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Moore E, Robson AJ, Crisp AR, Cockshell MP, Burzava ALS, Ganesan R, Robinson N, Al-Bataineh S, Nankivell V, Sandeman L, Tondl M, Benveniste G, Finnie JW, Psaltis PJ, Martocq L, Quadrelli A, Jarvis SP, Williams C, Ramage G, Rehman IU, Bursill CA, Simula T, Voelcker NH, Griesser HJ, Short RD, Bonder CS. Study of the Structure of Hyperbranched Polyglycerol Coatings and Their Antibiofouling and Antithrombotic Applications. Adv Healthc Mater 2024:e2401545. [PMID: 38924692 DOI: 10.1002/adhm.202401545] [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: 04/29/2024] [Revised: 06/10/2024] [Indexed: 06/28/2024]
Abstract
While blood-contacting materials are widely deployed in medicine in vascular stents, catheters, and cannulas, devices fail in situ because of thrombosis and restenosis. Furthermore, microbial attachment and biofilm formation is not an uncommon problem for medical devices. Even incremental improvements in hemocompatible materials can provide significant benefits for patients in terms of safety and patency as well as substantial cost savings. Herein, a novel but simple strategy is described for coating a range of medical materials, that can be applied to objects of complex geometry, involving plasma-grafting of an ultrathin hyperbranched polyglycerol coating (HPG). Plasma activation creates highly reactive surface oxygen moieties that readily react with glycidol. Irrespective of the substrate, coatings are uniform and pinhole free, comprising O─C─O repeats, with HPG chains packing in a fashion that holds reversibly binding proteins at the coating surface. In vitro assays with planar test samples show that HPG prevents platelet adhesion and activation, as well as reducing (>3 log) bacterial attachment and preventing biofilm formation. Ex vivo and preclinical studies show that HPG-coated nitinol stents do not elicit thrombosis or restenosis, nor complement or neutrophil activation. Subcutaneous implantation of HPG coated disks under the skin of mice shows no evidence of toxicity nor inflammation.
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Affiliation(s)
- Eli Moore
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
| | - Alexander J Robson
- Department of Chemistry, The University of Sheffield, Dainton Building, Brook Hill, Sheffield, S3 7HF, UK
| | - Amy R Crisp
- School of Engineering, Lancaster University, Lancaster, LA1 4YW, UK
| | - Michaelia P Cockshell
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
| | - Anouck L S Burzava
- Future Industries Institute, University of South Australia, Mawson Lakes, South Australia, 5095, Australia
| | - Raja Ganesan
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
| | - Nirmal Robinson
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, 5000, Australia
| | | | - Victoria Nankivell
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5000, Australia
| | - Lauren Sandeman
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5000, Australia
| | - Markus Tondl
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
| | | | - John W Finnie
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, 5000, Australia
| | - Peter J Psaltis
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, 5000, Australia
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5000, Australia
- Department of Cardiology, Central Adelaide Local Health Network, Adelaide, South Australia, 5000, Australia
| | - Laurine Martocq
- School of Engineering, Lancaster University, Lancaster, LA1 4YW, UK
| | | | - Samuel P Jarvis
- Department of Physics, Lancaster University, Lancaster, LA1 4YB, UK
| | - Craig Williams
- Microbiology Department, Royal Lancaster Infirmary, Lancaster, LA1 4RP, UK
| | - Gordon Ramage
- Department of Nursing and Community Health, Glasgow Caledonian University, Glasgow, G4 0BA, UK
| | - Ihtesham U Rehman
- School of Medicine, University of Central Lancashire, Preston, PR1 2HE, UK
| | - Christina A Bursill
- Vascular Research Centre, Heart and Vascular Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5000, Australia
| | - Tony Simula
- TekCyte Limited, Mawson Lakes, South Australia, 5095, Australia
| | - Nicolas H Voelcker
- Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria, 3052, Australia
- Melbourne Centre for Nanofabrication, Victorian Node of the Australian National Fabrication Facility, Clayton, Victoria, 3168, Australia
| | - Hans J Griesser
- Future Industries Institute, University of South Australia, Mawson Lakes, South Australia, 5095, Australia
| | - Robert D Short
- Department of Chemistry, The University of Sheffield, Dainton Building, Brook Hill, Sheffield, S3 7HF, UK
| | - Claudine S Bonder
- Centre for Cancer Biology, University of South Australia and SA Pathology, Adelaide, South Australia, 5000, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, 5000, Australia
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Kim SH, Shin S, Choo EH, Choi IJ, Lim S, Moon D, Kim CJ, Park MW, Kim MC, Hwang BH, Lee KY, Choi YS, Kim HY, Yoo KD, Jeon DS, Ahn Y, Chang K. Clinical Impact of Dyspnea after Ticagrelor Treatment and the Effect of Switching to Clopidogrel in Patients with Myocardial Infarction. Thromb Haemost 2024. [PMID: 38574757 DOI: 10.1055/a-2299-4537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Dyspnea is frequent during ticagrelor-based dual antiplatelet therapy (DAPT) for acute myocardial infarction (AMI). However, its clinical characteristics or management strategy remains uncertain. METHODS The study assessed 2,617 AMI patients from the Ticagrelor versus Clopidogrel in Stabilized Patients with AMI (TALOS-AMI) trial. Dyspnea during 1-month ticagrelor-based DAPT and following DAPT strategies with continued ticagrelor or de-escalation to clopidogrel from 1 to 12 months were evaluated for drug adherence, subsequent dyspnea, major adverse cardiovascular events (MACE), and bleeding events. RESULTS Dyspnea was reported by 538 patients (20.6%) during 1 month of ticagrelor-based DAPT. Adherence to allocated DAPT over the study period was lower in the continued ticagrelor arm than the de-escalation to clopidogrel, particularly among the dyspneic population (81.1% vs. 91.5%, p < 0.001). Among ticagrelor-treated patients with dyspnea, those switched to clopidogrel at 1 month had a lower frequency of dyspnea at 3 months (34.3% vs. 51.7%, p < 0.001) and 6 months (25.5% vs. 38.4%, p = 0.002) than those continued with ticagrelor. In patients with dyspnea in their 1-month ticagrelor-based DAPT, de-escalation was not associated with increased MACE (1.3% vs. 3.9%, hazard ratio [HR]: 0.31, 95% confidence interval [CI]: 0.08-1.11, p = 0.07) or clinically relevant bleeding (3.2% vs. 6.2%, HR: 0.51, 95% CI: 0.22-1.19, p = 0.12) at 1 year. CONCLUSION Dyspnea is a common side effect among ticagrelor-based DAPTs in AMI patients. Switching from ticagrelor to clopidogrel after 1 month in AMI patients may provide a reasonable option to alleviate subsequent dyspnea in ticagrelor-relevant dyspneic patients, without increasing the risk of ischemic events (NCT02018055).
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Affiliation(s)
- Sang Hyun Kim
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, The Armed Forces Capital Hospital, Seongnam, Korea
| | - Sanghoon Shin
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Ik Jun Choi
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Sungmin Lim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Donggyu Moon
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Chan Joon Kim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Mahn-Won Park
- Division of Cardiology, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Byung-Hee Hwang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kwan Yong Lee
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yun Seok Choi
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Hee-Yeol Kim
- Division of Cardiology, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Ki-Dong Yoo
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Doo Soo Jeon
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
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De Luca L, Di Fusco SA, Iannopollo G, Mistrulli R, Rizzello V, Aimo A, Navazio A, Bilato C, Corda M, Di Marco M, Geraci G, Iacovoni A, Milli M, Pascale V, Riccio C, Scicchitano P, Tizzani E, Gabrielli D, Grimaldi M, Colivicchi F, Oliva F. Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on the simplification of the drug regimen for secondary cardiovascular prevention. Eur Heart J Suppl 2024; 26:ii236-ii251. [PMID: 38784670 PMCID: PMC11110452 DOI: 10.1093/eurheartjsupp/suae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The issue of suboptimal drug regimen adherence in secondary cardiovascular prevention presents a significant barrier to improving patient outcomes. To address this, the utilization of drug combinations, specifically single pill combinations (SPCs) and polypills, was proposed as a strategy to simplify treatment regimens. This approach aims to enhance treatment accessibility, affordability, and adherence, thereby reducing healthcare costs and improving patient health. The document is an Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO) scientific statement on simplifying drug regimens for secondary cardiovascular prevention. It discusses the underuse of treatments despite available, effective, and accessible options, highlighting a significant gap in secondary prevention across different socio-economic statuses and countries. The statement explores barriers to implementing evidence-based treatments, including patient, healthcare provider, and system-related challenges. The paper also reviews international guidelines, the role of SPCs and polypills in clinical practice, and their economic impact, advocating for their use in secondary prevention to improve patient outcomes and adherence.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy
| | - Stefania Angela Di Fusco
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | | | - Raffaella Mistrulli
- Dipartimento di Medicina Clinica e Molecolare, Università degli studi di Roma La Sapienza, Rome, Italy
| | | | - Alberto Aimo
- UOC Cardiologia, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alessandro Navazio
- SOC Cardiologia Ospedaliera, Presidio Ospedaliero Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia—IRCCS, Reggio Emilia, Italy
| | - Claudio Bilato
- UOC Cardiologia, Ospedali dell'Ovest Vicentino, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Marco Corda
- SC Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | | | - Giovanna Geraci
- UOC Cardiologia, Ospedale Sant'Antonio Abate, Trapani, Italy
| | - Attilio Iacovoni
- SSD Chirurgia dei Trapianti e del Trattamento Chirurgico dello Scompenso, Dipartimento Cardiovascolare, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Milli
- Cardiologia Firenze 1 (Ospedali S. Maria Nuova e Nuovo San Giovanni di Dio), Azienda USL Toscana Centro, Firenze, Italy
| | - Vittorio Pascale
- UTIC-Emodinamica e Cardiologia Interventistica, Ospedale Civile Pugliese, Catanzaro, Italy
| | - Carmine Riccio
- U.O.S.D. Follow-up del Paziente Post-Acuto, Dipartimento Cardio-Vascolare, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | | | - Emanuele Tizzani
- Dipartimento di Cardiologia, Ospedale degli Infermi, Rivoli, TO, Italy
| | - Domenico Gabrielli
- Dipartimento Cardio-Toraco-Vascolare, U.O.C. Cardiologia, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Massimo Grimaldi
- U.O.C. Cardiologia-UTIC, Ospedale Miulli, Acquaviva delle Fonti, BA, Italy
| | - Furio Colivicchi
- UOC Cardiologia Clinica e Riabilitativa, Presidio Ospedaliero San Filippo Neri—ASL Roma 1, Rome, Italy
| | - Fabrizio Oliva
- Cardiologia 1-Emodinamica, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
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Vallejo C, Bvute K, Hernandez OL. Complex Antiplatelet Therapy Management in Patients Requiring Urgent Interventions for Pseudoachalasia and Esophageal Obstruction. Cureus 2024; 16:e57209. [PMID: 38681452 PMCID: PMC11056216 DOI: 10.7759/cureus.57209] [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: 03/29/2023] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
This case report describes the use of intravenous (IV) cangrelor as a transient tool for antiplatelet bridging therapy in a 70-year-old male with coronary artery disease and esophageal strictures who underwent recent percutaneous coronary intervention (PCI) and subsequently required a pre-oral endoscopic myomectomy (POEM) procedure. The patient was switched from oral clopidogrel to IV cangrelor drip prior to the procedure, which was successful in preventing stent thrombosis. The case highlights the potential benefits of IV antiplatelet therapy in patients unable to tolerate oral medications in the setting of esophageal obstructions following recent coronary stent placement in a critical care setting.
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Affiliation(s)
- Charles Vallejo
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
| | - Kushinga Bvute
- Internal Medicine, Florida Atlantic University, Boca Raton, USA
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes. Pharmacoepidemiol Drug Saf 2024; 33:e5704. [PMID: 37771242 DOI: 10.1002/pds.5704] [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: 04/02/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.
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Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California, USA
| | | | - Maneesh Sud
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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Park LG, Ng F, Handley MA. The use of the Capability-Opportunity- Motivation Behavior (COM-B) model to identify barriers to medication adherence and the application of mobile health technology in adults with coronary heart disease: A qualitative study. PEC INNOVATION 2023; 3:100209. [PMID: 37753273 PMCID: PMC10518702 DOI: 10.1016/j.pecinn.2023.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/06/2023] [Accepted: 09/01/2023] [Indexed: 09/28/2023]
Abstract
Objective Among patients with coronary heart disease, we sought to address the research questions of: 1) What is the acceptability of applying a technology-enabled approach to support medication adherence?; and 2) What are barriers to medication adherence using the Capability-Opportunity-Motivation Behavior (COM-B) model as a guiding framework? Methods Applying qualitative research methods, we employed a series of 3 focus groups per individual (total 9 sessions). Coded data from thematic analysis were mapped to the COM-B model components for meaningful associations. Results Fourteen participants were recruited (median age 69.5 ± 11, 50% female). Barriers to medication adherence were organized along these COM-B domains: psychological capability (forgetfulness, distractions, fear of side effects), physical opportunity (inaccessible medications, inability to renew prescriptions), reflective (burdening family members), and automatic motivation (medication fatigue, health decline). Conclusions Tailored text messaging and mobile phone apps were perceived as helpful tools for medication adherence. The COM-B model was useful to provide a comprehensive, theory-driven evaluation of patients' beliefs and motivations on whether to engage in medication adherence. Innovation To date, text messaging and mobile applications have not been widely implemented in the clinical setting and provide a major opportunity to innovate on approaches to address medication adherence.
