1
|
Ullah W, Sandhyavenu H, Taha A, Narayana Gowda S, Mukhtar M, Reddy Polam A, Zahid S, Fischman DL, Savage MP, Rao SV, Alkhouli M. Antiplatelet Strategy for Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e032490. [PMID: 39392170 DOI: 10.1161/jaha.122.032490] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 07/10/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Optimal duration and choice of antiplatelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention remain controversial. METHODS AND RESULTS Digital databases (PubMed, Cochrane, and Embase) were queried to select all randomized controlled trials on a post-percutaneous coronary intervention population with acute coronary syndrome. Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel for 12 months was compared with 4 major strategies: high-potency, high- to low-potency, low-dose, and short-duration DAPT. A network meta-analysis was performed to compare the safety and efficacy of different antiplatelet strategies. This study was the second updated manuscript under the International Prospective Register of Systematic Review registration (CRD42021286552). Thirty-two randomized controlled trials comprising 103 459 (51 750 experimental, 51 709 control) patients were included. Compared with DAPT with aspirin and clopidogrel for 12 months, high- to low-potency DAPT (risk ratio [RR], 0.69 [95% CI, 0.52-0.92]) and aspirin+prasugrel containing DAPT for 12 months (RR, 0.84 [95% CI, 0.72-0.98]) had a significantly lower, whereas DAPT for 1 month followed by clopidogrel only (RR, 1.59 [95% CI, 1.06-2.39]) had a higher, incidence of major adverse cardiovascular events at 1 year (median follow-up). Prasugrel (RR, 1.35 [95% CI, 1.09-1.66]) and ticagrelor (RR, 1.38 [95% CI, 1.17-1.62]) containing DAPT for 12 months had significantly higher rates, whereas high- to low-potency DAPT (RR, 0.85 [95% CI, 0.63-1.15]) had no significant risk of major bleeding. CONCLUSIONS Aspirin and ticagrelor for 3 months, followed by aspirin and clopidogrel for the remaining duration, can be considered the optimal strategy for treating post-percutaneous coronary intervention patients with acute coronary syndrome because of a significantly reduced risk of major adverse cardiovascular events without increasing the risk of bleeding.
Collapse
Affiliation(s)
- Waqas Ullah
- Thomas Jefferson University Hospitals Philadelphia PA
| | | | | | | | - Maryam Mukhtar
- University Hospitals of Leicester National Health Service Trust Leicester UK
| | | | - Salman Zahid
- Oregon Health and Science University Portland OR
| | | | | | - Sunil V Rao
- New York University Langone Health New York NY
| | | |
Collapse
|
2
|
Hernandez-Sómerson MA, Montoya-Agudelo F, Huertas-Rodriguez G. Efficacy and safety of drugs in residual cardiovascular risk: A systematic review of the literature. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200298. [PMID: 38983606 PMCID: PMC11231711 DOI: 10.1016/j.ijcrp.2024.200298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/04/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
Background The objective of this research is to evaluate the efficacy and safety of drugs in the residual risk in any of its three components: lipid, inflammatory and thrombotic risk. Methods A systematic review was conducted of randomized clinical trials that included as a primary outcome, at least one of the conditions related to atherosclerotic cardiovascular disease. The databases used were PUBMED/MEDLINE, Scopus and ClinicalTrials.gov. The risk of bias of the studies was assessed using the Risk of Bias 2 tool. Results and discussion: 18 studies were included in the analysis. Half of the studies had low risk of bias or some concerns. Several drugs were effective in reducing the primary outcome: ethyl eicosapentaenoeic acid (17.2 % E-EPA versus 22 % placebo HR: 0.75; 95 % CI 0.68-0.83; p < 0.001), colchicine in stable coronary artery disease (6.8 % vs placebo 9.6 %, HR 0.59, 95 % CI 0.57-0.83; p < 0.001), Canakinumab (150 mg vs placebo ARR 15 %, HR 0.85, 95 % CI 0.74-0.98; p = 0.021) and Rivaroxaban with Aspirin in stable atherosclerotic disease (4.1 % versus aspirin 5.4 %, HR 0.76, 95 % CI 0.66-0.86, P < 0.001). Serious adverse events did not differ between study groups, except for a higher rate of bleeding with the use of combination antithrombotic therapy. Conclusion The residual risk can be reduced through the use of different drugs that act by modifying atherogenic lipid levels, modulating inflammatory pathways and the risk of thrombosis, with an acceptable safety profile in most studies.
Collapse
Affiliation(s)
- Mario Andres Hernandez-Sómerson
- Department of Medical Clinics, Hospital Universitario Mayor - MEDERI, 111411, Bogotá, Colombia
- Universidad del Rosario, 111411, Bogotá, Colombia
- Internal Medicine Service, Clínica de la Mujer, 110221, Bogotá, Colombia
| | | | | |
Collapse
|
3
|
Corballis N, Bhalraam U, Merinopoulos I, Gunawardena T, Tsampasian V, Wickramarachchi U, Eccleshall S, Vassiliou VS. One-Month Duration Compared with Twelve-Month Duration of Dual Antiplatelet Therapy in Elective Angioplasty for Coronary Artery Disease: Bleeding and Ischaemic Outcomes. J Clin Med 2024; 13:4521. [PMID: 39124787 PMCID: PMC11312761 DOI: 10.3390/jcm13154521] [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: 07/09/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Background/Objectives: The need to determine the safest duration of dual antiplatelet therapy duration after elective angioplasty to reduce bleeding events without an adverse effect on major adverse cardiovascular events (MACE) remains a challenge. Methods: In this investigator-initiated, single-centre cohort study, we identified all patients who underwent PCI for de novo coronary disease for stable angina between January 2015 and November 2019. We compared 1-month and 12-month durations of dual antiplatelet therapy (DAPT) to determine if there was any difference in the primary outcome of major bleeding. The secondary outcome was a patient-oriented composite endpoint of all-cause mortality; any myocardial infarction, stroke, or revascularisation; and the individual components of this composite endpoint. Data were analysed using Cox regression models and cumulative hazard plots. Results: A total of 1025 patients were analysed, of which 340 received 1 month of DAPT and 685 received 12 months of DAPT. There was no difference in major bleeding between the two groups (2.6% vs. 2.5% respectively). On univariable cox regression analysis, no characteristics were predictors of major bleeding. A proportion of 99.7% of patients in the 1-month DAPT arm were treated with a DCB strategy, whilst 93% in the 12-month DAPT group were treated with a DES. There was no difference between the two groups with regards to the composite patient-oriented MACE (11% vs. 12%, respectively) or any individual component of this. These results were unchanged after propensity score matched analysis. Conclusions: A 1-month duration of DAPT, for which 99.7% of patients were treated with a DCB strategy, appears safe and effective when compared with a 12-month duration of DAPT with no difference in major bleeding or MACE.
Collapse
Affiliation(s)
- Natasha Corballis
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - U. Bhalraam
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Ioannis Merinopoulos
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Tharusha Gunawardena
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Vasiliki Tsampasian
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Upul Wickramarachchi
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Simon Eccleshall
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| | - Vassilios S. Vassiliou
- Centre of Metabolic Health, Norwich Medical School, University of East Anglia, Bob Champion Research and Education, Rosalind Franklin Road, Norwich NR4 7UQ, UK (I.M.)
- Department of Cardiology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich NR4 7LJ, UK;
| |
Collapse
|
4
|
Cheng M, Xu Y, Liu W, Mu L, Lian X, Gao G, Sun L. Regulatory science promotes the translation of transcatheter tricuspid valve repair/replacement devices. Regen Biomater 2024; 11:rbae084. [PMID: 39220742 PMCID: PMC11364518 DOI: 10.1093/rb/rbae084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/01/2024] [Accepted: 06/08/2024] [Indexed: 09/04/2024] Open
Abstract
For patients with symptomatic and severe tricuspid regurgitation but inoperable with open surgery, transcatheter tricuspid valve intervention (TTVI) is a procedure of great clinical value. TTVI products include repair and replacement devices. TTVI products are one of the hotspots of investigation now, with different innovative biomaterials and structural designs in trials to satisfy divergent indications and reduce complications. With the emerging biomaterials, the technical difficulty of structural design will be greatly reduced, spurring further product innovation and development. The innovativeness and complexity of TTVI products have brought challenges to academia, industry, and regulatory agencies. Regulatory science provides a bridge to address these difficulties and challenges. This perspective article introduces the latest development of the TTVI products. With traditional methods, regulatory agencies face challenges in evaluating the safety and efficacy of TTVr/TTVR devices given the uncertainty of clinical use and the diversity of innovative structural design. This perspective article analyzes the regulatory challenges and discusses regulatory science that can be developed to assess the safety, efficacy, quality and performance of such products: including new approaches for innovative devices, pre-review path, computer modeling and simulation, accelerated wear testing methods for transcatheter heart valves and evidence-based research. This article reveals for the first time how to apply regulatory science systematically to TTVI products, which is of great relevance to their development and translation.
Collapse
Affiliation(s)
- Maobo Cheng
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| | - Yun Xu
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| | - Wei Liu
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| | - Lanlan Mu
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| | - Xiaoqi Lian
- Guangdong-Hong Kong-Macao Greater Bay Area, Center for Medical Device Evaluation and Inspection of NMPA, Shenzhen 518045, China
| | - Guobiao Gao
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| | - Lei Sun
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing 100081, China
| |
Collapse
|
5
|
Li Y, Li J, Wang B, Jing Q, Zeng Y, Hou A, Wang Z, Liu A, Zhang J, Zhang Y, Zhang P, Jiang D, Liu B, Fan J, Zhang J, Li L, Su G, Yang M, Jiang W, Qu P, Zeng H, Li L, Qiu M, Ru L, Chen S, Zhou Y, Qiao S, Stone GW, Angiolillo DJ, Han Y. Extended Clopidogrel Monotherapy vs DAPT in Patients With Acute Coronary Syndromes at High Ischemic and Bleeding Risk: The OPT-BIRISK Randomized Clinical Trial. JAMA Cardiol 2024; 9:523-531. [PMID: 38630489 PMCID: PMC11024736 DOI: 10.1001/jamacardio.2024.0534] [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] [Received: 07/04/2023] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Importance Purinergic receptor P2Y12 (P2Y12) inhibitor monotherapy after a certain period of dual antiplatelet therapy (DAPT) may be an attractive option of maintenance antiplatelet treatment for patients undergoing percutaneous coronary intervention (PCI) who are at both high bleeding and ischemic risk (birisk). Objective To determine if extended P2Y12 inhibitor monotherapy with clopidogrel is superior to ongoing DAPT with aspirin and clopidogrel after 9 to 12 months of DAPT after PCI in birisk patients with acute coronary syndromes (ACS). Design, Setting, and Participants This was a multicenter, double-blind, placebo-controlled, randomized clinical trial including birisk patients with ACS who had completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months at 101 China centers between February 2018 and December 2020. Study data were analyzed from April 2023 to May 2023. Interventions Patients were randomized either to clopidogrel plus placebo or clopidogrel plus aspirin for an additional 9 months. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding 9 months after randomization. The key secondary end point was major adverse cardiac and cerebral events (MACCE; the composite of all-cause death, myocardial infarction, stroke or clinically driven revascularization). The primary end point was tested for superiority, and the MACCE end point was tested for sequential noninferiority and superiority. Results A total of 7758 patients (mean [SD] age, 64.8 [9.0] years; 4575 male [59.0%]) were included in this study. The primary end point of BARC types 2, 3, or 5 bleeding occurred in 95 of 3873 patients (2.5%) assigned to clopidogrel plus placebo and 127 of 3885 patients (3.3%) assigned to clopidogrel plus aspirin (hazard ratio [HR], 0.75; 95% CI, 0.57-0.97; difference, -0.8%; 95% CI, -1.6% to -0.1%; P = .03). The incidence of MACCE was 2.6% (101 of 3873 patients) in the clopidogrel plus placebo group and 3.5% (136 of 3885 patients) in the clopidogrel plus aspirin group (HR, 0.74; 95% CI, 0.57-0.96; difference, -0.9%; 95% CI, -1.7% to -0.1%; P < .001 for noninferiority; P = .02 for superiority). Conclusions and Relevance Among birisk patients with ACS who completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months before randomization, an extended 9-month clopidogrel monotherapy regimen was superior to continuing DAPT with clopidogrel in reducing clinically relevant bleeding without increasing ischemic events. Trial Registration ClinicalTrials.gov Identifier: NCT03431142.
