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Khan R, Kaul P, Islam S, Savu A, Bagai A, van Diepen S, Bainey KR, Welsh RC, Goodman SG. Drug Adherence and Long-Term Outcomes in Non-Revascularized Patients Following Acute Myocardial Infarction. Am J Cardiol 2021; 152:49-56. [PMID: 34120704 DOI: 10.1016/j.amjcard.2021.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022]
Abstract
This study examined long-term outcomes and adherence to guideline-based medications in non-revascularized acute myocardial infarction (MI) patients undergoing and not undergoing angiography. We analyzed non-revascularized MI patients hospitalized in Alberta, Canada between 2010-2016 and categorized them according to whether they had undergone coronary angiography. Adherence to guideline-based medications was determined by the proportion of days covered (PDC) and subdivided into categories based on PDC: 0% (none), 1-40% (low), 40-79% (intermediate) and ≥ 80% (high). Patients not undergoing angiography were older, less frequently male, and had more comorbidities. Those not receiving angiography had higher rates of 2-year myocardial infarction (9.9% vs 6.1%, p <0.001), heart failure (14.9% vs 6.1%, p <0.001), and mortality (29.4% vs 7.4%, p <0.001). Optimal medial therapy (OMT), defined by high PDC for the combination of lipid-modifying agents, β-blockers and angiotensin converting enzyme-inhibitors/receptor blockers (ACE-I/ARBs), was achieved in 32.9%. Patients not undergoing angiography had lower rates of OMT adherence (p <0.001). In patients not undergoing angiography, high-adherence to lipid-modifying agents (HR 0.70 [95% CI 0.57-0.87]), β-blockers (HR 0.78 [0.62-0.97]), ACE-I/ARBs (HR 0.64 [0.52-0.79]) and OMT (HR 0.56 [0.40-0.77]) was independently associated with lower 2-year mortality. In conclusion, MI patients not receiving angiography had low adherence rates to guideline-based pharmacotherapies and high rates of long-term outcomes, suggesting potential treatment targets to improve prognosis in non-invasively managed MI patients.
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Liu MM, Peng J, Guo YL, Wu NQ, Zhu CG, Gao Y, Dong Q, Li JJ. Impact of diabetes on coronary severity and cardiovascular outcomes in patients with heterozygous familial hypercholesterolaemia. Eur J Prev Cardiol 2021; 28:1807-1816. [PMID: 33778872 DOI: 10.1093/eurjpc/zwab042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/31/2021] [Accepted: 03/06/2021] [Indexed: 01/21/2023]
Abstract
AIMS Type 2 diabetes mellitus (T2DM) is an independent risk factor for cardiovascular disease. However, the association between T2DM and coronary artery disease (CAD) in patients with heterozygous familial hypercholesterolaemia (HeFH) has not been thoroughly evaluated. Our study aimed to assess the effect of T2DM on CAD severity and hard cardiovascular endpoints in a HeFH cohort. METHODS AND RESULTS A total of 432 patients with HeFH with a molecular and/or clinical Dutch Lipid Clinic Network score ≥6 (definite and probable) were enrolled. Patients were divided into a T2DM group (n = 99) and a non-T2DM group (n = 333). The severity of coronary stenosis was assessed by the number of diseased vessels and Gensini, SYNTAX, and Jeopardy scores. Hard endpoints included a composite of non-fatal myocardial infarction, non-fatal stroke, and cardiac death. Cox regression and Kaplan-Meier analyses were used to evaluate the effect of T2DM on hard cardiovascular endpoints. The prevalence of CAD was higher in patients with T2DM compared with those without (96.0% vs. 77.5%, respectively; P < 0.001). Patients with T2DM demonstrated a greater number of diseased vessels (P = 0.029) and more severe coronary lesions with high Gensini, SYNTAX, and Jeopardy score tertiles (P = 0.031, P = 0.001, and P = 0.024, respectively). During a median of 3.75 years up to a maximum of 9 years of follow-up, hard endpoints occurred in 13 of 99 patients with T2DM and 16 of 333 without T2DM at baseline. Compared with patients without T2DM, patients with T2DM were at a significantly greater risk of hard endpoints [multivariate adjusted hazard ratio (HR) 2.32, 95% confidence interval (CI) 1.02-4.84; P = 0.025]. Additionally, patients with T2DM and good glucose control (HbA1c < 7.0%) were at a lower risk of hard endpoints compared with those with poor glucose control (HbA1c ≥ 7.0%, HR 0.08, 95% CI 0.01-0.56; P = 0.011). CONCLUSION We conclude that T2DM is an independent predictor of CAD severity when assessed by number of diseased vessels, Gensini, SYNTAX, Jeopardy scores, and hard cardiovascular endpoints, suggesting that T2DM could be further used for risk stratification of patients with HeFH.