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Affiliation(s)
- Linda G. Park
- University of California, San Francisco School of Nursing, Department of Community Health Systems, San Francisco Veterans Affair Medical Center, 2 Koret Way, Room 531A, San Francisco, CA 94143-0610, United States of America
| | - Fion Ng
- Department of Community Health Programs for Youth, San Francisco Department of Public Health, United States of America
| | - Margaret A. Handley
- Departments of Epidemiology and Biostatistics and Medicine, Division of General Internal Medicine, University of California, San Francisco, United States of America
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Jayawardena R, Kodithuwakku W, Sooriyaarachchi P. The impact of the Sri Lankan economic crisis on medication adherence: An online cross-sectional survey. DIALOGUES IN HEALTH 2023; 2:100137. [PMID: 38515479 PMCID: PMC10953977 DOI: 10.1016/j.dialog.2023.100137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/20/2023] [Accepted: 05/11/2023] [Indexed: 03/23/2024]
Abstract
Background The economic crisis in Sri Lanka has disarrayed the country's healthcare services, posing a challenge to people with chronic diseases on routine care. This study investigated the changes in medication adherence during the economic crisis. Methods A web-based cross-sectional survey was undertaken in July-August 2022. It assessed socio-demographics, diseases, medication adherence, and reasons for changes in compliance of respondents and their family members during the economic crisis. Descriptive statistics and multivariable logistic regression analysis were used. Findings A total of 1214 respondents, aged ≥18 years were included in the survey. The majority were females (60%). The main finding was that 39%, 41%, and 37% of participants, their family members, or children respectively have changed medication use during the crisis. Among those who changed their medication practices, the most significant change was the change in the brand, reported by 44.7% of the respondents. A similar pattern was observed among other family members, with 61.3% of adults and 53.8% of children switching brands. Respondents who lived outside the Colombo district had a significantly increased risk of changing medication (OR = 1.425, 95% CI = 1.020-1.992, P = 0.038). Respondents with monthly incomes of less than 100,000 LKR had a twofold greater risk of medication nonadherence compared to participants who earned more than 100,000 LKR per month (OR = 2.278, 95% CI = 1.37-3.78, P = 0.001). The most stated reason for changing medication among adults was the high cost of drugs, whereas among, children, the lack of access to drugs in the public or private sector was the leading cause of non-compliance. Interpretation The population's adherence to medication is negatively impacted by the economic crisis in Sri Lanka.
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Affiliation(s)
- Ranil Jayawardena
- Department of Physiology, Faculty of Medicine, University of Colombo, Sri Lanka
- Health and Wellness Unit, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Wasana Kodithuwakku
- Department of Physiology, Faculty of Medicine, University of Colombo, Sri Lanka
| | - Piumika Sooriyaarachchi
- Health and Wellness Unit, Faculty of Medicine, University of Colombo, Sri Lanka
- School of Exercise & Nutrition Sciences, Faculty of Health, Queensland University of Technology (QUT), Australia
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Gorog DA, Ferreiro JL, Ahrens I, Ako J, Geisler T, Halvorsen S, Huber K, Jeong YH, Navarese EP, Rubboli A, Sibbing D, Siller-Matula JM, Storey RF, Tan JWC, Ten Berg JM, Valgimigli M, Vandenbriele C, Lip GYH. De-escalation or abbreviation of dual antiplatelet therapy in acute coronary syndromes and percutaneous coronary intervention: a Consensus Statement from an international expert panel on coronary thrombosis. Nat Rev Cardiol 2023; 20:830-844. [PMID: 37474795 DOI: 10.1038/s41569-023-00901-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/22/2023]
Abstract
Conventional dual antiplatelet therapy (DAPT) for patients with acute coronary syndromes undergoing percutaneous coronary intervention comprises aspirin with a potent P2Y purinoceptor 12 (P2Y12) inhibitor (prasugrel or ticagrelor) for 12 months. Although this approach reduces ischaemic risk, patients are exposed to a substantial risk of bleeding. Strategies to reduce bleeding include de-escalation of DAPT intensity (downgrading from potent P2Y12 inhibitor at conventional doses to either clopidogrel or reduced-dose prasugrel) or abbreviation of DAPT duration. Either strategy requires assessment of the ischaemic and bleeding risks of each individual. De-escalation of DAPT intensity can reduce bleeding without increasing ischaemic events and can be guided by platelet function testing or genotyping. Abbreviation of DAPT duration after 1-6 months, followed by monotherapy with aspirin or a P2Y12 inhibitor, reduces bleeding without an increase in ischaemic events in patients at high bleeding risk, particularly those without high ischaemic risk. However, these two strategies have not yet been compared in a head-to-head clinical trial. In this Consensus Statement, we summarize the evidence base for these treatment approaches, provide guidance on the assessment of ischaemic and bleeding risks, and provide consensus statements from an international panel of experts to help clinicians to optimize these DAPT approaches for individual patients to improve outcomes.
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Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK.
| | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain
- Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Spain
| | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital Cologne, Academic Teaching Hospital University of Cologne, Cologne, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Eliano P Navarese
- Interventional Cardiology and Cardiovascular Medicine Research, Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Bydgoszcz, Poland
- Faculty of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea Rubboli
- Department of Emergency, Internal Medicine and Cardiology, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Ludwig-Maximilians University München, Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Privatklinik Lauterbacher Mühle am Ostsee, Seeshaupt, Germany
| | | | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Jack W C Tan
- National Heart Centre Singapore and Sengkang General Hospital, Singapore, Singapore
| | - Jurrien M Ten Berg
- St Antonius Hospital, Nieuwegein, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Marco Valgimigli
- Cardiocentro Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland
- University of Bern, Bern, Switzerland
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, UK
- Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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9
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Angiolillo DJ, Cao D, Sartori S, Baber U, Dangas G, Zhang Z, Vogel B, Kunadian V, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Ielasi A, Stefanini GG, Pivato CA, Mehta S, Moliterno DJ, Ohman EM, Escaned J, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Steg PG, Pocock S, Mehran R. Dyspnea-Related Ticagrelor Discontinuation After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:2514-2524. [PMID: 37879803 DOI: 10.1016/j.jcin.2023.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Nearly 20% of patients on ticagrelor experience dyspnea, which may lead to treatment discontinuation in up to one-third of cases. OBJECTIVES The authors sought to evaluate the incidence, predictors, and outcomes of dyspnea-related ticagrelor discontinuation after percutaneous coronary intervention (PCI). METHODS In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, patients were maintained on ticagrelor and randomized to aspirin or placebo for 1 year. The occurrence of dyspnea associated with ticagrelor discontinuation was evaluated among all patients enrolled in the trial. A landmark analysis was performed at 3 months after PCI, that is, the time of randomization. Predictors of dyspnea-related ticagrelor discontinuation were obtained from multivariable Cox regression with stepwise selection of candidate variables. RESULTS The incidence of dyspnea-related ticagrelor discontinuation was 6.4% and 9.1% at 3 and 15 months after PCI, respectively. Independent predictors included Asian race (lower risk), smoking, prior PCI, hypercholesterolemia, prior coronary artery bypass, peripheral artery disease, obesity, and older age. Among 179 patients who discontinued ticagrelor because of dyspnea after randomization, ticagrelor monotherapy was not associated with a higher risk of subsequent ischemic events (composite of all-cause death, myocardial infarction, or stroke) compared with ticagrelor plus aspirin (5.0% vs 7.1%; P = 0.566). CONCLUSIONS In the TWILIGHT trial, dyspnea-related ticagrelor discontinuation occurred in almost 1 in 10 patients and tended to occur earlier rather than late after PCI. Several demographic and clinical conditions predicted its occurrence, and their assessment may help identify subjects at risk for therapy nonadherence.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St. Francis Hospital, Roslyn, Roslyn, New York, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Kurt Huber
- 3rd Dept Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carlo A Pivato
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Giora Weisz
- NewYork Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA
| | | | - P Gabriel Steg
- Université de Paris and Assistance Paris-Hôpitaux de Paris, Paris, France
| | - Stuart Pocock
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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10
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Marrs JC, Orlando ST, Saseen JJ, Novins-Montague S, Sandy LC, Waughtal J, Glorioso TJ, Ho PM. Description of patient questions received by clinical pharmacists in the Nudge Study. Am J Health Syst Pharm 2023; 80:1247-1254. [PMID: 37353220 PMCID: PMC10845234 DOI: 10.1093/ajhp/zxad139] [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: 06/15/2023] [Indexed: 06/25/2023] Open
Abstract
PURPOSE The Nudge Study is a patient level-randomized trial testing different text message medication refill reminders sent to patients assigned to 4 arms: (1) usual care, (2) generic text, (3) optimized text, and (4) optimized text plus chatbot. This report describes the frequency and types of patient questions sent to clinical pharmacists (CPs) following text reminders. METHODS Patients were enrolled from Denver Health and Hospital Authority (DHHA) and Veterans Affairs Eastern Colorado Health Care System (VA ECHCS) from October 1, 2019, through May 30, 2021. Included patients responded to at least 1 text or interactive voice response (IVR) message. Patients were dichotomized as those who posed at least 1 question to a CP and those who posed no questions. RESULTS Of the 6,325 patients enrolled in an intervention arm, 3,323 (52.5%) responded to at least 1 text or IVR message, and among those responding, 305 (9.2%) responded with a pharmacist question. Patient factors associated with submitting a CP question included age (45-74 years), enrollment from DHHA, and receipt of the optimized text or optimized text plus chatbot message versus the generic text. Questions to CP were in the following categories: medication related (48.2%), refill logistics (38.4%), cost (9.2%), and other (17.7%). CONCLUSION In a text messaging intervention focused on medication refills, there were few questions directed to the CP. Patients assigned to receive optimized texts were more likely to have questions. We hypothesize that this may suggest greater patient engagement regarding their condition, resulting in more questions.
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Affiliation(s)
- Joel C Marrs
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center, Nashville, TN, and Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven T Orlando
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO, USA
| | - Joseph J Saseen
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, and Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sylvie Novins-Montague
- ACCORDS (Adult and Child Consortium for Health Outcomes Research and Delivery Science), Aurora, CO, USA
| | - Lisa Caputo Sandy
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joy Waughtal
- mHealth Impact Laboratory, Colorado School of Public Health, Aurora, CO, USA
| | | | - P Michael Ho
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO, and Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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11
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Tao S, Tang X, Yu L, Li L, Zhang G, Zhang L, Huang L, Wu J. Prognosis of coronary heart disease after percutaneous coronary intervention: a bibliometric analysis over the period 2004-2022. Eur J Med Res 2023; 28:311. [PMID: 37658418 PMCID: PMC10472664 DOI: 10.1186/s40001-023-01220-5] [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: 04/12/2023] [Accepted: 07/10/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND As the complexity and diversity of the percutaneous coronary intervention (PCI) are being explored and reported, burgeoning research has progressed in this field. However, there is no comprehensive analysis available on PCI-related studies published in the literature. This study aimed to analyze and visualize the changes of scientific output regarding prognosis of coronary heart disease (CHD) after PCI over the past 20 years and to reveal the knowledge domain and development trends in this field by using CiteSpace software. METHODS Relevant articles published over the period 2004-2022 were retrieved from the Web of Science Core Collection database. After manual selection, qualified documents were included and recorded with the information of their title, abstract, keyword, author, descriptor, citation, identifier, publishing year and publishing organization. We transferred the data to CiteSpace V5.8.R2 (Version 5.8.R2) to draw knowledge maps and to conduct co-occurrence analysis, cluster analysis, timeline analysis, burst term detection and citation analysis. RESULTS A total of 14,699 literature records were found relating prognosis of CHD after PCI in the past 20 years (2004-2022), including 14,212 original articles and reviews, and they were published in 153 different journals. Publication production has increased annually and a total of 1182 authors, 796 institutes and 147 countries have contributed to these publications. Moreover, the most representative author was Gregg W Stone from the CardioVascular Research Foundation (CVRF) with 368 publications, whose team mainly focused on exploring the efficacy and safety of revascularization and the characteristics of susceptible population. The global productivity ranking was led by the USA with 3326 published papers, followed by Italy (n = 1355), Japan (n = 1080), China (n = 1075) and Germany (n = 937). And the keywords of these publications were "percutaneous coronary intervention" (n = 2271), "outcome" (n = 1756), "mortality" (n = 1730) and "impact" (n = 1334). Other commonly-used words were "predictor" (n = 1324), "intervention" (n = 1310), "angioplasty" (n = 1299), "risk" (n = 1144), "acute myocardial infarction" (n = 1136) and "artery disease" (n = 1098). Cluster analysis showed that 15 high connected clusters were generated with a modularity Q of 0.831 and a weighted mean silhouette of 0.9388 by applying the log-likelihood ratio algorithm, and the top 5 clusters were #0 optical coherence tomography, #1 dual antiplatelet therapy, #2 bleeding, #3 clopidogrel and #4 thrombus aspiration. Furthermore, the frontiers in the field of prognosis of CHD after PCI mainly involved "decision making", "reperfusion", "angioplasty", "balloon", "unstable angina", "dual antiplatelet therapy", "cardiac surgical score", "restenosis", "reperfusion", "thrombolytic therapy", etc. CONCLUSIONS: To sum up, efficacy and safety of different types of stents, the risk factors of restenosis and thrombotic events after PCI, early risk assessment, and secondary prevention and complications of patients with CHD after PCI were research hotspots and frontier topics in the area by bibliometric analysis. The results could provide a comprehensive overview of the research hotspots and frontier topics relating prognosis of CHD after PCI, promoting a better understanding of the knowledge domain and development trends in this field during the past 20 years.
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Affiliation(s)
- Shiyi Tao
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Xianwen Tang
- Department of Cardiology, Beijing University of Chinese Medicine Shenzhen Hospital (Longgang), Shenzhen, Guangdong, China
| | - Lintong Yu
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Lingling Li
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Gaoyu Zhang
- Graduate School, Beijing University of Chinese Medicine, Beijing, China
| | - Lanxin Zhang
- Department of Oncology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Li Huang
- Department of Integrative Cardiology, China-Japan Friendship Hospital, Beijing, China
| | - Jiayun Wu
- Department of Cardiology, Beijing University of Chinese Medicine Shenzhen Hospital (Longgang), Shenzhen, Guangdong, China.
