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Wang S, He H, Mao Y, Zhang Y, Gu N. Advances in Atherosclerosis Theranostics Harnessing Iron Oxide-Based Nanoparticles. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2308298. [PMID: 38368274 PMCID: PMC11077671 DOI: 10.1002/advs.202308298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 02/06/2024] [Indexed: 02/19/2024]
Abstract
Atherosclerosis, a multifaceted chronic inflammatory disease, has a profound impact on cardiovascular health. However, the critical limitations of atherosclerosis management include the delayed detection of advanced stages, the intricate assessment of plaque stability, and the absence of efficacious therapeutic strategies. Nanotheranostic based on nanotechnology offers a novel paradigm for addressing these challenges by amalgamating advanced imaging capabilities with targeted therapeutic interventions. Meanwhile, iron oxide nanoparticles have emerged as compelling candidates for theranostic applications in atherosclerosis due to their magnetic resonance imaging capability and biosafety. This review delineates the current state and prospects of iron oxide nanoparticle-based nanotheranostics in the realm of atherosclerosis, including pivotal aspects of atherosclerosis development, the pertinent targeting strategies involved in disease pathogenesis, and the diagnostic and therapeutic roles of iron oxide nanoparticles. Furthermore, this review provides a comprehensive overview of theranostic nanomedicine approaches employing iron oxide nanoparticles, encompassing chemical therapy, physical stimulation therapy, and biological therapy. Finally, this review proposes and discusses the challenges and prospects associated with translating these innovative strategies into clinically viable anti-atherosclerosis interventions. In conclusion, this review offers new insights into the future of atherosclerosis theranostic, showcasing the remarkable potential of iron oxide-based nanoparticles as versatile tools in the battle against atherosclerosis.
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Affiliation(s)
- Shi Wang
- State Key Laboratory of Digital Medical EngineeringJiangsu Key Laboratory for Biomaterials and DevicesSchool of Biological Sciences & Medical EngineeringSoutheast UniversityNanjing210009P. R. China
| | - Hongliang He
- State Key Laboratory of Digital Medical EngineeringJiangsu Key Laboratory for Biomaterials and DevicesSchool of Biological Sciences & Medical EngineeringSoutheast UniversityNanjing210009P. R. China
| | - Yu Mao
- School of MedicineNanjing UniversityNanjing210093P. R. China
| | - Yu Zhang
- State Key Laboratory of Digital Medical EngineeringJiangsu Key Laboratory for Biomaterials and DevicesSchool of Biological Sciences & Medical EngineeringSoutheast UniversityNanjing210009P. R. China
| | - Ning Gu
- School of MedicineNanjing UniversityNanjing210093P. R. China
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Gianesini S, De Luca L, Feodor T, Taha W, Bozkurt K, Lurie F. Cardiovascular Insights for the Appropriate Management of Chronic Venous Disease: A Narrative Review of Implications for the Use of Venoactive Drugs. Adv Ther 2023; 40:5137-5154. [PMID: 37768506 PMCID: PMC10611621 DOI: 10.1007/s12325-023-02657-0] [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: 07/06/2023] [Accepted: 08/17/2023] [Indexed: 09/29/2023]
Abstract
Evidence suggests that chronic venous disease (CVD) may be a cardiovascular disorder, as patients with CVD are prone to developing arterial (atherosclerosis) and venous (thromboembolism) diseases. This may be partly explained by shared risk factors. Thus, patients with CVD or cardiovascular disease require careful history-taking and physical assessment to identify coexisting pathologies and risk factors. This article summarises a symposium at the XIX World Congress of the International Union of Phlebology held in Istanbul, Turkey, in September 2022. Common pathophysiological features of CVD and cardiovascular disease are endothelial injury, hypercoagulability and systemic inflammation. In CVD, inflammation primarily affects the microcirculation, with changes in capillary permeability, vein wall and valve remodelling and increase in oxidative stress. Once patients develop symptoms/signs of CVD, they tend to reduce their physical activity, which may contribute to increased risk of cardiovascular disease. Data show that the presence of CVD is associated with an increased risk of cardiovascular disease, including peripheral arterial disease and heart failure (HF), and the risk of adverse cardiovascular events increases with CVD severity. In addition, patients with cardiovascular disease, particularly those with HF, are at increased risk of venous thromboembolism (VTE) and should be assessed for VTE risk if they are hospitalised with cardiovascular disease. Therefore, CVD management must include a multi-specialty approach to assess risk factors associated with both the venous and arterial systems. Ideally, treatment should focus on the resolution of endothelial inflammation to control both CVD and cardiovascular disease. International guidelines recommend various conservative treatments, including venoactive drugs (VADs), to improve the symptoms/signs of CVD. Micronized purified flavonoid fraction (MPFF) is a VAD, with high-quality evidence supporting its use in relieving symptoms/signs of CVD and improving quality of life. Moreover, in large-scale observational studies, MPFF has shown superior effectiveness in real-world populations compared with other VADs. Video Abstract. (MP4 97173 kb).