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Affiliation(s)
- Ming-Ming Liu
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Jia Peng
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Yuan-Lin Guo
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Na-Qiong Wu
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Cheng-Gang Zhu
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Ying Gao
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Qian Dong
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
| | - Jian-Jun Li
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing 100037, China
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Nanna MG, Peterson ED, Chiswell K, Overton RA, Nelson AJ, Kong DF, Navar AM. The incremental value of angiographic features for predicting recurrent cardiovascular events: Insights from the Duke Databank for Cardiovascular Disease. Atherosclerosis 2021; 321:1-7. [PMID: 33582446 DOI: 10.1016/j.atherosclerosis.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/25/2021] [Accepted: 02/03/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIMS Identifying patient subgroups with cardiovascular disease (CVD) at highest risk for recurrent events remains challenging. Angiographic features may provide incremental value in risk prediction beyond clinical characteristics. METHODS We included all cardiac catheterization patients from the Duke Databank for Cardiovascular Disease with significant coronary artery disease (CAD; 07/01/2007-12/31/2012) and an outpatient follow-up visit with a primary care physician or cardiologist in the same health system within 3 months post-catheterization. Follow-up occurred for 3 years for the primary major adverse cardiovascular event endpoint (time to all-cause death, myocardial infarction [MI], or stroke). A multivariable model to predict recurrent events was developed based on clinical variables only, then adding angiographic variables from the catheterization. Next, we compared discrimination of clinical vs. clinical plus angiographic risk prediction models. RESULTS Among 3366 patients with angiographically-defined CAD, 633 (19.2%) experienced cardiovascular events (death, MI, or stroke) within 3 years. A multivariable model including 18 baseline clinical factors and initial revascularization had modest ability to predict future atherosclerotic cardiovascular disease events (c-statistic = 0.716). Among angiographic predictors, number of diseased vessels, left main stenosis, left anterior descending stenosis, and the Duke CAD Index had the highest value for secondary risk prediction; however, the clinical plus angiographic model only slightly improved discrimination (c-statistic = 0.724; delta 0.008). The net benefit for angiographic features was also small, with a relative integrated discrimination improvement of 0.05 (95% confidence interval: 0.03-0.08). CONCLUSIONS The inclusion of coronary angiographic features added little incremental value in secondary risk prediction beyond clinical characteristics.
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Affiliation(s)
- Michael G Nanna
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Duke University Medical Center, Department of Medicine, Durham, NC, USA.
| | - Eric D Peterson
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Robert A Overton
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Adam J Nelson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - David F Kong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Duke University Medical Center, Department of Medicine, Durham, NC, USA
| | - Ann Marie Navar
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
Patients with coronary artery disease (CAD) presenting with acute coronary syndrome or undergoing coronary stenting are indicated to treatment with dual antiplatelet therapy (DAPT) combining aspirin with a P2Y12 receptor inhibitor. The management of patients with CAD who present with a complex clinical profile due to multiple comorbidities, and/or undergoing complex interventional procedures, remains challenging as a high risk for both ischemic and bleeding events is often present; hence, the risk-benefit balance on the optimal DAPT duration is difficult to evaluate. The complexity of antiplatelet therapy in CAD patients is due to the fact that this complexity embraces several aspects: the coronary anatomy, the number of vascular districts at risk for atherothrombosis, and patient comorbidities, including global frailty. Recent randomized and epidemiological studies have highlighted subgroups that could benefit from prolonged antithrombotic treatment, as well as frail patients, who may be better suited to a shorter course of therapy. We provide an overview of the current knowledge regarding treatment with DAPT, along with suggestions on its management.