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12
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Liu L, Xu L, Guo N, Yang Y, Liu X, Qi T, Liang F. Ticagrelor is related to nuisance bleeding after flow diversion of unruptured intracranial aneurysms. Neurosurg Rev 2023; 46:134. [PMID: 37269331 DOI: 10.1007/s10143-023-02043-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Abstract
Nuisance bleeding (NB) without urgent medical attention is rarely characterized despite its frequent occurrence in patients with cerebral aneurysms undergoing flow diversion (FD) who are maintained on dual antiplatelet therapy (DAPT). This study explored the risk factors for NB. Patients with unruptured cerebral aneurysms who underwent intervention using FD (July 2018 to May 2022) and had follow-up data were enrolled. Patient demographics, clinical characteristics, aneurysm features and follow-up data were analysed. Bleeding complications were classified as NB, internal bleeding and alarming bleeding. NB was characterized by easy bruising, bleeding from small cuts and nonfatal petechiae and ecchymosis. Univariate and multivariate logistic regression analyses were performed to determine risk factors for NB. This study assessed 121 patients. Of these, 52 (43.0%) patients had NB. Compared with the non-bleeding group, the NB group had more females (82.7% vs. 56.5%; p = 0.003), lower smoking rate (7.7% vs. 23.2%; p = 0.027) and smaller aneurysms (6.65 mm [4.60-9.60 mm] vs. 8.82 mm [5.65-15.65 mm]; p = 0.007) and had more patients maintained on ticagrelor-containing DAPT regimen (90.4% vs. 66.7%; p = 0.002). Multivariate logistic regression revealed that ticagrelor-containing DAPT regimen (odds ratio, 3.91; 95% confidence interval, 1.29-11.87; p = 0.016) was associated with NB. These results suggest that NB is a common bleeding complaint in patients on DAPT. In patients undergoing FD, DAPT with ticagrelor was the only independent risk factor for NB.
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Affiliation(s)
- Linfeng Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Lin Xu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Ning Guo
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Yibing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Xinman Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Tiewei Qi
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China
| | - Feng Liang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Sun Yat-sen University, Guangdong Province, Guangzhou, China.
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13
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Kosaraju R, Natour S, Yuan S, Cho G. A case study of recurrent myocardial infarction secondary to
socioeconomic challenges and nonadherence: Pre-discharge
screening. SAGE Open Med Case Rep 2023; 11:2050313X231162921. [PMID: 36968994 PMCID: PMC10034268 DOI: 10.1177/2050313x231162921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/21/2023] [Indexed: 03/24/2023] Open
Abstract
Medication nonadherence following myocardial infarction (MI) is prevalent and
increases the risk of recurrent cardiovascular events. Socioeconomic factors
including medication cost, financial insecurity, and poor health literacy are
associated with nonadherence. We present a patient with a history of recurrent
MI who was nonadherent due to socioeconomic challenges. Our patient subsequently
developed ST-elevation MI secondary to in-stent thrombosis. This case
illustrates the importance of pre-discharge screening for barriers to
adherence.
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Affiliation(s)
- Revanth Kosaraju
- David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
- Internal Medicine Residency Program,
UCLA Health, Los Angeles, CA, USA
- Revanth Kosaraju, Internal Medicine
Residency Program, UCLA Health, 757 Westwood Plaza, Suite 7236, Los Angeles, CA
90095, USA.
| | - Sami Natour
- David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
| | - Stanley Yuan
- David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
| | - Geoffrey Cho
- David Geffen School of Medicine at
UCLA, Los Angeles, CA, USA
- Cardiovascular Research Foundation of
Southern California, Beverly Hills, CA, USA
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14
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Case BC, Torguson R, Abramowitz J, Shea C, Zhang C, Sutton JA, Deksissa T, Satler LF, Ben-Dor I, Bernardo NL, Hashim H, Rogers T, Waksman R. Impact of Close Surveillance on Dual-Antiplatelet Therapy Compliance in Myocardial Infarction Patients Post-Percutaneous Coronary Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 48:7-14. [PMID: 36347732 DOI: 10.1016/j.carrev.2022.10.007] [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: 10/17/2022] [Accepted: 10/17/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay regimen for acute coronary syndrome (ACS) patients after percutaneous coronary intervention (PCI). We aimed to investigate DAPT compliance and switching patterns in ACS patients prescribed ticagrelor and aspirin. Secondly, we evaluated the impact of a pilot strategy of close surveillance telephone calls. METHODS The study enrolled 150 consecutive ACS patients who underwent PCI and were prescribed DAPT (aspirin and ticagrelor). This cohort, the "close surveillance arm," then received telephone calls from a healthcare professional to inquire about DAPT for up to one year. These findings, and clinical outcomes, were then compared to a "historical arm" of ACS patients (n = 505) who received PCI and were prescribed DAPT before initiation of the program. Finally, healthcare providers were surveyed about their experience with prescribing DAPT. RESULTS The rate of ticagrelor cessation trended lower in the close surveillance arm (22.00 % versus 31.70 %, p = 0.0783). The most common reasons for ticagrelor cessation were adverse medication reaction (dyspnea), bleeding, and financial burden. Nevertheless, the adverse events were few and similar between the two groups during follow-up. Over 96 % of healthcare providers surveyed stated that they worry about their patients' DAPT compliance post-PCI. CONCLUSION Noncompliance and switching medications are still common for patients who undergo PCI for ACS. A close surveillance program identified patients at risk for medication cessation or switching and could potentially mitigate this phenomenon and improve quality of care.
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Affiliation(s)
- Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Rebecca Torguson
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Jonathan Abramowitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Corey Shea
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Joseph A Sutton
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Teshome Deksissa
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Nelson L Bernardo
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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15
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Kinlay S, Young MM, Sherrod R, Gagnon DR. Long-Term Outcomes and Duration of Dual Antiplatelet Therapy After Coronary Intervention With Second-Generation Drug-Eluting Stents: The Veterans Affairs Extended DAPT Study. J Am Heart Assoc 2023; 12:e027055. [PMID: 36645075 PMCID: PMC9939065 DOI: 10.1161/jaha.122.027055] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/04/2022] [Indexed: 01/17/2023]
Abstract
Background Recent guidelines on dual antiplatelet therapy (DAPT) duration after percutaneous coronary intervention (PCI) balance the subsequent risks of major bleeding with ischemic events. Although generally favoring shorter DAPT duration with second-generation drug-eluting stents, the effects on long-term outcomes in the wider population are uncertain. Methods and Results We tracked all patients having PCI with second-generation drug-eluting stents in the Veterans Affairs Healthcare System between 2006 and 2016 for death, myocardial infarction, stroke, and major bleeding up to 13 years. We compared these outcomes with 4 DAPT durations of 1 to 5, 6 to 9, 10 to 12, and 13 to 18 months after the index PCI using hazard ratios (HRs) and 95% CIs from Cox proportional hazards models adjusted by inverse probability weighting. A total of 40 882 subjects with PCI were followed up for a median of 4.3 (25%-75%: 2.4-6.5) years. DAPT discontinuation was rare early after PCI (5.8% at 1-5 months and 6.3% at 6-9 months) but increased (19% and 44%) >9 months. The risk of cardiovascular and noncardiovascular death was higher (HR, 2.03-3.41) with DAPT discontinuation <9 months, likely reflecting premature cessation from factors related to early death. DAPT discontinuation after 9 months following PCI was associated with lower risks of death (HR, 0.93 [95% CI, 0.88-0.99]), cardiac death (HR, 0.79 [95% CI, 0.70-0.90]), myocardial infarction (HR, 0.75 [95% CI, 0.69-0.82]), and major bleeding (HR, 0.82 [95% CI, 0.74-0.91]). Results were similar with an index PCI for an acute coronary syndrome. Conclusions Stopping DAPT after 9 months is associated with lower long-term risks of adverse ischemic and bleeding events and supports recent guidelines of shorter duration DAPT after PCI with second-generation drug-eluting stents.
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Affiliation(s)
- Scott Kinlay
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Harvard Medical SchoolBostonMA
- Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA
- Brigham and Women’s HospitalBostonMA
- Boston University Medical SchoolBostonMA
| | - Melissa M. Young
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA
| | | | - David R. Gagnon
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of Biostatistics, Massachusetts Veterans Epidemiology Research & Information Center (MAVERIC)VA Boston Healthcare SystemBostonMA
- Boston University School of Public HealthBostonMA
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16
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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.
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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
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Perioperative Management of Antiplatelet Therapy: A Systematic Review and Meta-analysis. Mayo Clin Proc Innov Qual Outcomes 2022; 6:564-573. [PMID: 36304523 PMCID: PMC9594114 DOI: 10.1016/j.mayocpiqo.2022.09.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To summarize the available evidence about the perioperative management of patients who are receiving long-term antiplatelet therapy and require elective surgery/procedures. METHODS This systematic review supports the development of the American College of Chest Physicians guideline on the perioperative management of antiplatelet therapy. A literature search of MEDLINE, EMBASE, Scopus and Cochrane databases was conducted from each database's inception to July 16, 2020. Meta-analyses were conducted when possible. RESULTS In patients receiving long-term antiplatelet therapy and undergoing elective noncardiac surgery, the available evidence did not show a significant difference in major bleeding between a shorter vs longer antiplatelet interruption, with low certainty of evidence (COE). Compared with patients who received placebo perioperatively, aspirin continuation was associated with increased risk of major bleeding (relative risk [RR], 1.31; 95% CI, 1.15-1.50; high COE) and lower risk of major thromboembolism (RR, 0.74; 95% CI, 0.58-0.94; moderate COE). During antiplatelet interruption, bridging with low-molecular-weight heparin was associated with increased risk of major bleeding compared with no bridging (RR, 1.86; 95% CI, 1.24-2.79; very low COE). Continuation of antiplatelets during minor dental and ophthalmologic procedures was not associated with a statistically significant difference in the risk of major bleeding (very low COE). CONCLUSION This systematic review summarizes the current evidence about the perioperative management of antiplatelet therapy and highlights the urgent need for further research, particularly with the increasing prevalence of patients taking 1 or more antiplatelet agents.
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Key Words
- ACCP/CHEST, American College of Chest Physicians
- ASA, acetylsalicylic acid
- ATE, arterial thromboembolism
- CABG, coronary artery bypass graft
- COE, certainty of evidence
- CV, cardiovascular
- DES, drug-eluting stent
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- PE, pulmonary embolism
- PICO, patients–interventions–comparators–outcomes
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT, randomized clinical trial
- RR, relative risk
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18
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Rymer JA, Kaltenbach LA, Peterson ED, Cohen DJ, Fonarow GC, Choudhry NK, Henry TD, Cannon CP, Wang TY. Does the Effectiveness of a Medicine Copay Voucher Vary by Baseline Medication Out-Of-Pocket Expenses? Insights From ARTEMIS. J Am Heart Assoc 2022; 11:e026421. [PMID: 36250667 DOI: 10.1161/jaha.122.026421] [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] [Indexed: 11/16/2022]
Abstract
Background Persistence to P2Y12 inhibitors after myocardial infarction (MI) remains low. Out-of-pocket cost is cited as a factor affecting medication compliance. We examined whether a copayment intervention affected 1-year persistence to P2Y12 inhibitors and clinical outcomes. Methods and Results In an analysis of ARTEMIS (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study), patients with MI discharged on a P2Y12 inhibitor were stratified by baseline out-of-pocket medication burden: low ($0-$49 per month), intermediate ($50-$149 per month), and high (≥$150 per month). The impact of the voucher intervention on 1-year P2Y12 inhibitor persistence was examined using a logistic regression model with generalized estimating equations. We assessed the rates of major adverse cardiovascular events among the groups using a Kaplan-Meier estimator. Among 7351 MI-treated patients at 282 hospitals, 54.2% patients were in the low copay group, 32.0% in the middle copay group, and 13.8% in the high copay group. Patients in higher copay groups were more likely to have a history of prior MI, heart failure, and diabetes compared with the low copay group (all P<0.0001). Voucher use was associated with a significantly higher likelihood of 1-year P2Y12 inhibitor persistence regardless of copayment tier (low copay with versus without voucher: adjusted odds ratio [OR], 1.44 [95% CI, 1.25-1.66]; middle copay: adjusted OR, 1.63 [95% CI, 1.37-1.95]; high copay group: adjusted OR, 1.41 [95% CI, 1.05-1.87]; P interaction=0.42). Patients in the high copay group without a voucher had similar risk of 1-year major adverse cardiovascular events compared with patients in the high copay group with a voucher (adjusted hazard ratio, 0.89 [95% CI, 0.66-1.21]). Conclusions Medication copayment vouchers were associated with higher medication persistence at 1 year following an MI, regardless of out-of-pocket medication burden. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02406677.
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Affiliation(s)
- Jennifer A Rymer
- Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
| | | | | | - David J Cohen
- Cardiovascular Research Foundation New York NY.,St. Francis Hospital Roslyn NY
| | - Gregg C Fonarow
- University of California Los Angeles Medical Center Los Angeles CA
| | | | | | | | - Tracy Y Wang
- Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
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19
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Fiocca L, Rossini R, Carioli G, Carobbio A, Piazza I, Collaku E, Giubilato S, Amico F, Molfese M, De Benedictis M, Calabria P, Limbruno U, Valente S, Ferlini M, Spezzano T, Senni M, Gavazzi A. Adherence of ticagrelOr in real world patients with aCute coronary syndrome: The AD-HOC study. IJC HEART & VASCULATURE 2022; 42:101092. [PMID: 35873861 PMCID: PMC9301572 DOI: 10.1016/j.ijcha.2022.101092] [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: 04/25/2022] [Revised: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 10/24/2022]
Abstract
Background Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor antagonist is the cornerstone of therapy in patients with acute coronary syndrome (ACS). Adherence to medical therapy is an important issue, as premature DAPT discontinuation increases the risk of new ischemic events. The aim of the present observational prospective multicenter study was to evaluate in the real-world incidence and discontinuation patterns of ticagrelor during the first 12 months after ACS. Methods We analyzed 431 ACS patients, discharged with ticagrelor, by 7 Italian centers. The primary end-point was the incidence of cessation of ticagrelor up to 12 months from the index event. Results Definitive ticagrelor cessations occurred in 52 patients (12.1%), of which 35 were discontinuations (clinically driven) and 17 disruptions (due to acute events). Temporary cessation occurred in 14 cases (3.3%). Age ≥ 80 years and anticoagulant therapy were independent predictors of premature discontinuation. Bleeding occurred in 74 patients, of which 25 suffered a BARC ≥ 2 bleeding event. Bleeding were more frequent in female sex (27.0% vs 17.2%, p-value 0.049) and in patients with a history of bleeding (8.1% vs 2.9%, p-value 0.035). Conclusions Our study found that the adherence to DAPT with ticagrelor after an ACS is still an important issue, premature discontinuation occurred mainly in fragile patients, like elderly, who suffered a previous bleeding or underwent previous percutaneous coronary intervention.
