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Dabic P, Petrovic J, Vucurevic B, Bucic A, Bajcetic D, Ilijevski N, Sevkovic M. Caught Between Heart and Limbs: Navigating the Treatment of Patients With CAD and PAD in an Overwhelmed Healthcare System. Angiology 2023:33197231204087. [PMID: 37747707 DOI: 10.1177/00033197231204087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Peripheral arterial disease (PAD) and coronary artery disease (CAD) are manifestations of atherosclerosis, affecting a substantial proportion of the population. Despite their interrelation, the prevalence of CAD in severe PAD varies, prompting the need to understand their complex relationship. This study retrospectively analyzes prospectively collected data from a high-volume vascular center to assess CAD prevalence, risk factors, and implications for patients undergoing vascular surgery. Among 667 arterial disease patients, 19.5% underwent coronary angiography, with CAD detected in 61.5% of cases. CAD varied across vascular beds. Decision-making around preoperative coronary angiography and revascularization remains complex, with benefits for high-risk patients still being debated. In accordance with current guidelines, the routine practice of coronary revascularization preceding vascular surgery is generally discouraged. This study underscores the need for risk stratification to identify patients who might benefit from coronary revascularization prior to vascular surgery while adhering to cost-effectiveness and avoiding unnecessary and time-consuming diagnostics in the majority of patients. Patient demographics, risk factors, and clinical presentation were analyzed alongside hospital stay, mortality, and complications. The study highlights the challenges in managing patients with concurrent CAD and PAD and calls for improved protocols for treating this high-risk group.
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Affiliation(s)
- Petar Dabic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Jovan Petrovic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Bojan Vucurevic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Andriana Bucic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Danica Bajcetic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
| | - Nenad Ilijevski
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milorad Sevkovic
- Vascular Surgery Clinic, Institute for Cardiovascular Disease "Dedinje", Belgrade, Serbia
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Sheth MS, Yu B, Chu A, Porter J, Tam DY, Ferreira‐Legere LE, Goodman SG, Farkouh ME, Ko DT, Abdel‐Qadir H, Udell JA. Eligibility and Implementation of Rivaroxaban for Secondary Prevention of Atherothrombosis in Clinical Practice-Insights From the CANHEART Study. J Am Heart Assoc 2022; 11:e026553. [PMID: 36515238 PMCID: PMC9798819 DOI: 10.1161/jaha.122.026553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial decreased major adverse cardiovascular events with very low-dose rivaroxaban and aspirin in patients with coronary artery disease and peripheral artery disease. We examined the eligibility and potential real-world impact of this strategy on the COMPASS-eligible population. Methods and Results COMPASS eligibility criteria were applied to the CANHEART (Cardiovascular Health in Ambulatory Care Research Team) registry, a population-based cohort of Ontario adults. We compared 5-year major adverse cardiovascular events and major bleeding rates stratified by COMPASS eligibility and by clinical risk factors. We applied COMPASS trial rivaroxaban/aspirin arm hazard ratios to estimate the potential impact on the COMPASS-eligible cohort. Among 362 797 patients with coronary artery disease or peripheral artery disease, 38% were deemed eligible, 47% ineligible, and 15% indeterminate. Among eligible patients, a greater number of risk factors was associated with higher rates of cardiovascular outcomes, whereas bleeding rates increased minimally. Over 5 years, applying COMPASS treatment effects to eligible patients resulted in a 2.4% absolute risk reduction of major adverse cardiovascular events and a number needed to treat of 42, and a 1.3% absolute risk increase of major bleeding and number needed to harm (NNH) of 77. Those with at least 2 risk factors had a 3.0% absolute risk reduction of major adverse cardiovascular events (number needed to treat =34) and a 1.6% absolute risk increase of major bleeding (number needed to harm =61). Conclusions Implementation of very-low-dose rivaroxaban therapy would potentially impact ≈$$ \approx $$2 in 5 patients with atherosclerotic disease in Ontario. Eligible individuals with ≥$$ \ge $$2 comorbidities represent a high-risk subgroup that may derive the greatest benefit-to-risk ratio. Selection of patients with high-risk predisposing factors appears appropriate in routine practice.
