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Salcher-Konrad M, Nguyen M, Savovic J, Higgins JPT, Naci H. Treatment Effects in Randomized and Nonrandomized Studies of Pharmacological Interventions: A Meta-Analysis. JAMA Netw Open 2024; 7:e2436230. [PMID: 39331390 DOI: 10.1001/jamanetworkopen.2024.36230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2024] Open
Abstract
Importance Randomized clinical trials (RCTs) are widely regarded as the methodological benchmark for assessing clinical efficacy and safety of health interventions. There is growing interest in using nonrandomized studies to assess efficacy and safety of new drugs. Objective To determine how treatment effects for the same drug compare when evaluated in nonrandomized vs randomized studies. Data Sources Meta-analyses published between 2009 and 2018 were identified in MEDLINE via PubMed and the Cochrane Database of Systematic Reviews. Data analysis was conducted from October 2019 to July 2024. Study Selection Meta-analyses of pharmacological interventions were eligible for inclusion if both randomized and nonrandomized studies contributed to a single meta-analytic estimate. Data Extraction and Synthesis For this meta-analysis using a meta-epidemiological framework, separate summary effect size estimates were calculated for nonrandomized and randomized studies within each meta-analysis using a random-effects model and then these estimates were compared. The reporting of this study followed the Guidelines for Reporting Meta-Epidemiological Methodology Research and relevant portions of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline. Main Outcome and Measures The primary outcome was discrepancies in treatment effects obtained from nonrandomized and randomized studies, as measured by the proportion of meta-analyses where the 2 study types disagreed about the direction or magnitude of effect, disagreed beyond chance about the effect size estimate, and the summary ratio of odds ratios (ROR) obtained from nonrandomized vs randomized studies combined across all meta-analyses. Results A total of 346 meta-analyses with 2746 studies were included. Statistical conclusions about drug benefits and harms were different for 130 of 346 meta-analyses (37.6%) when focusing solely on either nonrandomized or randomized studies. Disagreements were beyond chance for 54 meta-analyses (15.6%). Across all meta-analyses, there was no strong evidence of consistent differences in treatment effects obtained from nonrandomized vs randomized studies (summary ROR, 0.95; 95% credible interval [CrI], 0.89-1.02). Compared with experimental nonrandomized studies, randomized studies produced on average a 19% smaller treatment effect (ROR, 0.81; 95% CrI, 0.68-0.97). There was increased heterogeneity in effect size estimates obtained from nonrandomized compared with randomized studies. Conclusions and Relevance In this meta-analysis of treatment effects of pharmacological interventions obtained from randomized and nonrandomized studies, there was no overall difference in effect size estimates between study types on average, but nonrandomized studies both overestimated and underestimated treatment effects observed in randomized studies and introduced additional uncertainty. These findings suggest that relying on nonrandomized studies as substitutes for RCTs may introduce additional uncertainty about the therapeutic effects of new drugs.
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Affiliation(s)
- Maximilian Salcher-Konrad
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- World Health Organization Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG)/Austrian National Public Health Institute, Vienna, Austria
| | - Mary Nguyen
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
- Department of Family and Community Medicine, University of California, San Francisco
| | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Julian P T Higgins
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- National Institute for Health and Care Research Applied Research Collaboration West, University Hospitals Bristol and Weston National Health Service Foundation Trust, Bristol, United Kingdom
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
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Li Y, Lei M, Zhao Z, Yang Y, An L, Wang J, Sun X, Li C, Xue Z. Effect of pretreatment with a P2Y 12 inhibitor in patients with non-ST-elevation acute coronary syndrome: a systematic review and network meta-analysis. Front Cardiovasc Med 2023; 10:1191777. [PMID: 37539086 PMCID: PMC10394276 DOI: 10.3389/fcvm.2023.1191777] [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: 03/22/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Background This study aimed to systematically evaluate the effects of different types and doses of pretreatment with P2Y12 inhibitors in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). Methods Electronic databases were searched for studies comparing pretreatment with different types and doses of P2Y12 inhibitors or comparison between P2Y12 inhibitor pretreatment and nonpretreatment. Electronic databases included the Cochrane Library, PubMed, EMBASE, and Web of Science. Literature was obtained from the establishment of each database until June 2022. The patients included in the study had pretreatment with P2Y12 inhibitors with long-term oral or loading doses, or conventional aspirin treatment (non-pretreatment). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCEs) during follow-up within 30 days after PCI, which included determining the composite endpoints of cardiac death, myocardial infarction, ischemia-driven revascularization, and stroke. The safety endpoint was a major bleeding event. Results A total of 119,014 patients from 21 studies were enrolled, including 13 RCTs and eight observational studies. A total of six types of interventions were included-nonpretreatment (placebo), clopidogrel pretreatment, ticagrelor pretreatment, prasugrel pretreatment, double loading pretreatment (double loading dose of clopidogrel, ticagrelor, prasugrel) and P2Y12 inhibitors pretreatment (the included studies did not distinguish the types of P2Y12 inhibitors, including clopidogrel, ticagrelor, and prasugrel). The network meta-analysis results showed that compared to patients without pretreatment, patients receiving clopidogrel pretreatment (RR = 0.78, 95% CI:0.66, 0.91, P < 0.05) and double-loading pretreatment (RR = 0.62, 95% CI:0.41, 0.95, P < 0.05) had a lower incidence of MACCEs. There was no statistically significant difference in the incidence of major bleeding events among the six pretreatments (P > 0.05). Conclusions In patients with NSTE-ACS, pretreatment with P2Y12 inhibitors before percutaneous intervention reduced the incidence of recurrent ischemic events without increasing the risk of major bleeding after PCI compared with nonpretreatment. Clopidogrel or double loading dose P2Y12 inhibitors can be considered for the selection of pretreatment drugs.
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Laudani C, Capodanno D, Angiolillo DJ. Bleeding in acute coronary syndrome: from definitions, incidence, and prognosis to prevention and management. Expert Opin Drug Saf 2023; 22:1193-1212. [PMID: 38048099 DOI: 10.1080/14740338.2023.2291865] [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: 06/24/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION In patients with acute coronary syndrome (ACS), the ischemic benefit of antithrombotic treatment is counterbalanced by the risk of bleeding. The recognition that bleeding events have prognostic implications (i.e. mortality) similar to recurrent ischemic events led to the development of treatment regimens aimed at balancing both ischemic and bleeding risks. AREAS COVERED This review aims at describing definitions, incidence, and prognosis related to bleeding events in ACS patients as well as bleeding-avoidance strategies for their prevention and management of bleeding complications. EXPERT OPINION Management of ACS patients has witnessed remarkable progress after the shift in focusing on the trade-off between ischemia and bleeding. Efforts in standardizing bleeding definitions will allow for better defining the prognostic impact of different types of bleeding events and enable to identify the high-bleeding risk patient. Such efforts will allow to balance the trade-off between the thrombotic and bleeding risk of the individual patient translating into better downward diagnostic and therapeutic decision-making. Novel strategies aiming at maximizing the safety and efficacy of antithrombotic regimens as well as the development of novel antithrombotic drugs and reversal agents and technological advances will allow for optimization of bleeding-avoidance strategies and management of bleeding complications.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Sigal AR, Rivero M, Meza M, Filippa G, Procopio G, Abud CM, Nani S, Odone M, Duronto E, Costabel JP. [Impact of pretreatment with P2Y12 inhibitors in patients with acute coronary syndromes without ST elevation. Analysis of 2 multicenter registries]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2023; 4:96-101. [PMID: 38046231 PMCID: PMC10688406 DOI: 10.47487/apcyccv.v4i3.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/22/2023] [Indexed: 12/05/2023]
Abstract
Objectives To evaluate the rate of use of antiplatelet pretreatment in patients with non-ST elevated acute coronary syndrome (NSTEACS) and its association with adverse events in two Argentine registries. Materials and methods We retrospectively analyzed two Argentine acute coronary syndrome (ACS) registries from 2017 and 2022. We explored the incidence of pretreatment and the drug used. We evaluated the relationship between this strategy and a composite clinical outcome of in-hospital events: death + myocardial infarction + stent thrombosis + post-MI angina + transient ischemic event/cerebrovascular event, and with bleeding events (BARC 2 or higher). Subsequently, we performed a multivariate analysis by logistic regression with other clinical variables. Results A total of 1297 patients were included; 75.6% were men, 25.6% diabetics, 27.1% smokers, 70.3% hypertensive, and 23.1% had a previous ACS. The mean age was 55.3 years. The mean GRACE score was 113.5, and the CRUSADE was 23.8. 44% of the patients received pretreatment, the majority with clopidogrel (93.5%). Pretreatment was significantly associated with a higher incidence of the composite clinical outcome (10.1% vs. 6.9%) (OR 1,56; IC 95%: 1,06-2,3; p=0,02). Bleeding events were numerically more frequent with pretreatment (8.7% vs. 5.9%) (OR 1,51; IC95%: 0,99 -2,3; p=0,054). In the multivariate analysis, pretreatment was no longer associated with a higher incidence of ischemic outcomes (OR 1,4; IC95%: 0,89-2,3; p=0,13). Conclusion Pretreatment was used in almost half of the patients, mainly with clopidogrel, and did not show a reduction in ischemic events in patients with NSTACS.