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Affiliation(s)
- Luigi Fiocca
- Cardiovascular Department, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Roberta Rossini
- Division of Cardiology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Greta Carioli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Isabelle Piazza
- Cardiovascular Department, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Elona Collaku
- Cardiovascular Department, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Simona Giubilato
- Division of Cardiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Francesco Amico
- Division of Cardiology, Azienda Ospedaliera Cannizzaro, Catania, Italy
| | - Maria Molfese
- Division of Cardiology, E.O. Ospedali Galliera, Genova, Italy
| | | | - Paolo Calabria
- UOSD Emodinamica, Ospedale della Misericordia, Grosseto, Italy
| | - Ugo Limbruno
- UOSD Emodinamica, Ospedale della Misericordia, Grosseto, Italy
| | - Serafina Valente
- Cardiothoracic and Vascular Department, AOU Careggi, Firenze, Italy
| | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Tiziana Spezzano
- Division of Cardiology, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Michele Senni
- Cardiovascular Department, ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Antonello Gavazzi
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
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20
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Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, Christensen MK, Butt JH, Gislason G, Køber L, Fosbøl EL, Sessa M, Bhatt DL, Torp-Pedersen C, Pareek M. Effectiveness and safety of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a nationwide registry-based study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:697-705. [PMID: 35950769 DOI: 10.1093/ehjacc/zuac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS To compare the effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS Nationwide, registry-based study of STEMI patients treated with primary PCI (2011-17) and subsequently with aspirin and a P2Y12 inhibitor. The effectiveness outcome was major adverse cardiovascular events (MACE) defined as a composite of recurrent myocardial infarction, repeat revascularization, stroke, or cardiovascular death at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate absolute and relative risks for outcomes standardized to the distributions of demographic characteristics of all included subjects. We included 10 832 patients; 1 697 were treated with clopidogrel, 7 508 with ticagrelor, and 1,627 with prasugrel. Median ages were 66, 63, and 59 years (P < 0.001). Standardized relative risks of MACE were 0.75 for ticagrelor vs. clopidogrel (95% confidence interval [CI], 0.64-0.83), 0.84 for prasugrel vs. clopidogrel (95% CI, 0.73-0.94), and 1.12 for prasugrel vs. ticagrelor (95% CI, 1.00-1.24). Standardized relative risks of bleeding were 0.77 for ticagrelor vs. clopidogrel (95% CI, 0.59-0.93), 0.89 for prasugrel vs. clopidogrel (95% CI, 0.64-1.15), and 1.17 for prasugrel vs. ticagrelor (95% CI, 0.89-1.45). CONCLUSION Ticagrelor and prasugrel were associated with lower risks of MACE after STEMI than clopidogrel, and ticagrelor was associated with a marginal reduction compared with prasugrel. The risk of bleeding was lower with ticagrelor compared with clopidogrel, but did not significantly differ between ticagrelor and prasugrel.
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Affiliation(s)
- Sissel J Godtfredsen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Peter Leutscher
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Steen Hylgaard Jørgensen
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Martin Kirk Christensen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Jagtvej 160 Building 22, 2100 Copenhagen, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
| | - Christian Torp-Pedersen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
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21
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LaRosa AR, Swabe GM, Magnani JW. Income and antiplatelet adherence following percutaneous coronary intervention. INTERNATIONAL JOURNAL OF CARDIOLOGY CARDIOVASCULAR RISK AND PREVENTION 2022; 14:200140. [PMID: 36060289 PMCID: PMC9434414 DOI: 10.1016/j.ijcrp.2022.200140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 11/29/2022]
Abstract
Objective To investigate the relation of annual household income to antiplatelet adherence following PCI. Background Treatment with 6–12 months of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) is a Class I recommendation. Adherence to these medications is essential to reduce risk of stent thrombosis and recurrent ischemic events. Social risk factors like household income modify how patients access and adhere to essential pharmacologic therapies such as antiplatelet agents. Methods We identified individuals presenting with PCI in an administrative claims database of commercially insured and Medicare Advantage beneficiaries from 2017 to 2019. We collected data on age, sex, race, ethnicity, educational attainment, and covariates (prevalent coronary disease, medications, healthcare visits, insurance type, copay, antiplatelet medications, and Elixhauser Comorbidity Index conditions). We related annual household income, categorized as <$40,000; $40–49,999; $50–59,999; $60–74,999; $75–99,999; and ≥$100 K, to proportion of days covered (PDC) in multivariable-adjusted regression models. We defined non-adherence as PDC <80%. Results Our dataset included 90,163 individuals (age 69.0 ± 10.9 years, 33.1% women, 25.1% non-White race) who underwent PCI. We observed graded, decreased antiplatelet adherence across income categories: rates of PDC≥80% decreased with successively lower income. Individuals with annual income <$40,000 had 1.5-fold higher odds of non-adherence (95% CI, 1.40–1.56) compared to those with income ≥$100,000 after multivariable adjustment. Conclusions In a claims-based analysis, we determined that lower income is associated with decreased likelihood of adherence to antiplatelet agents following PCI. Our results indicate the importance of considering social risk factors in the evaluation of barriers to antiplatelet adherence following PCI.
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Affiliation(s)
| | | | - Jared W. Magnani
- Corresponding author. Department of Medicine, Division of Cardiology, UPMC Heart and Vascular Institute, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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22
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Pollack CV, Steg PG, James S, Jolly S, Kosiborod M, Bonaca MP. International Perspectives on the Impact of the COVID-19 Pandemic on Adherence to Prescribed Dual Antiplatelet Therapy: A Window Into Acute Cardiovascular Care. Crit Pathw Cardiol 2022; 21:114-122. [PMID: 35994719 PMCID: PMC9389943 DOI: 10.1097/hpc.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
An international panel of expert clinicians and researchers in acute cardiac care was convened to review, describe, and contextualize their varied experiences delivering care and maintaining ongoing research during the first year of the COVID-19 pandemic and beyond. A proposed perspective from which care and outcomes could be viewed was the possibility that without routine follow-up and as-accustomed interactions with their care team, patients at risk of acute atherothrombotic events might be less adherent to prescribed antiplatelet medications. This might be manifested by more emergency coronary events or by an increased (and perhaps unidentifiable) incidence of out-of-hospital cardiovascular deaths related to patient anxiety about presenting to hospital during the pandemic. The experiences of the panel members were similar in many regards, which identified opportunities for improvement in cardiac care the next time there is a substantial disruption of usual practice. Regardless of geography or payor system, there was an identified need for better remote care platforms; but stronger infrastructure and consumer facility with remote care technology, improved provider-patient communication to help ensure adherence to primary and secondary prevention medications, and longer-term prescription fills and no-hassle refills on such medications. Profound disruptions in acute cardiovascular research highlighted the need for redundancy or back-up planning for teams engaged in time-sensitive research, to ensure both continuity of protocols and patient safety.
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Affiliation(s)
| | | | | | - Sanjit Jolly
- Cardiology, McMaster University, Hamilton, ON, Canada
| | - Mikhail Kosiborod
- Cardiology, Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO
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23
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Garcia RA, Spertus JA, Benton MC, Jones PG, Mark DB, Newman JD, Bangalore S, Boden WE, Stone GW, Reynolds HR, Hochman JS, Maron DJ. Association of Medication Adherence With Health Outcomes in the ISCHEMIA Trial. J Am Coll Cardiol 2022; 80:755-765. [PMID: 35981820 PMCID: PMC10548342 DOI: 10.1016/j.jacc.2022.05.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/27/2022] [Accepted: 05/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial randomized participants with chronic coronary disease (CCD) to guideline-directed medical therapy with or without angiography and revascularization. The study examined the association of nonadherence with health status outcomes. OBJECTIVES The study sought to compare 12-month health status outcomes of adherent and nonadherent participants with CCD with an a priori hypothesis that nonadherent patients would have better health status if randomized to invasive management. METHODS Self-reported medication-taking behavior was assessed at randomization with a modified 4-item Morisky-Green-Levine Adherence Scale, and participants were classified as adherent or nonadherent. Twelve-month health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ-7) summary score (SS), which ranges from 0 to 100 (higher score = better). The association of adherence with outcomes was evaluated using Bayesian proportional odds models, including an interaction by study arm (conservative vs invasive). RESULTS Among 4,480 randomized participants, 1,245 (27.8%) were nonadherent at baseline. Nonadherent participants had worse baseline SAQ-7 SS in both conservative (72.9 ± 19.3 vs 75.6 ± 18.4) and invasive (71.0 ± 19.8 vs 74.2 ± 18.7) arms. In adjusted analyses, adherence was associated with higher 12-month SAQ-7 SS in both treatment groups (mean difference in SAQ-7 SS with conservative treatment = 1.6 [95% credible interval: 0.3-2.9] vs with invasive management = 1.9 [95% credible interval: 0.8-3.1]), with no interaction by treatment. CONCLUSIONS More than 1 in 4 participants reported medication nonadherence, which was associated with worse health status in both conservative and invasive treatment strategies at baseline and 12 months. Strategies to improve medication adherence are needed to improve health status outcomes in CCD, regardless of treatment strategy. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- R Angel Garcia
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John A Spertus
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA.
| | - Mary C Benton
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Philip G Jones
- Cardiovascular Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA; Department of Biomedical and Health Informatics, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan D Newman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - William E Boden
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gregg W Stone
- Department of Medicine (Cardiology) and Population Health Science and Policy, Mount Sinai Hospital, New York, New York, USA
| | - Harmony R Reynolds
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Judith S Hochman
- Department of Cardiology, NYU Langone Health, NYU Grossman School of Medicine, New York, New York, USA
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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24
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Schwalm JD, Ivers NM, Bouck Z, Taljaard M, Natarajan MK, Nguyen F, Hijazi W, Thavorn K, Dolovich L, McCready T, O'Brien E, Grimshaw JM. Length of initial prescription at hospital discharge and long-term medication adherence for elderly, post-myocardial infarction patients: a population-based interrupted time series study. BMC Med 2022; 20:213. [PMID: 35725542 PMCID: PMC9210591 DOI: 10.1186/s12916-022-02401-5] [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: 10/05/2021] [Accepted: 05/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preliminary evidence suggests that providing longer duration prescriptions at discharge may improve long-term adherence to secondary preventative cardiac medications among post-myocardial infarction (MI) patients. We implemented and assessed the effects of two hospital-based interventions-(1) standardized prolonged discharge prescription forms (90-day supply with 3 repeats for recommended cardiac medications) plus education and (2) education only-on long-term cardiac medication adherence among elderly patients post-MI. METHODS We conducted an interrupted time series study of all post-MI patients aged 65-104 years in Ontario, Canada, discharged from hospital between September 2015 and August 2018 with ≥ 1 dispensation(s) for a statin, beta blocker, angiotensin system inhibitor, and/or secondary antiplatelet within 7 days post-discharge. The standardized prolonged discharge prescription forms plus education and education-only interventions were implemented at 2 (1,414 patients) and 4 (926 patients) non-randomly selected hospitals in September 2017 for 12 months, with all other Ontario hospitals (n = 143; 18,556 patients) comprising an external control group. The primary outcome, long-term cardiac medication adherence, was defined at the patient-level as an average proportion of days covered (over 1-year post-discharge) ≥ 80% across cardiac medication classes dispensed at their index fill. Primary outcome data were aggregated within hospital groups (intervention 1, 2, or control) to monthly proportions and independently analyzed using segmented regression to evaluate intervention effects. A process evaluation was conducted to assess intervention fidelity. RESULTS At 12 months post-implementation, there was no statistically significant effect on long-term cardiac medication adherence for either intervention-standardized prolonged discharge prescription forms plus education (5.4%; 95% CI - 6.4%, 17.2%) or education only (1.0%; 95% CI - 28.6%, 30.6%)-over and above the counterfactual trend; similarly, no change was observed in the control group (- 0.3%; 95% CI - 3.6%, 3.1%). During the intervention period, only 10.8% of patients in the intervention groups received ≥ 90 days, on average, for cardiac medications at their index fill. CONCLUSIONS Recognizing intervention fidelity was low at the pharmacy level, and no statistically significant post-implementation differences in adherence were found, the trends in this study-coupled with other published retrospective analyses of administrative data-support further evaluation of this simple intervention to improve long-term adherence to cardiac medications. TRIAL REGISTRATION ClinicalTrials.gov : NCT03257579 , registered June 16, 2017 Protocol available at: https://pubmed.ncbi.nlm.nih.gov/33146624/ .