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Affiliation(s)
- Maya S. Sheth
- Women’s College Research InstituteTorontoCanada,Dalla Lana School of Public HealthUniversity of TorontoCanada
| | | | | | | | - Derrick Y Tam
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | | | - Shaun G. Goodman
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada
| | - Michael E. Farkouh
- Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada
| | - Dennis T. Ko
- ICESTorontoCanada,Schulich Heart Centre, Sunnybrook Health Sciences CentreTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada
| | - Husam Abdel‐Qadir
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
| | - Jacob A. Udell
- Women’s College Research InstituteTorontoCanada,ICESTorontoCanada,Institute of Health Policy, Management, and EvaluationUniversity of TorontoCanada,Applied Health Research Centre, Li Ka Shing Knowledge InstituteSt Michael’s HospitalTorontoCanada,Department of Medicine, Faculty of MedicineUniversity of TorontoCanada,Peter Munk Cardiac CentreUniversity Health NetworkTorontoCanada,Cardiovascular Division, Department of MedicineWomen’s College HospitalTorontoCanada
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Verma S, Al‐Omran M, Leiter LA, Mazer CD, Rasmussen S, Saevereid HA, Sejersten Ripa M, Bonaca MP. Cardiovascular efficacy of liraglutide and semaglutide in individuals with diabetes and peripheral artery disease. Diabetes Obes Metab 2022; 24:1288-1299. [PMID: 35332654 PMCID: PMC9325529 DOI: 10.1111/dom.14700] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 01/14/2023]
Abstract
AIM To evaluate the cardiovascular (CV) efficacy of liraglutide and semaglutide in patients with type 2 diabetes (T2D) and peripheral artery disease (PAD). MATERIALS AND METHODS LEADER and SUSTAIN 6 trials investigated subcutaneous liraglutide (≤1.8 mg/day) and semaglutide (0.5 or 1.0 mg/week), respectively, versus placebo in patients with T2D and high CV risk (median follow-up: 3.8 and 2.1 years, respectively). The primary outcome was a composite of CV death, non-fatal myocardial infarction or non-fatal stroke (major adverse CV event [MACE]) according to the presence of PAD at baseline. RESULTS Overall, 1184/9340 (12.7%) patients in LEADER and 460/3297 (14.0%) in SUSTAIN 6 had PAD at baseline. Patients with PAD were at an ~35% increased risk of MACE versus those without (LEADER: hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.17-1.58; SUSTAIN 6: HR 1.33, 95% CI 0.94-1.83). The effects of both therapies on MACE were consistently beneficial in patients with PAD (liraglutide: HR 0.77, 95% CI 0.58-1.01; semaglutide: 0.61, 0.33-1.13) and without (liraglutide: HR 0.89, 95% CI 0.79-1.00; semaglutide: HR 0.77, 95% CI 0.58-1.01; Pinteraction = .34 for liraglutide and .49 for semaglutide). Absolute risk reductions for MACE were higher in patients with PAD (liraglutide: 4.13%-point, 95% CI -0.15-8.42; semaglutide: 4.63%-point, 95% CI -0.58-9.84) versus without (liraglutide:1.42%-point, 95% CI -0.03-2.87; semaglutide: 1.90%-point, 95% CI 0.00-3.80). CONCLUSION Both liraglutide and semaglutide reduce MACE with consistent CV efficacy regardless of PAD status.