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Affiliation(s)
- Alan R Sigal
- Instituto Cardiovascular de Buenos Aires. Buenos Aires, Argentina. Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina
| | - Mirza Rivero
- CEMIC. Buenos Aires, Argentina. CEMIC Buenos Aires Argentina
| | - Mayra Meza
- CEMIC. Buenos Aires, Argentina. CEMIC Buenos Aires Argentina
| | - Gerardo Filippa
- CEMEP. Tierra del Fuego, Argentina. CEMEP Tierra del Fuego Argentina
| | - Gastón Procopio
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Camila M Abud
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Sebastián Nani
- Clínica Olivos. Buenos Aires, Argentina. Clínica Olivos Buenos Aires Argentina
| | - Martín Odone
- Sanatorio San Lucas. Buenos Aires, Argentina. Sanatorio San Lucas Buenos Aires Argentina
| | - Ernesto Duronto
- Hospital Universitario Fundación Favaloro. Buenos Aires, Argentina. Hospital Universitario Fundación Favaloro Buenos Aires Argentina
| | - Juan P Costabel
- Instituto Cardiovascular de Buenos Aires. Buenos Aires, Argentina. Instituto Cardiovascular de Buenos Aires Buenos Aires Argentina
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Niezgoda P, Ostrowska M, Adamski P, Gajda R, Kubica J. Pretreatment with P2Y 12 Receptor Inhibitors in Acute Coronary Syndromes-Is the Current Standpoint of ESC Experts Sufficiently Supported? J Clin Med 2023; 12:jcm12062374. [PMID: 36983373 PMCID: PMC10054246 DOI: 10.3390/jcm12062374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/22/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Excessive platelet reactivity plays a pivotal role in the pathogenesis of acute myocardial infarction. Today, the vast majority of patients presenting with acute coronary syndromes qualify for invasive treatment strategy and thus require fast and efficient platelet inhibition. Since 2008, in cases of ST-elevation myocardial infarction, the European Society of Cardiology guidelines have recommended pretreatment with a P2Y12 inhibitor. This approach has become the standard of care in the majority of centers worldwide. Nevertheless, the latest guidelines for the management of patients presenting with acute coronary syndrome without persisting ST-elevation preclude routine pretreatment with the P2Y12 receptor inhibitor. Those who oppose pretreatment support their stance with trials failing to prove the benefits of this strategy at the cost of an increased risk of major bleeding, especially in individuals inappropriately diagnosed with an acute coronary syndrome, thus having no indication for platelet inhibition. However, adequate platelet inhibition requires even up to several hours after application of a loading dose of P2Y12 receptor inhibitors. Omission of data from pharmacokinetic and pharmacodynamic studies in the absence of data from clinical studies makes generalization of the pretreatment recommendations difficult to accept. We aimed to review the scientific evidence supporting the current recommendations regarding pretreatment with P2Y12 inhibitors.
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Affiliation(s)
- Piotr Niezgoda
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
| | - Robert Gajda
- Gajda-Med Medical Center, 06-100 Pułtusk, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
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O'Malley K, Hwang YJ, Trost J, Feldman L. Things We Do for No Reason™: Routine pretreatment with a P2Y12 receptor inhibitor before invasive coronary angiography for patients with a non-ST elevation acute coronary syndrome. J Hosp Med 2023; 18:177-180. [PMID: 35920593 DOI: 10.1002/jhm.12931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Kevin O'Malley
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yoseob Joseph Hwang
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey Trost
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Leonard Feldman
- Department of Medicine, Division of Hospital Medicine at Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bröckelmann N, Stadelmaier J, Harms L, Kubiak C, Beyerbach J, Wolkewitz M, Meerpohl JJ, Schwingshackl L. An empirical evaluation of the impact scenario of pooling bodies of evidence from randomized controlled trials and cohort studies in medical research. BMC Med 2022; 20:355. [PMID: 36274131 PMCID: PMC9590141 DOI: 10.1186/s12916-022-02559-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/09/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess treatment effects of medical interventions. We aimed to hypothetically pool bodies of evidence (BoE) from RCTs with matched BoE from cohort studies included in the same systematic review. METHODS BoE derived from systematic reviews of RCTs and cohort studies published in the 13 medical journals with the highest impact factor were considered. We re-analyzed effect estimates of the included systematic reviews by pooling BoE from RCTs with BoE from cohort studies using random and common effects models. We evaluated statistical heterogeneity, 95% prediction intervals, weight of BoE from RCTs to the pooled estimate, and whether integration of BoE from cohort studies modified the conclusion from BoE of RCTs. RESULTS Overall, 118 BoE-pairs based on 653 RCTs and 804 cohort studies were pooled. By pooling BoE from RCTs and cohort studies with a random effects model, for 61 (51.7%) out of 118 BoE-pairs, the 95% confidence interval (CI) excludes no effect. By pooling BoE from RCTs and cohort studies, the median I2 was 48%, and the median contributed percentage weight of RCTs to the pooled estimates was 40%. The direction of effect between BoE from RCTs and pooled effect estimates was mainly concordant (79.7%). The integration of BoE from cohort studies modified the conclusion (by examining the 95% CI) from BoE of RCTs in 32 (27%) of the 118 BoE-pairs, but the direction of effect was mainly concordant (88%). CONCLUSIONS Our findings provide insights for the potential impact of pooling both BoE in systematic reviews. In medical research, it is often important to rely on both evidence of RCTs and cohort studies to get a whole picture of an investigated intervention-disease association. A decision for or against pooling different study designs should also always take into account, for example, PI/ECO similarity, risk of bias, coherence of effect estimates, and also the trustworthiness of the evidence. Overall, there is a need for more research on the influence of those issues on potential pooling.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Julia Stadelmaier
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Jörg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Bröckelmann N, Balduzzi S, Harms L, Beyerbach J, Petropoulou M, Kubiak C, Wolkewitz M, Meerpohl JJ, Schwingshackl L. Evaluating agreement between bodies of evidence from randomized controlled trials and cohort studies in medical research: a meta-epidemiological study. BMC Med 2022; 20:174. [PMID: 35538478 PMCID: PMC9092682 DOI: 10.1186/s12916-022-02369-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/06/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Randomized controlled trials (RCTs) and cohort studies are the most common study design types used to assess the treatment effects of medical interventions. To evaluate the agreement of effect estimates between bodies of evidence (BoE) from randomized controlled trials (RCTs) and cohort studies and to identify factors associated with disagreement. METHODS Systematic reviews were published in the 13 medical journals with the highest impact factor identified through a MEDLINE search. BoE-pairs from RCTs and cohort studies with the same medical research question were included. We rated the similarity of PI/ECO (Population, Intervention/Exposure, Comparison, Outcome) between BoE from RCTs and cohort studies. The agreement of effect estimates across BoE was analyzed by pooling ratio of ratios (RoR) for binary outcomes and difference of mean differences for continuous outcomes. We performed subgroup analyses to explore factors associated with disagreements. RESULTS One hundred twenty-nine BoE pairs from 64 systematic reviews were included. PI/ECO-similarity degree was moderate: two BoE pairs were rated as "more or less identical"; 90 were rated as "similar but not identical" and 37 as only "broadly similar". For binary outcomes, the pooled RoR was 1.04 (95% CI 0.97-1.11) with considerable statistical heterogeneity. For continuous outcomes, differences were small. In subgroup analyses, degree of PI/ECO-similarity, type of intervention, and type of outcome, the pooled RoR indicated that on average, differences between both BoE were small. Subgroup analysis by degree of PI/ECO-similarity revealed high statistical heterogeneity and wide prediction intervals across PI/ECO-dissimilar BoE pairs. CONCLUSIONS On average, the pooled effect estimates between RCTs and cohort studies did not differ. Statistical heterogeneity and wide prediction intervals were mainly driven by PI/ECO-dissimilarities (i.e., clinical heterogeneity) and cohort studies. The potential influence of risk of bias and certainty of the evidence on differences of effect estimates between RCTs and cohort studies needs to be explored in upcoming meta-epidemiological studies.
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Affiliation(s)
- Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Sara Balduzzi
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Louisa Harms
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Maria Petropoulou
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Charlotte Kubiak
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Lukas Schwingshackl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany.
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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10
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Schwingshackl L, Bröckelmann N, Beyerbach J, Werner SS, Zähringer J, Schwarzer G, Meerpohl JJ. An Empirical Evaluation of the Impact Scenario of Pooling Bodies of Evidence from Randomized Controlled Trials and Cohort Studies in Nutrition Research. Adv Nutr 2022; 13:1774-1786. [PMID: 35416239 PMCID: PMC9526829 DOI: 10.1093/advances/nmac042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/16/2021] [Accepted: 04/08/2022] [Indexed: 01/28/2023] Open
Abstract
Only very few Cochrane nutrition reviews include cohort studies (CSs), but most evidence in nutrition research comes from CSs. We aimed to pool bodies of evidence (BoE) from randomized controlled trials (RCTs) derived from Cochrane reviews with matched BoE from CSs. The Cochrane Database of Systematic Reviews and MEDLINE were searched for systematic reviews (SRs) of RCTs and SRs of CSs. BoE from RCTs were pooled together with BoE from CSs using random-effects and common-effect models. Heterogeneity, 95% prediction intervals, contributed weight of BoE from RCTs to the pooled estimate, and whether integration of BoE from CSs modified the conclusion from BoE of RCTs were evaluated. Overall, 80 diet-disease outcome pairs based on 773 RCTs and 720 CSs were pooled. By pooling BoE from RCTs and CSs with a random-effects model, for 45 (56%) out of 80 diet-disease associations the 95% CI excluded no effect and showed mainly a reduced risk/inverse association. By pooling BoE from RCTs and CSs, median I2 = 46% and the median contributed weight of RCTs to the pooled estimates was 34%. The direction of effect between BoE from RCTs and pooled effect estimates was rarely opposite (n = 17; 21%). The integration of BoE from CSs modified the result (by examining the 95% CI) from BoE of RCTs in 35 (44%) of the 80 diet-disease associations. Our pooling scenario showed that the integration of BoE from CSs modified the conclusion from BoE of RCTs in nearly 50% of the associations, although the direction of effect was mainly concordant between BoE of RCTs and pooled estimates. Our findings provide insights for the potential impact of pooling both BoE in Cochrane nutrition reviews. CSs should be considered for inclusion in future Cochrane nutrition reviews, and we recommend analyzing RCTs and CSs in separate meta-analyses, or, if combined together, with a subgroup analysis.