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Affiliation(s)
- J D Schwalm
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, DBCVSRI, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada. .,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Noah M Ivers
- Family Practice Health Centre, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Zachary Bouck
- Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Toronto, ON, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, DBCVSRI, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Waseem Hijazi
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Tara McCready
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, DBCVSRI, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
| | - Erin O'Brien
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, DBCVSRI, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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25
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Zhang X, Jing J, Zhao X, Liu L, Wang A, Pan Y, Wang D, Johnston SC, Wang Y, Wang Y, Meng X. No rebound effect after a course of clopidogrel in patients with acute TIA or minor stroke. Neurol Res 2022; 44:957-963. [PMID: 35695332 DOI: 10.1080/01616412.2022.2075660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies demonstrated that discontinuation of clopidogrel in patients after ACS was associated with a rebound increase in risk of recurrent events. In this study, we aimed to investigate the rebound effect after discontinuation of clopidogrel therapy in patients with TIA or stroke. METHODS All patients with minor stroke or TIA were recruited from the Clopidogrel in High-Risk Patients With Acute Nondisabling Cerebrovascular Events (CHANCE) trial. Patients were divided into two groups: patients who discontinued clopidogrel and switched to aspirin therapy (Clopidogrel Discontinuation Group) and patients who continued one mono-antiplatelet therapy (non-Clopidogrel Discontinuation Group) during 90-180 days. The outcomes included risks of recurrent ischemic stroke, recurrent TIA, and composite events during 90-180 days. The prevalence of each outcome was compared between two groups for every 30 days. Further subgroup analysis was conducted in patients with and without CYP2C19 loss-of-function alleles. RESULTS Among the 3456 patients included, a total of 10 patients in the Clopidogrel Discontinuation Group and 11 patients in the non-Clopidogrel Discontinuation Group presented ischemic stroke recurrence during the 90-180-day period. The inter-group comparisons were not significant in each 30 days. Similar results were found for recurrent stroke, recurrent TIA, and composite events in these two groups, which were also found in CYP2C19 subgroup analysis. CONCLUSIONS No rebound increase in the risk of ischemic stroke and composite events was found during the 90 days after discontinuation of clopidogrel therapy in patients with TIA or minor stroke in the CHANCE trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00979589.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jing Jing
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Az, USA
| | | | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- Department of Neurology, Beijing Tiantan Hospital Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Pietrzykowski Ł, Kasprzak M, Michalski P, Kosobucka A, Fabiszak T, Kubica A. The influence of patient expectations on adherence to treatment regimen after myocardial infarction. PATIENT EDUCATION AND COUNSELING 2022; 105:426-431. [PMID: 34059362 DOI: 10.1016/j.pec.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 04/21/2021] [Accepted: 05/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE In-hospital patient education is one of the elements affecting patient adherence to treatment regimen after myocardial infarction (MI). Its effectiveness is determined by educator and patient-dependent factors. Previous studies did not identify patient expectations as an independent determinant of successful education. The aim of this study was to assess whether patient knowledge and expectations affect adherence to treatment regimen in a 1-year follow-up. METHODS This was a single-center, cohort study with a 1-year follow-up. Patient knowledge and expectations were evaluated using the Readiness for Hospital Discharge after Myocardial Infarction Scale (RHD-MIS scale). Medication adherence (including angiotensin converting enzyme inhibitors (ACEI), P2Y12 receptor inhibitors and statins) was verified based on prescription refill data extracted from The National Health Fund database. RESULTS The study included 225 patients aged 30-91 years (mean age 62.9 ± 11.9 years). In the 4th quarter of follow-up, patients with the highest expectations had lower adherence regarding ACEI (p = 0.01), P2Y12 receptor inhibitors (p = 0.03) and the combination of all three analysed medications (p = 0.003). CONCLUSIONS The initial results suggest presence of a relationship between patient expectations and long-term adherence to treatment. PRACTICE IMPLICATIONS Post-MI patient education directed at fulfilling or modification of patient expectations could possibly improve execution of treatment regimen.
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Affiliation(s)
- Łukasz Pietrzykowski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
| | - Michał Kasprzak
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
| | - Piotr Michalski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
| | - Agata Kosobucka
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
| | - Tomasz Fabiszak
- Department of Cardiology and Internal Diseases, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland.
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Riscado LVS, de Pinho JHS, Lobato ADC. Efficacy and safety of tirofiban bridge as an alternative to suspension of dual antiplatelet therapy in patients undergoing surgery: a systematic review. J Vasc Bras 2021; 20:e20210113. [PMID: 34925474 PMCID: PMC8668084 DOI: 10.1590/1677-5449.210113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/08/2021] [Indexed: 11/22/2022] Open
Abstract
Use of a tirofiban bridge is an alternative to simply withdrawing dual antiplatelet therapy prior to operating on patients at high risk of stent thrombosis and bleeding. We aimed to evaluate the efficacy and safety of this protocol in patients undergoing surgery within 12 months of a percutaneous coronary intervention involving stenting. We performed a systematic review based on searches of the PubMed, Web of Science, Cochrane, Embase, Lilacs, and Scielo databases and of the references of relevant articles on the topic. Five of the 107 studies identified were included after application of eligibility criteria and analysis of methodological quality, totaling 422 patients, 227 in control groups. Notwithstanding the limitations reported, four of the five studies included indicate that the tirofiban bridge technique is effective for reducing adverse cardiac events and is safe in terms of not interfering with the risk of hemorrhagic events or bleeding. However, randomized clinical trials are needed to provide robust evidence.
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Tien Hoang A, Quynh Nhu Tran T, Phuong Duy Le C, Ha Vo T. Adherence to dual antiplatelet therapy after coronary stenting: A study conducted at two Vietnamese hospitals. J Cardiovasc Thorac Res 2021; 13:330-335. [PMID: 35047138 PMCID: PMC8749365 DOI: 10.34172/jcvtr.2021.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/04/2021] [Accepted: 11/11/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Adherence to dual antiplatelet therapy (DAPT) is critical after drug-eluting stent(DES) placement. We aimed to assess patient’s knowledge, rates of DAPT adherence, trends in DAPT use over time, and patient‐level factors associated with nonadherence in the patient with acute coronary syndrome (ACS). Methods: ACS patients who received one or more DES between May and September 2018from two hospitals in Vietnam and used DAPT after stent placement were eligible for a direct interview to assess patient’s knowledge on disease and DAPT. Telephone interviews were conducted one, three, and six months following discharge. Nonadherence was defined as premature discontinuation of DAPT. Factors related to nonadherent patients were analyzed using the chi-square test. Results: Of the 200 patients identified, 154 (77%) participated. Of the ten questions related to knowledge, the mean score of correct answers was 8.2 ± 2.3, and 71.7% had good knowledge.Adherence to DAPT was high at one month (94.2%) but declined by three months (44.2%) and then by six months (46.8%). Aspirin adherence was 99.3%-100% throughout. Three factors associated with nonadherence of DAPT following DES placement by six months included: rural location, linactive occupation, and inadequate knowledge on disease and DAPT (p<0.05). Conclusion: DAPT adherence is high at one month but is suboptimal at three and six months.Factors associated with the nonadherence of DAPT will be helpful in the planning of patient education strategies.
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Affiliation(s)
- Anh Tien Hoang
- PCI Unit, Hue University Hospital, Hue, 52000, Vietnam
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue, 52000, Vietnam
| | - Thi Quynh Nhu Tran
- Department of Pharmacy, University of Medicine and Pharmacy, Hue University, Hue, 52000, Vietnam
| | | | - Thi Ha Vo
- Faculty of Pharmacy, Pham Ngoc Thach University of Medicine, Ho Chi Minh, V-70000, Vietnam
- Department of Pharmacy, Nguyen Tri Phuong Hospital, Ho Chi Minh, V-70000, Vietnam
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29
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Petry NJ, Curtis B, Feldhege E, Khan S, Leedahl DD, Breidenbach JL, Hines L. Impact of Automated Best Practice Advisories on Provider Response to CYP2C19 Genotyping Results for Patients on Clopidogrel. J Pharm Pract 2021; 36:487-493. [PMID: 34622701 DOI: 10.1177/08971900211049589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
ObjectiveThe study objective was to examine provider acceptance and genotyping responses to a best practice advisory (BPA) concerning clopidogrel and CYP2C19 intermediate and poor metabolizers within the context of a new pharmacogenomics program at a Midwestern health system. Other secondary objectives analyzed included appropriate BPA firing, the distribution of alleles in study population, indications for clopidogrel use, and impact of indication on therapy change. Methods: In this study, the progress of this program was assessed by quantifying how providers respond to BPAs generated in the electronic medical record (EMR), in the context of a single representative gene-drug-outcome relationship. Patient data was pulled via reports yielding patients with genotyped information in the EMR and cross-referenced with a report evaluating BPA firing occurrences. Results: By capturing antiplatelet therapy changes in response to CYP2C19 genotyping results, 37 patients were found that had 73 BPAs fire. Nine of those patients had alternative antiplatelet therapy ordered. Of these, 6 alternative antiplatelet therapies were ordered from the BPA. Conclusion: Providers utilized BPAs, but responded differently based on individual knowledge of genotypes and indications. Information obtained from this study can be used for provider education and as reference for future design and wording of BPAs.
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Affiliation(s)
- Natasha J Petry
- Department of Pharmacy Practice, School of Pharmacy, College of Health Professions, 3323North Dakota State University, Fargo, ND, USA.,Imagenetics, 24195Sanford Health, Sioux Falls, SD, USA
| | - Breanna Curtis
- Department of Pharmacy, 24195Sanford Health, Fargo, ND, USA
| | - Erica Feldhege
- Department of Pharmacy Practice, School of Pharmacy, College of Health Professions, 3323North Dakota State University, Fargo, ND, USA
| | - Shahjahan Khan
- Department of Internal Medicine, Sanford School of Medicine, 8191University of South Dakota, Sioux Falls, SD, USA
| | | | | | - Lindsay Hines
- Department of Neuropsychology, 24195Sanford Health, Fargo, ND, USA
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30
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Neville HL, Mann K, Killen J, Callaghan M. Pharmacist Intervention to Improve Medication Adherence in Patients with Acute Coronary Syndrome: The PRIMA-ACS Study. Can J Hosp Pharm 2021; 74:350-360. [PMID: 34602623 DOI: 10.4212/cjhp.v74i4.3198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background Despite ample evidence of benefit, adherence to secondary prevention medication therapy after acute coronary syndrome (ACS) is often suboptimal. Hospital pharmacists are uniquely positioned to improve adherence by providing medication education at discharge. Objective To determine whether a standardized counselling intervention at hospital discharge significantly improved patients' adherence to cardiovascular medications following ACS. Methods This single-centre, prospective, nonrandomized comparative study enrolled patients with a primary diagnosis of ACS (January 2014 to July 2015). Patients who received standardized discharge counselling from a clinical pharmacist were compared with patients who did not receive counselling. At 30 days and 1 year after discharge, follow-up patient surveys were conducted and community pharmacy refill data were obtained. Adherence was assessed using pharmacy refill data and patient self-reporting for 5 targeted medications: acetylsalicylic acid, P2Y purinoceptor 12 (P2Y12) inhibitors, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, β-blockers, and statins. Thirty-day and 1-year medication utilization, cardiovascular readmission rates, and all-cause mortality were also assessed. Results Of the 259 patients enrolled, 88 (34.0%) received discharge counselling. Medication data were obtained for 253 patients (97.7%) at 30 days and 242 patients (93.4%) at 1 year. At 1 year after discharge, there were no statistically significant differences between patients who did and did not receive counselling in terms of rates of nonadherence (11.9% versus 18.4%, p = 0.19), cardiovascular readmission (17.6% versus 22.3%, p = 0.42), and all-cause mortality (3.4% versus 4.2%, p > 0.99). Overall medication nonadherence was 2.8% (7/253) at 30 days and 16.1% (39/242) at 1 year. Conclusions Discharge medication counselling provided by hospital pharmacists after ACS was not associated with significantly better medication adherence at 1 year. Higher-quality evidence is needed to determine the most effective and practical interventions to ensure that patients adhere to their medication regimens and achieve positive outcomes after ACS.
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Affiliation(s)
- Heather L Neville
- , BScPharm, MSc, FCSHP, is with Nova Scotia Health, Halifax, Nova Scotia
| | - Kelsey Mann
- , BScPharm, was, at the time of this study, with Nova Scotia Health, Halifax, Nova Scotia
| | - Jessica Killen
- , BScPharm, ACPR, is with Nova Scotia Health, Halifax, Nova Scotia
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31
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B, Yoon DH. Prevalence and associated factors of premature discontinuation of antiplatelet therapy after ischemic stroke: a nationwide population-based study. BMC Neurol 2021; 21:349. [PMID: 34507550 PMCID: PMC8431917 DOI: 10.1186/s12883-021-02384-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND We tried to evaluate the prevalence of premature discontinuation of antiplatelets and its affecting factors after ischemic stroke using large-sized representative national claims data. METHODS Patients aged 20 years or older with newly confirmed ischemic stroke who started aspirin or clopidogrel for the first time were selected from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of South Korea (n = 4621), a randomly collected sample which accounts for 2.2% (n = 1,017,468) of total population (n = 46,605,433). The prevalence of discontinuation of antiplatelets was measured every 6 months until the 24 months since the first prescription. Then we classified the participants into 2 groups according to the discontinuation status at 12 months and assessed the factors influencing premature discontinuation of antiplatelets within 12 months. RESULTS Among total participants, 35.5% (n = 1640) discontinued antiplatelets within 12 months and 58.5% (n = 2704) discontinued them within 24 months. The remaining 41.5% (n = 1917) continued them for 24 months or more. In the multivariate logistic regression analysis, initiating treatment with aspirin monotherapy [adjusted OR (aOR), 2.66, 95% CI 2.17-3.25] was the most prominent determinant of premature discontinuation within 12 months followed by CCI score ≥ 6 (aOR 1.50, 95% CI 1.31-1.98), and beginning treatment with clopidogrel monotherapy (aOR 1.41, 95% CI 1.15-1.72). Rural residency (aOR 1.36, 95% CI 1.14-1.62), < 4 total prescribed drugs (aOR 1.24, 95% CI 1.05-1.47), lower income (aOR 1.20, 95% CI 1.03-1.40 for middle income class and OR 1.21, 95% CI 1.02-1.45 for low income class), and ages ≥70 years (aOR 1.15, 95% CI 1.00-1.31) were also significantly associated with premature discontinuation of antiplatelets within 12 months. CONCLUSIONS The prevalence of premature discontinuation of antiplatelets after ischemic stroke was quite high. Thus, by understanding factors associated with premature discontinuation, a more strategic approach is required for the physicians to improve persistence with antiplatelets.
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Affiliation(s)
- Seung Jae Kim
- International Healthcare Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 06591, Republic of Korea
| | | | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea.
- Nuvizen, Palo Alto, California, 94303, USA.
| | - Eung-Joon Lee
- Institute of Public Health and Medical Care, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
- Department of Neurology, Seoul National University Hospital, Seoul, 03080, Republic of Korea.