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Affiliation(s)
- Subodh Verma
- St. Michael's Hospital, University of TorontoTorontoOntarioCanada
| | | | | | - C. David Mazer
- St. Michael's Hospital, University of TorontoTorontoOntarioCanada
| | | | | | | | - Marc P. Bonaca
- CPC Clinical ResearchUniversity of Colorado School of MedicineAuroraColoradoUSA
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Rivera-Caravaca JM, Camelo-Castillo A, Ramírez-Macías I, Gil-Pérez P, López-García C, Esteve-Pastor MA, Orenes-Piñero E, Tello-Montoliu A, Marín F. Antithrombotic Therapy in Patients with Peripheral Artery Disease: A Focused Review on Oral Anticoagulation. Int J Mol Sci 2021; 22:7113. [PMID: 34281167 PMCID: PMC8267774 DOI: 10.3390/ijms22137113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 12/24/2022] Open
Abstract
Peripheral artery disease (PAD) is a major cause of morbidity and mortality but it is usually underdiagnosed and undertreated. Patients with PAD present dysregulated procoagulant, anticoagulant, and fibrinolytic pathways leading to arterial and venous thrombosis. The risk of several ischemic-related complications could be mitigated with appropriate antithrombotic therapy, which plays a central role in all types of PAD. For years, antiplatelets have been indicated in patients with symptomatic PAD or those who have undergone revascularization. Unfortunately, a non-negligible proportion of patients with PAD will suffer from adverse events during the follow-up, even despite proper medical therapies for the prevention of PAD complications. Thus, there is room for improving clinical outcomes in these patients. Given the implication of both, primary and secondary hemostasis in arterial thrombosis and the pathophysiology of PAD, the combination of antiplatelets and anticoagulants has emerged as a potential antithrombotic alternative to antiplatelets alone. In this narrative review article, we have highlighted the most recent evidence about antithrombotic therapy in PAD patients, with a special focus on oral anticoagulation. Certainly, COMPASS and VOYAGER PAD trials have shown promising results. Thus, rivaroxaban in combination with aspirin seem to reduce cardiovascular outcomes with a similar bleeding risk compared to aspirin alone. Nevertheless, results from real-world studies are needed to confirm these observations, and other trials will provide novel evidence about the safety and efficacy of emerging anticoagulant agents.
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Affiliation(s)
- José Miguel Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L7 8TX, UK
| | - Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Inmaculada Ramírez-Macías
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Pablo Gil-Pérez
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Cecilia López-García
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - María Asunción Esteve-Pastor
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Esteban Orenes-Piñero
- Department of Biochemistry and Molecular Biology-A, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain;
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, 30120 Murcia, Spain; (A.C.-C.); (I.R.-M.); (P.G.-P.); (C.L.-G.); (M.A.E.-P.); (A.T.-M.); (F.M.)
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Risk stratification of cardiovascular complications using CHA 2DS 2-VASc and CHADS 2 scores in chronic atherosclerotic cardiovascular disease. Int J Cardiol 2021; 337:9-15. [PMID: 33957178 DOI: 10.1016/j.ijcard.2021.04.067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 11/22/2022]
Abstract
Background The COMPASS (Cardiovascular Outcomes for People Using Anticoagulation Strategies) trial showed that rivaroxaban plus aspirin reduced major adverse cardiovascular events (MACE) in patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD). We explored whether CHA2DS2-VASc or CHADS2 scores, well-validated tools for assessing risk of thromboembolic events in atrial fibrillation, can identify vascular patients at highest risk of recurrent events who may derive greatest benefits of treatment. Methods Predictive accuracies of the CHA2DS2-VASc and CHADS2 scores for MACE, were assessed in this analysis of the COMPASS trial. Kaplan-Meier estimates of cumulative risk were used to compare the effects of rivaroxaban plus aspirin (n = 9152) with aspirin alone (n = 9126) according to risk scores. Results High CHA2DS2-VASc (6-9) or CHADS2 (3-6) scores were associated with over three times greater absolute risk of MACE compared with CHA2DS2-VASc score of 1-2 or CHADS2 score of 0. The effects of rivaroxaban plus aspirin compared with aspirin alone were consistent across CHA2DS2-VASc and CHADS2 score categories for MACE, bleeding and net clinical benefit, with greatest reduction in MACE observed in patients treated for 30 months with highest CHADS2 score (3-6) (hazard ratio = 0.67, 95% CI: 0.53-0.86, p = 0.0012, 25 events per 1000 patients prevented). Conclusion The CHA2DS2-VASc and CHADS2 scores can be used in patients with chronic CAD and/or PAD to identify patients who are at highest risk of MACE. Those identified at highest risk by CHADS2 scores had greatest benefit from dual pathway inhibition with rivaroxaban plus aspirin. Clinical Trial Registration: NCT01776424.