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Affiliation(s)
| | - Nils Bröckelmann
- Institute for Evidence in Medicine, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jessica Beyerbach
- Institute for Evidence in Medicine, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sarah S Werner
- Institute for Evidence in Medicine, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jasmin Zähringer
- Institute for Evidence in Medicine, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center—University of Freiburg, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center—University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Beygui F, Roule V, Ivanes F, Dechery T, Bizeau O, Roussel L, Dequenne P, Arnould MA, Combaret N, Collet JP, Commeau P, Cayla G, Montalescot G, Benamer H, Motreff P, Angoulvant D, Marcollet P, Chassaing S, Blanchart K, Koning R, Rangé G. Indirect Transfer to Catheterization Laboratory for ST Elevation Myocardial Infarction Is Associated With Mortality Independent of System Delays: Insights From the France-PCI Registry. Front Cardiovasc Med 2022; 9:793067. [PMID: 35360033 PMCID: PMC8962625 DOI: 10.3389/fcvm.2022.793067] [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: 10/11/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundFirst medical contact (FMC)-to-balloon time is associated with outcome of ST-elevation myocardial infarction (STEMI). We assessed the impact on mortality and the determinants of indirect vs. direct transfer to the cardiac catheterization laboratory (CCL).MethodsWe analyzed data from 2,206 STEMI patients consecutively included in a prospective multiregional percutaneous coronary intervention (PCI) registry. The primary endpoint was 1-year mortality. The impact of indirect admission to CCL on mortality was assessed using Cox models adjusted on FMC-to-balloon time and covariables unequally distributed between groups. A multivariable logistic regression model assessed determinants of indirect transfer.ResultsA total of 359 (16.3%) and 1847 (83.7%) were indirectly and directly admitted for PCI. Indirect admission was associated with higher risk features, different FMCs and suboptimal pre-PCI antithrombotic therapy.At 1-year follow-up, 51 (14.6%) and 137 (7.7%) were dead in the indirect and direct admission groups, respectively (adjusted-HR 1.73; 95% CI 1.22–2.45). The association of indirect admission with mortality was independent of pre-FMC and FMC characteristics. Older age, paramedics- and private physician-FMCs were independent determinants of indirect admission (adjusted-HRs 1.02 per year, 95% CI 1.003–1.03; 5.94, 95% CI 5.94 3.89–9.01; 3.41; 95% CI 1.86–6.2, respectively).ConclusionsOur study showed that, indirect admission to PCI for STEMI is associated with 1-year mortality independent of FMC to balloon time and should be considered as an indicator of quality of care. Indirect admission is associated with higher-risk features and suboptimal antithrombotic therapy. Older age, paramedics-FMC and self-presentation to a private physician were independently associated with indirect admission. Our study, supports population education especially targeting elderly, more adequately dispatched FMC and improved pre-CCL management.
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Affiliation(s)
- Farzin Beygui
- Cardiology Department, CHU de Caen, Caen, France
- *Correspondence: Farzin Beygui
| | | | | | - Thierry Dechery
- Cardiology Department, Center Hospitalier de Bourges, Bourges, France
| | | | - Laurent Roussel
- Cardiology Department, Les Hôpitaux de Chartres, Chartres, France
| | | | - Marc-Antoine Arnould
- Cardiology Department, Nouvelle clinique Tourangelle, Saint-Cyr-sur-Loire, France
| | - Nicolas Combaret
- Cardiology Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Philippe Commeau
- Cardiology Department, Polyclinique les fleurs, Ollioules, France
| | | | - Gilles Montalescot
- Cardiology Department, Groupe hospitalier Pitié-Salpêtrière, Paris, France
| | - Hakim Benamer
- Cardiology Department, Clinique de la Roseraie, Aubervilliers, France
| | - Pascal Motreff
- Cardiology Department, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Pierre Marcollet
- Cardiology Department, Center Hospitalier de Bourges, Bourges, France
| | - Stephan Chassaing
- Cardiology Department, Nouvelle clinique Tourangelle, Saint-Cyr-sur-Loire, France
| | | | - René Koning
- Cardiology Department, Clinique Saint Hilaire, Saint Hilaire, France
| | - Grégoire Rangé
- Cardiology Department, Les Hôpitaux de Chartres, Chartres, France
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12
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Meta-Regression Analysis of the Impact of Medical Therapy on Long-Term Mortality in Type 2 Myocardial Infarction. Am J Cardiol 2022; 165:33-36. [PMID: 34895872 DOI: 10.1016/j.amjcard.2021.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/22/2022]
Abstract
The first approach for Type-2 myocardial infarction (T2MI) consists of the elimination of the condition determining the oxygen supply/demand mismatch. However, the long-term impact of medical therapy with beta blockers, statins, aspirin, and P2Y12 inhibitors, used in the case of Type-1 myocardial infarction has been poorly investigated and remains unclear. We, therefore, sought to assess the impact of medical therapy on 1-year mortality in patients with T2MI using a meta-regression analysis. A meta-regression analysis was performed with studies involving in patients with T2MI: 1-year all-cause mortality, rates of beta blockers, statins, aspirin, and P2Y12 inhibitors use were recorded and analyzed. After careful study selection, 8 observational studies were pooled in the analysis, including 3,756 in patients. During meta-regression analysis, a borderline correlation between rates of aspirin, P2Y12 inhibitors, and statins use and 1-year mortality (p = 0.087, p = 0.05, and p = 0.067, respectively) was found; no significant correlation was found at multivariable analysis. In conclusion, in a meta-regression analysis, no significant correlation was found between rates of use of usual drug therapy indicated for Type-1 myocardial infarction (statins, aspirin, P2Y12 inhibitors, β-blockers) and 1-year mortality in T2MI patients.
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13
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Dawson LP, Chen D, Dagan M, Bloom J, Taylor A, Duffy SJ, Shaw J, Lefkovits J, Stub D. Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2134322. [PMID: 34797371 PMCID: PMC8605486 DOI: 10.1001/jamanetworkopen.2021.34322] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear. OBJECTIVE To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS. DATA SOURCES On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception. STUDY SELECTION Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy. DATA EXTRACTION AND SYNTHESIS This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site. MAIN OUTCOMES AND MEASURES The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies). RESULTS A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients. CONCLUSIONS AND RELEVANCE In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.
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Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David Chen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Misha Dagan
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
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14
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Risk Stratification of Patients with Acute Coronary Syndrome. J Clin Med 2021; 10:jcm10194574. [PMID: 34640592 PMCID: PMC8509298 DOI: 10.3390/jcm10194574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/17/2022] Open
Abstract
Defining the risk factors affecting the prognosis of patients with acute coronary syndrome (ACS) has been a challenge. Many individual biomarkers and risk scores that predict outcomes during different periods following ACS have been proposed. This review evaluates known outcome predictors supported by clinical data in light of the development of new treatment strategies for ACS patients during the last three decades.
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15
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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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16
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Dillinger JG, Laine M, Bouajila S, Paganelli F, Henry P, Bonello L. Antithrombotic strategies in elderly patients with acute coronary syndrome. Arch Cardiovasc Dis 2021; 114:232-245. [PMID: 33632631 DOI: 10.1016/j.acvd.2020.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/22/2022]
Abstract
Elderly patients represent a growing proportion of the acute coronary syndrome population in Western countries. However, their frequent atypical symptoms at presentation often lead to delays in management and to misdiagnosis. Furthermore, their prognosis is poorer than that of younger patients because of physiological changes in platelet function, haemostasis and fibrinolysis, but also a higher proportion of comorbidities and frailty, both of which increase the risk of recurrent thrombotic and bleeding events. This complex situation, with ischaemic and haemorrhagic risk factors often being intertwined, may lead to confusion about the required treatment strategy, sometimes resulting in inadequate management or even to therapeutic nihilism. It is therefore critical to provide a comprehensive overview of our understanding of the pathophysiological processes underlying acute coronary syndrome in elderly patients, and to summarise the results from the latest clinical trials to help decision making for these high-risk patients.