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Liu Y, Yao Y, Tang XF, Xu N, Jiang P, Jiang L, Zhao XY, Chen J, Yang YJ, Gao RL, Xu B, Yuan JQ. Evaluation of a novel score for predicting 2-year outcomes in patients with acute coronary syndrome after percutaneous coronary intervention. J Chin Med Assoc 2019; 82:616-622. [PMID: 31135575 DOI: 10.1097/jcma.0000000000000124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A novel risk model to predict long-term mortality in patients with acute coronary syndrome (ACS), derived from the EPICOR (long-term follow-up of antithrombotic management patterns in acute coronary syndrome patients) registry, has been released recently and its performance remains to be assessed. The objective is to evaluate the EPICOR score for 2-year mortality risk in ACS patients after percutaneous coronary intervention (PCI). METHODS From January to December in 2013, a total of 6087 consecutive patients presenting with ACS who were scheduled for PCI were enrolled. Use online simplified EPICOR calculator to assess the expected risk of death. RESULTS Sixty-eight patients (1.1%) died during 2-year follow-up. The areas under the receiver operating characteristics curve for mortality in the overall population, ST-segment elevation myocardial infarction (STEMI), and non-ST-segment elevation ACS were 0.712 (95% CI, 0.650-0.772; p < 0.001), 0.790 (95% CI, 0.676-0.903; p < 0.001), and 0.683 (95% CI, 0.615-0.751; p < 0.001), respectively. Moreover, it was noninferior to the updated Global Registry of Acute Coronary Events (GRACE) risk score. Patients were stratified into three categories: low-risk (n = 3382), medium-risk (n = 2547), and high-risk (n = 158). Kaplan-Meier curve demonstrated significant ongoing divergence in both mortality (0.6% vs 1.3% vs 9.5%; p < 0.001) and major adverse cardiovascular and cerebrovascular events (MACCEs) (11.8% vs 12.3% vs 19.6%; p = 0.014) among them. Multivariate Cox analysis revealed that medium- and high-risk groups predicted 2- and 12-fold hazards of death comparing to the lowest. Yet, it was not a significant predictor for MACCEs after adjusting confounding factors. CONCLUSION The simplified EPICOR score showed fair discriminatory power of 2-year mortality in patients with ACS and an improved performance in the STEMI subgroup. It could aid in risk stratification of ACS patients as an independent predictor.
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Affiliation(s)
- Yue Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Yao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Fang Tang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Na Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ping Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Jiang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Yan Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Run-Lin Gao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- Catheterization Laboratories, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jin-Qing Yuan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Shavadia J, Armstrong PW. Risk stratification in non-ST elevation acute coronary syndromes: searching for the right formula. Eur Heart J 2016; 37:3111-3113. [PMID: 26685972 DOI: 10.1093/eurheartj/ehv586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jay Shavadia
- Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Armstrong
- Canadian VIGOUR Centre, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
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7
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Feldman L, Steg PG, Amsallem M, Puymirat E, Sorbets E, Elbaz M, Ritz B, Hueber A, Cattan S, Piot C, Ferrières J, Simon T, Danchin N. Editor's Choice-Medically managed patients with non-ST-elevation acute myocardial infarction have heterogeneous outcomes, based on performance of angiography and extent of coronary artery disease. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:262-271. [PMID: 26758543 DOI: 10.1177/2048872615626354] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Medically managed individuals represent a high-risk group among patients with non-ST-elevation acute myocardial infarction (NSTE-AMI). We hypothesized that prognosis in this group is heterogeneous, depending on whether medical management was decided with or without coronary angiography (CAG). METHODS Using data from the French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction (FAST-MI), we analysed data from 798 patients with NSTE-AMI who were medically managed (i.e. without revascularization during the index hospitalization). Patients were categorized according to the performance of CAG and, if performed, to the extent of coronary artery disease (CAD). RESULTS There were marked differences in baseline demographics, according to whether CAG was performed and to the extent of CAD. While the overall mortality rate at five years was high (56.2%), it differed greatly between groups, with patients who did not undergo CAG having a higher mortality rate (77.4%) than patients who underwent CAG (36.7%, p<0.001), and a higher mortality rate even than patients with multivessel CAD (54.2%, p<0.001). By multivariable analysis, non-performance of CAG was an independent predictor of all-cause mortality among medically managed NSTE-AMI patients (adjusted hazard ratios (95% confidence intervals) 3.19 (1.79-5.67) at 30 days, 2.28 (1.60-3.26) at one year, and 1.63 (1.28-2.07) at five years; all p<0.001). CONCLUSION Medically managed patients with NSTE-AMI are a heterogeneous group in terms of baseline characteristics and outcomes. The highest risk patients are those who do not undergo CAG. Non-performance of CAG is a strong predictor of death. (FAST-MI, NCT00673036).