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Affiliation(s)
- Sergio Gianesini
- Translational Medicine Department, University of Ferrara, Via Porta a Mare 11, 45100, Ferrara, Rovigo, Italy.
| | - Leonardo De Luca
- Division of Cardiology, Department of Cardio-Thoracic and Vascular Medicine and Surgery, A.O. San Camillo-Forlanini, Rome, Italy
| | - Toni Feodor
- Medical Center for Diagnosis, Ambulatory Treatment and Medical Prevention, Surgery Clinic 'Sf. Nicolae', Bucharest, Romania
| | - Wassila Taha
- Non-Invasive Vascular Laboratory, AlSalam Hospital Mohandessin, Cairo, Egypt
| | - Kursat Bozkurt
- Department of Cardiovascular Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Fedor Lurie
- Jobst Vascular Institute, Toledo, OH, USA
- Division of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
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Xi Y, Mao Y, Yang F, Xi P, Zhu W, Song Y, Yan W, Liao X, Zhou L. Integrin β Expression as a New Diagnostic Marker for Arteriovenous Thrombosis: A Single-Center Prospective Study. J Cardiovasc Dev Dis 2023; 10:461. [PMID: 37998519 PMCID: PMC10672679 DOI: 10.3390/jcdd10110461] [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: 10/07/2023] [Revised: 10/21/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
Integrin β plays an important role in the pathogenesis of thrombosis and inflammation, and it may be a shared pathogenic mechanism between arterial and venous thromboses. With the goal of identifying new treatment targets for thrombotic diseases and specific diagnostic markers for venous thromboembolism (VTE), this prospective clinical study was performed to clarify the relationship between integrin and thrombosis. The levels of integrin β1-3, interleukin-6 (IL-6), and C-reactive protein were significantly higher in patients with acute myocardial infarction (AMI; n = 44) and acute VTE (n = 43) compared to healthy controls (n = 33). The IL-6 and integrin β1-3 levels were also significantly higher in the AMI group compared to the VTE and control groups. Logistic regression analysis identified IL-6 and integrin β1-3 levels as independent risk factors for thrombotic disease. Based on the receiver-operating characteristic curve, Youden index, sensitivity, and specificity, the diagnostic accuracy value for VTE was greater than 0.8 when integrins β1, β2, and β3 were combined. Overall, these results suggest that integrin β levels can contribute to improving the diagnosis and treatment of arteriovenous thrombosis.
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Affiliation(s)
- Yan Xi
- Department of General Practice, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China; (Y.X.); (W.Z.)
| | - Yu Mao
- Department of Cardiology, Tongji Hospital, Tongji University, Shanghai 200065, China; (Y.M.); (P.X.); (W.Y.); (X.L.)
| | - Fan Yang
- Department of Clinical Laboratory, Tongji Hospital, Tongji University, Shanghai 200065, China;
| | - Peng Xi
- Department of Cardiology, Tongji Hospital, Tongji University, Shanghai 200065, China; (Y.M.); (P.X.); (W.Y.); (X.L.)
| | - Wei Zhu
- Department of General Practice, Tongji Hospital, School of Medicine, Tongji University, Shanghai 200065, China; (Y.X.); (W.Z.)
| | - Yanli Song
- Department of Emergency Internal Medicine, Tongji Hospital, Tongji University, Shanghai 200065, China;
| | - Wenwen Yan
- Department of Cardiology, Tongji Hospital, Tongji University, Shanghai 200065, China; (Y.M.); (P.X.); (W.Y.); (X.L.)
| | - Xudong Liao
- Department of Cardiology, Tongji Hospital, Tongji University, Shanghai 200065, China; (Y.M.); (P.X.); (W.Y.); (X.L.)
| | - Lin Zhou
- Department of Cardiology, Tongji Hospital, Tongji University, Shanghai 200065, China; (Y.M.); (P.X.); (W.Y.); (X.L.)