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Affiliation(s)
- Jean-Guillaume Dillinger
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - Marc Laine
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
| | - Sara Bouajila
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Franck Paganelli
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France
| | - Patrick Henry
- Department of cardiology, Hôpital Lariboisière, AP-HP, Inserm U-942, Université de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Laurent Bonello
- Mediterranean Association for research and studies in cardiology (MARS cardio), Centre for cardiovascular and nutrition research, AP-HM, Aix-Marseille University, INSERM 1263, INRA 1260, 13015 Marseille, France; Cardiology department, Hôpital Nord, 13015 Marseille, France; Mediterranean Association for research and studies in cardiology (MARS cardio), 13015 Marseille, France
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17
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Lunardi M, Gao C, Hara H, Ono M, Kawashima H, Wang R, Wijns W, Serruys PW, Onuma Y. Coronary interventions in 2020: the year in review. EUROINTERVENTION 2021; 16:e1215-e1226. [PMID: 33478939 PMCID: PMC9724941 DOI: 10.4244/eij-d-20-01343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Mattia Lunardi
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Charlie Gao
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Amsterdam UMC, University of Amsterdam, Heart Center; Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Rutao Wang
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - William Wijns
- The Lambe Institute for Translational Medicine (Floor 2), University Road, National University of Ireland Galway, Galway, Ireland, H91 TK33
| | - Patrick W. Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland,NHLI, Imperial College London, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland
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18
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Guedeney P, Collet JP. Antithrombotic Therapy in Acute Coronary Syndromes: Current Evidence and Ongoing Issues Regarding Early and Late Management. Thromb Haemost 2021; 121:854-866. [PMID: 33506483 DOI: 10.1055/s-0040-1722188] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A few decades ago, the understanding of the pathophysiological processes involved in the coronary artery thrombus formation has placed anticoagulant and antiplatelet agents at the core of the management of acute coronary syndrome (ACS). Increasingly potent antithrombotic agents have since been evaluated, in various association, timing, or dosage, in numerous randomized controlled trials to interrupt the initial thrombus formation, prevent ischemic complications, and ultimately improve survival. Primary percutaneous coronary intervention, initial parenteral anticoagulation, and dual antiplatelet therapy with potent P2Y12 inhibitors have become the hallmark of ACS management revolutionizing its prognosis. Despite these many improvements, much more remains to be done to optimize the onset of action of the various antithrombotic therapies, for further treating and preventing thrombotic events without exposing the patients to an unbearable hemorrhagic risk. The availability of various potent P2Y12 inhibitors has opened the door for individualized therapeutic strategies based on the clinical setting as well as the ischemic and bleeding risk of the patients, while the added value of aspirin has been recently challenged. The strategy of dual-pathway inhibition with P2Y12 inhibitors and low-dose non-vitamin K antagonist oral anticoagulant has brought promising results for the early and late management of patients presenting with ACS with and without indication for oral anticoagulation. In this updated review, we aimed at describing the evidence supporting the current gold standard of antithrombotic management of ACS. More importantly, we provide an overview of some of the ongoing issues and promising therapeutic strategies of this ever-evolving topic.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie, Pitié Salpêtrière (AP-HP), Paris, France
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19
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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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20
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Valina C, Neumann FJ, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Aytekin A, Richardt G, Witzenbichler B, Sibbing D, Cassese S, Angiolillo DJ, Kufner S, Liebetrau C, Hamm CW, Xhepa E, Hapfelmeier A, Sager HB, Wustrow I, Joner M, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Ticagrelor or Prasugrel in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2020; 76:2436-2446. [DOI: 10.1016/j.jacc.2020.09.584] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
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21
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Dworeck C, Redfors B, Angerås O, Haraldsson I, Odenstedt J, Ioanes D, Petursson P, Völz S, Persson J, Koul S, Venetsanos D, Ulvenstam A, Hofmann R, Jensen J, Albertsson P, Råmunddal T, Jeppsson A, Erlinge D, Omerovic E. Association of Pretreatment With P2Y12 Receptor Antagonists Preceding Percutaneous Coronary Intervention in Non-ST-Segment Elevation Acute Coronary Syndromes With Outcomes. JAMA Netw Open 2020; 3:e2018735. [PMID: 33001202 PMCID: PMC7530628 DOI: 10.1001/jamanetworkopen.2020.18735] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE Pretreatment of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) with P2Y12 receptor antagonists is a common practice despite the lack of definite evidence for its benefit. OBJECTIVE To investigate the association of P2Y12 receptor antagonist pretreatment vs no pretreatment with mortality, stent thrombosis, and in-hospital bleeding in patients with NSTE-ACS undergoing percutaneous coronary intervention (PCI). DESIGN, SETTING, AND PARTICIPANTS This cohort study used prospective data from the Swedish Coronary Angiography and Angioplasty Registry of 64 857 patients who underwent procedures between 2010 and 2018. All patients who underwent PCI owing to NSTE-ACS in Sweden were stratified by whether they were pretreated with P2Y12 receptor antagonists. Associations of pretreatment with P2Y12 receptor antagonists with the risks of adverse outcomes were investigated using instrumental variable analysis and propensity score matching. Data were analyzed from March to June 2019. EXPOSURES Pretreatment with P2Y12 receptor antagonists. MAIN OUTCOMES AND MEASURES The primary end point was all-cause mortality within 30 days. Secondary end points were 1-year mortality, stent thrombosis within 30 days, and in-hospital bleeding. RESULTS In total, 64 857 patients (mean [SD] age, 64.7 [10.9] years; 46 809 [72.2%] men) were included. A total of 59 894 patients (92.4%) were pretreated with a P2Y12 receptor antagonist, including 27 867 (43.7%) pretreated with clopidogrel, 34 785 (54.5%) pretreated with ticagrelor, and 1148 (1.8%) pretreated with prasugrel. At 30 days, there were 971 deaths (1.5%) and 101 definite stent thromboses (0.2%) in the full cohort. Pretreatment was not associated with better survival at 30 days (odds ratio [OR], 1.17; 95% CI, 0.66-2.11; P = .58), survival at 1 year (OR, 1.34; 95% CI, 0.77-2.34; P = .30), or decreased stent thrombosis (OR, 0.81; 95% CI, 0.42-1.55; P = .52). However, pretreatment was associated with increased risk of in-hospital bleeding (OR, 1.49; 95% CI, 1.06-2.12; P = .02). CONCLUSIONS AND RELEVANCE This cohort study found that pretreatment of patients with NSTE-ACS with P2Y12 receptor antagonists was not associated with improved clinical outcomes but was associated with increased risk of bleeding. These findings support the argument that pretreatment with P2Y12 receptor antagonists should not be routinely used in patients with NSTE-ACS.
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Affiliation(s)
- Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jonas Persson
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | | | - Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Jens Jensen
- Department of Clinical Science and Education, Karolinska Institutet, Cardiology Capio Sankt Goran Hospital, Stockholm, Sweden
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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22
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P2Y12 inhibitor loading dose before catheterization in ST-segment elevation myocardial infarction: Is this the best strategy? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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23
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Oral Antiplatelet Therapy Administered Upstream to Patients With NSTEMI. Crit Pathw Cardiol 2020; 19:166-172. [PMID: 32947379 PMCID: PMC7664955 DOI: 10.1097/hpc.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To describe from a noninterventional registry (Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Acute Coronary Syndrome), the short-term ischemic and hemorrhagic outcomes in patients with non-ST elevation myocardial infarction (MI) are managed with a loading dose (LD) of a P2Y12 inhibitor (P2Y12i) given at least 4 hours before diagnostic angiography and delineation of coronary anatomy. Prior data on the effects of such “upstream loading” have been inconsistent.
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24
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The Challenge of Researching Pre-Treatment Omission With Invasive Strategy Timing in NSTEACS. JACC Cardiovasc Interv 2020; 13:1726. [PMID: 32703600 DOI: 10.1016/j.jcin.2020.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 11/21/2022]
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25
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Biondi-Zoccai G, Antonazzo B, Giordano A, Versaci F, Frati G, Ronzoni S, Nudi A, Nudi F. Oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review. J Thorac Dis 2020; 12:1656-1664. [PMID: 32395309 PMCID: PMC7212118 DOI: 10.21037/jtd.2019.12.87] [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: 02/05/2023]
Abstract
Percutaneous coronary intervention has become a mainstay in the management of coronary artery disease. While initially advanced age was considered a relative contraindication to invasive management of coronary artery disease, current cardiovascular practice stands solidly on an early invasive approach for elderly patients, typically based on radial access and drug-eluting stent implantation. Since the advent of coronary stents, oral antiplatelet therapy has proved crucial to maximize the benefits and minimize the risks of stenting, and this holds even truer in older patients rather than in younger ones. Indeed, the elderly is typically at higher risk of thrombotic events as well as bleeding complications, and thus careful decision making must be exercised to prescribe the most appropriate antiplatelet regimen. We thus conducted an umbrella review with scoping purposes on oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention, retrieving 8 pertinent systematic reviews. We found that, while several drugs are available, ranging from aspirin to cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, and ticlopidine, most commonly a dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor is recommended, with subtle adjustments for pretreatment, loading, dose, duration, escalation or de-escalation, with the potential adjunct in selected patients of novel oral anticoagulants. Indeed, a flexible and individualized approach to oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention is paramount, factoring patient features (exploiting thrombotic, bleeding and frailty scores), triage (including when appropriate non-invasive assessment of anatomic and functional significance of coronary artery disease), angiographic and other invasive imaging features, interventional technique, stent choice, rehabilitation, and secondary prevention.
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Affiliation(s)
- Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Napoli, Italy
| | | | - Arturo Giordano
- Unità Operativa di Interventistica Cardiovascolare, Presidio Ospedaliero Pineta Grande, Castel Volturno, Italy
| | - Francesco Versaci
- Unità Operativa Complessa di UTIC, Emodinamica e Cardiologia, Ospedale Santa Maria Goretti, Latina, Italy
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,IRCCS NEUROMED, Pozzilli, Italy
| | | | - Alessandro Nudi
- Service of Hybrid Cariac Imaging, Madonna della Fiducia Clinic, Rome, Italy
| | - Francesco Nudi
- Service of Hybrid Cariac Imaging, Madonna della Fiducia Clinic, Rome, Italy
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26
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Silvain J, Zeitouni M, Kerneis M. Selatogrel for Acute Myocardial Infarction. J Am Coll Cardiol 2020; 75:2598-2601. [DOI: 10.1016/j.jacc.2020.03.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 11/26/2022]
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27
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Ferreiro JL. Pre-Treatment With Oral P2Y 12 Inhibitors in Non-ST-Segment Elevation Acute Coronary Syndromes: Does One Size Fit All? JACC Cardiovasc Interv 2020; 13:918-920. [PMID: 32327088 DOI: 10.1016/j.jcin.2020.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 11/18/2022]
Affiliation(s)
- José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge - IDIBELL, CIBER-CV, L'Hospitalet de Llobregat, Barcelona, Spain.