Collapse
Affiliation(s)
- Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zeng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aijie Hou
- The People’s Hospital of Liaoning Province, Shenyang, China
| | | | - Aijun Liu
- Benxi Central Hospital, Benxi, China
| | | | | | - Ping Zhang
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | | | - Bin Liu
- The Second Hospital of Jilin University, Changchun, China
| | | | - Jun Zhang
- Cangzhou Central Hospital, Cangzhou, China
| | - Li Li
- Guangzhou Red Cross Hospital, Guangzhou, China
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical University, Ji’nan, China
| | - Ming Yang
- Yingkou Central Hospital, Yingkou, China
| | - Weihong Jiang
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Peng Qu
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Lu Li
- The Second Affiliated Hospital of Shenyang Medical College, Shenyang, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Leisheng Ru
- Bethune International Peace Hospital, Shijiazhuang, China
| | | | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
6
|
Zhang Y, Wu L. Effect of post-hospital care intervention on the prognosis of patients treated with direct percutaneous coronary intervention for acute myocardial infarction. Panminerva Med 2024; 66:211-213. [PMID: 37462676 DOI: 10.23736/s0031-0808.23.04918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Affiliation(s)
- Yanchun Zhang
- Department of Cardiology, Zhejiang Hospital, Hangzhou, Zhejiang, China
| | - Lingxiao Wu
- Health Management Center, Zhejiang Hospital, Hangzhou, Zhejiang, China -
| |
Collapse
|
7
|
Agbaedeng TA, Noubiap JJ, Roberts KA, Chew DP, Psaltis PJ, Amare AT. Sex-Based Outcomes of Dual-Antiplatelet Therapy After Percutaneous Coronary Intervention: A Pairwise and Network Meta-Analysis. Drugs 2024; 84:685-701. [PMID: 38809372 DOI: 10.1007/s40265-024-02034-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND Although dual antiplatelet therapy (DAPT) improves the outcomes of patients undergoing percutaneous coronary intervention (PCI), sex-specific differences in efficacy and safety of DAPT remain unresolved. We compared sex differences for DAPT outcomes and DAPT durations (1-3 months [short-term], 6 months [mid-term], and >12 months [extended] vs. 12 months). METHODS We searched databases through 31 December 2023 for trials reporting DAPT after PCI. The endpoints were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical and cerebrovascular events (NACCE), and any bleeding. Extracted data were pooled in a frequentist network and pairwise, random-effects meta-analysis. RESULTS Twenty-two trials (99,591 participants, 25.2% female) were included. Female sex was significantly associated with a higher 1-year MACCE risk (hazard ratio 1.14 [95% confidence interval 1.02-1.28]) and bleeding (1.13 [1.00-1.28]), but not NACCE (1.12 [0.96-1.31]). In sub-analyses, the association between female sex and MACCE was related to use of clopidogrel as the second antiplatelet agent (1.11 [1.03-1.20]), whereas higher bleeding events were related to newer P2Y12 inhibitors (P2Y12i) (1.58 [1.01-2.46]). For DAPT duration, short-term DAPT followed by P2Y12i monotherapy was non-inferior for MACCE in females and males (0.95 [95% CI 0.83-1.10; and 0.96 [0.80-1.16]) but tended to be superior in males for NACCE versus 12-month DAPT (0.96 [0.91-1.01]); mid-term DAPT tended to be associated with a lower bleeding risk in males (0.43 [0.17-1.09]). CONCLUSIONS Female sex is associated with higher MACCE and bleeding when newer P2Y12i agents are used. Short-term DAPT followed by P2Y12i monotherapy is safe and effective in both sexes undergoing PCI. CLINICAL TRIALS REGISTRATION PROSPERO ID: CRD42021278663.
Collapse
Affiliation(s)
- Thomas A Agbaedeng
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7BN, UK.
| | - Jean Jacques Noubiap
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Division of Cardiology, Department of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Kirsty A Roberts
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Derek P Chew
- Monash Data Futures Institute, Monash University , Clayton, Victoria , Australia
| | - Peter J Psaltis
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Vascular Research Centre, Lifelong Health Theme, SAHMRI, Adelaide, SA, Australia
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Azmeraw T Amare
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| |
Collapse
|
8
|
Zhang X, Zhou D, Song S, Huang X, Ding Y, Meng R. Efficacy and Safety of Long-Term Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2024; 30:10760296241244772. [PMID: 38571479 PMCID: PMC10993673 DOI: 10.1177/10760296241244772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/04/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is a standard therapy in patients with ischemic vascular diseases (IVD) including coronary artery, cerebrovascular and peripheral arterial diseases, although the optimal duration of this treatment is still debated. Previous meta-analyses reported conflicting results about the effects of long-term and short-term as well as non-DAPT use in various clinical settings. Herein, we conducted a comprehensive meta-analysis to assess the efficacy and safety of different durations of DAPT. METHODS We reviewed relevant articles and references from database, which were published prior to April 2023. Data from prospective studies were processed using RevMan5.0 software, provided by Cochrane Collaboration and transformed using relevant formulas. The inclusion criteria involved randomization to long-term versus short-term or no DAPT; the endpoints included at least one of total or cardiovascular (CV) mortalities, IVD recurrence, and bleeding. RESULTS A total of 34 randomized studies involving 141 455 patients were finally included. In comparison with no or short-term DAPT, long-term DAPT reduced MI and stroke, but did not reduce the total and CV mortalities. Meanwhile, bleeding events were increased, even though intracranial and fatal bleedings were not affected. Besides, the reduction of MI and stroke recurrence showed no statistical significance between long-term and short-term DAPT groups. CONCLUSION Long-term DAPT may not reduce the mortality of IVD besides increasing bleeding events, although reduced the incidences of MI and stroke early recurrence to a certain extent and did not increase the risk of fatal intracranial bleeding.
Collapse
Affiliation(s)
- Xiaoming Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Da Zhou
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Siying Song
- Division of Neurocritical Care and Emergency Neurology, Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xiangqian Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ran Meng
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- National Center for Neurological Disorders, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
9
|
Serebruany VL, Tanguay JF, Gurvich ML, Marciniak TA, Atar D. Strokes and Transient Ischemic Attacks Occurrence During Annual Dual Antiplatelet Therapy. Am J Ther 2023; 30:e411-e415. [PMID: 37713684 DOI: 10.1097/mjt.0000000000001622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND The incidence of stroke/TIA during annual dual antiplatelet therapy (ADAPT) for acute coronary syndrome (ACS) remains high. Some evidence suggests that shorter than ADAPT may diminish such risk, still providing adequate vascular protection. However, the precise timing of strokes/TIA occurrences during ADAPT is unclear but may be important for determining optimal preventive treatment duration. STUDY QUESTION The precise timing of secondary cerebrovascular events over ADAPT. STUDY DESIGN Access was gained to the FDA-issued Platelet Inhibition and Outcomes (PLATO) trial data set on which post hoc analyses of stroke/TIA timing after ticagrelor and clopidogrel on top of aspirin was explored. MEASURES AND OUTCOMES Events were counted and plotted over time from day 1 till day 365 after the index ACS event. RESULTS Among 18,624 enrollees, 252 strokes and 49 TIAs were reported. After the exclusion of entries with missing dates, unclear randomization codes, and events beyond 1-year follow-up, 238 strokes and 45 TIAs were analyzed. Overall, most frequent strokes/TIAs occurred within the first day after qualifying ACS, with the gradual declines after day 7 and day 40 reaching background counts thereafter. The strokes/TIAs patterns did not differ much between P 2 Y12 inhibitors except for twice more events at day 1 and excess exclusions after day 365 in the ticagrelor arm. CONCLUSIONS Most cerebrovascular events emerged very early after ACS despite ADAPT. This large hypothesis-generating evidence may justify shorter than the ADAPT duration after ACS. Twice more events at day 1 and excess late ticagrelor exclusions in PLATO deserve further scrutiny. REGISTRATION URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00391872.
Collapse
Affiliation(s)
| | | | | | | | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval; and
- Institute of Clinical Medicine, University of Oslo, Norway
| |
Collapse
|
10
|
Bainey KR, Marquis-Gravel G, MacDonald BJ, Bewick D, Yan A, Turgeon RD. Short dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk patients: Systematic review and meta-analysis. PLoS One 2023; 18:e0291061. [PMID: 37656721 PMCID: PMC10473507 DOI: 10.1371/journal.pone.0291061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) reduces major adverse cardiovascular events (MACE) and stent thrombosis. However, DAPT duration is a concern in high bleeding risk (HBR) patients. We evaluated the effect of short DAPT (1-3 months) compared to standard DAPT (6-12 months) on bleeding and ischemic events in HBR PCI. METHODS We searched MEDLINE, Embase and CENTRAL up to August 18, 2022. Randomized controlled trials (RCTs) comparing short DAPT (1-3 months) versus standard DAPT in HBR PCI were included. We assessed risk of bias (RoB) using the Cochrane RoB2 tool, and certainty of evidence using GRADE criteria. Outcomes included MACE, all-cause death, stent thrombosis, major bleeding, and the composite of major or clinically-relevant non-major bleeding. We estimated risk ratios (RR) and 95% confidence intervals (CI) using a random-effects model. RESULTS From 503 articles, we included five RCTs (n = 7,242) at overall low risk of bias with median follow-up of 12-months. Compared to standard DAPT, short DAPT did not increase MACE (RR 1.02, 95% CI 0.84-1.23), all-cause death (RR 0.92, 95% CI 0.71-1.20) or stent thrombosis (RR 1.47, 95% CI 0.73-2.93). Short DAPT reduced major bleeding (RR 0.34, 95% CI 0.13-0.90) and the composite of major or clinically-relevant non-major bleeding (RR 0.60, 95% CI 0.44-0.81), translating to 21 and 34 fewer events, respectively, per 1000 patients. CONCLUSIONS In HBR PCI, DAPT for 1-3 months compared to 6-12 months reduced clinically-relevant bleeding events without jeopardizing ischemic risk. Short DAPT should be considered in HBR patients receiving PCI.
Collapse
Affiliation(s)
- Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta
| | | | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia
| | - David Bewick
- New Brunswick Heart Center, Horizon Health Network, Saint John, New Brunswick
| | - Andrew Yan
- Division of Cardiology, Canadian Heart Research Centre and Terrence Donnelly Heart Centre, St Michael’s Hospital, University of Toronto, Toronto, Ontario
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
11
|
Yu Y, Pan D, Bai R, Luo J, Tan Y, Duan W, Shi D. P2y 12 inhibitor monotherapy after 1-3 months dual antiplatelet therapy in patients with coronary artery disease and chronic kidney disease undergoing percutaneous coronary intervention: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197161. [PMID: 37485257 PMCID: PMC10357506 DOI: 10.3389/fcvm.2023.1197161] [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: 03/30/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction In patients with coronary artery disease (CAD) and chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), whether short-term dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitors confers benefits compared with standard DAPT remains unclear. This study aimed to assess the efficacy and safety of 1-3 months of DAPT followed by P2Y12 monotherapy in patients with CAD and CKD undergoing PCI. Methods PubMed, Embase, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) comparing the P2Y12 inhibitor monotherapy after a 1-3 months DAPT vs. DAPT in patients with CAD and CKD after PCI. The primary outcome was the incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, target-vessel revascularization, and stroke. The safety outcome was the major bleeding events, defined as a composite of TIMI major bleeding or Bleeding Academic Research and Consortium (BARC) type 2, 3, or 5 bleeding. The pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated with a fixed- or random-effects model depending on the heterogeneity among studies. Results Four RCTs including 20,468 patients (2,833 patients with CKD and 17,635 without CKD) comparing P2Y12 inhibitor monotherapy with DAPT were included in our meta-analysis. Patients with CAD and CKD had higher risk of ischemic and bleeding events. P2Y12 inhibitor monotherapy after 1-3 months of DAPT significantly reduced the risk of major bleeding compared to DAPT in CKD patients (RR: 0.69, 95% CI: 0.51-0.95, P = 0.02) and non-CKD patients (RR: 0.66, 95% CI: 0.49-0.89, P = 0.01). No significant difference regarding MACEs between P2Y12 inhibitor monotherapy and DAPT was found in CKD patients (RR: 0.88, 95% CI: 0.59-1.31, P = 0.53) and non-CKD (RR: 0.91, 95% CI: 0.79-1.04, P = 0.17). Conclusion P2Y12 inhibitor monotherapy after 1-3 months of DAPT was an effective strategy for lowering major bleeding complications without increasing the risk of cardiovascular events in patients with CAD and CKD undergoing PCI as compared with DAPT. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/, CRD42022355228.
Collapse
Affiliation(s)
- Yanqiao Yu
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Deng Pan
- Department of Graduate School, Beijing University of Chinese Medicine, Beijing, China
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruina Bai
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jinwen Luo
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yu Tan
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wenhui Duan
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Dazhuo Shi
- National Clinical Research Center for Chinese Medicine Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| |
Collapse
|
12
|
Kim S, Lee JS, Lee J, Kim YH, Kim JS, Lim SY, Kim SH, Ahn JC, Song WH. Fifteen-Year Nationwide Trend in Antiplatelet Treatment among Drug-Eluting Stent Recipients in Korea: Many Patients Receive Very Prolonged Dual-Antiplatelet Treatment, and Newer Drugs Are Replacing the Older Ones. J Clin Med 2023; 12:jcm12072675. [PMID: 37048759 PMCID: PMC10095404 DOI: 10.3390/jcm12072675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/21/2023] [Accepted: 03/31/2023] [Indexed: 04/07/2023] Open
Abstract
Drug-eluting stent (DES) recipients require 6–12 months of dual antiplatelet treatment (DAPT) and long-term aspirin mono-antiplatelet treatment (MAPT). Given the diversity of contemporary antiplatelet agents, antiplatelet treatment (APT) selection is becoming more complicated. We evaluated 15-year APT trends based on nationwide prescription data of 79,654 patients who underwent percutaneous coronary intervention (PCI) using DESs from 2002 to 2018 in Korea. DAPT (80.7%) was the most preferred initial APT post-PCI. Many DES recipients received prolonged DAPT (post-PCI 3 years: 41.0%; 10 years: 27.7%). There was a noticeable delay in DAPT-to-MAPT conversion from the mid to late 2000s (after the late-stent thrombosis concerns of first-generation DESs raised); the conversion after that was similar during the 2010s, occurring most robustly at 12–18 months post-PCI. Clopidogrel had long and increasingly been used for MAPT, surpassing aspirin. The recent increase in newer P2Y12 inhibitor prescriptions was noted. The patients treated with newer P2Y12 inhibitors were more likely younger men and presented with acute myocardial infarction. Real-world APT is evolving, and guideline–practice gaps exist. Further studies exploring the impact of diverse APT strategies on patient outcomes are expected to provide insights into optimal APT that can sophisticatedly balance the ischemic and bleeding risks.