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Dae Hyun Yoon
- Department of Psychiatry, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul, 06236, Republic of Korea
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32
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Glasgow RE, Knoepke CE, Magid D, Grunwald GK, Glorioso TJ, Waughtal J, Marrs JC, Bull S, Ho PM. The NUDGE trial pragmatic trial to enhance cardiovascular medication adherence: study protocol for a randomized controlled trial. Trials 2021; 22:528. [PMID: 34380527 PMCID: PMC8356469 DOI: 10.1186/s13063-021-05453-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 07/13/2021] [Indexed: 11/30/2022] Open
Abstract
Background Nearly half of patients do not take their cardiovascular medications as prescribed, resulting in increased morbidity, mortality, and healthcare costs. Mobile and digital technologies for health promotion and disease self-management offer an opportunity to adapt behavioral “nudges” using ubiquitous mobile phone technology to facilitate medication adherence. The Nudge pragmatic clinical trial uses population-level pharmacy data to deliver nudges via mobile phone text messaging and an artificial intelligent interactive chat bot with the goal of improving medication adherence and patient outcomes in three integrated healthcare delivery systems. Methods The Theory of mHealth, the Expanded RE-AIM/PRISM, and the PRECIS-2 frameworks were used for program planning, implementation, and evaluation, along with a focus on dissemination and cost considerations. During the planning phase, the Nudge study team developed and piloted a technology-based nudge message and chat bot of optimized interactive content libraries for a range of diverse patients. Inclusion criteria are very broad and include patients in one of three diverse health systems who take medications to treat hypertension, atrial fibrillation, coronary artery disease, diabetes, or hyperlipidemia. A target of approximately 10,000 participants will be randomized to one of 4 study arms: usual care (no intervention), generic nudge (text reminder), optimized nudge, and optimized nudge plus interactive AI chat bot. The PRECIS-2 tool indicated that the study protocol is very pragmatic, although there is variability across PRECIS-2 dimensions. Discussion The primary effectiveness outcome is medication adherence defined by the proportion of days covered (PDC) using pharmacy refill data. Implementation outcomes are assessed using the RE-AIM framework, with a particular focus on reach, consistency of implementation, adaptations, cost, and maintenance/sustainability. The project has limitations including limited power to detect some subgroup effects, medication complications (bleeding), and longer-term outcomes (myocardial infarction). Strengths of the study include the diverse healthcare systems, a feasible and generalizable intervention, transparent reporting using established pragmatic research and implementation science frameworks, strong stakeholder engagement, and planning for dissemination and sustainment. Trial registration ClinicalTrials.govNCT03973931. Registered on 4 June 2019. The study was funded by the NIH; grant number is 4UH3HL144163-02 issued 4/5/19. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05453-9.
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Affiliation(s)
- Russell E Glasgow
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Denver, USA. .,Dissemination and Implementation Science Program of ACCORDS (Adult and Child Consortium for Health Outcomes Research and Delivery Science), Aurora, USA.
| | - Christopher E Knoepke
- Department of Medicine, Division of Cardiology, University of Colorado Denver - Anschutz Medical Campus, Denver, USA.,ACCORDS (Adult and Child Consortium for Health Outcomes Research and Delivery Science), Aurora, USA
| | - David Magid
- University of Colorado Denver - Anschutz, Denver, USA
| | - Gary K Grunwald
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver, USA.,U.S. Department of Veterans Affairs, Washington, DC, USA
| | | | - Joy Waughtal
- mHealth Impact Laboratory Colorado School of Public Health, Aurora, USA
| | - Joel C Marrs
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Sheana Bull
- mHealth Impact Laboratory Colorado School of Public Health, Aurora, USA.,Department of Community and Behavioral Health, Aurora, USA.,Digital Education, Denver, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado School of Medicine, Aurora, USA.,VA Eastern Colorado Health Care System, Aurora, USA
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Romagnoli A, Santoleri F, Costantini A. Adherence and persistence analysis in patients treated with double antiplatelet therapy (DAPT) at two years in real life. PATIENT EDUCATION AND COUNSELING 2021; 104:2012-2017. [PMID: 33461875 DOI: 10.1016/j.pec.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/09/2020] [Accepted: 01/05/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Double antiplatelet therapy (DAPT) is indicated for the treatment of coronary artery diseases (CAD). The optimal duration of therapy with DAPT continues to be a subject of debate in the scientific community. To improve adherence to DAPT, the FDC (fixed dose combination) of Acetylsalicylic acid (ASA) and clopidogrel was developed into a single pill instead of two separate pills thus facilitating the dosage and administration of the therapy and increasing compliance. The aim of this study was to assess adherence and persistence over a period of two years in patients treated with DAPT composed of: ASA/clopidogrel, ASA/prasugrel, ASA/ticagrelor and FDC with ASA and clopidogrel in real life and to assess whether the use of ASA and clopidogrel FDC is associated with improved adherence. MATERIALS AND METHODS In the following retrospective pharmacological-observational non-interventional study, all patients treated with DAPT in the Hospital of Pescara from January 2010 to October 2019 were considered. Persistence to treatment is defined as the duration of time from initiation to discontinuation of treatment. Adherence was calculated as the ratio between Received Daily Dose (RDD) and Prescribed Daily Dose (PDD). RESULTS 277 patients treated with ASA/clopidogrel, 77 patients treated with ASA/prasugrel, 57 patients treated with ASA/ticagrelor and 108 patients treated with FDC of ASA/clopidogrel were analysed. Persistence curves at two years showed a statistically significant difference (p < 0.001). Adherence to therapy was optimal with an absolute value at two years of 0.96. Adherence was better in patients treated with ASA/prasugrel with a value of 0.98 and with 97 % of patients with an adherence value greater than or equal to 0.8, while, it was worse in patients treated with FDC ASA/clopidogrel with an absolute value of 0.94 and with 88 % of patients with an optimal adherence value. No statistically significant difference was found between the ASA/clopidogrel FDC in comparison to each component taken as a separate pill (p = 0.0752). CONCLUSION DAPT along with ASA/clopidogrel showed a statistically significant better persistence than ASA/ticagrelor and ASA/prasugrel. Whereas, to our knowledge and as per the current literature no statistically significant differences were found, in terms of adherence in real life, between the use of ASA/Clopidogrel FDC and the use of two different pills.
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Affiliation(s)
- Alessia Romagnoli
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
| | - Fiorenzo Santoleri
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
| | - Alberto Costantini
- Hospital Pharmacy of "SS. Spirito" Hospital of Pescara, Address Renato Paolini 47, 65124, Pescara, Italy.
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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.
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35
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Partow-Navid R, Prasitlumkum N, Mukherjee A, Varadarajan P, Pai RG. Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings. Int J Angiol 2021; 30:67-75. [PMID: 34025097 DOI: 10.1055/s-0041-1723944] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.
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Affiliation(s)
- Rod Partow-Navid
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Narut Prasitlumkum
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ashish Mukherjee
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Padmini Varadarajan
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
| | - Ramdas G Pai
- Department of Cardiology, St Bernardine Medical Center, San Bernardino, California.,UC Riverside School of Medicine, Riverside, California
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36
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Diab S, Arazi M, Sternik L, Raanani E, Kachel E, Grosman-Rimon L, Shalabi A, Amir O, Carasso S. Coronary artery bypass graft surgery in patients on ticagrelor therapy is not associated with adverse perioperative outcomes. J Cardiothorac Surg 2021; 16:139. [PMID: 34022927 PMCID: PMC8141141 DOI: 10.1186/s13019-021-01521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Management of patients treated with Ticagrelor is challenging, as stopping Ticagrelor prior to coronary bypass graft surgery (CABG) may increase the risk of acute stent thrombosis. The aim of the study was to compare bleeding complications in patients treated with ticagrelor combined with acetylsalicylic acid (ASA) versus ASA alone until 1 day before surgery. METHODS Bleeding complications, defined as the composite of red blood cell transfusion ≥1000 ml, chest drainage ≥2000 ml, and bleeding requiring surgical re-exploration, were compared in 161 patients, with 101 on preoperative acetylsalicylic acid (ASA) alone (group A) and 65 on ticagrelor + ASA (group B). RESULTS There were no differences in bleeding complications between the two groups (26% vs. 27% in group A and B, respectively), with similar chest drainage in the first 24 h (569 ± 393 ml and 649 ± 427 ml, respectively). CONCLUSIONS Continuing ticagrelor until coronary artery bypass surgery was not associated with increased bleeding complications, suggesting that continued management with ticagrelor until surgery may be safe.
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Affiliation(s)
- Sammer Diab
- Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, Tiberias, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Mattan Arazi
- Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Leonid Sternik
- Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ehud Raanani
- Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Erez Kachel
- Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, Tiberias, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Liza Grosman-Rimon
- Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, Tiberias, Israel
| | - Amjad Shalabi
- Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, Tiberias, Israel
| | - Offer Amir
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.,Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shemy Carasso
- Division of Cardiovascular Medicine and Surgery, Poriya Medical Center, Tiberias, Israel. .,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel.
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37
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Kinlay S, Quach L, Cormack J, Morgenstern N, Hou Y, Young M, Sherrod R, Cho K, Faxon DP, Ramadan R, Gaziano M, Gagnon D. Premature Discontinuation of Dual Antiplatelet Therapy After Coronary Stenting in Veterans: Characteristics and Long-Term Outcomes. J Am Heart Assoc 2021; 10:e018481. [PMID: 33899501 PMCID: PMC8200740 DOI: 10.1161/jaha.120.018481] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/04/2021] [Indexed: 11/30/2022]
Abstract
Background Premature discontinuation of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention is related to higher short-term risks of adverse outcomes. Whether these risks persist in the long-term is uncertain. Methods and Results We assessed all patients having percutaneous coronary intervention with coronary second- or first-generation drug-eluting stents in the Veterans Affairs healthcare system between 2006 and 2012 who were free of major ischemic or bleeding events in the first 12 months. The characteristics of patients who stopped DAPT prematurely (1-9 months duration), compared with >9 to 12 months, or extended duration (>12 months) were assessed by odds ratios (ORs) from multivariable logistic models. The risk of adverse clinical outcomes over a mean 5.1 years in patients who stopped DAPT prematurely was assessed by hazard ratios (HRs) and 95% CIs from Cox regression models. A total of 14 239 had second-generation drug-eluting stents, and 8583 had first-generation drug-eluting stents. Premature discontinuation of DAPT was more likely in Black patients (OR, 1.54; 95% CI, 1.40-1.68), patients with greater frailty (OR, 1.04; 95% CI, 1.03-1.05), and patients with higher low-density lipoprotein cholesterol, and less likely in patients on statins (OR, 0.87; 95% CI, 0.80-0.95). Patients who stopped DAPT prematurely had higher long-term risks of death (second-generation drug-eluting stents: HR, 1.35; 95% CI, 1.19-1.56), myocardial infarction (second-generation drug-eluting stents: HR, 1.46; 95% CI, 1.22-1.74), and repeated coronary revascularization (second-generation drug-eluting stents: HR, 1.24; 95% CI, 1.08-1.41). Conclusions Patients who stop DAPT prematurely have features that reflect greater frailty, poorer medication use, and other social factors. They continue to have higher risks of major adverse outcomes over the long-term and may require more intensive surveillance many years after percutaneous coronary intervention.
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Affiliation(s)
- Scott Kinlay
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Lien Quach
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Jean Cormack
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Natalie Morgenstern
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Ying Hou
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - Melissa Young
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | | | - Kelly Cho
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - David P. Faxon
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Ronnie Ramadan
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Michael Gaziano
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Brigham and Women’s HospitalBostonMA
- Harvard Medical SchoolBostonMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
| | - David Gagnon
- Veterans Affairs Boston Healthcare SystemWest RoxburyMA
- Department of BiostatisticsMassachusetts Veterans Epidemiology Research and Information Center (MAVERIC) VA Boston Healthcare SystemBostonMA
- Boston University School of Public HealthBostonMA
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Luong P, Glorioso TJ, Grunwald GK, Peterson P, Allen LA, Khanna A, Waughtal J, Sandy L, Ho PM, Bull S. Text Message Medication Adherence Reminders Automated and Delivered at Scale Across Two Institutions: Testing the Nudge System: Pilot Study. Circ Cardiovasc Qual Outcomes 2021; 14:e007015. [PMID: 33993727 PMCID: PMC8153195 DOI: 10.1161/circoutcomes.120.007015] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 03/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medication refill behavior in patients with cardiovascular diseases is suboptimal. Brief behavioral interventions called Nudges may impact medication refill behavior and can be delivered at scale to patients using text messaging. METHODS Patients who were prescribed and filled at least one medication for hypertension, hyperlipidemia, diabetes, atrial fibrillation, and coronary artery disease were identified for the pilot study. Patients eligible for the pilot (N=400) were enrolled with an opportunity to opt out. In phase I of the pilot, we tested text message delivery to 60 patients. In phase II, we tested intervention feasibility by identifying those with refill gap of ≥7 days and randomized them to intervention or control arms. Patients were texted Nudges and assessed whether they refilled their medications. RESULTS Of 400 patients sent study invitations, 56 (14%) opted out. In phase I, we successfully delivered text messages to 58 of 60 patients and captured patient responses via text. In phase II, 207 of 286 (72.4%) patients had a medication gap ≥7 days for one or more cardiovascular medications and were randomized to intervention or control. Enrolled patients averaged 61.7 years old, were primarily male (69.1%) and White (72.5%) with hypertension being the most prevalent qualifying condition (78.7%). There was a trend towards intervention patients being more likely to refill at least 1 gapping medication (30.6% versus 18.0%; P=0.12) and all gapping medications (17.8% versus 10.0%; P=0.27). CONCLUSIONS It is possible to set up automated processes within health care delivery systems to identify patients with gaps in medication adherence and send Nudges to facilitate medication refills. Text message Nudges could potentially be a feasible and effective method to facilitate medication refills. A large multi-site randomized trial to determine the impact of text-based Nudges on overall CVD morbidity and mortality is now underway to explore this further. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03973931.
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Affiliation(s)
- Phat Luong
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Thomas J Glorioso
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Gary K Grunwald
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Pamela Peterson
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Denver Health and Hospital System, Denver, CO (P.P.)