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28
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Lemesle G, Laine M, Pankert M, Boueri Z, Motreff P, Paganelli F, Baumstarck K, Roch A, Kerbaul F, Puymirat E, Bonello L. Optimal Timing of Intervention in NSTE-ACS Without Pre-Treatment. JACC Cardiovasc Interv 2020; 13:907-917. [DOI: 10.1016/j.jcin.2020.01.231] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 10/24/2022]
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29
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Abtan J, Ducrocq G, Steg PG, Stone GW, Mahaffey KW, Gibson CM, Hamm CW, Price MJ, Prats J, Deliargyris EN, White HD, Harrington RA, Bhatt DL. Periprocedural Outcomes According to Timing of Clopidogrel Loading Dose in Patients Who Did Not Receive P2Y 12 Inhibitor Pretreatment. Circ Cardiovasc Interv 2020; 12:e007445. [PMID: 30871355 DOI: 10.1161/circinterventions.118.007445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), who did not receive P2Y12 inhibitor pretreatment, the optimal timing of P2Y12 inhibitor loading dose remains debated. We sought to examine whether the choice of administration of the clopidogrel loading dose before or after the start of PCI had an impact on periprocedural complications, including bleeding. METHODS AND RESULTS The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) double-blind randomized trial compared cangrelor with clopidogrel loading dose at the time of PCI. Pretreatment with clopidogrel before randomization was not permitted per protocol. In the clopidogrel-only group (n=5438), a loading dose was given before (early load [EL]) or after the start of PCI (late load [LL]) according to physician choice. Overall, 3442 (63.3%) patients had EL and 1997 LL (36.7%). Median times were 5 minutes before and 20 minutes after the start of PCI, respectively. EL was more frequently used among patients with ST-segment-elevation myocardial infarction (84.4%) and non-ST-segment-elevation acute coronary syndromes (71.5%) than in stable patients (53.7%). At 48 hours, rates of the primary outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis were similar (6.0% versus 5.4%) for EL versus LL, respectively (odds ratio [OR], 1.11 [95% CI, 0.87-1.41]; P=0.41), and remained so after adjustment for potential confounders, including clinical presentation (OR [95% CI], 1.39 [0.90-2.15]; P=0.14). Compared with clopidogrel, cangrelor consistently reduced the primary outcome in both EL (4.8% versus 6.0%; OR [95% CI], 0.80 [0.64-0.98]) and LL (4.3% versus 5.4%; OR [95% CI], 0.79 [0.59-1.06]; interaction P=0.99). Global Use of Strategies to Open Occluded Coronary Arteries severe/moderate bleeding rates were similar between treatment arms for both EL (OR [95% CI], 1.24 [0.58-2.66]) and LL (OR [95% CI], 2.53 [0.98-6.54]; interaction P=0.25). CONCLUSIONS In a nonrandomized comparison of patients with clopidogrel loading before or after the start of PCI, the rates of periprocedural PCI complications, including bleeding, were similar, as were the benefits of cangrelor, regardless of the timing. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01156571.
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Affiliation(s)
- Jeremie Abtan
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.)
| | - Gregory Ducrocq
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.)
| | - Philippe Gabriel Steg
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.).,NLHI, ICMS, Royal Brompton Hospital, Imperial College, London, United Kingdom (P.G.S.)
| | - Gregg W Stone
- Division of Cardiology, Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (G.W.S.)
| | - Kenneth W Mahaffey
- Cardiovascular Medicine, Stanford Center for Clinical Research (K.W.M., R.A.H.), Stanford School of Medicine, CA.,Department of Medicine (K.W.M., R.A.H.), Stanford School of Medicine, CA
| | - C Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.M.G.)
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.)
| | - Matthew J Price
- Scripps Clinic, Scripps Translational Science Institute, La Jolla, CA (M.J.P.)
| | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- Cardiovascular Medicine, Stanford Center for Clinical Research (K.W.M., R.A.H.), Stanford School of Medicine, CA.,Department of Medicine (K.W.M., R.A.H.), Stanford School of Medicine, CA
| | - Deepak L Bhatt
- Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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Bell SM, Kovach C, Kataruka A, Brown J, Hira RS. Management of Out-of-Hospital Cardiac Arrest Complicating Acute Coronary Syndromes. Curr Cardiol Rep 2019; 21:146. [PMID: 31758275 DOI: 10.1007/s11886-019-1249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF THE REVIEW Out-of-hospital cardiac arrest (OHCA) complicating acute coronary syndromes (ACS) continues to carry a high rate of morbidity and mortality despite significant advances in EMS and interventional cardiology services. In this review, we discuss an evidence-based approach to the initial care and management of patients with OHCA complicating ACS from the pre-hospital response and initial resuscitation strategy, to advanced therapies such as coronary angiography, targeted-temperature management, neuro-prognostication, and care of the post-arrest patient. RECENT FINDINGS Early recognition of cardiac arrest and prompt initiation of bystander CPR are the most important factors associated with improved survival. A comprehensive and coordinated approach to in-hospital management, including PCI, targeted temperature management, critical care, and hemodynamic support represents a significant critical link in the chain of survival. OHCA complicated by ACS continues to be one of the most challenging disease states facing healthcare practitioners and maintains a high mortality rate despite substantial advancements in healthcare delivery. A comprehensive approach to in-hospital management and further exploration of novel interventions, including ECMO, may yield opportunities to optimize care and improve outcomes for cardiac arrest patients.
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Affiliation(s)
- Sean M Bell
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Christopher Kovach
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Akash Kataruka
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Josiah Brown
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ravi S Hira
- Division of Cardiology, Department of Medicine, University of Washington, Seattle, WA, USA. .,Cardiac Care Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, WA, USA.
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31
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Antithrombotic therapy in the early phase of non-ST-elevation acute coronary syndromes: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:43-56. [DOI: 10.1093/ehjcvp/pvz031] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/27/2019] [Accepted: 07/20/2019] [Indexed: 12/13/2022]
Abstract
Abstract
Aims
Despite the increasing use of early invasive strategies in non-ST-elevation acute coronary syndromes (NSTE-ACS), optimal initial antithrombotic therapy (ATT) based on the safety/efficacy profile of all guideline-recommended combinations remains crucial for the early management of both medically and invasively treated NSTE-ACS patients.
Methods and results
Randomized controlled trials on ATT in NSTE-ACS/unstable angina reporting early (within 14 days) major adverse cardiovascular events (MACE) and major bleeding were selected. Overall, 3799 studies were screened, 117 clinical trials were assessed as potentially eligible, 20 trials were included in the study. According to treatment and type of intervention, nine different meta-analyses were performed including a total of 88 748 patients. A significant reduction of trial-defined MACE was found for aspirin vs. placebo [odds ratio (OR), 0.57; 95% confidence interval (CI), 0.34–0.96], heparin vs. placebo (OR, 0.38; 95% CI, 0.15–0.97), aspirin + heparin vs. placebo (OR, 0.32; 95% CI, 0.18–0.59), aspirin + heparin vs. aspirin (OR, 0.57; 95% CI, 0.42–0.79), aspirin + low molecular weight heparin (LMWH) vs. aspirin + unfractionated heparin (UFH; OR, 0.81; 95% CI, 0.69–0.95) and aspirin + ticagrelor/prasugrel + heparins vs. aspirin + clopidogrel + heparins (OR, 0.76; 95% CI, 0.62–0.94). A significant decrease in major bleeding was found only for fondaparinux vs. LMWH on the background of aspirin + clopidogrel (OR, 0.52; 95% CI, 0.44–0.62) despite a clear trend towards increased bleeding for heparin compared to aspirin, aspirin + heparin compared to placebo, aspirin + heparin compared to aspirin, aspirin + P2Y12inhibitors + UFH/LMWH compared to aspirin + UFH/LMWH, and aspirin + ticagrelor/prasugrel + heparins compared to aspirin + clopidogrel + heparins.
Conclusion
To our knowledge, these findings are the first to report the safety and efficacy of all the various combinations of currently recommended ATT for the early management of NSTE-ACS, providing a comprehensive evidence-base to guide decisions depending on the patients’ bleeding risk and treatment strategy.
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32
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Bonello L, Laine M, Lemesle G. Letter by Bonello et al Regarding Article, "Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial". Circulation 2019; 139:e959-e960. [PMID: 31082298 DOI: 10.1161/circulationaha.118.037810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Laurent Bonello
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Régional et Universitaire de Lille, France (L.B., M.L.).,Faculté de Médecine de l'Université de Lille, France (L.B., M.L.).,Institut Pasteur de Lille, Unité INSERM UMR 1011, France (L.B., M.L.).,FACT (French Alliance for Cardiovascular Trials), Lille, France (L.B., M.L.)
| | - Marc Laine
- USIC et Centre Hémodynamique, Institut Coeur Poumon, Centre Hospitalier Régional et Universitaire de Lille, France (L.B., M.L.).,Faculté de Médecine de l'Université de Lille, France (L.B., M.L.).,Institut Pasteur de Lille, Unité INSERM UMR 1011, France (L.B., M.L.).,FACT (French Alliance for Cardiovascular Trials), Lille, France (L.B., M.L.)
| | - Gilles Lemesle
- Aix-Marseille Université, MARS Cardio, Mediterraneen Association for Research and Studies in Cardiology, INSERM UMR-S 1076, Vascular Research Center of Marseille, France (G.L.)