Collapse
Affiliation(s)
- Sunwon Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Jong-Seok Lee
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Jungkuk Lee
- Hanmi Pharmaceuticals, Songpa-gu, Seoul 05545, Republic of Korea
| | - Yong-Hyun Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Jin-Seok Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Sang-Yup Lim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Seong Hwan Kim
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Jeong-Cheon Ahn
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| | - Woo-Hyuk Song
- Cardiovascular Center, Korea University Ansan Hospital, Ansan-si 15355, Republic of Korea
| |
Collapse
|
13
|
Serebruany VL, Tanguay JF, Gurvich ML, Marciniak TA, Atar D. Time Course of Death After Acute Coronary Syndrome Treated With Dual Antiplatelet Therapy for 1 Year. Am J Med 2023; 136:484-488. [PMID: 36828207 DOI: 10.1016/j.amjmed.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Excess mortality remains the cornerstone concern despite dual antiplatelet therapy (DAPT) after acute coronary syndrome. Some data suggest that shorter periods than 12 months of DAPT diminish bleeding risks yet still provide adequate vascular protection and improving survival. However, the precise timing of deaths after acute coronary syndrome has not been mapped in many studies. This knowledge may be critical for defining optimal treatment duration. METHODS Access was gained to the data set for the Platelet Inhibition and Outcomes (PLATO) trial, which was issued by the Food and Drug Administration, in which post hoc analyses of timing of death events during DAPT (with either aspirin/ticagrelor or aspirin/clopidogrel) were performed. All-cause individual deaths were counted and plotted over time from day 1 to day 365 after the index event. RESULTS Among 18,624 enrollees, 938 total deaths were reported to the Food and Drug Administration in PLATO. After exclusion of deceased patients with missing dates, randomization errors, and deaths beyond 1 year of follow-up, 913 fatalities (509 after clopidogrel and 404 after ticagrelor) were analyzed. The PLATO records did not indicate where exactly deaths occurred making impossible to triage in the hospital versus outpatient fatalities. Most frequent deaths occurred within the Day 1 (n = 41); Day 2 (n = 48); and Day 3 (n = 33) and overall during the first week (n = 202; 22.1%) after the index acute coronary syndrome, with a gradual decline after Day 10 and Day 60, reaching background counts after Day 220. CONCLUSION Focusing on mortality reduction, this large data set may support a shorter than 12 months' duration of DAPT.
Collapse
Affiliation(s)
| | | | | | | | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| |
Collapse
|
14
|
Li Y, Zhao R, Yu P, Xu Y, Zhang Q, Han Y. The Increased Ischemic Risk During the Early Period After Clopidogrel Noncompliance in Patients with Acute Coronary Syndrome: A Meta-Analysis. Clin Appl Thromb Hemost 2023; 29:10760296231196477. [PMID: 37644847 PMCID: PMC10469223 DOI: 10.1177/10760296231196477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 08/03/2023] [Indexed: 08/31/2023] Open
Abstract
Although dual antiplatelet therapy for secondary prevention in acute coronary syndrome (ACS) is highly recommended by current guidelines, P2Y12 inhibitor non-adherence often occurs and devastates prognosis. To evaluate whether the ischemic risk during the early period of clopidogrel noncompliance was increased among ACS patients, a comprehensive search of PubMed, Embase, and Web of Science was conducted to identify studies reporting early ischemic risk after clopidogrel noncompliance in ACS patients. The primary endpoint was a composite of death or myocardial infarction (MI). Effect sizes were synthesized in patients with or without revascularization. A total of 7 observational studies focusing on clopidogrel noncompliance were included in this meta-analysis, whereas no studies involving ticagrelor or prasugrel were retrieved. A significantly increased risk of death or MI 0 to 90 days after clopidogrel noncompliance was found compared with that during 90 to 180 or 90 to 360 days regardless of revascularization (incidence rate ratio [IRR]: 2.01, 95% confidence interval (CI): 1.62-2.49, P < .001, I2 = 9%) or not (IRR: 1.61, 95% CI: 1.05-2.48, P < .001, I2 = 74%). Patients undergoing percutaneous coronary intervention had a higher risk of death or MI 0 to 90 days after clopidogrel noncompliance compared with 90-180 or 90-360 days irrespective of drug-eluting stent or bare metal stent implantation (P < .05 for both). The early ischemic risk after clopidogrel noncompliance is significantly higher than the late risk in ACS patients. Antiplatelet noncompliance remains a serious concern.
Collapse
Affiliation(s)
- Yushan Li
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Ruting Zhao
- Department of Internal Medicine, Chinese PLA No. 31694 Army Health Company, Benxi, China
| | - Peng Yu
- Department of Internal Medicine, Chinese PLA No. 65529 Army Health Company, Liaoyang, China
| | - Yan Xu
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanyu Zhang
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- National Key Laboratory of Frigid Zone Cardiovascular Diseases, Department of Cardiovascular Diseases, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
15
|
Zhu YX, Liang L, Parasa R, Li Z, Li Q, Chang S, Ma WR, Feng SL, Wang Y, Xu B, Bourantas CV, Zhang YJ. Early vascular healing after neXt-generation drug-eluting stent implantation in Patients with non-ST Elevation acute Coronary syndrome based on optical coherence Tomography guidance and evaluation (EXPECT): study protocol for a randomized controlled trial. Front Cardiovasc Med 2023; 10:1003546. [PMID: 36910518 PMCID: PMC9995825 DOI: 10.3389/fcvm.2023.1003546] [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: 07/26/2022] [Accepted: 02/06/2023] [Indexed: 02/25/2023] Open
Abstract
Background There is limited evidence about vessel wall healing response following implantation of next-generation drug-eluting stents (DES) in patients admitted with a non-ST elevation acute coronary syndrome (NSTE-ACS). Cumulative data indicate that optical coherence tomography (OCT) imaging can optimize percutaneous coronary intervention results and expedite stent endothelialization in the general population but there is lack of data in NSTE-ACS patients. Methods The EXPECT study is an investigator-initiated, prospective, randomized trial to assess early vascular healing response following next-generation DES implantation in patients admitted with NSTE-ACS based on OCT guidance and evaluation. Sixty patients are randomized at 1:1:1 ratio to OCT-guided percutaneous coronary intervention (PCI) with 3-month follow-up OCT imaging (O3 group, n = 20), to angiography-guided PCI with 3-month follow-up OCT imaging (A3 group, n = 20) and to angiography-guided PCI with 6-month follow-up OCT imaging (A6 group, n = 20). The primary endpoint of the study is stent strut coverage rate at 3- or 6- month follow-up in the studied groups. The secondary endpoints of the study include OCT imaging endpoints, clinical endpoints, and molecular biology endpoints at the different time points. The clinical endpoints comprised of major cardiovascular adverse events and individual components. The molecular biology endpoints comprised of lipid levels and the levels of inflammatory indicators. Discussion The findings of the EXPECT study are anticipated to provide novel insights into vessel wall healing in NSTE-ACS population following implantation of next-generation DES, underscore the value of OCT imaging in expediting strut coverage in this setting, and explore the potential of an early discontinuation of dual antiplatelet therapy (DAPT) in this population. Clinical Trial Registration ClinicalTrials.gov, NCT04375319.
Collapse
Affiliation(s)
- Yong-Xiang Zhu
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Li Liang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Ramya Parasa
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Zheng Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Qian Li
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Shang Chang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Wen-Rui Ma
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Si-Li Feng
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Yang Wang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Christos V Bourantas
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,Cardiovascular Devices Hub, Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Yao-Jun Zhang
- Department of Cardiology, Xuzhou Third People's Hospital, Xuzhou Medical University, Xuzhou, China
| |
Collapse
|
16
|
Xu JJ, Jia SD, Jiang L, Song Y, Zhu P, Yuan DS, Yao Y, Zhao XY, Li JX, Yang YJ, Qiao SB, Xu B, Gao RL, Yuan JQ. Prolonged dual antiplatelet therapy after drug-eluting stent implantation improves long-term prognosis for acute coronary syndrome: five-year results from a large cohort study. World J Emerg Med 2023; 14:25-30. [PMID: 36713350 PMCID: PMC9842462 DOI: 10.5847/wjem.j.1920-8642.2023.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 10/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To investigate the most appropriate dual antiplatelet therapy (DAPT) duration for patients with acute coronary syndrome (ACS) after drug-eluting stent (DES) implantation in the largest cardiovascular center of China. METHODS We enrolled 5,187 consecutive patients with ACS who received DES from January to December 2013. Patients were divided into four groups based on DAPT duration: standard DAPT group (11-13 months, n=1,568) and prolonged DAPT groups (13-18 months [n=308], 18-24 months [n=2,125], and >24 months [n=1,186]). Baseline characteristics and 5-year clinical outcomes were recorded. RESULTS Baseline characteristics were similar across the four groups. Among the four groups, those with prolonged DAPT (18-24 months) had the lowest incidence of major adverse cardiovascular and cerebrovascular events (MACCEs) (14.1% vs. 11.7% vs. 9.6% vs. 24.2%, P<0.001), all-cause death (4.8% vs. 3.9% vs. 2.1% vs. 2.6%, P<0.001), cardiac death (3.1% vs. 2.6% vs. 1.4% vs. 1.9%, P=0.004), and myocardial infarction (MI) (3.8% vs. 4.2% vs. 2.5% vs. 5.8%, P<0.001). The incidence of bleeding was not different among the four groups (9.9% vs. 9.4% vs. 11.0% vs. 9.4%, P=0.449). Cox multivariable analysis showed that prolonged DAPT (18-24 months) was an independent protective factor for MACCEs (hazard ratio [HR] 0.802, 95% confidence interval [CI] 0.729-0.882, P<0.001), all-cause death (HR 0.660, 95% CI 0.547-0.795, P<0.001), cardiac death (HR 0.663, 95% CI 0.526-0.835, P<0.001), MI (HR 0.796, 95% CI 0.662-0.957, P=0.015), and target vessel revascularization (HR 0.867, 95% CI 0.755-0.996, P=0.044). Subgroup analysis for high bleeding risk showed that prolonged DAPT remained an independent protective factor for all-cause death and MACCEs. CONCLUSION For patients with ACS after DES, appropriately prolonging the DAPT duration may be associated with a reduced risk of adverse ischemic events without increasing the bleeding risk.
Collapse
Affiliation(s)
- Jing-jing Xu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Si-da Jia
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lin Jiang
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Ying Song
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Pei Zhu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - De-shan Yuan
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Yao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xue-yan Zhao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-xin Li
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yue-jin Yang
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shu-bin Qiao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Bo Xu
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Run-lin Gao
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China,Run-lin Gao,
| | - Jin-qing Yuan
- Department of Cardiology, Fuwai Hospital and Cardiovascular Institute, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China,Corresponding Author: Jin-qing Yuan, ;
| |
Collapse
|
17
|
Chen X, Ma Y, Xie Y, Pu J. Aptamer-based applications for cardiovascular disease. Front Bioeng Biotechnol 2022; 10:1002285. [PMID: 36312558 PMCID: PMC9606242 DOI: 10.3389/fbioe.2022.1002285] [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: 07/25/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiovascular disease (especially atherosclerosis) is a major cause of death worldwide, and novel diagnostic tools and treatments for this disease are urgently needed. Aptamers are single-stranded oligonucleotides that specifically recognize and bind to the targets by forming unique structures in vivo, enabling them to rival antibodies in cardiac applications. Chemically synthesized aptamers can be readily modified in a site-specific way, so they have been engineered in the diagnosis of cardiac diseases and anti-thrombosis therapeutics. Von Willebrand Factor plays a unique role in the formation of thrombus, and as an aptamer targeting molecule, has shown initial success in antithrombotic treatment. A combination of von Willebrand Factor and nucleic acid aptamers can effectively inhibit the progression of blood clots, presenting a positive diagnosis and therapeutic effect, as well as laying a novel theory and strategy to improve biocompatibility paclitaxel drug balloon or implanted stent in the future. This review summarizes aptamer-based applications in cardiovascular disease, including biomarker discovery and future management strategy. Although relevant applications are relatively new, the significant advancements achieved have demonstrated that aptamers can be promising agents to realize the integration of diagnosis and therapy in cardiac research.
Collapse
Affiliation(s)
| | | | | | - Jun Pu
- *Correspondence: Yuquan Xie, ; Jun Pu,
| |
Collapse
|
18
|
Yang J, Ding Y, Wang R, Wang K, Liu X, Shen H, Sun Y, Ge H, Fang Z. Comparison of Short-Term DAPT and Long-Term DAPT on the Prognosis of PCI Patients: A Meta-Analysis of Randomized Controlled Trials. Rev Cardiovasc Med 2022; 23:326. [PMID: 39077148 PMCID: PMC11267325 DOI: 10.31083/j.rcm2310326] [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: 06/08/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 07/31/2024] Open
Abstract
Background Dual antiplatelet therapy (DAPT) is the primary medication for patients after percutaneous coronary intervention (PCI). However, the best DAPT duration is still controversial. This systematic review and meta-analysis aims to assess the safety and effectiveness of short-term (3-6 months) DAPT compared to long-term (12 months) DAPT. Methods We searched PubMed, Embase, Cochrane Library, and Web of Science systematically for all the randomized controlled trials (RCTs) which compared the different strategies for DAPT in patients undergoing PCI within ten years prior to January 2021. Major bleeding and any bleeding were identified as the safe endpoints. All causes of death, cardiac death, myocardial infarction, definite/probable stent thrombosis, target vessel revascularization, and stroke were identified as the efficacy endpoints. The hazard ratio (HR) and 95% confidence interval (CI) in each study were abstracted. Results Overall, 11 trials and 24,242 patients were included in this meta-analysis with 15-month median follow-up time. Short-term DAPT was related to reduced risks of major bleeding (HR 0.65, 95% CI 0.48-0.89) and any bleeding (HR 0.64, 95% CI 0.53-0.79). No obvious differences in any of the other endpoints were observed. In acute coronary syndrome (ACS) patients with drug-eluting stents (DES), short-term compared with long-term DAPT was related to a decreased risk of major bleeding (HR 0.57, 95% CI 0.37-0.87) without significant increasing in the risks of any bleeding and ischemic endpoints. Furthermore, short-term DAPT followed by P2Y12 receptor inhibitor monotherapy appreciably lowered the risk of major bleeding (HR 0.64, 95% CI 0.42-0.96) and any bleeding (HR 0.58, 95% CI 0.36-0.93). There were no obvious differences concerning death between the different strategies for DAPT. Conclusions After PCI with DES, short-term DAPT is safer than long-term DAPT, and is not inferior in effectiveness, even in ACS patients. P2Y12 receptor inhibitor monotherapy following short-term DAPT is also related to a decreased risk of bleeding and may be an alternative anti-platelet strategy.