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Affiliation(s)
- Laurent Feldman
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France
| | - Philippe G Steg
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,5 Imperial College, Royal Brompton Hospital, London, UK
| | - Myriam Amsallem
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France
| | - Etienne Puymirat
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,6 Hôpital Européen Georges Pompidou, APHP, France.,7 Université Paris Descartes, France
| | - Emmanuel Sorbets
- 1 Département de Cardiologie, Hôpital Bichat, Assistance Publique Hôpitaux de Paris (APHP), France.,3 U1148, Institut National de la Santé et de la Recherche Médicale (INSERM) INSERM, France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France
| | - Meyer Elbaz
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,8 Hôpital Rangueil, Toulouse, France
| | | | | | - Simon Cattan
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,11 Hôpital Le Raincy-Montfermeil, France
| | | | | | - Tabassome Simon
- 3 U1148, Institut National de la Santé et de la Recherche Médicale (INSERM) INSERM, France.,4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,13 Département de Pharmacologie Clinique, Hôpital Saint-Antoine, APHP, France.,14 Université Pierre et Marie Curie, France
| | - Nicolas Danchin
- 4 French Alliance for Cardiovascular Clinical Trials (FACT), France.,6 Hôpital Européen Georges Pompidou, APHP, France.,7 Université Paris Descartes, France.,14 Université Pierre et Marie Curie, France
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8
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Bettinger N, Palmerini T, Caixeta A, Dressler O, Litherland C, Francese DP, Giustino G, Mehran R, Leon MB, Stone GW, Généreux P. Risk stratification of patients undergoing medical therapy after coronary angiography. Eur Heart J 2015; 37:3103-3110. [DOI: 10.1093/eurheartj/ehv674] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 11/19/2015] [Indexed: 12/17/2022] Open
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9
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Pan HC, Sheu WHH, Lee WJ, Lee WL, Liao YC, Wang KY, Lee IT, Wang JS, Liang KW. Coronary severity score and C-reactive protein predict major adverse cardiovascular events in patients with stable coronary artery disease (from the Taichung CAD study). Clin Chim Acta 2015; 445:93-100. [DOI: 10.1016/j.cca.2015.03.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 02/27/2015] [Accepted: 03/17/2015] [Indexed: 11/16/2022]
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10
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Janzon M, James S, Cannon CP, Storey RF, Mellström C, Nicolau JC, Wallentin L, Henriksson M. Health economic analysis of ticagrelor in patients with acute coronary syndromes intended for non-invasive therapy. Heart 2014; 101:119-25. [PMID: 25227704 PMCID: PMC4316918 DOI: 10.1136/heartjnl-2014-305864] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective To investigate the cost effectiveness of ticagrelor versus clopidogrel in patients with acute coronary syndromes (ACS) in the Platelet Inhibition and Patient Outcomes (PLATO) study who were scheduled for non-invasive management. Methods A previously developed cost effectiveness model was used to estimate long-term costs and outcomes for patients scheduled for non-invasive management. Healthcare costs, event rates and health-related quality of life under treatment with either ticagrelor or clopidogrel over 12 months were estimated from the PLATO study. Long-term costs and health outcomes were estimated based on data from PLATO and published literature sources. To investigate the importance of different healthcare cost structures and life expectancy for the results, the analysis was carried out from the perspectives of the Swedish, UK, German and Brazilian public