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Redfors B, Dworeck C, Haraldsson I, Angerås O, Odenstedt J, Ioanes D, Petursson P, Völz S, Albertsson P, Råmunddal T, Persson J, Koul S, Erlinge D, Omerovic E. Pretreatment with P2Y12 receptor antagonists in ST-elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry. Eur Heart J 2019; 40:1202-1210. [DOI: 10.1093/eurheartj/ehz069] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/27/2018] [Accepted: 01/31/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Christian Dworeck
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Inger Haraldsson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Dan Ioanes
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Petur Petursson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Per Albertsson
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Truls Råmunddal
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
| | - Jonas Persson
- Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
| | - Sasha Koul
- Department of Cardiology, Skåne University Hospital, Lund, Sweden
| | | | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Bruna stråket 16, Gothenburg, Sweden
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Silvain J, Rakowski T, Lattuca B, Liu Z, Bolognese L, Goldstein P, Hamm C, Tanguay JF, ten Berg J, Widimsky P, Miller D, Portal JJ, Collet JP, Vicaut E, Montalescot G, Dudek D. Interval From Initiation of Prasugrel to Coronary Angiography in Patients With Non–ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2019; 73:906-914. [DOI: 10.1016/j.jacc.2018.11.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 11/24/2018] [Accepted: 11/25/2018] [Indexed: 01/18/2023]
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Capodanno D, Angiolillo DJ. Pre-Treatment With Oral P2Y12 Inhibitors in Acute Coronary Syndromes Without ST-Segment Elevation. J Am Coll Cardiol 2019; 73:915-918. [DOI: 10.1016/j.jacc.2018.12.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/05/2018] [Indexed: 11/25/2022]
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Prada-Ramallal G, Roque F, Herdeiro MT, Takkouche B, Figueiras A. Primary versus secondary source of data in observational studies and heterogeneity in meta-analyses of drug effects: a survey of major medical journals. BMC Med Res Methodol 2018; 18:97. [PMID: 30261846 PMCID: PMC6161342 DOI: 10.1186/s12874-018-0561-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 09/18/2018] [Indexed: 12/17/2022] Open
Abstract
Background The data from individual observational studies included in meta-analyses of drug effects are collected either from ad hoc methods (i.e. “primary data”) or databases that were established for non-research purposes (i.e. “secondary data”). The use of secondary sources may be prone to measurement bias and confounding due to over-the-counter and out-of-pocket drug consumption, or non-adherence to treatment. In fact, it has been noted that failing to consider the origin of the data as a potential cause of heterogeneity may change the conclusions of a meta-analysis. We aimed to assess to what extent the origin of data is explored as a source of heterogeneity in meta-analyses of observational studies. Methods We searched for meta-analyses of drugs effects published between 2012 and 2018 in general and internal medicine journals with an impact factor > 15. We evaluated, when reported, the type of data source (primary vs secondary) used in the individual observational studies included in each meta-analysis, and the exposure- and outcome-related variables included in sensitivity, subgroup or meta-regression analyses. Results We found 217 articles, 23 of which fulfilled our eligibility criteria. Eight meta-analyses (8/23, 34.8%) reported the source of data. Three meta-analyses (3/23, 13.0%) included the method of outcome assessment as a variable in the analysis of heterogeneity, and only one compared and discussed the results considering the different sources of data (primary vs secondary). Conclusions In meta-analyses of drug effects published in seven high impact general medicine journals, the origin of the data, either primary or secondary, is underexplored as a source of heterogeneity. Electronic supplementary material The online version of this article (10.1186/s12874-018-0561-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Guillermo Prada-Ramallal
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, c/ San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain.,Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Clinical University Hospital of Santiago de Compostela, 15706, Santiago de Compostela, Spain
| | - Fatima Roque
- Research Unit for Inland Development, Polytechnic of Guarda (Unidade de Investigação para o Desenvolvimento do Interior - UDI/IPG), 6300-559, Guarda, Portugal.,Health Sciences Research Centre, University of Beira Interior (Centro de Investigação em Ciências da Saúde - CICS/UBI), 6200-506, Covilhã, Portugal
| | - Maria Teresa Herdeiro
- Department of Medical Sciences & Institute for Biomedicine - iBiMED, University of Aveiro, 3810-193, Aveiro, Portugal.,Higher Polytechnic & University Education Co-operative (Cooperativa de Ensino Superior Politécnico e Universitário - CESPU), Institute for Advanced Research & Training in Health Sciences & Technologies, 4585-116, Gandra, Portugal
| | - Bahi Takkouche
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, c/ San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain.,Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Clinical University Hospital of Santiago de Compostela, 15706, Santiago de Compostela, Spain.,Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Santiago de Compostela, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, c/ San Francisco s/n, 15786, Santiago de Compostela, A Coruña, Spain. .,Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela - IDIS), Clinical University Hospital of Santiago de Compostela, 15706, Santiago de Compostela, Spain. .,Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública - CIBERESP), Santiago de Compostela, Spain.
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Gibler WB, Racadio JM, Hirsch AL, Roat TW. Continuum of Care for Acute Coronary Syndrome: Optimizing Treatment for ST-Elevation Myocardial Infarction and Non-St-Elevation Acute Coronary Syndrome. Crit Pathw Cardiol 2018; 17:114-138. [PMID: 30044253 PMCID: PMC6072372 DOI: 10.1097/hpc.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- W Brian Gibler
- President, EMCREG-International, Professor of Emergency Medicine, Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
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38
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Bellemain-Appaix A, Bégué C, Bhatt DL, Ducci K, Harrington RA, Roe M, Wiviott SD, Cucherat M, Silvain J, Collet JP, Bernasconi F, Montalescot G. The efficacy of early versus delayed P2Y12 inhibition in percutaneous coronary intervention for ST-elevation myocardial infarction: a systematic review and meta-analysis. EUROINTERVENTION 2018; 14:78-85. [DOI: 10.4244/eij-d-17-00852] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Koul S, Smith JG, Götberg M, Omerovic E, Alfredsson J, Venetsanos D, Persson J, Jensen J, Lagerqvist B, Redfors B, James S, Erlinge D. No Benefit of Ticagrelor Pretreatment Compared With Treatment During Percutaneous Coronary Intervention in Patients With ST-Segment–Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2018; 11:e005528. [DOI: 10.1161/circinterventions.117.005528] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
Background—
The effects of ticagrelor pretreatment in patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) is debated. This study investigated the effects of ticagrelor pretreatment on clinical outcomes in this patient group.
Methods and Results—
Patients with ST-segment–elevation myocardial infarction undergoing primary PCI were included from October 2010 to October 2014 in Sweden. Screening was done using the SWEDEHEART register (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies). A total of 7433 patients were included for analysis with 5438 patients receiving ticagrelor pretreatment and 1995 patients with ticagrelor given only in the catheterization laboratory. The primary end point of the study was 30-day event rates of a composite of all-cause mortality, myocardial infarction (MI), and stent thrombosis. Secondary end points were mortality, MI, or stent thrombosis alone and major in-hospital bleeding. Crude event rates showed no difference in 30-day composite end point (6.2% versus 6.5%;
P=0
.69), mortality (4.5% versus 4.7%;
P=0
.86), MI (1.6% versus 1.7%;
P=0
.72), or stent thrombosis (0.5% versus 0.4%;
P=0
.80) with ticagrelor pretreatment. Three different statistical models were used to correct for baseline differences. No difference in the composite end point, mortality, MI, or stent thrombosis was seen between the 2 groups after statistical adjustment. No increase in in-hospital major bleeding rate was observed with ticagrelor pretreatment.
Conclusions—
Ticagrelor pretreatment versus ticagrelor given in the catheterization laboratory in patients with ST-segment–elevation myocardial infarction undergoing primary PCI did not improve the composite end point of all-cause mortality or MI or stent thrombosis or its individual components at 30 days.
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Affiliation(s)
- Sasha Koul
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - J. Gustav Smith
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Matthias Götberg
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Elmir Omerovic
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Joakim Alfredsson
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Dimitrios Venetsanos
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Jonas Persson
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Jens Jensen
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Bo Lagerqvist
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Björn Redfors
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - Stefan James
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
| | - David Erlinge
- From the Department of Cardiology (S.K., J.G.S., M.G., D.E.) and Department of Clinical Sciences (S.K., J.G.S., M.G., D.E.), Skane University Hospital Lund, Lund University, Sweden; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (E.O., B.R.); Department of Cardiology (J.A., D.V.) and Department of Medical and Health Sciences (J.A., D.V.), Linköping University, Sweden; Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital (J
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Widmer RJ, Pollak PM, Bell MR, Gersh BJ, Anavekar NS. The Evolving Face of Myocardial Reperfusion in Acute Coronary Syndromes: A Primer for the Internist. Mayo Clin Proc 2018; 93:199-216. [PMID: 29329796 DOI: 10.1016/j.mayocp.2017.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/25/2017] [Accepted: 11/01/2017] [Indexed: 02/07/2023]
Abstract
Acute coronary syndromes (ACSs) account for a large proportion of disease burden in the United States and worldwide, and our understanding of ACS management continues to evolve. In this review we take a practical approach to evaluating and treating a patient with ACS, focusing on the optimal timing and methods of coronary reperfusion. Beginning with initial assessment and risk stratification, a provider managing the patient with ACS must be able to expeditiously decide on and implement the correct guideline-directed pathway to optimize outcomes. With an ever-growing body and weight of knowledge in this field, the clinician is tasked with several challenges. First, there are a variety of pathways of care to be considered; second, adjunctive medical therapies are expanding; and third, when coupled with the multiple combinations of adjunctive supportive therapies for revascularization, the variety of potential therapeutic options can be overwhelming and confusing. Herein, we carefully review all the relevant guidelines and the contributing literature, taking a 4-step approach: (1) review the importance of risk stratification before engaging in a particular strategy of care, (2) define the reperfusion strategies available, (3) review the specific agents (antiplatelet and anticoagulant) that support reperfusion strategies, and (4) apply the strategies of care in the context of the clinical presentation.