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Amber Khanna
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Joy Waughtal
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - Lisa Sandy
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
| | - P Michael Ho
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
- Veteran Affairs Eastern Colorado Health Care System, Aurora, CO (T.J.G., G.K.G., P.M.H.)
| | - Sheana Bull
- University of Colorado Anschutz Medical Campus, Aurora, CO (P.L., G.K.G., P.P., L.A.A., A.K., J.W., L.S., P.M.H., S.B.)
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Kim SJ, Kwon OD, Choi HC, Lee EJ, Cho B. Effect of antiplatelet persistence on long-term mortality and predictors of non-persistence in ischemic stroke patients 75 years and older: a nationwide cohort study. BMC Geriatr 2021; 21:232. [PMID: 33827445 PMCID: PMC8028245 DOI: 10.1186/s12877-021-02171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
Background We aimed to provide real-world evidence on the benefit of persistence with antiplatelet therapy (APT) on long-term all-cause mortality (ACM) in ischemic stroke patients aged 75 years and older. Methods Newly diagnosed ischemic stroke patients aged 75 years and older who initiated aspirin or clopidogrel for the first time were chosen from 2003 to 2010 National Health Insurance Service-National Sample Cohort (NHIS-NSC) of Korea (n = 887), a random cohort sample accounting for 2.2% (n = 1,017,468) of total population (n = 46,605,433). Then subjects were divided into persistent (n = 556) and non-persistent (n = 321) groups according to the persistent status at 6 months. Survivor analysis was performed between the two groups and predictors of non-persistence were analyzed by multivariate logistic regression analysis. Patients were followed up until death or December 31, 2013. Results Non-persistence with APT was significantly associated with increased risk of ACM (adjusted hazard ration [aHR] 2.13, 95% confidence interval [CI] 1.72–2.65), cerebro-cardiovascular disease (CVD) mortality (aHR 2.26, 95% CI 1.57–3.24), and non-CVD mortality (aHR 2.06, 95% CI 1.5702.70). More comorbidities (Charlson comorbidity index score ≥ 6) (adjusted odds ratio [aOR], 2.56, 95% CI 1.43–4.55), older age (aOR 1.52, 95% CI 1.11–2.09 for 80–84 years, aOR 1.73, 95% CI 1.17–2.57 for ≥85 years), and less than 4 total prescribed drugs (aOR 1.54, 95% CI 1.08–2.21) were independent predictors of non-persistence. Conclusions Persistent with APT after ischemic stroke featured long-term mortality benefit even in patients aged 75 years and older. Thus, improving APT persistence for ischemic stroke patients in this age group is also recommended by understanding factors associated with non-persistence.
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Affiliation(s)
- Seung Jae Kim
- Department of Family Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,International Healthcare Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Oh Deog Kwon
- Republic of Korea Navy 2nd Fleet Medical Corps, Pyeongtaek-si, Gyeonggi-do, Republic of Korea
| | - Ho Chun Choi
- Department of Family Medicine, Healthcare System Gangnam Center, Seoul National University Hospital, 39th Floor, Gangnam Finance Center, 152 Teheran-ro, Gangnam-gu, Seoul, 06236, Republic of Korea.
| | - Eung-Joon Lee
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - BeLong Cho
- Department of Family Medicine, Seoul National University Hospital, Seoul, Republic of Korea
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40
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Sandhu AT, Do R, Lam J, Blankenship J, Van Decker W, Rich J, Gonzalez O, Wu X, Pershing S, Lin E, MaCurdy TE, Bhattacharya J, Nagavarapu S. Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure. Circ Cardiovasc Qual Outcomes 2021; 14:e006461. [PMID: 33653117 DOI: 10.1161/circoutcomes.119.006461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI. METHODS Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures. RESULTS We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs. CONCLUSIONS The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.
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Affiliation(s)
- Alexander T Sandhu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA (A.T.S.)
| | - Rose Do
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Cardiology, Department of Medicine, University of California Irvine, Irvine, CA (R.D.).,Veterans Affairs Long Beach Health Care System, Long Beach, CA (R.D.)
| | - Joyce Lam
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - James Blankenship
- Division of Cardiology, Department of Internal Medicine, University of New Mexico, Albuquerque, NM (J. Blankenship)
| | - William Van Decker
- Division of Cardiology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.V.D.)
| | - Jeffrey Rich
- Heart and Vascular Institute, Cleveland Clinic, OH (J.R.)
| | - Oscar Gonzalez
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - Xiaolu Wu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
| | - Suzann Pershing
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Stanford, CA (S.P.).,Veterans Affairs Palo Alto Health Care System, Palo Alto, CA (S.P.)
| | - Eugene Lin
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Division of Nephrology, Department of Medicine, Keck School of Medicine of USC and the USC Price School of Public Policy, Los Angeles, CA (E.L.)
| | - Thomas E MaCurdy
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Department of Economics (T.E.M.), Stanford University, Stanford, CA.,Hoover Institution (T.E.M.), Stanford University, Stanford, CA
| | - Jay Bhattacharya
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.).,Center for Health Policy/Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA. (J. Bhattacharya)
| | - Sriniketh Nagavarapu
- Acumen LLC, Burlingame, CA (A.T.S., R.D., J.L., O.G., X.W., S.P., E.L., T.E.M., J. Bhattacharya, S.N.)
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Hishikari K, Hikita H, Abe F, Ito N, Kanno Y, Iiya M, Murai T, Takahashi A, Yonetsu T, Sasano T. Risk factors and prognostic impact of post-discharge bleeding after endovascular therapy for peripheral artery disease. Vasc Med 2021; 26:281-287. [PMID: 33645340 DOI: 10.1177/1358863x21992863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This study evaluated the incidence, predictors, and impact of bleeding requiring hospitalization following successful endovascular therapy (EVT) for peripheral artery disease. Platelet inhibition after EVT reduces the risk of major adverse limb events but increases the risk of bleeding. The incidence of post-discharge bleeding after EVT, its independent predictors, and its prognostic importance in clinical practice have not been fully addressed. We evaluated 779 consecutive patients who underwent EVT. We found that 77 patients (9.9%) were hospitalized for major bleeding during follow-up after EVT (median 39 months, range 22-66 months), with almost half (48.1%) of the bleeding categorized as gastrointestinal bleeding. Significant predictors of post-discharge bleeding were hemodialysis (hazard ratio (HR), 3.12; 95% CI: 1.93 to 5.05; p < 0.001) and dual antiplatelet therapy (DAPT) use (HR, 1.87; 95% CI: 1.03 to 3.41; p = 0.041). During follow-up, the all-cause mortality-free survival rate was significantly worse in patients who had experienced major bleeding than in those who had not (log-rank test χ2 = 54.6; p < 0.001). Cox proportional hazards analysis showed that major bleeding (HR, 2.78; 95% CI: 1.90 to 4.06; p < 0.001) was an independent predictor of all-cause death after EVT. Hospitalization for post-discharge bleeding after EVT is associated with a substantially increased risk of death, even after successful EVT. We concluded that patients' predicted bleeding risk should be considered when selecting patients likely to benefit from EVT, and that the risk should be considered especially thoroughly in hemodialysis patients.
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Affiliation(s)
- Keiichi Hishikari
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan.,Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Hikita
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Fumichika Abe
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Naruhiko Ito
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Yoshinori Kanno
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Munehiro Iiya
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Tadashi Murai
- Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | | | - Taishi Yonetsu
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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Kupó P, Tornyos D, Bálint A, Lukács R, Jánosi A, Komócsi A. Use of drug-eluting stents in elderly patients with acute myocardial infarction: An analysis of the Hungarian Myocardial Infarction Registry. Int J Clin Pract 2021; 75:e13652. [PMID: 32851755 DOI: 10.1111/ijcp.13652] [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: 01/04/2020] [Accepted: 08/04/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Bare-metal stents (BMS) are frequently implanted in elderly patients instead of drug-eluting stents (DES). We aimed to compare the prognosis of patients treated for myocardial infarction with the two types of stents over the age of 75. METHODS Data of patients registered in the Hungarian Myocardial Infarction Registry, a mandatory nationwide programme for hospitals treating patients with myocardial infarction were processed. From patients included between January 2014 and December 2017 we created two groups according to DES and BMS implantation. The outcome measures included all-cause mortality, the composite of cardiac events (MACE), repeated revascularisation and transfusion. Propensity score matching was used to balance the groups and Cox proportional hazards' models to estimate the risk during the 1st year after the index event. RESULTS From 7383 patients (age: 81.08 ± 4.38 years) 3266 (44.2%) patients received DES. The PS-matched cohort included 5780 cases with balanced characteristics. In the DES group, the mortality (HR 0.66 [0.60-0.72]), MACE (HR 0.66 [0.60-0.72]) and the rate of transfusion (HR 0.84 [0.73-0.97]) were significantly lower. The PS-matched cohort showed a similar trend but with a lower rate of benefits with a 21% reduction of mortality and 23% of MACE. Difference in transfusion did not reach the level of significance. In multivariate models, stent type prevailed as an independent predictor of mortality and but not of transfusion. CONCLUSIONS Based on our analysis of a real-life, high-risk population, implantation of DES seems to be an advantageous strategy for elderly patients.
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Affiliation(s)
- Péter Kupó
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Tornyos
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Bálint
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Lukács
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - András Jánosi
- Hungarian Myocardial Infarction Registry, Gyorgy Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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Rymer JA, Fonseca E, Bhandary DD, Kumar D, Khan ND, Wang TY. Difference in Medication Adherence Between Patients Prescribed a 30-Day Versus 90-Day Supply After Acute Myocardial Infarction. J Am Heart Assoc 2020; 10:e016215. [PMID: 33342227 PMCID: PMC7955468 DOI: 10.1161/jaha.119.016215] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Evidence-based medication adherence rates after a myocardial infarction are low. We hypothesized that 90-day prescriptions are underused and may lead to higher evidence-based medication adherence compared with 30-day fills. Methods and Results We examined patients with myocardial infarction treated with percutaneous coronary intervention between 2011 and 2015 in the National Cardiovascular Data Registry. Linking to Symphony Health pharmacy data, we described the prevalence of patients filling 30-day versus 90-day prescriptions of statins, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and P2Y12 inhibitors after discharge. We compared 12-month medication adherence rates by evidence-based medication class and prescription days' supply and rates of medication switches and dosing changes. Among 353 259 patients with myocardial infarction treated with percutaneous coronary intervention, 90-day evidence-based medication fill rates were low: 13.0% (statins), 12.3% (β-blockers), 14.6% (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers), and 9.7% (P2Y12 inhibitors). Patients filling 90-day prescriptions were more likely older (median 69 versus 62 years) with a history of prior myocardial infarction (25.0% versus 17.9%) or percutaneous coronary intervention (30.3% versus 19.5%; P<0.01 for all) than patients filling 30-day prescriptions. The 12-month adherence rates were higher for patients who filled 90-day versus 30-day supplies: statins, 83.1% versus 75.3%; β-blockers, 72.7% versus 62.9%; angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 71.1% versus 60.9%; and P2Y12 inhibitors, 78.5% versus 66.6% (P<0.01 for all). Medication switches and dosing changes within 12 months were infrequent for patients filling 30-day prescriptions-14.7% and 0.3% for 30-day P2Y12 inhibitor fills versus 6.3% and 0.2% for 90-day fills, respectively. Conclusions Patients who filled 90-day prescriptions had higher adherence and infrequent medication changes within 1 year after discharge. Ninety-day prescription strategies should be encouraged to improve post-myocardial infarction medication adherence.
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Pietrzykowski Ł, Kasprzak M, Michalski P, Kosobucka A, Fabiszak T, Kubica A. Therapy Discontinuation after Myocardial Infarction. J Clin Med 2020; 9:E4109. [PMID: 33352811 PMCID: PMC7766090 DOI: 10.3390/jcm9124109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 01/08/2023] Open
Abstract
The discontinuation of recommended therapy after myocardial infarction predisposes patients to serious thrombotic complications. The aim of this study was a comprehensive analysis of permanent as well as short- and long-term discontinuation of pharmacotherapy, taking into consideration the basic groups of medications and nonadherence determinants in a one-year follow-up in post-myocardial infarction (MI) patients. MATERIAL AND METHODS The study was a single center cohort clinical trial with a one-year follow-up including 225 patients (73.3% men, 26.7% women) aged 62.9 ± 11.9 years. In eight cases (3.6%), the follow-up duration was less than one year due to premature death. The following factors were analyzed: lack of post-discharge therapy initiation; short-term therapy discontinuation (<30 days); long-term therapy discontinuation (≥30 days); and permanent cessation of therapy. The analysis of therapy discontinuation was performed based on prescription filling data. RESULTS Occupational activity (Odds Ratio (OR) 5.15; 95% Confidence interval (CI) 1.42-18.65; p = 0.013) and prior MI (OR 5.02; 95% CI 1.45-16.89; p = 0.009) were found to be independent predictors of a lack of post-discharge therapy initiation with P2Y12 receptor inhibitors. We found no independent predictors of lack of post-discharge therapy initiation with other medications, whether analyzed separately or together. Age above 65 years (Hazard Ratio (HR)-1.59; 95% CI 1.15-2.19; p = 0.0049) and prior revascularization (HR-1.44; 95% CI 1.04-2.19; p = 0.0273) were identified as independent predictors of therapy discontinuation. Multilogistic regression analysis showed no independent predictors of the cessation of any of the medications as well as the permanent or temporary simultaneous discontinuation of all medications. CONCLUSIONS The vast majority of post-MI patients discontinue, either temporarily or permanently, one of the essential medications within one year following myocardial infarction. The most likely medication class to be discontinued are statins. Older age and prior cardiac revascularization are independent determinants of therapy discontinuation.
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Affiliation(s)
- Łukasz Pietrzykowski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
| | - Michał Kasprzak
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (M.K.); (T.F.)
| | - Piotr Michalski
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
| | - Agata Kosobucka
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
| | - Tomasz Fabiszak
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (M.K.); (T.F.)