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Hernandez-Suarez DF, Melin K, Marin-Maldonado F, Nunez HJ, Gonzalez AF, Gonzalez-Sepulveda L, Rivas-Tumanyan S, Naik H, Ruaño G, Scott SA, Duconge J. Implementing a pharmacogenetic-driven algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics: protocol for a non-randomised clinical trial. BMJ Open 2020; 10:e038936. [PMID: 32764090 PMCID: PMC7412606 DOI: 10.1136/bmjopen-2020-038936] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Minority populations in the USA are disproportionately affected by cardiovascular conditions. Reduced responsiveness to clopidogrel among carriers of CYP2C19 variants has been reported in patients with either coronary artery disease (CAD) or acute coronary syndrome (ACS) after the percutaneous coronary intervention (PCI). Previous studies have evaluated CYP2C19 genotyping-guided antiplatelet therapy in selected populations; however, this has yet to be tested among Hispanics. Given the paucity of clinical research on CYP2C19 and antiplatelet clinical outcomes in Hispanics, our study will test the safety and efficacy of a genetic-driven treatment algorithm to guide dual antiplatelet therapy (DAPT) in Caribbean Hispanics. METHODS AND ANALYSIS This is a multicentre, prospective, non-randomised clinical trial that proposes an assessment of pharmacogenomic-guided DAPT in post-PCI Caribbean Hispanic patients with ACS or CAD. We will recruit 250 patients to be compared with a matched non-concurrent cohort of 250 clopidogrel-treated patients (standard-of-care). Major adverse cardiovascular events (MACEs) such as all-cause death, myocardial infarction (MI), stroke, coronary revascularisation, stent thrombosis and bleedings over 6 months will be the study endpoints. Among the recruited, high-risk patients will be escalated to ticagrelor and low-risk patients will remain on clopidogrel. The primary objective is to determine whether genetic-guided therapy is superior to standard of care. The secondary objective will determine if clopidogrel treatment in low-risk patients is not associated with a higher rate of MACEs compared with escalated antiplatelet therapy in high-risk patients. Patients will be enrolled up to the group's completion. ETHICS AND DISSEMINATION Approval was obtained from the Institutional Review Board of the University of Puerto Rico Medical Sciences Campus (protocol # A4070417). The study will be carried out in compliance with the Declaration of Helsinki and International Conference on Harmonization Good Clinical Practice Guidelines. Findings will be published in a peer-reviewed journal and controlled access to experimental data will be available. TRIAL REGISTRATION NUMBER NCT03419325; Pre-results.