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Affiliation(s)
- R Jay Widmer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Peter M Pollak
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Malcolm R Bell
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Lemesle G, Laine M, Pankert M, Puymirat E, Cuisset T, Boueri Z, Maillard L, Armero S, Cayla G, Bali L, Motreff P, Peyre JP, Paganelli F, Kerbaul F, Roch A, Michelet P, Baumstarck K, Bonello L. Early versus delayed invasive strategy for intermediate- and high-risk acute coronary syndromes managed without P2Y 12 receptor inhibitor pretreatment: Design and rationale of the EARLY randomized trial. Clin Cardiol 2018; 41:5-12. [PMID: 29356001 DOI: 10.1002/clc.22852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/13/2017] [Accepted: 11/15/2017] [Indexed: 01/23/2023] Open
Abstract
According to recent literature, pretreatment with a P2Y12 ADP receptor antagonist before coronary angiography appears no longer suitable in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) due to an unfavorable risk-benefit ratio. Optimal delay of the invasive strategy in this specific context is unknown. We hypothesize that without P2Y12 ADP receptor antagonist pretreatment, a very early invasive strategy may be beneficial. The EARLY trial (Early or Delayed Revascularization for Intermediate- and High-Risk Non-ST-Segment Elevation Acute Coronary Syndromes?) is a prospective, multicenter, randomized, controlled, open-label, 2-parallel-group study that plans to enroll 740 patients. Patients are eligible if the diagnosis of intermediate- or high-risk NSTE-ACS is made and an invasive strategy intended. Patients are randomized in a 1:1 ratio. In the control group, a delayed strategy is adopted, with the coronary angiography taking place between 12 and 72 hours after randomization. In the experimental group, a very early invasive strategy is performed within 2 hours. A loading dose of a P2Y12 ADP receptor antagonist is given at the time of intervention in both groups. Recruitment began in September 2016 (n = 558 patients as of October 2017). The primary endpoint is the composite of cardiovascular death and recurrent ischemic events at 1 month. The EARLY trial aims to demonstrate the superiority of a very early invasive strategy compared with a delayed strategy in intermediate- and high-risk NSTE-ACS patients managed without P2Y12 ADP receptor antagonist pretreatment.
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Affiliation(s)
- Gilles Lemesle
- USIC et Centre Hémodynamique, Institut Cœur Poumon, Centre Hospitalier Régional et Universitaire de Lille; Faculté de Médecine de l'Université de Lille; Institut Pasteur de Lille, Unité INSERM UMR 1011; and FACT (French Alliance for Cardiovascular Trials), Lille, F-59000, France
| | - Marc Laine
- Aix-Marseille Université, AP-HM, Unité INSERM 1076, Unité de Soins Intensifs Cardiologiques, Department of Cardiology, Hôpital Nord, Marseille, France.,Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France
| | - Mathieu Pankert
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France.,Department of Cardiology, Centre Hospitalier Henri Duffaut, Avignon, France
| | - Etienne Puymirat
- Département de Cardiologie, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Paris, France; Université Paris Descartes, INSERM U-970, Paris, France
| | - Thomas Cuisset
- Aix-Marseille Université, AP-HM, Unité INSERM 1062, Unité de Soins Intensifs Cardiologiques, Department of Cardiology, Hôpital Nord, Marseille, France
| | - Ziad Boueri
- Department of Cardiology, Centre Hospitalier de Bastia, France
| | - Luc Maillard
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France.,Department of Cardiology, Clinique Axium, Aix-en-Provence, France
| | - Sébastien Armero
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France.,Department of Cardiology, Hôpital Européen, Marseille, France
| | - Guillaume Cayla
- Department of Cardiology, Centre Hospitalier Universitaire de Nîmes, Université de Montpellier, Nîmes, France
| | - Laurent Bali
- Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France.,Department of Cardiology, Centre Hospitalier de Cannes, France
| | - Pascal Motreff
- Department of Cardiology, Centre Hospitalier Universitaire Gabriel Montpied, Clermont-Ferrand, France
| | - Jean-Pascal Peyre
- Department of Cardiology, Hôpital Privé Beauregard, Marseille, France
| | - Franck Paganelli
- Aix-Marseille Université, AP-HM, Unité INSERM 1076, Unité de Soins Intensifs Cardiologiques, Department of Cardiology, Hôpital Nord, Marseille, France
| | - François Kerbaul
- Pole RUSH, Assistance-Publique Hôpitaux de Marseille, Marseille, France
| | - Antoine Roch
- Emergency Department, Hôpital Nord, Marseille, France
| | | | - Karine Baumstarck
- Unité d'Aide Méthodologique à la Recherche Clinique, EA 3279, Laboratoire de Santé Publique, Aix-Marseille Université, Marseille, France
| | - Laurent Bonello
- Aix-Marseille Université, AP-HM, Unité INSERM 1076, Unité de Soins Intensifs Cardiologiques, Department of Cardiology, Hôpital Nord, Marseille, France.,Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), France
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Abstract
BACKGROUND Patients over 75 account for more than one third of those presenting with myocardial infarction and more than 50% of intrahospital mortality. There are no specific guidelines for the management of acute coronary syndromes (ACS) in the elderly. SETTING Although antithrombotic therapy seems to be effective and safe in such patients, it requires specific precautions and treatment adjustments because of the higher bleeding risk due to comorbidities such as renal function impairment and malnutrition. RESULTS Scientific evidence concerning elderly patients is scarce as they are either excluded or underrepresented in most randomized trials. Overall, the antithrombotic therapy needs to be adapted to avoid complications, mainly bleeding complications, without compromising the effectiveness of the treatment in this high-risk population. CONCLUSION In the present paper, we review the current treatment strategies in ACS while focusing on data concerning the elderly, according to available data in pivotal trials and in both AHA/ACC and ESC guidelines.
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Velagapudi P, Turagam M, Kolte D, Khera S, Parikh P, Hyder O, Aronow H, Abbott JD. Less than two versus greater than two hour invasive strategy in non-ST elevation myocardial infarction: a meta-analysis of randomized controlled trials. Expert Rev Cardiovasc Ther 2017; 16:67-72. [PMID: 29034751 DOI: 10.1080/14779072.2018.1391092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Optimal timing for an invasive strategy in non-ST elevation myocardial infarction (NSTEMI) is unclear. Whether clinical outcomes are improved with a less than two (LT2) compared with greater than two hour (GT2) invasive strategy remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) comparing LT2 vs GT2 for NSTEMI. METHODS A comprehensive literature search for RCTs comparing LT2 vs. GT2 in NSTEMI patients was performed. Three eligible studies consisting of 1,075 patients (LT2: 537, GT2: 538) with NSTEMI were identified. Follow-up ranged from 1 to 12 months. RESULTS Time from randomization to sheath insertion ranged from 0.5-2.2 and 14.0-85.0 hours in the LT2 and GT2 groups. More percutaneous coronary interventions and fewer coronary artery bypass grafting were performed in the LT2 vs. GT2 group. There was no significant difference in all-cause mortality, myocardial infarction (MI), and major bleeding between the two groups. LT2 was numerically, but not statistically superior to GT2 at preventing recurrent ischemia/urgent revascularization/refractory ischemia. CONCLUSION Our meta-analysis found no significant difference in outcomes between less than two versus greater than two hours invasive strategy for NSTEMI. The differences observed in the mode of revascularization according to timing of catheterization deserve further study.
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Affiliation(s)
- Poonam Velagapudi
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
| | - Mohit Turagam
- b Division of Cardiovascular Medicine , University of Missouri Health Care , Columbia , MO , USA
| | - Dhaval Kolte
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
| | - Sahil Khera
- c Division of Cardiovascular Medicine , New York Medical College , Valhalla , NY , USA
| | - Parag Parikh
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
| | - Omar Hyder
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
| | - Herbert Aronow
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
| | - J Dawn Abbott
- a Division of Cardiovascular Medicine , Brown University Warren Alpert Medical School , Providence , RI , USA
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Jenkins AT, Kantorovich A, Burman L. Contemporary Use of Oral Antithrombotic Agents: Focus on Dual and Triple Therapeutic Approaches. Pharmacotherapy 2017; 37:1545-1564. [PMID: 28981961 DOI: 10.1002/phar.2041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Atherosclerotic cardiovascular disease (ASCVD) represents a long-standing health care burden in most industrialized countries. Management of ASCVD is multifaceted, and utilization of antithrombotic agents is a key component of care to reduce vascular events. Minimizing thrombotic risk can be accomplished via antiplatelet or anticoagulant drugs; however, combination therapy is warranted for some indications. Although reducing thrombotic complications is important, it is equally vital to consider the safety of combination regimens. Thus clinicians must effectively balance both individualized thrombotic and bleeding risks when using this strategy. Scenarios occur in practice when determining the role for combination therapy is not clear, especially for patients with ASCVD who require both dual antiplatelet therapy plus anticoagulation. The aim of this review is to discuss the role of dual or triple antithrombotic therapies across the spectrum of thrombotic disease states. In addition to critiquing relevant research studies and evaluating key recommendations from nationally published guidelines and consensus statements involving the use of these agents, we offer practical considerations that can be utilized when managing patients with ASCVD.