Collapse
Affiliation(s)
- Jiaxin Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Yaodong Ding
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Rui Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Kexin Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Xiaoli Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Hua Shen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Yan Sun
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Hailong Ge
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 100029 Beijing, China
| | - Zhe Fang
- Department of Cardiology, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 330006 Nanchang, Jiangxi, China
| |
Collapse
|
19
|
Tritschler T, Patel A, Kraaijpoel N, Bhatt DL, De Luca G, Di Santo P, Feres F, Costa RA, Hibbert B, Isshiki T, Le Gal G, Castellucci LA. Case-fatality rate of major bleeding events in patients on dual antiplatelet therapy after percutaneous coronary intervention: A systematic review and meta-analysis. Res Pract Thromb Haemost 2022; 6:e12834. [PMID: 36349260 PMCID: PMC9634492 DOI: 10.1002/rth2.12834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background Assessment of the case-fatality rate (CFR) of major bleeding on dual antiplatelet therapy (DAPT) may improve balancing risks and benefits of different durations of DAPT following percutaneous coronary intervention (PCI). Objectives To determine the CFR of major bleeding in patients on DAPT after PCI and to compare rates among different durations of DAPT. Methods Medline, Embase, and CENTRAL were searched from inception to August 2021 for randomized trials that reported fatal bleeding among patients who were randomized to ≥1 month of DAPT following PCI. Summary estimates for CFRs of major bleeding were calculated using the random-effects inverse-variance method. Statistical heterogeneity was evaluated using the I 2 statistic. Results Of 2777 citations obtained by the search, 15 (48%) of 31 potentially eligible studies were excluded because fatal bleeding was not reported, leaving 16 studies that were included in the analysis. Overall, there were 823 major bleeding events including 91 fatal events in 48,884 patients who were assigned to receive DAPT during study follow-up. The CFR of major bleeding was 10.8% (95% confidence interval [CI], 7.1-16.2; I 2 = 50%) in the entire study population, and 13.8% (95% CI, 6.5-27.1; I 2 = 28%), 11.2% (95% CI, 6.7-18.0; I 2 = 0%), and 5.8% (95% CI, 3.0-11.1; I 2 = 0%) in those on short-term (≤6 months; n = 16,553), standard-term (12 months; n = 19,453), and long-term DAPT (>12 months; n = 10,238), respectively. Conclusion Fatal bleeding is not reported in many studies evaluating DAPT after PCI. The CFR of major bleeding on DAPT is substantial and may be higher in the first 12 months of DAPT than during long-term DAPT.
Collapse
Affiliation(s)
- Tobias Tritschler
- Department of General Internal MedicineInselspital, Bern University Hospital, University of BernBernSwitzerland
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Anuj Patel
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Noémie Kraaijpoel
- Department of Vascular Medicine, Amsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart and Vascular CenterHarvard Medical School, BostonBostonMassachusettsUSA
| | - Giuseppe De Luca
- Division of CardiologyAzienda Ospedaliera‐Universitaria “Maggiore della Carità”, Eastern Piedmont UniversityNovaraItaly
| | | | - Fausto Feres
- Department of Invasive CardiologyInstituto Dante Pazzanese de CardiologiaSao PauloBrazil
| | - Ricardo A. Costa
- Department of Invasive CardiologyInstituto Dante Pazzanese de CardiologiaSao PauloBrazil
| | | | | | - Grégoire Le Gal
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| | - Lana A. Castellucci
- Department of MedicineOttawa Hospital Research Institute, University of OttawaOttawaOntarioCanada
| |
Collapse
|
20
|
Hutchinson N, Moyer H, Zarin DA, Kimmelman J. The proportion of randomized controlled trials that inform clinical practice. eLife 2022; 11:79491. [PMID: 35975784 PMCID: PMC9427100 DOI: 10.7554/elife.79491] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Prior studies suggest that clinical trials are often hampered by problems in design, conduct and reporting that limit their uptake in clinical practice. We have described 'informativeness' as the ability of a trial to guide clinical, policy or research decisions. Little is known about the proportion of initiated trials that inform clinical practice. We created a cohort of randomized interventional clinical trials in three disease areas (ischemic heart disease, diabetes mellitus and lung cancer), that were initiated between 1 January 2009 and 31 December 2010 using ClinicalTrials.gov. We restricted inclusion to trials aimed at answering a clinical question related to the treatment or prevention of disease. Our primary outcome was the proportion of clinical trials fulfilling four conditions of informativeness: importance of the clinical question, trial design, feasibility, and reporting of results. Our study included 125 clinical trials. The proportion meeting four conditions for informativeness was 26.4% (95% CI 18.9 - 35.0). Sixty-seven percent of participants were enrolled in informative trials. The proportion of informative trials did not differ significantly between our three disease areas. Our results suggest that the majority of clinical trials designed to guide clinical practice possess features that may compromise their ability to do so. This highlights opportunities to improve the scientific vetting of clinical research.
Collapse
Affiliation(s)
- Nora Hutchinson
- Studies of Translation, Ethics and Medicine, McGill University, Montreal, Canada
| | - Hannah Moyer
- Studies of Translation, Ethics and Medicine, McGill University, Montreal, Canada
| | - Deborah A Zarin
- Multi-Regional Clinical Trials Center, Brigham and Women's Hospital, Boston, United States
| | - Jonathan Kimmelman
- Studies of Translation, Ethics and Medicine Research Group, Biomedical Ethics Unit, McGill University, Montreal, Canada
| |
Collapse
|
21
|
Han Y, Yuan X, Hu X, Fang Y, Jiang M, Feng H, Gao L. Dual antiplatelet therapy after percutaneous coronary intervention in patients at high bleeding risk: A systematic review and meta-analysis. Cardiol J 2022; 30:556-566. [PMID: 35912712 PMCID: PMC10508065 DOI: 10.5603/cj.a2022.0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/09/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To date, it has not been ascertained whether shortening the duration of dual antiplatelet therapy (DAPT) can benefit high bleeding risk (HBR) patients. This systematic review and meta-analysis was performed to investigate the safety and efficacy of short (≤ 3 months) DAPT in HBR patients after percutaneous coronary intervention (PCI). METHODS The PubMed, Embase, and Clinical Trials databases were searched from inception until November 2021 to identify studies that evaluated the safety and efficacy of short DAPT in HBR patients implanted with new-generation drug-eluting stents (DES). Primary endpoints included major bleeding, definite or probable stent thrombosis (ST), and myocardial infarction (MI), while secondary endpoints included all-cause death and ischemic stroke. Based on the fixed and random effect model, the risk ratio (RR) and 95% confidence interval of each endpoint were measured. RESULTS Five observational studies and one randomized controlled trial were included, involving 15,432 HBR patients. Short DAPT for HBR patients undergoing PCI had a lower incidence of major bleeding in comparison with standard (> 3 months) DAPT (2.3% vs. 3.2%, RR 0.64 [0.44, 0.95], p = 0.03), while short DAPT was comparable to standard DAPT with regard to definite or probable ST (0.4% vs. 0.3%, RR 1.31 [0.77, 2.23], p = 0.32) and MI (2.4% vs. 2.0%, RR 1.17 [0.95, 1.45], p = 0.14). CONCLUSIONS Among HBR patients implanted with new-generation DES, short DAPT was associated with reduced risk of major bleeding without significantly increasing the risk of definite or probable ST and MI in comparison with standard DAPT.
Collapse
Affiliation(s)
- Yan Han
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaohang Yuan
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xin Hu
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yan Fang
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Mengting Jiang
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huanhuan Feng
- Department of Emergency, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lei Gao
- Senior Department of Cardiology, Sixth Medical Center of Chinese PLA General Hospital, Beijing, China.
| |
Collapse
|
22
|
The Optimal Strategy of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Drug-Eluting Stent. J Clin Med 2022; 11:jcm11154465. [PMID: 35956082 PMCID: PMC9370028 DOI: 10.3390/jcm11154465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: To test the optimal strategy of dual antiplatelet therapy (DAPT) after implantation of drug-eluting stents (DESs) according to specific DAPT time and subsequent monotherapy. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and Web of Science to identify randomized controlled trials (RCTs). Six DAPT strategies were compared: 1-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by aspirin monotherapy, 6-month DAPT followed by aspirin monotherapy, 12-month DAPT, and >12-month DAPT. Pooled odd ratios (ORs) with 95% credible intervals (CrIs) were calculated to summarize the effect of each strategy tested. Results: We identified 24 RCTs containing 81,405 patients. In comparison with 12-month DAPT, 3-month DAPT followed by P2Y12 inhibitor monotherapy reduced net clinical events (OR: 0.72; CrI: 0.55−0.94). Major bleeding (OR: 0.57; CrI: 0.34−1.00) was marginally decreased without impact on ischemic events (OR: 0.93; CrI: 0.68−1.29). Moreover, the benefits of 3-month DAPT (P2Y12 inhibitor) were consistent for male patients with acute coronary disease, young age, complex lesion, single-vessel disease, low body mass index, and without diabetes. Although >12-month DAPT was associated with a lower risk of myocardial infarction (OR: 0.67; CrI: 0.51−0.93), the risk of major bleeding (OR: 1.70; CrI: 1.10−2.70) was increased. Conclusion: Among patients treated with DESs, 3-month DAPT followed by P2Y12 inhibitor monotherapy may be the optimal antiplatelet strategy, while DAPT beyond 1 year reduces myocardial infarction at the expense of increased major bleeding.
Collapse
|
23
|
Park DY, An S, Kumar A, Malhotra S, Jolly N, Kaur A, Kattoor A, Doukky R, Kalra A, Vij A. Abbreviated versus Standard Duration of DAPT after PCI: A Systematic Review and Network Meta-analysis. Am J Cardiovasc Drugs 2022; 22:633-645. [PMID: 35781867 DOI: 10.1007/s40256-022-00541-w] [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] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) is typically continued for 6-12 months depending on clinical presentation. Recent studies have evaluated the safety of shorter durations of DAPT across stable and unstable coronary syndrome but are limited by smaller patient pools and varying indications. METHODS The present study performed a systematic review and network meta-analysis comparing abbreviated (1-3 months) with standard (6-12 months) duration of DAPT. Both conventional and frequentist network meta-analyses with a random-effects model were conducted. RESULTS Seventeen randomized controlled trials, nine of which included 1-3 months of DAPT, were selected. The risks of any bleeding (RR 0.68, 95% CI 0.54-0.85), major bleeding (RR 0.66, 95% CI 0.50-0.86), and net adverse clinical events (NACE) (RR 0.87, 95% CI 0.76-0.99) were lower with abbreviated (1-3 months) than standard-term (6-12 months) DAPT. No significant differences in the risk of myocardial infarction (RR 1.02, 95% CI 0.87-1.18), definite or probable stent thrombosis (RR 1.11, 95% CI 0.83-1.50), and major adverse cardiac events (MACE) (RR 0.96, 95% CI 0.86-1.06) were observed. Network meta-analysis demonstrated lower risk of any bleeding, major bleeding, and NACE with shorter durations of DAPT compared with 12 months. Risks of definite or probable stent thrombosis, myocardial infarction, and MACE were not significantly different. CONCLUSION The results support the growing body of evidence that abbreviated duration (1-3 months) of DAPT may be considered to reduce the risk of bleeding without any differences in myocardial infarction, stent thrombosis, or MACE.
Collapse
Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, IL, USA
| | - Seokyung An
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, USA.,Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Neeraj Jolly
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Amandeep Kaur
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, USA
| | - Ajoe Kattoor
- Division of Cardiology, Rush University Medical Center, Chicago, IL, USA
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, IL, USA.,Division of Cardiology, Rush Medical College, Chicago, IL, USA
| | - Ankur Kalra
- Section of Invasive and Interventional Cardiology, Cleveland Clinic, Akron, OH, USA
| | - Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, IL, USA. .,Division of Cardiology, Rush Medical College, Chicago, IL, USA.
| |
Collapse
|
24
|
Lahu S, Bristot P, Gewalt S, Goedel A, Giacoppo D, Schüpke S, Schunkert H, Kastrati A, Sarafoff N. Meta-Analysis of Short vs. Prolonged Dual Antiplatelet Therapy after Drug-Eluting Stent Implantation and Role of Continuation with either Aspirin or a P2Y 12 Inhibitor Thereafter. J Atheroscler Thromb 2022; 29:1001-1019. [PMID: 34248087 PMCID: PMC9252616 DOI: 10.5551/jat.63000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/10/2021] [Indexed: 11/11/2022] Open
Abstract
AIM The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is an ongoing debate and novel data has emerged. The aim of this meta-analysis was to assess outcomes of short vs. control DAPT duration. In addition, the role of single antiplatelet therapy (SAPT) after DAPT with either aspirin or P2Y12 inhibitor monotherapy was analyzed. METHODS The authors searched MEDLINE and Cochrane databases and proceedings of international meetings for randomized controlled trials (RCT) comparing ≤ 3 months with ≥ 6 months DAPT after DES implantation. The primary and co-primary outcomes of interest were definite or probable stent thrombosis (ST) and bleeding. In addition, we performed an analysis on studies who continued with either aspirin or P2Y12 monotherapy after DAPT. RESULTS 9 RCTs comprising 41,864 patients were included and we analyzed a short DAPT duration of median 1.5 months vs. 12.1 months in the control group. The risk for ST was similar with short vs. control DAPT duration (0.5 vs. 0.5%; hazard ratio 1.17[95% CI 0.89-1.54]; p=0.26). Bleeding was significantly reduced with short vs. control DAPT duration (1.9 vs. 3.0%; 0.65[0.54-0.77]; p<0.0001).ST was not different between short vs. control DAPT duration in the analysis of the 4 RCTs who continued with aspirin after DAPT and the 5 P2Y12 RCTs, respectively, and no heterogeneity was detected (p=0.861). Bleeding was also reduced with short vs. control DAPT in both the aspirin (1.2 vs. 1.7%; 0.71[0.51-0.99]; p=0.04) and P2Y12 inhibitor studies (2.1 vs. 3.4%; 0.62[0.47-0.80]; p=0.0003) and no heterogeneity was detected (p=0.515). CONCLUSIONS Our meta-analysis shows that short DAPT ≤ 3 months followed by SAPT reduces bleeding and is not associated with an increase in ST. The results were consistent within the aspirin and P2Y12 SAPT studies.