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Rahmani G, O'Sullivan GJ. Acute and chronic venous occlusion. Br J Radiol 2023; 96:20230242. [PMID: 37750946 PMCID: PMC10607425 DOI: 10.1259/bjr.20230242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/04/2023] [Accepted: 08/04/2023] [Indexed: 09/27/2023] Open
Abstract
This review article provides an overview of acute and chronic venous occlusion, a condition that can cause significant morbidity and mortality if not diagnosed and treated promptly. The article begins with an introduction to the anatomy of the venous system, followed by a discussion of the causes and clinical features of venous occlusion. The diagnostic tools available for the assessment of venous occlusion, including imaging modalities such as ultrasound, CT, and MRI, are then discussed, along with their respective advantages and limitations. The article also covers the treatment options for acute and chronic venous occlusion, including anticoagulant therapy and endovascular interventions. This review aims to provide radiologists with an updated understanding of the pathophysiology, diagnosis, and management of acute and chronic venous occlusion.
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Affiliation(s)
- George Rahmani
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
| | - Gerard J O'Sullivan
- Department of Interventional Radiology, Galway University Hospitals, Galway, Ireland
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Bejjani A, Khairani CD, Piazza G. Right Ventricular Recovery: Early and Late Changes after Acute PE Diagnosis. Semin Thromb Hemost 2023; 49:797-808. [PMID: 35777420 DOI: 10.1055/s-0042-1750025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Right ventricular (RV) failure is a critical cause of morbidity and mortality in patients presenting with pulmonary embolism (PE). The presentation of RV failure is based on the combination of clinical findings, laboratory abnormalities, and imaging evidence. An improved understanding of the pathophysiology of RV dysfunction following PE has given rise to more accurate risk stratification and broader therapeutic approaches. A subset of patients with PE develop chronic RV dysfunction with or without pulmonary hypertension. In this review, we focus on the impact of PE on the RV and its implications for risk stratification, prognosis, acute management, and long-term therapy.
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Affiliation(s)
- Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Piero Perna G, Vora P, Gandini E, Francesca Lusona C, Tosarello D. Persistence to rivaroxaban therapy for stroke prevention in clinical practice in Italy: Rationale and design of the RITMUS-AF prospective observational cohort study. IJC HEART & VASCULATURE 2023; 47:101229. [PMID: 37292062 PMCID: PMC10244690 DOI: 10.1016/j.ijcha.2023.101229] [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: 01/05/2023] [Revised: 05/09/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023]
Abstract
Background Non-valvular atrial fibrillation (NVAF) is a cardiac rhythm disturbance that increases the risk of stroke and is highly prevalent in Europe and Italy, increasingly with advancing age. Oral anticoagulation is a key component of stroke prevention in patients with NVAF, yet withdrawal or interruption of anticoagulation may transiently increase the risk of embolic events. Treatment persistence to anticoagulation is an important metric but one that is not well studied in patients with NVAF in Italy. The RITMUS-AF study aims to evaluate the persistence with rivaroxaban treatment for stroke prevention in patients with NVAF in Italy. Methods RITMUS-AF is a prospective, observational cohort study of patients with NVAF in hospital cardiology departments with a non-vitamin K antagonist oral anticoagulant surveillance program across all 20 regions of Italy. The study population comprises consecutively screened, consenting patients with NVAF naïve to and newly treated with rivaroxaban for stroke prevention in routine clinical practice. The target enrollment is 800 patients; each patient will be followed for a maximum duration of 24 months. The primary endpoint is the proportion of patients who discontinue rivaroxaban treatment. Secondary endpoints are reasons for rivaroxaban discontinuation, dose changes and reasons for changes, switches to alternative therapies and the reasons for these decisions, and self-reported adherence. Data analyses will be exploratory and descriptive. Conclusion RITMUS-AF will help to address the limited data in Italian clinical practice on treatment persistence and reasons for drug interruptions in patients with NVAF on rivaroxaban.
