The primary safety end point was clinically significant bleeding. Secondary end points were the components of primary end points. Trial-level pairwise and Bayesian network meta-analyses, reconstructed Kaplan-Meier analyses, and trial sequential analysis were performed. Four randomized controlled trials (10 969 patients) were included. No differences were found in terms of major adverse cardiac events (hazard ratio [HR], 1.07; 95% CI, 0.94-1.22), and the NOAC+SAPT strategy showed a lower rate of clinically significant bleeding compared with VKA + DAPT (HR, 0.56; 95% CI, 0.39-0.80). These results were consistent in reconstructed Kaplan-Meier analyses. In the Bayesian network meta-analysis, different NOACs displayed diverse risk-benefit profiles. Trial sequential analyses suggest that the evidence for the similarity in major adverse cardiac events compared with VKA + DAPT and the bleeding risk reduction observed with NOAC+SAPT is likely to be conclusive. Conclusions NOAC+SAPT does not increase the risk of major adverse cardiac events and reduces the risk of bleeding compared with VKA + DAPT in AF patients undergoing percutaneous coronary intervention. Various NOACs may have different risk-benefit profiles in combination strategies. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020151089.
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Affiliation(s)
- Davide Capodanno
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Marco Di Maio
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
- Division of CardiologyDepartment of Translational Medical SciencesUniversity of Campania "Luigi Vanvitelli"NaplesItaly
| | - Antonio Greco
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Deepak L. Bhatt
- Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - C. Michael Gibson
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Andreas Goette
- Atrial Fibrillation NetworkMunsterGermany
- Cardiology and Intensive Care MedicineSt Vincenz‐HospitalPaderbornGermany
- Working Group of Molecular ElectrophysiologyUniversity Hospital MagdeburgMagdeburgGermany
| | | | - Roxana Mehran
- Cardiovascular InstituteMount Sinai Medical CenterIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Pascal Vranckx
- Jessa ZiekenhuisFaculty of Medicine and Life Sciences at the Hasselt UniversityHasseltBelgium
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