Collapse
Affiliation(s)
- Shqipdona Lahu
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| | - Peter Bristot
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| | - Senta Gewalt
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| | - Alexander Goedel
- Klinik und Poliklinik fuer Innere Medizin I, Klinikum rechts der Isar, Technische Universitaet Munich, Germany
| | - Daniele Giacoppo
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| | - Stefanie Schüpke
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| | - Heribert Schunkert
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
- Deutsches Zentrum fuer Herz- und Kreislauferkrankungen (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Adnan Kastrati
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
- Deutsches Zentrum fuer Herz- und Kreislauferkrankungen (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Nikolaus Sarafoff
- Klinik fuer Herz- und Kreislauferkrankungen, Deutsches Herzzentrum Munich, Technische Universitaet Muenchen, Munich, Germany
| |
Collapse
|
25
|
Huang G, Tian FY, An W, Ai LS, Yu YB. Effects of antithrombotic therapy on bleeding after endoscopic sphincterotomy: A systematic review and meta-analysis. Endosc Int Open 2022; 10:E865-E873. [PMID: 35692927 PMCID: PMC9187383 DOI: 10.1055/a-1793-9479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/31/2022] [Indexed: 10/25/2022] Open
Abstract
Background and study aims Bleeding is a common complication of following endoscopy sphincterotomy (EST), and antithrombotic therapy use during the procedure often increases risk of it. Although several guidelines have been released regarding the use of antithrombotic agents during EST, many issues about it remain controversial. We carried out a systematic review and meta-analysis to evaluate the effect of antithrombotic medication on the risk of EST bleeding. Methods A structured literature search was carried out in Web of Science, EMBASE, PubMed, and Cochrane Library databases. RevMan 5.2 was used for meta-analysis to investigate the rate of post-EST bleeding. Results Seven retrospective articles were included. Compared with patients who had never taken antithrombotic drugs, patients who discontinued antithrombotic drugs 1 day before the procedure had a significantly increased risk of post-EST bleeding (OR, 1.95; 95 %CI, 1.57-2.43), particularly for severe bleeding (OR, 1.83; 95 %CI, 1.44-2.34). In addition, compared with patients who discontinued antithrombotic therapy for at least 1 day, patients who continued taking antithrombotic drugs did have an increased risk of post-EST bleeding (OR, 0.70; 95 %CI, 0.40-1.23). Conclusions The use of antithrombotic drugs may increase the bleeding rate of EST, but discontinuing therapy 1 day before endoscopy does not significantly reduce the bleeding rate.
Collapse
Affiliation(s)
- Gang Huang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Feng-Yu Tian
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Wen An
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Li-Si Ai
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| | - Yan-Bo Yu
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, Shandong Province, P. R. China
| |
Collapse
|
26
|
Cao D, Camaj A, Mehran R. Balance of Ischemia and Bleeding in Selecting Intensity and Duration of Antithrombotic Regimens. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch43] [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
|
27
|
Ma CX, Ma XN, Guan CH, Li YD, Mauricio D, Fu SB. Cardiovascular disease in type 2 diabetes mellitus: progress toward personalized management. Cardiovasc Diabetol 2022; 21:74. [PMID: 35568946 PMCID: PMC9107726 DOI: 10.1186/s12933-022-01516-6] [Citation(s) in RCA: 118] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/28/2022] [Indexed: 01/10/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the main cause of death among patients with type 2 diabetes mellitus (T2DM), particularly in low- and middle-income countries. To effectively prevent the development of CVDs in T2DM, considerable effort has been made to explore novel preventive approaches, individualized glycemic control and cardiovascular risk management (strict blood pressure and lipid control), together with recently developed glucose-lowering agents and lipid-lowering drugs. This review mainly addresses the important issues affecting the choice of antidiabetic agents and lipid, blood pressure and antiplatelet treatments considering the cardiovascular status of the patient. Finally, we also discuss the changes in therapy principles underlying CVDs in T2DM.
Collapse
Affiliation(s)
- Cheng-Xu Ma
- Department of Endocrinology, The First Hospital of Lanzhou University, No. 1 West Donggang Road, Lanzhou, Gansu, 730000, People's Republic of China.,The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Xiao-Ni Ma
- Department of Endocrinology, The First Hospital of Lanzhou University, No. 1 West Donggang Road, Lanzhou, Gansu, 730000, People's Republic of China.,The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Cong-Hui Guan
- Department of Endocrinology, The First Hospital of Lanzhou University, No. 1 West Donggang Road, Lanzhou, Gansu, 730000, People's Republic of China.,The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, Gansu, China
| | - Ying-Dong Li
- College of Integrated Traditional Chinese and Western Medicine, Gansu University of Chinese Medicine, Lanzhou, 730000, Gansu, China
| | - Dídac Mauricio
- Department of Endocrinology & Nutrition, CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, 08041, Barcelona, Spain.
| | - Song-Bo Fu
- Department of Endocrinology, The First Hospital of Lanzhou University, No. 1 West Donggang Road, Lanzhou, Gansu, 730000, People's Republic of China. .,The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, Gansu, China.
| |
Collapse
|
28
|
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
|
29
|
Challenges of long-term dual antiplatelet therapy use following acute coronary syndromes. Am Heart J 2022; 246:44-64. [PMID: 34933000 DOI: 10.1016/j.ahj.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/24/2021] [Accepted: 12/15/2021] [Indexed: 11/20/2022]
Abstract
An acute coronary syndrome (ACS) event is associated with a high risk of recurrent ACS, stroke, and death. To ameliorate the risk of subsequent events, current guidelines for ST-segment elevation myocardial infarction and non-ST-segment elevation ACS recommend long-term management strategies for secondary prevention including risk factor modification and anti-ischemic and antiplatelet therapies. Dual antiplatelet therapy (DAPT), comprising aspirin plus a P2Y12 inhibitor, is a critical component of secondary prevention therapy following ACS. However, despite the importance of DAPT for secondary prevention after ACS, questions remain over the optimal duration of therapy. Clinical evidence is emerging that maintenance DAPT >12 months lowers the risk of recurrent ACS events; however, this benefit must be considered against any potential risks of prolonged DAPT such as bleeding. Several tools for bleeding risk assessment have shown promise; however, their limited accuracy and discriminative power necessitates further development. Assessment of patient ischemic risk should consider the complexity of the percutaneous coronary intervention (PCI) procedure, anatomic burden of coronary artery disease, and additional underlying risk factors. Consequently, identifying patients in whom the risk:benefit ratio favors prolonged DAPT may prove invaluable for clinicians in deciding which patients should continue or stop taking DAPT at 12 months after PCI, or consider P2Y12 inhibitor monotherapy as an option. This article reviews the most recent information about the risks and benefits of DAPT continued for >12 months after ACS and provides critical guidance to assist physicians in identifying patients most likely to benefit from a secondary prevention strategy with DAPT.
Collapse
|
30
|
Han Y, Claessen BE, Chen SL, Chunguang Q, Zhou Y, Xu Y, Hailong L, Chen J, Qiang W, Zhang R, Luo S, Li Y, Zhu J, Zhao X, Cheng X, Wang J, Su X, Tao J, Sun Y, Wang G, Li Y, Bian L, Goel R, Sartori S, Zhang Z, Angiolillo DJ, Cohen DJ, Gibson CM, Kastrati A, Krucoff M, Mehta SR, Ohman EM, Steg PG, Liu Y, Dangas G, Sharma S, Baber U, Mehran R. Ticagrelor With or Without Aspirin in Chinese Patients Undergoing Percutaneous Coronary Intervention: A TWILIGHT China Substudy. Circ Cardiovasc Interv 2022; 15:e009495. [PMID: 35317615 DOI: 10.1161/circinterventions.120.009495] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk/benefit tradeoff of dual antiplatelet therapy after percutaneous coronary intervention may vary in East Asian patients as compared with their non-East Asian counterparts. METHODS The double-blind, placebo-controlled, randomized TWILIGHT trial (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) enrolled patients undergoing high-risk percutaneous coronary intervention. After 3 months of treatment with ticagrelor plus aspirin, event-free and adherent patients remained on ticagrelor and were randomly assigned to receive aspirin or placebo for 1 year. The primary end point was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding; the key secondary end point was the first occurrence of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS Of 9006 enrolled and 7119 randomized patients in TWILIGHT, 1169 patients (13.0%) were enrolled at 27 Chinese sites in this prespecified substudy, of whom 1028 (14.4%) patients were randomized after 3 months. The incidence of the primary end point was 6.2% in the ticagrelor+aspirin group versus 3.5% in the ticagrelor+placebo group between randomization and 1 year (hazard ratio, 0.56 [95% CI, 0.31-0.99]; P=0.048). The key secondary end point occurred in 3.4% of patients in the ticagrelor+aspirin group versus 2.4% in the ticagrelor+placebo group (hazard ratio, 0.70 [95% CI, 0.33-1.46]; P=0.34). There was no interaction between the region of randomization (China versus the rest of the world) and randomized treatment assignment in terms of the primary or key secondary end points. CONCLUSIONS Ticagrelor monotherapy significantly reduced clinically relevant bleeding without increasing ischemic events as compared with ticagrelor plus aspirin in Chinese patients undergoing high-risk percutaneous coronary intervention. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02270242.
Collapse
Affiliation(s)
- Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital Jiangsu, China (S.-L.C.)
| | - Qiu Chunguang
- Department of Cardiology' The First Affiliated Hospital of Zhengzhou University, China (Q.C.)
| | - Yujie Zhou
- Department of Cardiology' Beijing Anzhen Hospital Capital Medical University, China (Y.Z.)
| | - Yawei Xu
- Department of Cardiology' Shanghai Tenth Peoples Hospital, China (Y.X.)
| | - Lin Hailong
- Department of Cardiology' Dalian Municipal Central Hospital Affiliated of Dalian Medical University, China (L.H.)
| | - Jiyan Chen
- Department of Cardiology' Guangdong Provincial People's Hospital, Guangzhou, China (J.C.)
| | - Wu Qiang
- Department of Cardiology' Guizhou Provincial People's Hospital, Guiyang, China (W.Q.)
| | - Ruiyan Zhang
- Department of Cardiology' Rui Jin Hospital Shanghai Jiaotong University School of Medicine, Changhai, China (R.Z.)
| | - Suxin Luo
- Department of Cardiology' The First Affiliated Hospital of Chongqing Medical University, China (S.L.)
| | - Yongjun Li
- Department of Cardiology' The Second Hospital of Hebei Medical University (4th Ward), Shijiazhuang, China (Yongjun Li)
| | - Jianhua Zhu
- Department of Cardiology' The First Affiliated Hospital College of Medicine of Zheijang University, Hangzhou, China (J.Z.)
| | - Xianxian Zhao
- Department of Cardiology' Shanghai Changhai Hospital, China (X.Z.)
| | - Xiang Cheng
- Department of Cardiology' Wuhan Union Hospital, China (X.C.)
| | - Jian'an Wang
- Department of Cardiology' The Second Affiliated Hospital of Zhejiang University of Medicine, Hangzhou, China (J.W.)
| | - Xi Su
- Department of Cardiology' WuHan Asia Heart Hospital, China (X.S.)
| | - Jianhong Tao
- Department of Cardiology' Sichuan Provincial People's Hospital, Chengdu, China (J.T.)
| | - Yingxian Sun
- Department of Cardiology' The First Hospital of China Medical University, Shenyang (Y.S.)
| | - Geng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Liya Bian
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - David J Cohen
- Department of Cardiology' University of Missouri-Kansas City (D.J.C.)
| | - C Michael Gibson
- Department of Cardiology' Beth Israel Deaconess Medical Center' Boston' MA (C.M.G.)
| | - Adnan Kastrati
- Department of Cardiology' Deutsches Herzzentrum München, Munich, Germany (A.K.)
| | - Mitchell Krucoff
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Shamir R Mehta
- Department of Cardiology' Duke University Medical Center, Durham' NC (S.R.M.)
| | - E Magnus Ohman
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Philippe Gabriel Steg
- Department of Cardiology' Université de Paris, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
| | - Yuqi Liu
- Department of Cardiology, People's Liberation Army General Hospital, Beijing (Y. Liu)
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| |
Collapse
|
31
|
Tian J, Song X, Wang Y, Cheng M, Lu S, Xu W, Gao G, Sun L, Tang Z, Wang M, Zhang X. Regulatory perspectives of combination products. Bioact Mater 2022; 10:492-503. [PMID: 34901562 PMCID: PMC8637005 DOI: 10.1016/j.bioactmat.2021.09.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Combination products with a wide range of clinical applications represent a unique class of medical products that are composed of more than a singular medical device or drug/biological product. The product research and development, clinical translation as well as regulatory evaluation of combination products are complex and challenging. This review firstly introduced the origin, definition and designation of combination products. Key areas of systematic regulatory review on the safety and efficacy of device-led/supervised combination products were then presented. Preclinical and clinical evaluation of combination products was discussed. Lastly, the research prospect of regulatory science for combination products was described. New tools of computational modeling and simulation, novel technologies such as artificial intelligence, needs of developing new standards, evidence-based research methods, new approaches including the designation of innovative or breakthrough medical products have been developed and could be used to assess the safety, efficacy, quality and performance of combination products. Taken together, the fast development of combination products with great potentials in healthcare provides new opportunities for the advancement of regulatory review as well as regulatory science.