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Affiliation(s)
- Antoine T Jenkins
- Department of Pharmacy Practice, Chicago State University-College of Pharmacy, Chicago, Illinois
| | - Alexander Kantorovich
- Department of Pharmacy Practice, Chicago State University-College of Pharmacy, Chicago, Illinois
| | - Luba Burman
- Department of Pharmacy Practice, Chicago State University-College of Pharmacy, Chicago, Illinois
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45
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Sukul D, Seth M, Dixon SR, Khandelwal A, LaLonde TA, Gurm HS. Contemporary Trends and Outcomes Associated With the Preprocedural Use of Oral P2Y12 Inhibitors in Patients Undergoing Percutaneous Coronary Intervention: Insights From the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). THE JOURNAL OF INVASIVE CARDIOLOGY 2017; 29:340-351. [PMID: 28420804 PMCID: PMC5699908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES We sought to describe trends in the use of preprocedural P2Y12 inhibitors and their clinical impact in patients undergoing percutaneous coronary intervention (PCI). BACKGROUND Oral P2Y12 inhibitors are ubiquitously used medications; however, the specific timing of initial P2Y12 inhibitor administration remains intensely debated. METHODS Our study population comprised 74,053 consecutive patients undergoing PCI at 47 hospitals in Michigan from January 2013 through June 2015. In-hospital outcomes included stent thrombosis, bleeding, need for transfusion, and death. Hierarchical logistic regression, propensity matching, and targeted maximum likelihood estimation were used to adjust for baseline patient differences and clustering, and to minimize bias. RESULTS Of 24,733 patients who received a preprocedural P2Y12 inhibitor, 82% received clopidogrel, 8% prasugrel, and 10% ticagrelor. Preprocedural administration of P2Y12 inhibitors declined during the study (49.3% to 24.8%; P<.001), and varied greatly across hospitals (14.5%-95.9%). No significant differences in outcomes were observed between patients receiving preprocedural clopidogrel and a matched cohort of those not receiving any preprocedural P2Y12 inhibitor (stent thrombosis: adjusted odds ratio [OR], 1.55; 95% confidence interval [CI], 0.30-7.84; bleeding: OR, 0.96; 95% CI, 0.63-1.46; transfusion: OR, 1.03; 95% CI, 0.69-1.55; and death: OR, 0.95; 95% CI, 0.38-2.37). Similar findings were demonstrated for preprocedural ticagrelor and prasugrel. Results from a subgroup analysis of patients with non-ST segment elevation acute coronary syndrome (n = 28,072) were consistent with the overall findings. CONCLUSIONS There was a substantial decline in the rate of preprocedural P2Y12 inhibitor administration during the study. Furthermore, there were no significant differences in outcomes between patients treated with preprocedural P2Y12 inhibitors and those who were not.
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Affiliation(s)
| | | | | | | | | | - Hitinder S Gurm
- University of Michigan Cardiovascular Center, 2A 394, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5853 USA.
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Abtan J, Steg PG, Stone GW, Mahaffey KW, Gibson CM, Hamm CW, Price MJ, Abnousi F, Prats J, Deliargyris EN, White HD, Harrington RA, Bhatt DL. Efficacy and Safety of Cangrelor in Preventing Periprocedural Complications in Patients With Stable Angina and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: The CHAMPION PHOENIX Trial. JACC Cardiovasc Interv 2017; 9:1905-13. [PMID: 27659566 DOI: 10.1016/j.jcin.2016.06.046] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 06/19/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The purpose of this study was to examine the safety and efficacy of cangrelor in patients with stable angina (SA) or acute coronary syndrome (ACS). BACKGROUND The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) trial demonstrated that cangrelor significantly reduced periprocedural ischemic events in all-comer percutaneous coronary intervention with a modest increase in mild and moderate bleeding. Whether this benefit is consistent across SA and ACS has not been explored fully. METHODS The CHAMPION PHOENIX trial compared periprocedural administration of cangrelor or clopidogrel, with either a 300- or 600-mg loading dose for the prevention of periprocedural complications in patients undergoing percutaneous coronary intervention. Among the 10,942 patients in the modified intention to treat population, 6,358 patients were classified as having SA, and 4,584 patients had ACS (including unstable angina, non ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction) at randomization. The primary composite endpoint was death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h. A key secondary endpoint was stent thrombosis, and the primary safety endpoint was GUSTO (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) severe bleeding. RESULTS Cangrelor consistently reduced the primary endpoint in SA and ACS (odds ratio [OR]: 0.83 [95% confidence interval (CI): 0.67 to 1.01] and OR: 0.71 [95% CI: 0.52 to 0.96], respectively; interaction p = 0.41). Cangrelor also consistently reduced stent thrombosis in SA and ACS (OR: 0.55 [95% CI: 0.30 to 1.01] and OR: 0.67 [95% CI: 0.42 to 1.06], respectively; interaction p = 0.62). The impact of cangrelor on GUSTO severe/moderate bleeding was also similar for SA and ACS (OR: 1.49 [95% CI: 0.67 to 3.33] and OR: 1.79 [95% CI: 0.79 to 4.07], respectively; interaction p = 0.75). CONCLUSIONS The benefits and risks of cangrelor were consistent in patients with SA and ACS. (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]; NCT01156571).
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Affiliation(s)
- Jérémie Abtan
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France
| | - P Gabriel Steg
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France; NLHI, ICMS, Royal Brompton Hospital, Imperial College, London, United Kingdom.
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, New York
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR); Department of Medicine; Stanford School of Medicine, Stanford, California
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Division of Cardiology, Harvard Medical School, Boston, Massachusetts
| | | | - Matthew J Price
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Freddy Abnousi
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Jayne Prats
- The Medicines Company, Parsippany, New Jersey
| | | | - Harvey D White
- University of Auckland, Auckland City Hospital, Auckland, New Zealand
| | - Robert A Harrington
- Stanford Center for Clinical Research (SCCR); Department of Medicine; Stanford School of Medicine, Stanford, California
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
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Benefits and risks of P2Y12 inhibitor preloading in patients with acute coronary syndrome and stable angina. J Thromb Thrombolysis 2017; 44:303-315. [DOI: 10.1007/s11239-017-1529-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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De Luca L, Colivicchi F, Gulizia MM, Pugliese FR, Ruggieri MP, Musumeci G, Cibinel GA, Romeo F. Clinical pathways and management of antithrombotic therapy in patients with acute coronary syndrome (ACS): a Consensus Document from the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Cardiology (SIC), Italian Society of Emergency Medicine (SIMEU) and Italian Society of Interventional Cardiology (SICI-GISE). Eur Heart J Suppl 2017; 19:D130-D150. [PMID: 28751840 PMCID: PMC5520755 DOI: 10.1093/eurheartj/sux013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is the cornerstone of the pharmacologic management of patients with acute coronary syndrome (ACS). Over the last years, several studies have evaluated old and new oral or intravenous antiplatelet agents in ACS patients. In particular, research was focused on assessing superiority of two novel platelet ADP P2Y12 receptor antagonists (i.e., prasugrel and ticagrelor) over clopidogrel. Several large randomized controlled trials have been undertaken in this setting and a wide variety of prespecified and post-hoc analyses are available that evaluated the potential benefits of novel antiplatelet therapies in different subsets of patients with ACS. The aim of this document is to review recent data on the use of current antiplatelet agents for in-hospital treatment of ACS patients. In addition, in order to overcome increasing clinical challenges and implement effective therapeutic interventions, this document identifies all potential specific care pathway for ACS patients and accordingly proposes individualized therapeutic options.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, San Giovanni Evangelista Hospital, Via Parrozzani, 3, 00019 Tivoli, Rome, Italy
| | | | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | | | | | - Giuseppe Musumeci
- Division of Cardiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
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Meta-analysis of clopidogrel pretreatment in acute coronary syndrome patients undergoing invasive strategy. Int J Cardiol 2017; 229:82-89. [DOI: 10.1016/j.ijcard.2016.11.226] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/07/2016] [Indexed: 11/21/2022]
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Capodanno D, Angiolillo DJ. Pretreatment with Antiplatelet Agents in the Setting of Percutaneous Coronary Intervention: When and Which Drugs? Interv Cardiol Clin 2016; 6:13-24. [PMID: 27886816 DOI: 10.1016/j.iccl.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Administering antiplatelet agents before coronary angiography to patients referred to elective or urgent percutaneous coronary intervention (PCI) requires a careful evaluation of advantages and disadvantages associated with platelet inhibition to avoid overtreatment on one side and undertreatment on the other. The delicate balance between ischemic protection and bleeding demands the ability to undertake risk stratification and individualized decisions, which is particularly challenging in the setting of ad hoc PCI and urgent procedures. This review analyzes the current evidence on pretreatment with oral and intravenous P2Y12 inhibitors in patients undergoing coronary angiography with intent to undergo PCI.
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Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular Department, Ferrarotto Hospital, University of Catania, Via Citelli, 6, Catania 95124, Italy.
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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