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Affiliation(s)
- Dagmar F Hernandez-Suarez
- Division of Cardiovascular Medicine, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Kyle Melin
- Department of Pharmacy Practice, University of Puerto Rico School of Pharmacy, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Frances Marin-Maldonado
- RCMI Program, Academic Affairs Deanship, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Hector J Nunez
- Division of Cardiovascular Medicine, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Ariel F Gonzalez
- Division of Cardiovascular Medicine, University of Puerto Rico School of Medicine, Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Lorena Gonzalez-Sepulveda
- Research Design and Biostatistics Core, Puerto Rico Clinical and Translational Research Consortium (PRCTRC), Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Sona Rivas-Tumanyan
- Research Design and Biostatistics Core, Puerto Rico Clinical and Translational Research Consortium (PRCTRC), Medical Sciences Campus, San Juan, Puerto Rico, USA
| | - Hetanshi Naik
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Gualberto Ruaño
- Hartford Hospital Institute of Living, Hartford, Connecticut, USA
| | - Stuart A Scott
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jorge Duconge
- Department of Pharmaceutical Sciences, University of Puerto Rico School of Pharmacy, Medical Sciences Campus, San Juan, Puerto Rico, USA
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Berger A, Simpson A, Leeper NJ, Murphy B, Nordstrom B, Ting W, Zhao Q, Berger J. Real-World Predictors of Major Adverse Cardiovascular Events and Major Adverse Limb Events Among Patients with Chronic Coronary Artery Disease and/or Peripheral Arterial Disease. Adv Ther 2020; 37:240-252. [PMID: 31705434 DOI: 10.1007/s12325-019-01132-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Collectively, coronary artery disease (CAD) and peripheral artery disease (PAD) are highly prevalent and are associated with increased risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Improved ability to identify those at highest risk of these events may help optimize secondary prevention efforts in this population. METHODS Using the Optum Integrated Database, a healthcare claims database linked to electronic medical records (EMR), we identified patients with CAD and/or PAD between January 1, 2009, and September 30, 2016. Index date was the earliest date on which chronic and stable disease was established. Follow-up ran from index date until earliest of patient death, plan disenrollment, or end of study. We developed multivariate Cox proportional hazards models to identify predictors of MACE and/or MALE, limited to measures presumed available to clinicians during patient encounters (e.g., age, presence of selected comorbidities). RESULTS A total of 20,932 patients met all selection criteria; 86.9% had CAD and 26.1% had PAD; 13% (n = 2753) experienced MACE and/or MALE during a mean follow-up of 2.3 years, for a rate of 7.1 events per 100 person-years (PYs). We identified 11 predictors of MACE and/or MALE. Most (95.1%) patients had ≥ 1 predictors; 34.0% and 6.9% had ≥ 4 and ≥ 6, respectively. Incidence of MACE and/or MALE was strongly correlated with number of predictors (r2 = 0.98), ranging from 2.3 per 100 PYs among those without predictors (4.9% of patients) to 18.7 per 100 PYs among those with ≥ 6 (6.9%). Patients with ≥ 1 predictor experienced 7.4 MACE and/or MALE per 100 PYs. CONCLUSION Readily identifiable predictors can be used to identify subgroups with chronic CAD and/or PAD at elevated risk of MACE and/or MALE. Further research is required to understand the degree to which these subgroups may benefit from early identification and treatment with secondary prevention therapies. FUNDING Janssen Pharmaceuticals.
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Affiliation(s)
| | | | | | | | | | | | - Qi Zhao
- Janssen Pharmaceuticals, Raritan, NJ, USA
| | - Jeffrey Berger
- Center for the Prevention of Cardiovascular Disease, New York University School of Medicine, New York, NY, USA
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Khalil P, Kabbach G. Direct Oral Anticoagulants in Addition to Antiplatelet Therapy for Secondary Prevention after Acute Coronary Syndromes: a Review. Curr Cardiol Rep 2019; 21:5. [PMID: 30689068 DOI: 10.1007/s11886-019-1088-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW As the management of acute coronary syndrome (ACS) continues to evolve, many old practices proved to be of a little benefit and other approaches established the new pillars of modern medicine. Treating ACS patients with dual antiplatelet therapy (DAPT) for a year by combining aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) has resulted in better outcomes and is currently the standard of therapy. However, owing to the persistent activation of the coagulation cascade, patients may continue to experience recurrent ischemia and high mortality rates despite compliance with the dual antiplatelet therapy. Research is underway to establish new treatment modalities for secondary prevention post-ACS, including the use of the novel direct oral anticoagulants (DOACs). RECENT FINDINGS Multiple trials have been conducted to evaluate the use of DOACs for the secondary prevention after ACS. Recent emerging data showed that the addition of rivaroxaban in a very low dose of 2.5 mg twice daily to the regular DAPT regimen after ACS is beneficial in the reduction of major cardiovascular events, including recurrent myocardial infarction (MI) and strokes. On the other hand, other DOACs, including apixaban, did not show similar efficacy and did not improve the cardiovascular outcomes. Patients who experience an ACS continue to suffer long-term consequences and thromboembolic complications. Many studies have shown that after the initial ACS event, patients remain in a hypercoagulable state and are more prone to recurrent ischemic attacks including stroke, recurrent MI, or unstable angina (UA). With the objective of seeking better outcomes, it is imperative to explore more aggressive anticoagulation strategies in ACS patients. In this article, we discuss the progress that was made and the limitations we face regarding the role of different anticoagulants in this setting.