Collapse
Affiliation(s)
- Jiaxin Tian
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Xu Song
- NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial & Institute of Regulatory Science for Medical Devices & NMPA Research Base of Regulatory Science for Medical Devices, Sichuan University, Chengdu, China
- National Engineering Research Center for Biomaterials & College of Biomedical Engineering, Sichuan University, Chengdu, China
| | - Yongqing Wang
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Maobo Cheng
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Shuang Lu
- Center for Drug Evaluation, National Medical Products Administration, Beijing, China
| | - Wei Xu
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Guobiao Gao
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Lei Sun
- Center for Medical Device Evaluation, National Medical Products Administration, Beijing, China
| | - Zhonglan Tang
- NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial & Institute of Regulatory Science for Medical Devices & NMPA Research Base of Regulatory Science for Medical Devices, Sichuan University, Chengdu, China
- National Engineering Research Center for Biomaterials & College of Biomedical Engineering, Sichuan University, Chengdu, China
| | - Minghui Wang
- NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial & Institute of Regulatory Science for Medical Devices & NMPA Research Base of Regulatory Science for Medical Devices, Sichuan University, Chengdu, China
- National Engineering Research Center for Biomaterials & College of Biomedical Engineering, Sichuan University, Chengdu, China
| | - Xingdong Zhang
- NMPA Key Laboratory for Quality Research and Control of Tissue Regenerative Biomaterial & Institute of Regulatory Science for Medical Devices & NMPA Research Base of Regulatory Science for Medical Devices, Sichuan University, Chengdu, China
- National Engineering Research Center for Biomaterials & College of Biomedical Engineering, Sichuan University, Chengdu, China
| |
Collapse
|
32
|
Alkhalil M, Džavík V, Bhatt DL, Mehran R, Mehta SR. Antiplatelet Therapy in Patients Undergoing Elective Percutaneous Coronary Intervention. Curr Cardiol Rep 2022; 24:277-293. [PMID: 35294730 DOI: 10.1007/s11886-022-01645-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW The evidence for use of dual antiplatelet therapy (DAPT) for patients undergoing percutaneous coronary intervention (PCI) in the elective setting is relatively sparse and is based on data from more than two decades ago. We will review the evidence supporting the use of DAPT with focus on stable patients undergoing elective PCI, including the role of potent P2Y12 inhibitors, modified DAPT durations, and more recently, aspirin discontinuation. RECENT FINDINGS Clopidogrel is the recommended P2Y12 inhibitor in the elective PCI setting. The benefit of more potent P2Y12 inhibitors such as ticagrelor or prasugrel in stable patients is unproven, but their use might be reasonable in those with high clinical or angiographic features of increased ischemic risk without increased risk of bleeding. Moreover, extending DAPT beyond 12 months is associated with a reduction in ischemic events but also increased bleeding. In contrast, shortening DAPT (3-6 months) reduces bleeding compared with 1 year of treatment, but it is also probably associated with increased ischemic events, mainly in higher-risk patients undergoing complex PCI. Recently, early aspirin discontinuation at 3 months (and perhaps as early as 1 month) following PCI reduces bleeding, with no evidence to suggest an increase in ischemic events. Clopidogrel is the P2Y12 inhibitor of choice, while more data are required to support the use of more potent P2Y12 inhibitors in stable patients. The duration of DAPT should be tailored to individual patient ischemic and bleeding risks. New strategies, such as early aspirin discontinuation, are promising to reduce bleeding risk without increase in ischemic risk.
Collapse
Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada.,Cardiothoracic Centre, Freeman Hospital, Newcastle-upon-Tyne, UK.,Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| |
Collapse
|
33
|
Januszek R, Bil J, Gilis-Malinowska N, Staszczak B, Figatowski T, Milewski M, Mielczarek M, Dylewski Ł, Wybraniec M, Tomasiewicz B, Kübler P, Walczak T, Hrymniak B, Desperak P, Niezgoda P, Wolny R, Chudzik M, Smolka G, Ciećwierz D, Reczuch K, Gruchała M, Kubica J, Gil RJ, Kedhi E, D’Ascenzo F, Balan R, Pawlik A, Kuźma Ł, Dobrzycki S, Hudziak D, Bartuś S, Gąsior M, Ochała A, Witkowski A, Jaguszewski M, Wojakowski W, Wańha W. Long-term outcomes following drug-eluting balloon or thin-strut drug-eluting stents for treatment of in-stent restenosis stratified by duration of dual antiplatelet therapy (DEB-Dragon Registry). ADVANCES IN INTERVENTIONAL CARDIOLOGY 2022; 18:14-26. [PMID: 35982740 PMCID: PMC9199027 DOI: 10.5114/aic.2022.115631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/03/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Data regarding the duration of dual antiplatelet therapy (DAPT) in patients with drug-eluting stent restenosis (DES-ISR) treated with percutaneous coronary intervention (PCI) and drug-eluting balloons (DEB) or DES are not unambiguous. Aim To evaluate the relationship between long-term outcomes and the length of DAPT in patients treated with PCI due to DES-ISR with DEB or DES. Material and methods Overall, a total of 1,367 consecutive patients with DES-ISR, who underwent PCI with DEB or DES between 2008 and 2019 entered the study. The mean length of the follow-up was 1,298.7 ±794 days. We assessed study endpoints according to the duration of DAPT (≤ 3 vs. > 3 and ≤ 6 vs. > 6 months) before and after propensity score matching (PSM): stroke, target lesion revascularisation (TLR), target vessel revascularisation (TVR), myocardial infarction (MI), death and device oriented composite endpoints (DOCE). Kaplan-Meier estimates were created to differentiate long-term outcomes. Results Pairwise contrast analysis considering type of PCI (DES vs. DEB) and duration of DAPT (≤ 6 vs. > 6 months) before PSM revealed superiority of DES + DAPT > 6 months vs. DEB + DAPT > 6 months for DOCE (p < 0.001), TVR (p = 0.02) and TLR (p = 0.01). Also, DES + DAPT ≤ 6 months was found to be superior compared to DEB + DAPT ≤ 6 months for DOCE (p < 0.001), TVR (p = 0.02) and TLR (p = 0.01). Kaplan-Meier estimate analysis confirmed that DAPT > 6 months is related to a higher stroke rate (p = 0.01) when compared to ≤ 6 months. Conclusions Treatment with DAPT in patients with DES-ISR is related to better long-term outcomes in the case of PCI with DES than DEB. DAPT > 6 months is related to the greater rate of strokes, independently of the type of treatment (DES and DEB) than DAPT ≤ 6 months.
Collapse
Affiliation(s)
- Rafał Januszek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | | | - Bartłomiej Staszczak
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Tomasz Figatowski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Marek Milewski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Łukasz Dylewski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Brunon Tomasiewicz
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Poland
| | - Piotr Kübler
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Poland
| | - Tomasz Walczak
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Poland
- Department of Cardiology, 4 Military Hospital, Wroclaw, Poland
| | - Bruno Hrymniak
- Department of Cardiology, 4 Military Hospital, Wroclaw, Poland
| | - Piotr Desperak
- Third Department of Cardiology, Medical University of Katowice, Zabrze, Poland
| | - Piotr Niezgoda
- Cardiovascular Institute, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Rafał Wolny
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | | | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Dariusz Ciećwierz
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Krzysztof Reczuch
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Poland
| | - Marcin Gruchała
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Jacek Kubica
- Cardiovascular Institute, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Robert J. Gil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Elvin Kedhi
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
- AZ Sint Jan Brugge, Belgium
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Robert Balan
- Department of Cardiac Surgery, Klinikum Passau, Passau, Germany
| | - Artur Pawlik
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Damian Hudziak
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Stanisław Bartuś
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Krakow, Poland
| | - Mariusz Gąsior
- Third Department of Cardiology, Medical University of Katowice, Zabrze, Poland
| | - Andrzej Ochała
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Miłosz Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, Gdansk, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| |
Collapse
|
34
|
Outcomes of prolonged dual anti-platelet therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A nationwide registry-based study. Am Heart J 2022; 245:81-89. [PMID: 34902311 DOI: 10.1016/j.ahj.2021.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 09/29/2021] [Accepted: 11/20/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Randomized controlled trials have shown a reduced risk of ischemic events and an increased risk of bleeding in patients treated with prolonged dual anti-platelet therapy (DAPT) beyond 12 months following acute coronary syndrome (ACS). We aimed to investigate outcomes of prolonged DAPT vs aspirin monotherapy (ASA) in a real-world population. METHODS AND RESULTS Using nationwide registries, we identified all patients with ACS who underwent percutaneous coronary intervention and received 12-month DAPT between January 2013 and October 2016. Patients still on DAPT were compared to patients on ASA at index date (15 months after ACS-date) and followed for up to 2 years. Cox regression models were employed to calculate standardized risks of all-cause mortality, major adverse cardiovascular event (MACE), and major bleeding. The study included 7,449 patients, 1,901 on DAPT (median age 66, 72.1% male) and 5,548 on ASA (median age 65, 75.1% male). Standardized absolute 2-year risk of all-cause mortality, MACE, and major bleeding was 2.7%, 3.7%, and 5.4% for DAPT vs 2.2%, 3.8%, and 1.3% for ASA. DAPT was not associated with a significant standardized 2-year risk difference (SRD) of all-cause mortality (SRD: 0.5%, 95% confidence interval [CI]: -0.9 to 1.7) or MACE (SRD: -0.1%, 95% CI -1.8 to 1.6), but a significantly higher risk of major bleeding (SRD: 4.1%, 95% CI 1.8-6.6). CONCLUSIONS In a nationwide cohort of ACS patients undergoing percutaneous coronary intervention, prolonged DAPT was not significantly associated with a reduced risk of all-cause mortality or MACE, but an increased risk of major bleeding. Future randomized controlled trials should investigate the optimal anti-platelet regimen in this patient group.
Collapse
|
35
|
AL-Obaidi FR, Hutchings HA, Yong AS, Alrubaiy L, Al- Farhan H, Al-Ali MH, Al-Kinani T, Al-Myahi M, Al-Kenzawi H, Al-Sudani N. Efficacy and Safety Outcomes of Short Duration Antiplatelet Therapy with Early Cessation of Aspirin Post Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis. Curr Cardiol Rev 2021; 17:e051121190712. [PMID: 33573571 PMCID: PMC8950498 DOI: 10.2174/1573403x17666210126104053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/04/2020] [Accepted: 12/21/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy is a matter of ongoing research. Clinical studies are assessing the optimal duration with the most favourable risk to benefit ratio. The efficacy of P2Y12 receptor inhibitors comparable to aspirin in preventing recurrent ischaemic events in patients with coronary artery diseases. OBJECTIVES To investigate the outcomes of short-duration dual antiplatelet therapy after PCI with early discontinuation of aspirin while maintaining patients on P2Y12 inhibitor through systematic review and meta-analysis of available literature. METHODS We systematically searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov. We included randomized controlled studies that measured clinical outcomes of efficacy (mortality and ischaemic events) and safety (bleeding) of short and standard-duration dual antiplatelet therapy. The protocol of this study was registered in the international prospective register of systematic reviews PROSPERO registry (CRD42020171468). RESULTS Four randomized controlled trials were included; GLOBAL LEADERS, SMARTCHOICE, STOPDAPT-2, and TWILIGHT. The total number of patients was 29,089. The safety outcomes showed a significant reduction in major bleeding events with short-duration dual antiplatelet therapy; the risk ratio was 0.61 (95% CI 0.38-0.99; z=2,00, p=0.05). There was no difference between short and standard-duration dual antiplatelet therapy regarding efficacy outcomes (all- cause death, major adverse cardiovascular events, myocardial infarction, stroke, and stent thrombosis). CONCLUSION Short-duration dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy after PCI is a feasible option and can be adopted, especially in patients with a high risk of bleeding.
Collapse
Affiliation(s)
- Firas R. AL-Obaidi
- Address correspondence to this author at the Al-Zahra College of Medicine/University of Basrah, Basrah, Iraq; E-mail:
| | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Zhang Y, Zhang X, Dong Q, Chen D, Xu Y, Jiang J. Duration of Dual Antiplatelet Therapy After Implantation of Drug-Coated Balloon. Front Cardiovasc Med 2021; 8:762391. [PMID: 34926613 PMCID: PMC8671702 DOI: 10.3389/fcvm.2021.762391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/08/2021] [Indexed: 12/28/2022] Open
Abstract
The drug-coated balloon (DCB) is an emerging percutaneous coronary intervention (PCI) device with theoretical advantages and promising results. Recent clinical observations have demonstrated that DCB tends to have both good efficacy and a good safety profile in the treatment of in-stent restenosis (ISR) for both bare-metal and drug-eluting stents (DES), de novo coronary artery disease (CAD), and other situation, such as high bleeding risk, chronic total occlusion, and acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) has become an essential medication in daily clinical practice, but the optimal duration of DAPT after the implantation of a DCB remains unknown. At the time of the first in vivo implantation of paclitaxel-DCB for the treatment of ISR in 2006, the protocol-defined DAPT duration was only 1 month. Subsequently, DAPT duration ranging from 1 to 12 months has been recommended by various trials. However, there have been no randomized controlled trials (RCTs) on the optimal duration of DAPT after DCB angioplasty. Current clinical guidelines normally recommend the duration of DAPT after DCB-only angioplasty based on data from RCTs on the optimal duration of DAPT after stenting. In this review, we summarized current clinical trials on DCB-only angioplasty for different types of CADs and their stipulated durations of DAPT, and compared their clinical results such as restenosis, target lesion revascularization (TLR) and stent thrombosis event. We hope this review can assist clinicians in making reasonable decisions about the duration of DAPT after DCB implantation.