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Exploring phenotypes of deep vein thrombosis in relation to clinical outcomes beyond recurrence. JOURNAL OF THROMBOSIS AND HAEMOSTASIS : JTH 2023; 21:1238-1247. [PMID: 36736833 DOI: 10.1016/j.jtha.2023.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/15/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a multifactorial disease with several outcomes, but current classifications solely stratify it based on recurrence risk. OBJECTIVES We aimed to identify DVT phenotypes and assess their relation to recurrent venous thromboembolism (VTE), postthrombotic syndrome, arterial events, and cancer. PATIENTS/METHODS Hierarchical clustering was performed on a DVT cohort with a follow-up of up to 5 years using 23 baseline characteristics. Phenotypes were summarized by discriminative characteristics. Hazard ratios (HRs) were calculated using Cox regression; the recurrence risk was adjusted for the anticoagulant therapy duration. The study was carried out in accordance with the Declaration of Helsinki and approved by the medical ethics committee. RESULTS In total, 825 patients were clustered into 4 phenotypes: 1. women using estrogen therapy (n = 112); 2. patients with a cardiovascular risk profile (n = 268); 3. patients with previous VTE (n = 128); and 4. patients without discriminant characteristics (n = 317). Overall, the risks of recurrence, postthrombotic syndrome, arterial events, and cancer were low in phenotype 1 (reference), intermediate in phenotype 4 (HR: 4.6, 1.2, 2.2, 1.8), and high in phenotypes 2 (HR: 6.1, 1.6, 4.5, 2.9) and 3 (HR: 5.7, 2.5, 2.3, 3.7). CONCLUSIONS This study identified 4 distinct phenotypes among patients with DVT that are not only associated with the increasing recurrence risk but also with outcomes beyond recurrence. Our results thereby highlight the limitations of current risk stratifications that stratify based on the predictors of the recurrence risk only. Overall, risks were lowest in women using estrogen therapy and highest in patients with a cardiovascular risk profile. These findings might inform a more personalized approach to clinical management.
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Wang J, Tan J, Hua L, Sheng Q, Huang X, Liu P. Genetic Predisposition of Both Waist Circumference and Hip Circumference Increased the Risk of Venous Thromboembolism. Thromb Haemost 2023; 123:347-361. [PMID: 36384228 PMCID: PMC9981277 DOI: 10.1055/a-1980-8852] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obesity, especially abdominal obesity, is an independent indicator of increased cardiovascular risk. Observational studies have shown an observational association between obesity and venous thromboembolism (VTE). As a type of VTE, pulmonary embolism (PE) is also associated with obesity. However, it is unclear whether the observed associations are causal or caused by confounding bias or reverse causality. METHODS We performed a two-sample test by obtaining the exposure dataset of waist circumference (WC) and hip circumference (HC) from the Neale Laboratory Consortium's genome-wide association study summary data and the summary-level outcome data of VTE and PE from FinnGen Biobank of European ancestry to determine the causal effect of WC and HC on VTE and PE. RESULTS All three Mendelian randomization methods displayed a positive association between WC/HC and VTE/PE. WC and HC were positively associated with VTE (odds ratio [OR] = 1.803 per 1 standard deviation [SD] increase in WC, 95% confidence interval [CI] = 1.393-2.333; p < 0.001; OR = 1.479 per 1 SD increase in HC, 95% CI = 1.219-1.796; p < 0.001, respectively). Furthermore, we found a causal association between genetically predicted WC/HC and a higher risk of PE (OR = 1.929 per 1 SD increase in WC, 95% CI = 1.339-2.778, p < 0.001; OR = 1.431 per 1 SD increase in HC, 95% CI =1.095-1.869; p = 0.009, respectively). CONCLUSION There is a significant causal relationship between WC/HC and VTE/PE, which is consistent with observational studies. Taking measures to reduce WC/HC of obesity may help reduce the incidence of VTE/PE.