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Affiliation(s)
- Peter Khalil
- Department of Internal Medicine, Texas Tech University Health Sciences Center. Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
| | - Ghazal Kabbach
- Department of Internal Medicine, Texas Tech University Health Sciences Center. Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA
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Harky A, Maskell P, Burgess M. Anti-platelet and anti-coagulant therapy in peripheral arterial disease prior to surgical intervention. Vascular 2018; 27:299-311. [PMID: 30539687 DOI: 10.1177/1708538118818622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Peripheral artery disease is a major clinical co-morbidity that can significantly affect quality of life, especially in the presence of diabetes mellitus and older age. The focus of this literature review is on medical management, through anti-platelet and anti-coagulation, of peripheral artery disease prior to undergoing surgical or endovascular management. METHOD Extensive electronic literature search performed in four major databases (PubMed, SCOPUD, Embase and Ovid) to identify the published randomized and non-randomized studies that compared and discussed the management of peripheral artery disease with different anti-thrombotic agents. RESULTS A total of 17 studies were identified to meet the inclusion criteria of this review. Among them, 4 were systematic review and meta-analyses, 1 was observational study and 12 were randomized controlled trials. The reported outcomes in each study are summarized and reported separately within this review. CONCLUSION Peripheral artery disease is a complex and multifactorial clinical condition. The use of dual anti-platelets, such as aspirin and clopidogrel, are the key in preventing major cardiovascular events as well as stroke and death. Utilization of anti-coagulation such as direct oral anti-coagulants' as additional parameters for the prevention of disease progression, is paramount. Eventually, the choice of either dual-antiplatelet therapy or combined anti-coagulation with anti-platelets should be carefully considered, particularly following the most recent published debatable studies.
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Affiliation(s)
- Amer Harky
- 1 Department of Vascular Surgery, Countess of Chester, Chester, UK.,2 School of Medicine, University of Liverpool, Liverpool, UK
| | - Perry Maskell
- 1 Department of Vascular Surgery, Countess of Chester, Chester, UK
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Schaller MS, Ramirez JL, Gasper WJ, Zahner GJ, Hills NK, Grenon SM. Frailty Is Associated with an Increased Risk of Major Adverse Cardiac Events in Patients with Stable Claudication. Ann Vasc Surg 2018; 50:38-45. [PMID: 29477684 DOI: 10.1016/j.avsg.2017.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 12/11/2017] [Accepted: 12/18/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Frailty, a syndrome characterized by decreased physiologic reserves and resistance to stressors, is associated with disability, poor surgical outcomes, and mortality. We evaluated the impact of frailty on cardiovascular disease (CVD) events in peripheral arterial disease (PAD) patients with intermittent claudication. METHODS We conducted a retrospective review of patients with stable intermittent claudication enrolled in the OMEGA-PAD study between 2010 and 2015. The modified frailty index (mFI) is a retrospectively validated index of frailty derived from the Canadian Study of Health and Aging and was used in this study to categorize frailty as low, medium, or high. Our outcome was time to occurrence of a major adverse cardiac event (MACE), defined as a composite endpoint of myocardial infarction, coronary revascularization, stroke, or CVD-related death. Cox proportional hazards models were used to calculate relative hazards ratio. RESULTS There were 129 subjects with a mean age of 67 years, 97% were men, 36% were diabetic, and 33% had known coronary heart disease. When the mFI criteria were applied, 38 subjects were "low" frailty, 72 were "medium" frailty, and 19 were "high" frailty. During the median follow-up period of 34 months (interquartile range: 25-43), 29 subjects experienced a MACE. When compared to the lowest mFI, patients with medium frailty were 2.8 times more likely to have an event (95% confidence interval [CI]: 0.95-8.46, P = 0.06), whereas patients with a high mFI were 4.8 times as likely (95% CI: 1.43-15.8, P = 0.01). In a model adjusted for age, smoking status, and presence of diabetes, those with a medium mFI were 4.3 times more likely to have an event (95% CI: 1.37-13.7, P = 0.01) and those with a high mFI were 9.2 times as likely (95% CI: 2.6-32.4, P = 0.001). CONCLUSIONS Higher mFI category is associated with a significantly increased risk of MACE in PAD patients with stable claudication. Frailty may serve as a useful adjunct for assessment of overall cardiac risk, particularly as treatment options are being contemplated.