Collapse
Affiliation(s)
- Yuxuan Zhang
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xinyi Zhang
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qichao Dong
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Delong Chen
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Xu
- Department of Cardiology, Ningbo First Hospital, Ningbo, China
| | - Jun Jiang
- Department of Cardiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| |
Collapse
|
37
|
Zhang J, Zheng YY, Wu TT, Ma X, Ma YT, Xie X, Tang BP. Blood Routine Test Parameters Score, a Novel Predictor of Adverse Outcomes of Coronary Artery Disease Patients with or without Diabetes Who Underwent Percutaneous Coronary Intervention: A Retrospective Cohort Study. ACS OMEGA 2021; 6:32508-32516. [PMID: 34901600 PMCID: PMC8655762 DOI: 10.1021/acsomega.1c03990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/15/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND In this study, we developed a novel risk score named the blood routine test parameters (BRTP) score to predict the clinical outcomes in coronary artery disease (CAD) patients who had undergone percutaneous coronary intervention (PCI). METHODS There were 6049 patients with CAD after PCI enrolled in CORFCHD-PCI from January 2008 to December 2016. We divided these patients into two groups according to diabetes (diabetic group, n = 3809, and nondiabetic group, n = 2240). During a follow-up time of 35.9 ± 22.6 months, we compared the incidences of all-cause mortality (ACM) and cardiac mortality (CM), which were assigned as the primary outcomes between patients with a high BRTP score (≥5 points) and those with a low BRTP score (<5 points). RESULTS We found that the BRTP score independently predicted the risk for ACM and CM in both diabetic patients [ACM, hazard risk (HR) = 1.748 (95% confidence interval (CI): 1.186-2.575), P = 0.005; CM, HR = 1.728 (95% CI: 1.120-2.667), P = 0.014] and nondiabetic patients [ACM, HR = 1.682 (95% CI: 1.208-2.340), P = 0.002; CM, HR = 1.718 (95% CI: 1.188-2.484), P = 0.004]. However, the BRTP score was found to be an independent predictor for major adverse cardiovascular event (MACE) and major adverse cardiovascular and cerebrovascular event (MACCE) in diabetic patients [MACE, HR = 1.366 (95% CI: 1.076-1.734), P = 0.010; MACCE, HR = 1.330 (95% CI: 1.035-1.710), P = 0.026] but not in nondiabetic patients [MACE, HR = 1.241 (95% CI: 0.994-1.549), P = 0.056; MACCE, HR = 1.238 (95% CI: 0.981-1.562), P = 0.072]. CONCLUSIONS This study suggests that the BRTP score is an independent and novel predictor of mortality in CAD patients who had undergone PCI, especially in patients with comorbidity of diabetes. TRIAL REGISTRATION ChiCTR-ROC-16010153. Registered 14, December, 2016.
Collapse
Affiliation(s)
- Jian Zhang
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| | - Ying-Ying Zheng
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
- Department
of Cardiology, First Affiliated Hospital
of Zhengzhou University, Zhengzhou 450052 P. R. China
- Key
Laboratory of Cardiac Injury and Repair of Henan Province, No. 1, Jianshe East Road, Erqi District, Zhengzhou 450052, Henan, P. R. China
| | - Ting-Ting Wu
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| | - Xiang Ma
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| | - Yi-Tong Ma
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| | - Xiang Xie
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| | - Bao-Peng Tang
- Department
of Cardiology, First Affiliated Hospital
of Xinjiang Medical University, No. 137, Liyushan Road, Xinshi
District, Urumqi 830011 P. R. China
| |
Collapse
|
38
|
Yokoyama R, Kanzaki Y, Watanabe T, Yamamura K, Komori T, Takeda Y, Nakajima O, Sohmiya K, Hoshiga M. Prevalence and Risk Factors of Silent Cerebral Microbleeds in Patients with Coronary Artery Disease. J Stroke Cerebrovasc Dis 2021; 31:106211. [PMID: 34823092 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Cerebral microbleeds (CMBs), which can be detected by gradient-echo T2*-weighted magnetic resonance imaging (MRI), represent small chronic brain hemorrhages caused by structural abnormalities in cerebral small vessels. CMBs are known to be a potential predictor of future stroke, and are associated with age, various cardiovascular risk factors, cognitive impairment, and the use of antithrombotic drugs. Patients with coronary artery disease (CAD) are at potentially high risk of CMBs due to the presence of coexistent conditions. However, little is known about CMBs in patients with CAD. We aimed to identify the factors associated with the presence of CMBs among patients with CAD. METHODS We evaluated 356 consecutive patients [mean age, 72 ± 10 years; men = 276 (78%)] with angiographically proven CAD who underwent T2*-weighted brain MRI. The brain MRI was assessed by researchers blinded to the patients' clinical details. RESULTS CMBs were found in 128 (36%) patients. Among 356 patients, 119 (33%) had previously undergone percutaneous coronary intervention (PCI), and 26 (7%) coronary artery bypass grafting (CABG). There was no significant relationship between CMBs and sex, hypertension, dyslipidemia, diabetes mellitus, anticoagulation therapy, antiplatelet therapy, or prior PCI. CMBs were significantly associated with advanced age, previous CABG, eGFR, non-HDL cholesterol, carotid artery disease, long-term antiplatelet therapy, and long-term dual antiplatelet therapy (DAPT) using univariate logistic regression analysis. The multivariate logistic regression analysis showed that long-term antiplatelet therapy (odds ratio, 1.73; 95% CI, 1.06 - 2.84; P = 0.03) or long-term DAPT (odds ratio, 2.92; 95% CI, 1.39 - 6.17; P = 0.004) was significantly associated with CMBs after adjustment for confounding variables. CONCLUSIONS CMBs were frequently observed in patients with CAD and were significantly associated with long-term antiplatelet therapy, especially long-term DAPT.
Collapse
Affiliation(s)
- Ryo Yokoyama
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan; Department of Cardiology, Hirakata City Hospital
| | - Yumiko Kanzaki
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan.
| | - Tomohiko Watanabe
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
| | - Kenichiro Yamamura
- Departments of Radiology, Osaka Medical and Pharmaceutical University, Japan
| | - Tsuyoshi Komori
- Departments of Radiology, Osaka Medical and Pharmaceutical University, Japan
| | - Yoshihiro Takeda
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan; Department of Cardiology, Hirakata City Hospital
| | | | - Koichi Sohmiya
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
| | - Masaaki Hoshiga
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
| |
Collapse
|
39
|
Han J, Attar N. Shortened dual antiplatelet therapy in contemporary percutaneous coronary intervention era. World J Cardiol 2021; 13:243-253. [PMID: 34589163 PMCID: PMC8436679 DOI: 10.4330/wjc.v13.i8.243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/19/2021] [Accepted: 07/26/2021] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary intervention with stenting is followed by a duration of dual antiplatelet therapy (DAPT) to reduce stent thrombosis and avoid target lesion failure. The period of DAPT recommended in international guidelines following drug-eluting stent implantation is 12 mo for most patients with acute coronary syndrome, and 6 mo for patients with chronic coronary syndrome or high bleeding risk. The new generation of drug-eluting stents have metallic platforms with thinner struts, associated with significantly less stent thrombosis. Shortened DAPT has been investigated with these stents, with evidence from randomised clinical trials for some individual stents showing non-inferior safety and efficacy outcomes. This has to be balanced by the effect of DAPT on secondary prevention of systemic cardiovascular disease especially in high-risk populations. This review will outline the current evidence for individual stents with regards to DAPT duration for both acute coronary syndrome and chronic coronary syndrome and discuss further directions for research and personalised medicine in this contemporary percutaneous coronary intervention era.
Collapse
Affiliation(s)
- Jennie Han
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster LA1 4RP, Lancashire, United Kingdom
| | - Nadeem Attar
- Department of Cardiology, Royal Lancaster Infirmary, Lancaster LA1 4RP, Lancashire, United Kingdom
- Department of Cardiology, Blackpool Victoria Hospital, Blackpool FY3 8NR, Lancas, United Kingdom
| |
Collapse
|
40
|
Ganesh R, Kebede E, Mueller M, Gilman E, Mauck KF. Perioperative Cardiac Risk Reduction in Noncardiac Surgery. Mayo Clin Proc 2021; 96:2260-2276. [PMID: 34226028 DOI: 10.1016/j.mayocp.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 02/20/2021] [Accepted: 03/04/2021] [Indexed: 11/21/2022]
Abstract
Major adverse cardiovascular events are a significant source of morbidity and mortality in the perioperative setting, estimated to occur in approximately 5% of patients undergoing nonemergent noncardiac surgery. To minimize the incidence and impact of these events, careful attention must be paid to preoperative cardiovascular assessment to identify patients at high risk of cardiovascular complications. Once identified, cardiovascular risk reduction is achieved through optimization of medical conditions, appropriate management of medication, and careful monitoring to allow for early identification of-and intervention for-any new conditions that would increase the risk of adverse cardiovascular outcomes. The major cardiovascular and anesthesiology societies in the United States, Europe, and Canada have published guidelines for perioperative management of patients undergoing noncardiac surgery. However, since publication of these guidelines, there has been a practice-changing evolution in the medical literature. In this review, we attempt to reconcile the recommendations made in these 3 comprehensive guidelines, while updating recommendations, based on new evidence, when available.
Collapse
Affiliation(s)
- Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Esayas Kebede
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Michael Mueller
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Elizabeth Gilman
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
41
|
Knijnik L, Fernandes M, Rivera M, Cardoso R, Goyal A, Liberman H, Sperling LS, McDaniel MC. Meta-Analysis of Duration of Dual Antiplatelet Therapy in Acute Coronary Syndrome Treated With Coronary Stenting. Am J Cardiol 2021; 151:25-29. [PMID: 34049672 DOI: 10.1016/j.amjcard.2021.04.014] [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: 02/25/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
We aimed to evaluate if a shorter course of DAPT followed by P2Y12 inhibitor monotherapy is as effective as a 12-month course with fewer bleeding events. PubMed, Scopus, and Cochrane Central were searched for randomized controlled trials of ACS patients comparing dual antiplatelet therapy (DAPT) for 1 to 3 months followed by a P2Y12 inhibitor to 12-month DAPT. Quality assessment was performed with the Cochrane Collaboration risk of bias assessment tool. Five randomized clinical trials were included, with a total of 18,046 participants. Antiplatelet strategies were aspirin and P2Y12 inhibitor for 12 months compared with aspirin and P2Y12 inhibitor for 1 to 3 months followed by P212 inhibitor alone. Patients randomized to 1 to 3 months of DAPT followed by P2Y12 inhibitor monotherapy had lower rates of major bleeding (1.42% vs 2.53%; OR 0.53; 95% CI 0.42-0.67; p < 0.001; I2 = 0%) and all-cause mortality (1.00% vs 1.42%; OR 0.71; 95% CI 0.53-0.95; p = 0.02; I2=0%) with similar major adverse cardiac events (MACE) (2.66% vs 3.11%; OR 0.86; 95% CI 0.71 - 1.03; p = 0.10; I2 = 0 %) compared to 12 months of DAPT. In conclusion, shorter course of DAPT for 1 to 3 months followed by P2Y12 inhibitor monotherapy reduces major bleeding and all course mortality without increasing major adverse cardiac events compared with traditional DAPT for 12 months.
Collapse
|
42
|
Bularga A, Meah MN, Doudesis D, Shah ASV, Mills NL, Newby DE, Lee KK. Duration of dual antiplatelet therapy and stability of coronary heart disease: a 60 000-patient meta-analysis of randomised controlled trials. Open Heart 2021; 8:e001707. [PMID: 34341097 PMCID: PMC8330558 DOI: 10.1136/openhrt-2021-001707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) has important implications for clinical outcomes in coronary disease. However, the optimal DAPT duration remains uncertain. METHODS AND RESULTS We searched four major databases for randomised controlled trials comparing long-term (≥12 months) with short-term (≤6 months) or shorter (≤3 months) DAPT in patients with coronary syndromes. The primary outcome was all-cause mortality. Secondary outcomes were any bleeding and major bleeding (safety), cardiac death, myocardial infarction, stent thrombosis, revascularisation and stroke (efficacy). Nineteen randomised controlled trials (n=60 111) satisfied inclusion criteria, 8 assessed ≤3 months DAPT. Compared with long-term (≥12 months), short-term DAPT (≤6 months) was associated with a trend towards reduced all-cause mortality (RR: 0.90, 95% CI: 0.80 to 1.01) and significant bleeding reduction (RR: 0.68, 95% CI: 0.55 to 0.83 and RR: 0.66, 95% CI: 0.56 to 0.77 for major and any bleeding, respectively). There were no significant differences in efficacy outcomes. These associations persisted in sensitivity analysis comparing shorter duration DAPT (≤3 months) to long-term DAPT (≥12 months) for all-cause mortality (RR: 0.91, 95% CI: 0.79 to 1.05). In subgroup analysis, short-term DAPT was associated with lower risk of bleeding in patients with acute or chronic coronary syndromes (RR: 0.66, 95% CI: 0.54 to 0.81 and RR: 0.53, 95% CI: 0.33 to 0.65, respectively), but higher risk of stent thrombosis in acute coronary syndrome (RR: 1.49, 95% CI: 1.02 to 2.17 vs RR: 1.25, 95% CI 0.44 to 3.58). CONCLUSION Our meta-analysis suggests that short (≤6 months) and shorter (≤3 months) durations DAPT are associated with lower risk of bleeding, equivalent efficacy and a trend towards lower all-cause mortality irrespective of coronary artery disease stability.
Collapse
Affiliation(s)
- Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Mohammed N Meah
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Anoop S V Shah
- Department of Non-Communicable Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
- Usher Institute, University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| |
Collapse
|
43
|
Genz C, C Braun-Dullaeus R. Inhibition of Platelet Aggregation After Coronary Stenting in Patients Receiving Oral Anticoagulation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0150. [PMID: 33637173 PMCID: PMC8372776 DOI: 10.3238/arztebl.m2021.0150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 02/04/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Approximately 18% of patients with atrial fibrillation undergo a percutaneous coronary intervention (PCI) to treat coronary heart disease. Pharmacological anticoagulation in patients with atrial fibrillation and PCI involves a trade-off of potential ischemic and hemorrhagic complications. METHODS This review is based on pertinent publications that were retrieved by a selective literature search, including current guidelines and recommendations. RESULTS Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor protects against stent thrombosis, but not against thromboembolic stroke. In contrast, oral anticoagulation does provide effective prevention against stroke during atrial fibrillation. Combining DAPT with oral anticoagulation (triple therapy) over the long term, as has been recommended to date, carries an elevated risk of hemorrhage. In a randomized controlled trial, 44% of patients with atrial fibrillation receiving triple therapy sustained a hemorrhagic event, compared to 19.4% of patients receiving dual therapy. A meta-analysis has shown that clinically relevant hemorrhage is less common under combined treatment with one of the new oral anticoagulants (NOAC) and a single antiplatelet drug than under triple therapy including a vitamin K antagonist (hazard ratio, 0.56; 95% confidence interval 0.39; 0.80]), but no significant difference was found with respect to stent thrombosis, myocardial infarction, or overall mortality. CONCLUSION After coronary stent implantation, dual therapy with a NOAC and a P2Y12 inhibitor is recommended, subsequent to triple therapy given only during the peri-interventional period.