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, M. Curie Skłodowskiej 9 St., 85-094 Bydgoszcz, Poland; (P.M.); (A.K.); (A.K.)
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Schwalm JD, Ivers NM, Bouck Z, Taljaard M, Natarajan MK, Dolovich L, Thavorn K, McCready T, O'Brien E, Grimshaw JM. Length of Initial Prescription at Hospital Discharge and Long-Term Medication Adherence for Elderly, Post-Myocardial Infarction Patients: Protocol for an Interrupted Time Series Study. JMIR Res Protoc 2020; 9:e18981. [PMID: 33146624 PMCID: PMC7673978 DOI: 10.2196/18981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 10/01/2020] [Accepted: 10/02/2020] [Indexed: 01/27/2023] Open
Abstract
Background Based on high-quality evidence, guidelines recommend the long-term use of secondary prevention medications post-myocardial infarction (MI) to avoid recurrent cardiovascular events and death. Unfortunately, discontinuation of recommended medications post-MI is common. Observational evidence suggests that prescriptions covering a longer duration at discharge from hospital are associated with greater long-term medication adherence. The following is a proposal for the first interventional study to evaluate the impact of longer prescription duration at discharge post-MI on long-term medication adherence. Objective The overarching goal of this study is to reduce morbidity and mortality among post-MI patients through improved long-term cardiac medication adherence. The specific objectives include the following. First, we will assess whether long-term cardiac medication adherence improves among elderly, post-MI patients following the implementation of (1) standardized discharge prescription forms with 90-day prescriptions and 3 repeats for recommended cardiac medication classes, in combination with education and (2) education alone compared to (3) usual care. Second, we will assess the cost implications of prolonged initial discharge prescriptions compared with usual care. Third, we will compare clinical outcomes between longer (>60 days) versus shorter prescription durations. Fourth, we will collect baseline information to inform a multicenter interventional study. Methods We will conduct a quasiexperimental, interrupted time series design to evaluate the impact of a multifaceted intervention to implement longer duration prescriptions versus usual care on long-term cardiac medication adherence among post-MI patients. Intervention groups and their corresponding settings include: (1) intervention group 1: 1 cardiac center and 1 noncardiac hospital allocated to receive standardized discharge prescription forms supporting the dispensation of 90 days’ worth of cardiac medications with 3 repeats, coupled with education; (2) intervention group 2: 4 sites (including 1 cardiac center) allocated to receive education only; and (3) control group: all remaining hospitals within the province that did not receive an intervention (ie, usual care). Administrative databases will be used to measure all outcomes. Adherence to 4 classes of cardiac medications — statins, beta blockers, angiotensin system inhibitors, and secondary antiplatelets (ie, prasugrel, clopidogrel, or ticagrelor) — will be assessed. Results Enrollment began in September 2017, and results are expected to be analyzed in late 2020. Conclusions The results have the potential to redefine best practices regarding discharge prescribing policies for patients post-MI. A policy of standardized maximum-duration prescriptions at the time of discharge post-MI is a simple intervention that has the potential to significantly improve long-term medication adherence, thus decreasing cardiac morbidity and mortality. If effective, this low-cost intervention to implement longer duration prescriptions post-MI could be easily scaled. Trial Registration ClinicalTrials.gov NCT03257579; https://clinicaltrials.gov/ct2/show/NCT03257579 International Registered Report Identifier (IRRID) DERR1-10.2196/18981
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Affiliation(s)
- J D Schwalm
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Noah M Ivers
- Family Practice Health Centre, Women's College Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Zachary Bouck
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Drug Policy and Evaluation, Unity Health Toronto, Toronto, ON, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Toronto, ON, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.,Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kednapa Thavorn
- ICES, Toronto, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tara McCready
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Erin O'Brien
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Kupó P, Pap R, Sághy L, Tényi D, Bálint A, Debreceni D, Basu-Ray I, Komócsi A. Ultrasound guidance for femoral venous access in electrophysiology procedures-systematic review and meta-analysis. J Interv Card Electrophysiol 2020; 59:407-414. [PMID: 31823233 PMCID: PMC7591449 DOI: 10.1007/s10840-019-00683-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures. METHODS Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI). RESULTS Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = - 92.1 s, 95% CI, - 142.12 - - 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001). CONCLUSION Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time.
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Affiliation(s)
- Péter Kupó
- Heart Institute, Medical School, University of Pécs, Ifjúság útja 13, Pécs, H-7624, Hungary.
- Second Department of Internal Medicine and Cardiology Centre, Medical School, University of Szeged, Szeged, Hungary.
| | - Róbert Pap
- Second Department of Internal Medicine and Cardiology Centre, Medical School, University of Szeged, Szeged, Hungary
| | - László Sághy
- Second Department of Internal Medicine and Cardiology Centre, Medical School, University of Szeged, Szeged, Hungary
| | - Dalma Tényi
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Bálint
- Heart Institute, Medical School, University of Pécs, Ifjúság útja 13, Pécs, H-7624, Hungary
| | - Dorottya Debreceni
- Heart Institute, Medical School, University of Pécs, Ifjúság útja 13, Pécs, H-7624, Hungary
| | - Indranill Basu-Ray
- St. Francis Hospital, Memphis, TN, USA
- All India Institute of Medical Sciences, Virbhadra Marg, Rishikesh, Uttarakhand, India
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Ifjúság útja 13, Pécs, H-7624, Hungary
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Rocca B, Rubboli A, Zaccardi F. Antithrombotic therapy and revascularisation strategies in people with diabetes and coronary artery disease. Eur J Prev Cardiol 2020; 26:92-105. [PMID: 31766921 DOI: 10.1177/2047487319880045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetes mellitus, largely type 2, affects nearly 10% of the global adult population according to the World Health Organization. Diabetes is an independent risk factor for atherosclerotic cardiovascular diseases, including coronary artery disease. Diabetes patients experience a two to three-fold increased incidence of coronary artery disease, despite improved metabolic control and management of other cardiovascular risk factors. DISCUSSION Platelet abnormalities and activation as well as reduced antiplatelet drug responsiveness characterise diabetes mellitus. Mechanisms linking diabetes to platelet and vascular abnormalities, atherogenesis and atherosclerotic cardiovascular disease are still only partially known, highlighting the unique complexity of the pro-atherogenic clinical scenario and its treatment. Consistently, a higher residual cardiovascular risk characterises patients with diabetes compared with those without, in spite of improved antiplatelet and antithrombotic treatment combinations. Randomised clinical trials aimed at optimising antiplatelet treatment specifically in patients with diabetes are lacking, both in acute and chronic coronary artery disease settings. Thus, patients with diabetes are treated with regimens validated in studies including only variable proportions of diabetes patients. Myocardial revascularisation appears to confer a comparable relative benefit between diabetes patients and patients without diabetes, and generally coronary artery bypass grafting has a better outcome in diabetes mellitus versus peripheral coronary intervention. New glucose-lowering drugs have been shown to reduce the incidence of major cardiovascular events in secondary prevention. Type 1 diabetes mellitus remains less explored than type 2 in this context. CONCLUSION Diabetes-tailored antithrombotic strategies in acute and chronic coronary artery disease remain an unmet clinical need, requiring ad-hoc trials and precision pharmacological strategies.
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Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Italy
| | - Andrea Rubboli
- Department of Cardiovascular Diseases, S Maria delle Croci Hospital, Italy
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Batchelor R, Dinh D, Brennan A, Lefkovits J, Reid C, Duffy SJ, Cox N, Liew D, Stub D. Incidence, Predictors and Clinical Outcomes of Stent Thrombosis Following Percutaneous Coronary Intervention in Contemporary Practice. Heart Lung Circ 2020; 29:1433-1439. [DOI: 10.1016/j.hlc.2019.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/30/2019] [Accepted: 10/14/2019] [Indexed: 10/25/2022]
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Medication adherence and its determinants in patients after myocardial infarction. Sci Rep 2020; 10:12028. [PMID: 32694522 PMCID: PMC7374107 DOI: 10.1038/s41598-020-68915-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/22/2020] [Indexed: 11/08/2022] Open
Abstract
Non-adherence to prescribed medication is a serious limitation of long-term treatment in patients after myocardial infarction (MI), which can be associated with medical, social and economical consequences. Improvement of medication adherence has been shown to be a challenge for healthcare providers. The aim of this study was to evaluate changes in medication adherence and variability of adherence determinants during follow-up in patients after MI. A single-center, cohort observational study was conducted in 225 post-MI patients treated with primary coronary intervention (PCI) (27% women and 73% men) aged 30–91 years. Adherence was defined as availability of evaluated drugs within 1-year after discharge from hospital, based on completed prescriptions data obtained from the National Health Fund. The analysis of therapeutic plan realization (adherence to medication prescribed at discharge from hospital) embraced only reimbursed drugs: ACEIs (ramipril, perindopril), P2Y12 receptor inhibitors (clopidogrel) and statins (atorvastatin, simvastatin, rosuvastatin). Sufficient adherence was defined as ≥ 80%. During 1-year follow-up, adherence for all three drug classes was 64 ± 25%, with 67 ± 32% for ACEIs, 62 ± 34% for P2Y12 receptor inhibitor and 64 ± 32% for statins. A gradual decline in adherence was observed from 65% ± 26% in the first quarter of follow-up to 51% ± 34% in the last quarter of follow-up (p < 0.00001). Sufficient adherence for all drugs classes was found only in 29% of patients throughout the whole follow-up period (44% for ACEI, 36% for P2Y12 receptor inhibitor and 41% for statins). According to a multivariate analysis, age, prior CABG, level of education, place of residence, economic status and marital status were independent predictors of drug adherence. Whereas patients > 65 years and having a history of prior CABG more often had an insufficient adherence to drugs, married and hypertensive patients, city inhabitants and patients with higher education tended to have a sufficient drug adherence. Adherence to pharmacotherapy after myocardial infarction decreases over time in a similar manner for all pivotal groups of drugs prescribed after MI. A number of socioeconomic and clinical factors have been identified to affect medication adherence over time.
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50
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Boyd AD, Ndukwe CI, Dileep A, Everin OF, Yao Y, Welland B, Field J, Baumann M, Flores JD, Shroff A, Groo V, Dickens C, Doukky R, Francis R, Peacock G, Wilkie DJ. Elderly Medication Adherence Intervention Using the My Interventional Drug-Eluting Stent Educational App: Multisite Randomized Feasibility Trial. JMIR Mhealth Uhealth 2020; 8:e15900. [PMID: 32579120 PMCID: PMC7381043 DOI: 10.2196/15900] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/20/2019] [Accepted: 01/24/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND A lifesaving treatment for myocardial infarction is the placement of a stent in a closed or obstructed coronary artery. The largest modifiable risk factor after receiving a stent is medication adherence to Dual AntiPlatelet Therapy, a combination of P2Y12 inhibitors and aspirin. OBJECTIVE This study aimed to determine the acceptability of a protocol and an intervention using the My Interventional Drug-Eluting Stent Educational App (MyIDEA) and to evaluate medication adherence using the proportion of days covered (PDC) and platelet activation tests in a multisite randomized controlled trial. METHODS Potential participants who received a post percutaneous coronary intervention (PCI) procedure with a drug-eluting stent were approached. All patients older than 50 years and who spoke English were recruited. Participants were recruited, baseline demographics were collected, and the Hospital Anxiety and Depression Scale (HADS), Rapid Estimate of Adult Literacy in Medicine-Short Form, Burden-Benefit questionnaire, 36-Item Short Form Health Survey, and PCI knowledge questionnaire were administered. Block randomization was used to randomize participants to either usual care or MyIDEA supplementation. MyIDEA is a personalized educational intervention based on the Kolb experiential learning theory using patient narratives for education. During the visits, participants' blood was collected to measure platelet suppression from medication. During the second and third encounters, the Morisky medication adherence score and cardiology outcomes were measured. The study was conducted at the University of Illinois Hospital and John H Stroger Jr Cook County Hospital with appropriate ethical approvals. Platelet suppression was measured through aspirin reactive units and P2Y12 reactive units. Medication adherence was measured using the PDC. The analysis team was blinded to the participants' group membership. The primary outcome was a feasibility analysis of recruitment and retention. RESULTS The mean age of participants was 60.4 years (SD 7.1); the majority of patients were black and non-Hispanic. The majority of patients' reading levels were seventh grade or above, and they were not very familiar with other electronic devices for information and communication. The number of control subjects was 21, and the number of participants in the interventional arm was 24. The interventional group was able to use MyIDEA in both the hospital and outpatient setting. However, there was no significant difference in platelet suppression or medication adherence between groups. There were also differences between the groups in terms of depression and anxiety, initially, as measured by HADS. No documented adverse event associated with the intervention was found. CONCLUSIONS Elderly patients are willing to use tablet devices to be educated about health conditions. Additional studies are required to measure the effectiveness and determine the most suitable timing and location for patient education. TRIAL REGISTRATION ClinicalTrials.gov NCT04439864; https://clinicaltrials.gov/ct2/show/NCT04439864.
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Affiliation(s)
- Andrew Dallas Boyd
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Chioma Iheanyi Ndukwe
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Anandu Dileep
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Olivia Frances Everin
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Yingwei Yao
- Biobehavioral Nursing Science, University of Florida, Gainesville, FL, United States
| | - Betty Welland
- Patient Advisor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Jerry Field
- Patient Advisor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Matt Baumann
- Patient Advisor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Jose D Flores
- Patient Advisor, Department of Biomedical and Health Information Sciences, University of Illinois at Chicago, Chicago, IL, United States
| | - Adhir Shroff
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Vicki Groo
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, United States
| | - Carolyn Dickens
- Department of Biomedical and Health Information Science, University of Illinois at Chicago, Chicago, United States
| | - Rami Doukky
- Divison of Cardiology, Cook County Health, Chicago, IL, United States
| | - Regeena Francis
- Divison of Cardiology, Cook County Health, Chicago, IL, United States
| | - Geraldine Peacock
- Divison of Cardiology, Cook County Health, Chicago, IL, United States
| | - Diana J Wilkie
- Biobehavioral Nursing Science, University of Florida, Gainesville, FL, United States
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