healthcare systems. Results Ticagrelor was associated with lifetime quality-adjusted life-year (QALY) gains of 0.17 in Sweden, 0.16 in the UK, 0.17 in Germany and 0.13 in Brazil compared with generic clopidogrel, with increased healthcare costs of €467, €551, €739 and €574, respectively. The cost per QALY gained with ticagrelor was €2747, €3395, €4419 and €4471 from a Swedish, UK, German and Brazilian public healthcare system perspective, respectively. Probabilistic sensitivity analyses indicated that the cost per QALY gained with ticagrelor was below conventional threshold values of cost effectiveness with a high probability. Conclusions Treatment of patients with ACS scheduled for 12 months’ non-invasive management with ticagrelor is associated with a cost per QALY gained below conventional threshold values of cost effectiveness compared with generic clopidogrel. Trial registration number NCT000391872.
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Affiliation(s)
- M Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden Division of Health Care Analysis, Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden
| | - S James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - C P Cannon
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - R F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | | | - J C Nicolau
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - L Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - M Henriksson
- Division of Health Care Analysis, Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden AstraZeneca Nordic-Baltic, Södertälje, Sweden
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11
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Accuracy of multidetector computed tomography for detection of coronary artery stenosis in acute coronary syndrome compared with stable coronary disease: a CORE64 multicenter trial substudy. Int J Cardiol 2014; 177:385-91. [PMID: 25281436 DOI: 10.1016/j.ijcard.2014.08.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 08/04/2014] [Accepted: 08/21/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multi-detector computed tomography angiography (MDCTA) is a promising method for risk assessment of patients with acute chest pain. However, its diagnostic performance in higher-risk patients has not been investigated in a large international multicenter trial. Therefore, in the present study we sought to estimate the diagnostic accuracy of MDCTA to detect significant coronary stenosis in patients with acute coronary syndrome (ACS). METHODS Patients included in the CORE64 study were categorized as suspected-ACS or non-ACS based on clinical data. A 64-row coronary MDCTA was performed before invasive coronary angiography (ICA) and both exams were evaluated by blinded, independent core laboratories. RESULTS From 371 patients included, 94 were categorized as suspected ACS and 277 as non-ACS. Patient-based analysis showed an area under the receiver-operating-characteristic curve (AUC) for detecting ≥ 50% coronary stenosis of 0.95 (95% CI: 0.88-0.98) in ACS and 0.92 (95% CI: 0.88-0.95) in non-ACS group (P=0.29). The sensitivity, specificity, positive and negative predictive values of MDCTA were 0.90(0.80-0.96), 0.88(0.70-0.98), 0.95(0.87-0.99) and 0.77(0.58-0.90) in suspected ACS patients and 0.87(0.81-0.92), 0.86(0.79-0.92), 0.91(0.85-0.95) and 0.82(0.74-0.89) in non-ACS patients (P NS for all comparisons). The mean calcium scores (CS) were 282 ± 449 in suspected ACS and 435 ± 668 in non-ACS group. The accuracy of CS to detect significant coronary stenosis was only moderate and the absence or minimal coronary artery calcification could not exclude the presence of significant coronary stenosis, particularly in ACS patients. CONCLUSIONS The diagnostic accuracy of MDCTA to detect significant coronary stenosis is high and comparable for both ACS and non-ACS patients.