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Affiliation(s)
- Jiayu Wang
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, China
| | - Jiangshan Tan
- Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiping Sheng
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, China
| | - Xianwei Huang
- Department of Emergency, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Ping Liu
- Department of Cardiology, The Second Hospital of Shandong University, Jinan, China,Address for correspondence Ping Liu Department of Cardiology, The Second Hospital of Shandong UniversityNo.247, Beiyuan Road, Jinan, Shandong 250033China
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9
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Hess CN, Szarek M, Anand SS, Bauersachs RM, Patel MR, Debus ES, Nehler MR, Capell WH, Beckman JA, Piazza G, Henkin S, Bura-Rivière A, Lawall H, Roztocil K, Hsia J, Muehlhofer E, Berkowitz SD, Haskell LP, Bonaca MP. Rivaroxaban and Risk of Venous Thromboembolism in Patients With Symptomatic Peripheral Artery Disease After Lower Extremity Revascularization. JAMA Netw Open 2022; 5:e2215580. [PMID: 35731517 PMCID: PMC9218845 DOI: 10.1001/jamanetworkopen.2022.15580] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Prior studies have observed an association between the burden of atherosclerotic vascular disease and the risk of venous thromboembolism (VTE). The association is not well described in peripheral artery disease (PAD) after lower extremity revascularization (LER). OBJECTIVE To describe the risk of, factors associated with, and outcomes after VTE, as well as the association of low-dose rivaroxaban plus antiplatelet therapy with VTE after LER. DESIGN, SETTING, AND PARTICIPANTS This global, multicenter cohort study used data from the Vascular Outcomes Study of ASA (acetylsalicylic acid) Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for PAD (VOYAGER PAD) randomized clinical trial, which enrolled patients from 2015 to 2018 with median follow-up of 28 months. Participants included patients with PAD undergoing LER. Patients with an indication for therapeutic anticoagulation were excluded. Data were analyzed from September 2020 to September 2021. EXPOSURE Randomization to rivaroxaban 2.5 mg twice daily or placebo on a background of aspirin 100 mg daily; short-term clopidogrel was used at the discretion of the treating physician. MAIN OUTCOMES AND MEASURES Symptomatic VTE was a prespecified secondary outcome and prospectively collected. RESULTS Among 6564 patients (median [IQR] age, 67 [61-73] years; 4860 [74.0%] men), 66 patients had at least 1 VTE. The 3-year rate of VTE in patients receiving placebo was 1.7%, and the pattern of risk was linear (year 1: 0.5%; year 2: 1.1%). After multivariable modeling, weight (hazard ratio [HR], 3.04; 95% CI, 1.09-8.43), hypertension (HR, 2.11; 95% CI, 0.91-4.89), prior amputation (HR, 2.07; 95% CI, 0.95-4.53), and older age (HR, 1.81; 95% CI, 1.06-3.11) were associated with increased risk of VTE. VTE was associated with risk of subsequent mortality (HR, 7.22; 95% CI, 4.66-11.19). Compared with aspirin alone, rivaroxaban plus aspirin was associated with lower VTE risk (HR, 0.61; 95% CI, 0.37-0.998; P = .047), with benefit apparent early and sustained over time. This association was not modified by use of clopidogrel at randomization (without clopidogrel: HR, 0.55; 95% CI, 0.29-1.07; with clopidogrel: HR, 0.69; 95% CI, 0.32-1.48; P for interaction = .67). CONCLUSIONS AND RELEVANCE In this cohort study, there was continuous risk for VTE after LER in patients with PAD, with greater risk in patients who were older and had obesity and those with more severe PAD, as reflected by prior amputation. Low-dose rivaroxaban plus aspirin was associated with lower VTE risk compared with aspirin alone, with benefits apparent early and continued over time. The spectrum of venous and arterial thrombotic events and overall benefits of more potent antithrombotic strategies for prevention should be considered after LER for PAD.