Collapse
Affiliation(s)
- Conrad Genz
- Department of Internal Medicine, Division of Cardiology and Angiology, University Hospital Magdeburg
| | - Ruediger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, University Hospital Magdeburg
| |
Collapse
|
44
|
Efficacy and Safety of Dual Antiplatelet Therapy in Patients Undergoing Coronary Stent Implantation: A Systematic Review and Network Meta-Analysis. J Interv Cardiol 2021; 2021:9934535. [PMID: 34035674 PMCID: PMC8118746 DOI: 10.1155/2021/9934535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/28/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction This network meta-analysis aimed to evaluate the efficacy and safety of different dual antiplatelet therapies (DAPTs) after percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). Methods Randomized controlled trials (RCTs) comparing longer-term (>12 months) DAPT (L-DAPT), 12-month DAPT (DAPT 12Mo), 6-month DAPT (DAPT 6Mo), 3-month DAPT followed by aspirin monotherapy (DAPT 3Mo + ASA), 3-month DAPT followed by a P2Y12 receptor inhibitor monotherapy (DAPT 3Mo + P2Y12), or 1-month DAPT with a P2Y12 receptor inhibitor monotherapy (DAPT 1Mo + P2Y12) were searched. Primary endpoints were all-cause mortality, cardiac death, myocardial infarction (MI), major bleeding, any bleeding, definite or probable stent thrombosis (ST), and net adverse clinical events (NACE). This Bayesian network meta-analysis was performed with the random-effects model. Results Twenty-four RCTs (n = 81339) were included. In comparison with L-DAPT, DAPT 6Mo (OR: 0.50, 95% CI: 0.29–0.83), DAPT 3Mo + P2Y12 (OR: 0.38, 95% CI: 0.18–0.82), DAPT 3Mo + ASA (OR: 0.44, 95% CI: 0.17–0.98), and DAPT 1Mo + P2Y12 (OR: 0.45, 95% CI: 0.14–0.93) were associated with a lower risk of major bleeding. DAPT 3Mo + P2Y12 (OR: 0.58, 95% CI: 0.38–0.88) reduced the risk of any bleeding when compared with DAPT 12Mo. L-DAPT decreased the risk of MI and definite or probable stent ST when compared with DAPT 6Mo. DAPT 3Mo + P2Y12 decreased the risk of NACE in comparison with DAPT 6Mo and DAPT 12Mo. No significant difference in all-cause mortality and cardiac death was observed. In patients with acute coronary syndrome, DAPT 6Mo was comparable to DAPT 12Mo. Conclusion Short-term (1–3 months) DAPT is noninferior to DAPT 6Mo after DESs implantation, while L-DAPT reduces MI and definite or probable ST rates. DAPT 3Mo + P2Y12 might be a reasonable trade-off in patients with high risk of bleeding accompanied by ischemia.
Collapse
|
45
|
Trials of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Lack Strategies to Ensure Appropriate Gastroprotection. Am J Gastroenterol 2021; 116:821-824. [PMID: 33982954 PMCID: PMC8119932 DOI: 10.14309/ajg.0000000000001134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Gastrointestinal bleeding is a morbid complication of dual antiplatelet therapy (DAPT). We evaluated the extent to which contemporary trials of DAPT included steps to ensure appropriate use of proton pump inhibitor (PPI) gastroprotection and reported rates of PPI use. METHODS A methodological review of randomized trials comparing varying durations of DAPT after percutaneous coronary intervention. RESULTS Among 21 trials, none incorporated protocol procedures or guidance for prescribing PPIs. Five reported rates of PPI use (range 25.6-69.1%). DISCUSSION PPI gastroprotection is overlooked in major trials of DAPT. Appropriate use of PPI gastroprotection represents an important opportunity to improve patient safety.
Collapse
|
46
|
Anti-apoptosis mechanism of triptolide based on network pharmacology in focal segmental glomerulosclerosis rats. Biosci Rep 2021; 40:222639. [PMID: 32285909 PMCID: PMC7189607 DOI: 10.1042/bsr20192920] [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: 12/16/2019] [Revised: 02/28/2020] [Accepted: 03/30/2020] [Indexed: 12/20/2022] Open
Abstract
Triptolide (TPL), the active component of Tripterygium wilfordii, exhibits anti-cancer and antioxidant functions. We aimed to explore the anti-apoptosis mechanism of TPL based on network pharmacology and in vivo and in vitro research validation using a rat model of focal segmental glomerulosclerosis (FSGS). The chemical structures and pharmacological activities of the compounds reported in T. wilfordii were determined and used to perform the network pharmacology analysis. The Traditional Chinese Medicine Systems Pharmacology Database (TCMSP) was then used to identify the network targets for 16 compounds from Tripterygium wilfordii. Our results showed that 47 overlapping genes obtained from the GeneCards and OMIM databases were involved in the occurrence and development of FSGS and used to construct the protein–protein interaction (PPI) network using the STRING database. Hub genes were identified via the MCODE plug-in of the Cytoscape software. IL4 was the target gene of TPL in FSGS and was mainly enriched in the cell apoptosis term and p53 signaling pathway, according to Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. TPL inhibited FSGS-induced cell apoptosis in rats and regulated IL4, nephrin, podocin, and p53 protein levels via using CCK8, TUNEL, and Western blot assays. The effects of IL4 overexpression, including inhibition of cell viability and promotion of apoptosis, were reversed by TPL. TPL treatment increased the expression of nephrin and podocin and decreased p53 expression in rat podocytes. In conclusion, TPL inhibited podocyte apoptosis by targeting IL4 to alleviate kidney injury in FSGS rats.
Collapse
|
47
|
Cha JJ, Park JH, Joo HJ, Hong SJ, Ahn TH, Kim BK, Shin W, Ahn SG, Yoon J, Kim YH, Cho YH, Kang WC, Kim W, Lim YH, Gwon HC, Choi WG, Lim DS. Impact of genetic variants on clinical outcome after percutaneous coronary intervention in elderly patients. Aging (Albany NY) 2021; 13:6506-6524. [PMID: 33707344 PMCID: PMC7993709 DOI: 10.18632/aging.202799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/16/2021] [Indexed: 12/02/2022]
Abstract
Elderly patients treated with percutaneous coronary intervention (PCI) have a higher risk of both ischemic and bleeding complications than younger patients. However, few studies have reported how genetic information of elderly patients treated with PCI affects clinical outcomes. We investigated the impact of genetic variants on clinical outcomes in elderly patients. Correlations between single-nucleotide polymorphisms (CYP2C19 and P2Y12 receptor gene G52T polymorphism) and clinical outcomes were analyzed in 811 elderly patients (≥75 years of age) from a prospective multicenter registry. The primary endpoint was a composite of myocardial infarction and death. Secondary endpoints were an individual event of death, cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, stroke, and major bleeding (Bleeding Academic Research Consortium ≥3). Regarding CYP2C19, patients with poor metabolizers had a significantly higher risk for the primary endpoint (hazard ratio [HR] 2.43; 95% confidence interval [95% CI] 1.12–5.24; p=0.024) and secondary endpoints (death and cardiac death). Regarding P2Y12 G52T, the TT group had a significantly higher occurrence of major bleeding than the other groups (HR 3.87; 95% CI 1.41–10.68; p=0.009). In conclusion, poor metabolizers of CYP2C19 and TT groups of P2Y12 G52T may be significant predictors of poor clinical outcomes in elderly patients.
Collapse
Affiliation(s)
- Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hyung Joon Joo
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Tae Hoon Ahn
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - WonYong Shin
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea
| | - Sung Gyun Ahn
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - JungHan Yoon
- Department of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Yun-Hyeong Cho
- Department of Internal Medicine, Hanyang University Myongji Hospital, Goyang, South Korea
| | - Woong Chol Kang
- Department of Cardiology, Gachon University Gil Medical Center, Incheon, South Korea
| | - Weon Kim
- Department of Internal Medicine, Division of Cardiology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Young-Hyo Lim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Hyeon Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Woong Gil Choi
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| |
Collapse
|
48
|
Ayoub A, Ayinapudi K, Al-Ogaili A, Panhwar MS, Dakkak W, LeJemtel T. Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI. Am J Cardiovasc Drugs 2021; 21:153-163. [PMID: 32780215 DOI: 10.1007/s40256-020-00430-0] [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: 11/27/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controversial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12 months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still benefit from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1-3 months reduces bleeding rates without significantly increasing ischemic event rates. These trials also suggested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice.
Collapse
Affiliation(s)
- Ali Ayoub
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA.
| | - Karnika Ayinapudi
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Ahmed Al-Ogaili
- Department of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Muhammad Siyab Panhwar
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Wael Dakkak
- Department of Medicine, Southern Illinois University, Springfield, IL, USA
| | - Thierry LeJemtel
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| |
Collapse
|
49
|
Liu Y, An T, Wan D, Yu B, Fan Y, Pei X. Targets and Mechanism Used by Cinnamaldehyde, the Main Active Ingredient in Cinnamon, in the Treatment of Breast Cancer. Front Pharmacol 2021; 11:582719. [PMID: 33536908 PMCID: PMC7848847 DOI: 10.3389/fphar.2020.582719] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/06/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Breast cancer has become one of the most common malignant tumors in women owing to its increasing incidence each year. Clinical studies have shown that Cinnamomum cassia (L.) J. Presl (cinnamon) has a positive influence on the prevention and treatment of breast cancer. Aim: We aimed to screen the potential targets of cinnamon in the treatment of breast cancer through network pharmacology and explore its potential therapeutic mechanism through cell experiments. Methods: We used the TCMSP, TCM Database @ Taiwan, and TCMID websites and established the active ingredient and target database of cinnamon. Thereafter, we used the GeneCards and OMIM databases to establish a breast cancer-related target database, which matched the cinnamon target database. Based on the matching results, the STRING database was used to analyze the interaction between the targets, and the biological information annotation database was used to analyze the biological process of the target (gene ontology) and the pathway enrichment of Kyoto Encyclopedia of Genes and Genomes (KEGG). After establishing the layout of the analysis, we used Cytoscape 3.6.0 software for network analysis. Finally, the cell experiment was used to verify the anti-breast cancer effect of cinnamaldehyde. Results: Our research showed that the main components of cinnamon, including cinnamaldehyde, can play a role in the treatment of breast cancer through 59 possible important targets. Subsequently, enrichment analysis by gene ontology and Kyoto Encyclopedia of Genes and Genomes showed that 83 cell biological processes and 37 pathways were associated with breast cancer (p < 0.05), including the peroxisome proliferator-activated receptor and PI3K-Akt pathway, which are closely related to tumor cell apoptosis. In vitro cell verification experiments showed that cinnamaldehyde can significantly inhibit cell proliferation, change cell morphology, inhibit cell migration and invasion ability, and promote cell apoptosis. Conclusion: Our results showed that cinnamaldehyde is a potential novel drug for the treatment and prevention of breast cancer.
Collapse
Affiliation(s)
- Yufei Liu
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
| | - Tian An
- Oncology Department of Integrated Traditional Chinese and Western Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Donggui Wan
- School of Traditional Chinese Medicine, Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Bowen Yu
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
| | - Yingyi Fan
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China
| | - Xiaohua Pei
- Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, China.,Xiamen Hospital, Beijing University of Chinese Medicine, Xiamen, China
| |
Collapse
|
50
|
Saito Y, Wijns W, Baumbach A, Xu B, Kelbaek H, Zheng M, Morel MA, Anderson R, Schächinger V, Lansky A. Differential impact of abluminal groove-filled biodegradable-polymer sirolimus-eluting stent versus durable-polymer everolimus-eluting stent on and off dual antiplatelet therapy. Catheter Cardiovasc Interv 2021; 99:357-365. [PMID: 33502809 DOI: 10.1002/ccd.29468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 01/08/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Current guidelines recommend dual antiplatelet therapy (DAPT) following percutaneous coronary intervention for 6-12 months in patients with acute coronary syndrome (ACS) and 3-6 months in those with chronic coronary syndromes (CCS). Whether DAPT duration has a differential effect on outcomes following treatment of ischemic coronary disease with durable versus biodegradable drug-eluting stent (DES) is poorly defined. METHODS The TARGET All Comer study was a randomized trial of patients with ischemic coronary artery disease assigned to treatment with either a biodegradable polymer DES (Firehawk) or a durable polymer DES (XIENCE). This pre-specified TARGET AC sub-analysis sought to evaluate the 2-year clinical outcomes before and after DAPT discontinuation. The primary endpoint was target lesion failure (TLF). RESULTS A total of 1,296 (78.4%) of 1,653 randomized patients were included in this substudy, of which 1,210 (93.4%) remained on DAPT at 6 months, 863 (66.6%) at 12 months, and 409 (31.6%) at 2 years. There was no difference in TLF between patients treated with Firehawk and XIENCE stents from index procedure to DAPT discontinuation (8.0 and 7.7%, p > .99) or after DAPT discontinuation (2.9 vs. 3.8%, p = .16). After DAPT discontinuation, target vessel myocardial infarction (1.3 vs. 3.3%, p = .07), and ischemia-driven target lesion revascularization (0.5 vs. 1.9%, p = .06) favored treatment with Firehawk. CONCLUSIONS Although TLF was comparable for both Firehawk and XIENCE stent groups before and after DAPT discontinuation, after DAPT discontinuation, there was a trend for less target vessel myocardial infarction and ischemia-driven revascularization with the biodegradable polymer DES.
Collapse
Affiliation(s)
- Yuichi Saito
- Yale University School of Medicine, New Haven, Connecticut
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland.,Saolta University Healthcare Group, University College Hospital Galway, Galway, Ireland
| | - Andreas Baumbach
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Bo Xu
- Fu Wai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Henning Kelbaek
- Department of Cardiology, Roskilde University Hospital, Roskilde, Denmark
| | - Ming Zheng
- Shanghai MicroPort Medical (Group) Co., Ltd., Shanghai, China
| | | | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff, UK
| | - Volker Schächinger
- Medizinische Klinik I, Herz-Thorax Zentrum, Klinikum Fulda, Fulda, Germany
| | - Alexandra Lansky
- Yale University School of Medicine, New Haven, Connecticut.,Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | | |
Collapse
|