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12
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Held C, Tricoci P, Huang Z, Van de Werf F, White HD, Armstrong PW, Ambrosio G, Aylward PE, Moliterno DJ, Wallentin L, Chen E, Erkan A, Jiang L, Strony J, Harrington RA, Mahaffey KW. Vorapaxar, a platelet thrombin-receptor antagonist, in medically managed patients with non-ST-segment elevation acute coronary syndrome: results from the TRACER trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:246-56. [DOI: 10.1177/2048872614527838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University/Uppsala Clinical Research Center, Uppsala, Sweden
| | | | - Zhen Huang
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | | | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University/Uppsala Clinical Research Center, Uppsala, Sweden
| | - Edmond Chen
- Bayer HealthCare Pharmaceuticals, Whippany, NJ, USA
| | | | - Lixin Jiang
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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13
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Angeli F, Verdecchia P, Savonitto S, Morici N, De Servi S, Cavallini C. Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: Impact of age. Catheter Cardiovasc Interv 2014; 83:686-701. [DOI: 10.1002/ccd.25307] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 10/31/2013] [Accepted: 11/22/2013] [Indexed: 11/09/2022]
Affiliation(s)
- Fabio Angeli
- Division of Cardiology and Cardiovascular Pathophysiology; Teaching Hospital “S.M. della Misericordia,”; Perugia Italy
| | - Paolo Verdecchia
- Department of Internal Medicine; Hospital of Assisi; Assisi Italy
| | - Stefano Savonitto
- Division of Cardiology; IRCCS “Arcispedale S. Maria Nuova,”; Reggio Emilia Italy
| | - Nuccia Morici
- Department of Cardiology; Hospital “Niguarda Ca' Granda,”; Milano Italy
| | | | - Claudio Cavallini
- Department of Cardiology; Teaching Hospital “S.M. della Misericordia,”; Perugia Italy
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De Servi S, Mariani G, Mariani M, D’Urbano M. The bivalirudin paradox. J Cardiovasc Med (Hagerstown) 2013; 14:334-41. [DOI: 10.2459/jcm.0b013e32835f1915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Refining the role of antiplatelet therapy in medically managed patients with acute coronary syndrome. Am J Cardiol 2013; 111:439-44. [PMID: 23168289 DOI: 10.1016/j.amjcard.2012.10.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 10/09/2012] [Accepted: 10/09/2012] [Indexed: 01/20/2023]
Abstract
Dual-antiplatelet therapy with aspirin plus a P2Y(12) receptor inhibitor is recommended for use as first-line therapy in patients with acute coronary syndromes (ACS) who undergo high-risk percutaneous coronary intervention. However, revascularization may not be a beneficial option for some subgroups of patients with ACS. This includes a broad spectrum of lower risk patients as well as high-risk patients with numerous previous revascularizations and those who are at high risk for complications, such as those with complex coronary anatomy and co-morbidities such as diabetes mellitus, chronic kidney disease, or advanced age and frailty. For such patients, there remains an unmet need for evaluation of alternatives to the currently recommended treatment options. Notably, there is a paucity of prospective data regarding management approaches to medically managed patients with ACS. Thus, this group of medically managed patients with ACS would benefit from inclusion in clinical trials investigating therapeutic options for patients not scheduled to undergo invasive procedures, such as those who are targeted for pharmacologic management only. In conclusion, in this review, the investigators revisit data from clinical studies of dual-antiplatelet therapy in ACS to highlight areas of unmet need in antiplatelet therapy in patients with ACS and to examine the use of newer agents in subgroups, such as medically managed patients with ACS, that would potentially benefit from more potent platelet inhibition after ACS.