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Affiliation(s)
- Melinda S Schaller
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, San Francisco, CA; Vascular Surgery Section, Veterans Affairs Medical Center, San Francisco, CA
| | - Greg J Zahner
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Nancy K Hills
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - S Marlene Grenon
- Department of Surgery, University of California, San Francisco, San Francisco, CA; Vascular Surgery Section, Veterans Affairs Medical Center, San Francisco, CA.
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Kaweewan R, Orrapin S, Kosachunhanun N, Sony K, Inpankaew N, Rerkasem K. Chronic leg ulcer is a strong predictor to determine the major cardiovascular events in diabetic patients with peripheral arterial disease in Thailand. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0593-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Michel I, De Haro J, Bleda S, Laime IV, Uyaguari J, Acin F. Rationale and Design of Randomized Clinical Trial for the Assessment of Macitentan Efficiency as Coadjuvant Treatment to Open and Endovascular Revascularization in Critical Limb Ischemia. CLINICAL MEDICINE INSIGHTS: CARDIOLOGY 2016; 10:181-185. [PMID: 27840580 PMCID: PMC5096766 DOI: 10.4137/cmc.s38448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/05/2016] [Accepted: 10/09/2016] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Critical limb ischemia (CLI) is defined by ischemic rest pain, tissue loss, or both, secondary to arterial insufficiency, and its prevalence is increasing mainly as a result of the worldwide high prevalence of diabetes. Currently, there are no available conclusive data on the efficacy of any coadjuvant therapy after revascularization procedure benefiting amputation and patency rates. Macitentan is an orally active dual endothelin (ET) receptor antagonist that may contribute to reduce the amputation rate and improve revascularization patency in CLI. METHODS/DESIGN REVASC is a proposed pilot, open-label, controlled, randomized, single-center clinical double-blind trial to be conducted in Spain on a study population of European patients with CLI, which will compare the clinical outcomes and cost-effectiveness of macitentan coadjuvant treatment after limb revascularization with the standard antiplatelet treatment strategy for severe limb ischemia. Patients are randomized 1:1 to receive macitentan or placebo for 12 weeks. The primary clinical end point will be amputation-free survival rate at 12 months, defined as the time to major (above the ankle) amputation for the index (trial) limb or death from any cause, whichever comes first. Secondary outcomes include overall survival, quality of life, in-hospital mortality and morbidity, repeat interventions, healing of tissue loss, and hemodynamic changes following revascularization. Sample size is estimated as 120 patients. The economic analysis will consist of two components: a "within-study" analysis, which will be based on study end points; and a "model-based" analysis, which will extrapolate and compare costs and effects likely to accrue beyond the study follow-up period. DISCUSSION The REVASC trial is designed to be pragmatic and represents current practice of the real-world population management after limb revascularization for CLI due to atherosclerosis. Current evidence does not support any coadjuvant treatment. A new pathway of treatment may be opened with the use of ET receptor antagonists in these patients.
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Affiliation(s)
- Ignacio Michel
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
| | - Joaquin De Haro
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
| | - Silvia Bleda
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
| | - Ilsem V Laime
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
| | - Jhenifer Uyaguari
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
| | - Francisco Acin
- Department of Angiology and Vascular Surgery, Getafe University Hospital, Getafe, Madrid, Spain
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