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Affiliation(s)
- Connie N. Hess
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- CPC Clinical Research, Aurora, Colorado
| | - Michael Szarek
- CPC Clinical Research, Aurora, Colorado
- The State University of New York Downstate Health Sciences University, Brooklyn
| | - Sonia S. Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Rupert M. Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Darmstadt, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Manesh R. Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - E. Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery–Angiology–Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R. Nehler
- CPC Clinical Research, Aurora, Colorado
- University of Colorado School of Medicine, Department of Surgery, Aurora
| | - Warren H. Capell
- CPC Clinical Research, Aurora, Colorado
- Division of Endocrinology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Joshua A. Beckman
- Cardiovascular Division, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Holger Lawall
- Praxis für Herzkreislaufkrankheiten und Akademie für Gefäßkrankheiten, Ettlingen, Germany
| | - Karel Roztocil
- Department of Transplantational Surgery, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Judith Hsia
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- CPC Clinical Research, Aurora, Colorado
| | | | - Scott D. Berkowitz
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- CPC Clinical Research, Aurora, Colorado
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora
| | | | - Marc P. Bonaca
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora
- CPC Clinical Research, Aurora, Colorado
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Both G protein-coupled and immunoreceptor tyrosine-based activation motif receptors mediate venous thrombosis in mice. Blood 2022; 139:3194-3203. [PMID: 35358299 PMCID: PMC9136879 DOI: 10.1182/blood.2022015787] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/27/2022] [Indexed: 01/26/2023] Open
Abstract
Platelets are critical in hemostasis and a major contributor to arterial thrombosis (AT). (Pre)clinical studies suggest platelets also contribute to venous thrombosis (VT), but the mechanisms are largely unknown. We hypothesized that in VT, platelets use signaling machinery distinct from AT. Here we aimed to characterize the contributions of platelet G protein-coupled (GPCR) and immunoreceptor tyrosine-based activation motif (ITAM) receptor signaling to VT. Wild-type (WT) and transgenic mice were treated with inhibitors to selectively inhibit platelet-signaling pathways: ITAM-CLEC2 (Clec2mKO), glycoprotein VI (JAQ1 antibody), and Bruton's tyrosine kinase (ibrutinib); GPCR-cyclooxygenase 1 (aspirin); and P2Y12 (clopidogrel). VT was induced by inferior vena cava stenosis. Thrombin generation in platelet-rich plasma and whole-blood clot formation were studied ex vivo. Intravital microscopy was used to study platelet-leukocyte interactions after flow restriction. Thrombus weights were reduced in WT mice treated with high-dose aspirin + clopidogrel (dual antiplatelet therapy [DAPT]) but not in mice treated with either inhibitor alone or low-dose DAPT. Similarly, thrombus weights were reduced in mice with impaired ITAM signaling (Clec2mKO + JAQ1; WT + ibrutinib) but not in Clec2mKO or WT + JAQ1 mice. Both aspirin and clopidogrel, but not ibrutinib, protected mice from FeCl3-induced AT. Thrombin generation and clot formation were normal in blood from high-dose DAPT- or ibrutinib-treated mice; however, platelet adhesion and platelet-neutrophil aggregate formation at the vein wall were reduced in mice treated with high-dose DAPT or ibrutinib. In summary, VT initiation requires platelet activation via GPCRs and ITAM receptors. Strong inhibition of either signaling pathway reduces VT in mice.
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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12
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Arrigo M, Huber LC. Pulmonary Embolism and Heart Failure: A Reappraisal. Card Fail Rev 2021; 7:e03. [PMID: 33708418 PMCID: PMC7926477 DOI: 10.15420/cfr.2020.26] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 10/30/2020] [Indexed: 12/20/2022] Open
Abstract
Acute heart failure and acute pulmonary embolism share many features, including epidemiological aspects, clinical presentation, risk factors and pathobiological mechanisms. As such, it is not surprising that diagnosis and management of these common conditions might be challenging for the treating physician, in particular when both are concomitantly present. While helpful guidelines have been elaborated for both acute heart failure and pulmonary embolism, not many studies have been published on the coexistence of these diseases. With a special focus on diagnostic tools and therapeutic options, the authors review the available literature and, when evidence is lacking, present their own approach to the management of dyspnoeic patients with acute heart failure and pulmonary embolism.