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Roe MT, Armstrong PW, Fox KAA, White HD, Prabhakaran D, Goodman SG, Cornel JH, Bhatt DL, Clemmensen P, Martinez F, Ardissino D, Nicolau JC, Boden WE, Gurbel PA, Ruzyllo W, Dalby AJ, McGuire DK, Leiva-Pons JL, Parkhomenko A, Gottlieb S, Topacio GO, Hamm C, Pavlides G, Goudev AR, Oto A, Tseng CD, Merkely B, Gasparovic V, Corbalan R, Cinteză M, McLendon RC, Winters KJ, Brown EB, Lokhnygina Y, Aylward PE, Huber K, Hochman JS, Ohman EM. Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Engl J Med 2012; 367:1297-309. [PMID: 22920930 DOI: 10.1056/nejmoa1205512] [Citation(s) in RCA: 620] [Impact Index Per Article: 51.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The effect of intensified platelet inhibition for patients with unstable angina or myocardial infarction without ST-segment elevation who do not undergo revascularization has not been delineated. METHODS In this double-blind, randomized trial, in a primary analysis involving 7243 patients under the age of 75 years receiving aspirin, we evaluated up to 30 months of treatment with prasugrel (10 mg daily) versus clopidogrel (75 mg daily). In a secondary analysis involving 2083 patients 75 years of age or older, we evaluated 5 mg of prasugrel versus 75 mg of clopidogrel. RESULTS At a median follow-up of 17 months, the primary end point of death from cardiovascular causes, myocardial infarction, or stroke among patients under the age of 75 years occurred in 13.9% of the prasugrel group and 16.0% of the clopidogrel group (hazard ratio in the prasugrel group, 0.91; 95% confidence interval [CI], 0.79 to 1.05; P=0.21). Similar results were observed in the overall population. The prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of severe and intracranial bleeding were similar in the two groups in all age groups. There was no significant between-group difference in the frequency of nonhemorrhagic serious adverse events, except for a higher frequency of heart failure in the clopidogrel group. CONCLUSIONS Among patients with unstable angina or myocardial infarction without ST-segment elevation, prasugrel did not significantly reduce the frequency of the primary end point, as compared with clopidogrel, and similar risks of bleeding were observed. (Funded by Eli Lilly and Daiichi Sankyo; TRILOGY ACS ClinicalTrials.gov number, NCT00699998.).
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Affiliation(s)
- Matthew T Roe
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC 27705, USA.
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17
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Roe MT, White JA, Kaul P, Tricoci P, Lokhnygina Y, Miller CD, van't Hof AW, Montalescot G, James SK, Saucedo J, Ohman EM, Pollack CV, Hochman JS, Armstrong PW, Giugliano RP, Harrington RA, Van de Werf F, Califf RM, Newby LK. Regional Patterns of Use of a Medical Management Strategy for Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes 2012; 5:205-13. [DOI: 10.1161/circoutcomes.111.962332] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Regional differences in the profile and prognosis of non–ST-segment elevation acute coronary syndrome (NSTE ACS) patients treated with medical management after angiography remain uncertain.
Methods and Results—
Using data from the Early Glycoprotein IIb/IIIa Inhibition in Non–ST-Segment Elevation Acute Coronary Syndromes (EARLY ACS) trial, we examined regional variations in the use of an in-hospital medical management strategy in NSTE ACS patients who had significant coronary artery disease (CAD) identified during angiography, factors associated with the use of a medical management strategy, and 1-year mortality rates. Of 9406 patients, 8387 (89%) underwent angiography and had significant CAD; thereafter, 1766 (21%) were treated solely with a medical management strategy (range: 18% to 23% across 4 major geographic regions). Factors most strongly associated with a medical management strategy were negative baseline troponin values, prior coronary artery bypass grafting, lower baseline hemoglobin values, and greater number of diseased vessels; region was not a significant factor. One-year mortality was higher among patients treated with a medical management strategy compared with those who underwent revascularization (7.8% versus 3.6%; adjusted hazard ratio, 1.46; 95% CI, 1.21–1.76), with no significant interaction by region (interaction probability value=0.42).
Conclusions—
Approximately 20% of NSTE ACS patients with significant CAD in an international trial were treated solely with an in-hospital medical management strategy after early angiography, with no regional differences in factors associated with medical management or the risk of 1-year mortality. These findings have important implications for the conduct of future clinical trials, and highlight global similarities in the profile and prognosis of medically managed NSTE ACS patients.
Clinical Trial Registration—
URL:
www.clinicaltrials.gov
. Unique identifier: NCT00089895.
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Affiliation(s)
- Matthew T. Roe
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Jennifer A. White
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Padma Kaul
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Pierluigi Tricoci
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Yuliya Lokhnygina
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Chadwick D. Miller
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Arnoud W. van't Hof
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Gilles Montalescot
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Stefan K. James
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Jorge Saucedo
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - E. Magnus Ohman
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Charles V. Pollack
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Judith S. Hochman
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Paul W. Armstrong
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Robert P. Giugliano
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Robert A. Harrington
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Frans Van de Werf
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - Robert M. Califf
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
| | - L. Kristin Newby
- From the Duke Clinical Research Institute, Durham, NC (M.T.R., J.A.W., P.T., Y.L., E.M.O., R.A.H., R.M.C., L.K.N.); University of Alberta, Edmonton, Alberta, Canada (P.K., P.W.A.); Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, NC (C.D.M.); Division of Cardiology, Hospital ‘De Weezenlanden,' Zwolle, The Netherlands (A.W.V.); Institut de Cardiologie, Pitié–Salpêtrière Hospital, Paris, France (G.M.); Uppsala Clinical Research Center, Uppsala University,
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18
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Lilly SM, Wilensky RL. Emerging therapies for acute coronary syndromes. Front Pharmacol 2011; 2:61. [PMID: 22028691 PMCID: PMC3199568 DOI: 10.3389/fphar.2011.00061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/25/2011] [Indexed: 01/15/2023] Open
Abstract
In the majority of cases acute coronary syndromes (ACS) are caused by activation and aggregation of platelets and subsequent thrombus formation leading to a decrease in coronary artery blood flow. Recent focus on the treatment of ACS has centered on reducing the response of platelets to vascular injury as well as inhibiting fibrin deposition. Novel therapies include more effective P2Y12 receptor blockers thereby reducing inter-individual variability, targeting the platelet thrombin receptor (protease activated receptor 1) as well as directly inhibiting factor Xa or thrombin activity. In this review we discuss the clinical data evaluating the effectiveness of these various new ACS treatment options.
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Affiliation(s)
- Scott M Lilly
- Cardiovascular Division, Hospital of the University of Pennsylvania Philadelphia, PA, USA
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19
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Tello-Montoliu A, Ueno M, Angiolillo DJ. Antiplatelet drug therapy: role of pharmacodynamic and genetic testing. Future Cardiol 2011; 7:381-402. [DOI: 10.2217/fca.11.14] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Antiplatelet therapy represents the cornerstone of treatment for the short- and long-term prevention of atherothrombotic disease processes, in particular in high-risk settings such as in patients with acute coronary syndrome and those undergoing percutaneous coronary intervention. Currently, dual antiplatelet therapy with aspirin and clopidogrel represents the most commonly used treatment regimen in these settings. However, a considerable number of patients continue to experience adverse outcomes, including both bleeding and recurrent ischemic events. Numerous investigations have demonstrated that this phenomenon may be, in part, attributed to the broad variability in individual response profiles to this standard antiplatelet treatment regimen, as identified by various assays of platelet function testing. In addition, recent studies have demonstrated that genetic polymorphisms may also have an important role in determining levels of platelet inhibition and may be considered as a tool to identify patients at risk of adverse events. This article provides an overview on antiplatelet drug response variability, an update on definitions, including the role of pharmacodynamic testing, underlying mechanisms – with emphasis on recent understandings on pharmacogenetics and drug–drug interactions – and current and future perspectives on individualized antiplatelet therapy.
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Affiliation(s)
- Antonio Tello-Montoliu
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
- Department of Cardiology-Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Masafumi Ueno
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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20
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Giugliano RP, Braunwald E. The year in non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 2011; 56:2126-38. [PMID: 21144974 DOI: 10.1016/j.jacc.2010.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 08/30/2010] [Accepted: 09/02/2010] [Indexed: 12/30/2022]
Affiliation(s)
- Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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21
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Brown C, Joshi B, Faraday N, Shah A, Yuh D, Rade JJ, Hogue CW. Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics. Anesth Analg 2011; 112:777-99. [PMID: 21385977 DOI: 10.1213/ane.0b013e31820e7e4f] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.
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Affiliation(s)
- Charles Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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