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Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Triemli Hospital Zurich Zurich, Switzerland
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13
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Marston NA, Melloni GEM, Gurmu Y, Bonaca MP, Kamanu FK, Roselli C, Lee C, Cavallari I, Giugliano RP, Scirica BM, Bhatt DL, Steg PG, Cohen M, Storey RF, Keech AC, Raz I, Mosenzon O, Braunwald E, Lubitz SA, Ellinor PT, Sabatine MS, Ruff CT. Genetic Risk Score to Identify Risk of Venous Thromboembolism in Patients With Cardiometabolic Disease. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2021; 14:e003006. [PMID: 33434447 DOI: 10.1161/circgen.120.003006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of cardiovascular morbidity and mortality and has a known genetic contribution. We tested the performance of a genetic risk score for its ability to predict VTE in 3 cohorts of patients with cardiometabolic disease. METHODS We included patients from the FOURIER (Further Cardiovascular Outcomes Research With PCSK9 Inhibition in Patients With Elevated Risk), PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin), and SAVOR-TIMI 53 (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus) trials (history of a major atherosclerotic cardiovascular event, myocardial infarction, and diabetes, respectively) who consented for genetic testing and were not on baseline anticoagulation. We calculated a VTE genetic risk score based on 297 single nucleotide polymorphisms with established genome-wide significance. Patients were divided into tertiles of genetic risk. Cox proportional hazards models were used to calculate hazard ratios for VTE across genetic risk groups. The polygenic risk score was compared with available clinical risk factors (age, obesity, smoking, history of heart failure, and diabetes) and common monogenic mutations. RESULTS A total of 29 663 patients were included in the analysis with a median follow-up of 2.4 years, of whom 174 had a VTE event. There was a significantly increased gradient of risk across VTE genetic risk tertiles (P-trend <0.0001). After adjustment for clinical risk factors, patients in the intermediate and high genetic risk groups had a 1.88-fold (95% CI, 1.23-2.89; P=0.004) and 2.70-fold (95% CI, 1.81-4.06; P<0.0001) higher risk of VTE compared with patients with low genetic risk. In a continuous model adjusted for clinical risk factors, each standard deviation increase in the genetic risk score was associated with a 47% (95% CI, 29-68) increased risk of VTE (P<0.0001). CONCLUSIONS In a broad spectrum of patients with cardiometabolic disease, a polygenic risk score is a strong, independent predictor of VTE after accounting for available clinical risk factors, identifying 1/3 of patients who have a risk of VTE comparable to that seen with established monogenic thrombophilia.
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Affiliation(s)
- Nicholas A Marston
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Giorgio E M Melloni
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yared Gurmu
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Marc P Bonaca
- CPC Clinical Research, Cardiovascular Division, Department of Medicine, University of Colorado School of Medicine, Aurora (M.P.B.)
| | - Frederick K Kamanu
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Carolina Roselli
- Cardiovascular Disease Initiative, Broad Institute of MIT & Harvard, Cambridge, MA (C.R., C.L., S.A.L., P.T.E.).,University Medical Center Groningen, University of Groningen, NL (C.R.)
| | - Christina Lee
- Cardiovascular Disease Initiative, Broad Institute of MIT & Harvard, Cambridge, MA (C.R., C.L., S.A.L., P.T.E.)
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy (I.C.)
| | - Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin M Scirica
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Department of Medicine (D.L.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Marc Cohen
- Newark Beth Israel Medical Center, Rutgers Medical School, NJ (M.C.)
| | | | - Anthony C Keech
- Sydney Medical School, National Health & Medical Research Council Clinical Trials Centre, University of Sydney, Australia (A.C.K.)
| | - Itamar Raz
- Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel (I.R., O.M.)
| | - Ofri Mosenzon
- Department of Endocrinology and Metabolism, Hadassah Hebrew University Hospital, Jerusalem, Israel (I.R., O.M.)
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Steven A Lubitz
- Cardiovascular Disease Initiative, Broad Institute of MIT & Harvard, Cambridge, MA (C.R., C.L., S.A.L., P.T.E.).,Cardiovascular Research Center, Massachusetts General Hospital, Boston (S.A.L., P.T.E.)
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute of MIT & Harvard, Cambridge, MA (C.R., C.L., S.A.L., P.T.E.).,Cardiovascular Research Center, Massachusetts General Hospital, Boston (S.A.L., P.T.E.)
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Christian T Ruff
- TIMI Study Group, Division of Cardiovascular Medicine, Department of Medicine (N.A.M., G.E.M.M., Y.G., F.K.K., R.P.G., B.M.S., E.B., M.S.S., C.T.R.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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14
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Abstract
IMPORTANCE Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event. OBSERVATIONS PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin. CONCLUSIONS AND RELEVANCE Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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15
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Anticoagulation in Italian patients with venous thromboembolism and thrombophilic alterations: findings from START2 register study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:486-495. [PMID: 32955425 DOI: 10.2450/2020.0091-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Randomised control trials have assessed the efficacy and safety of direct oral anticoagulants in the prophylaxis and treatment of venous thromboembolism (VTE). Positive but limited results have been reported in patients with inherited thrombophilia. Using an Italian, multicentre, prospective registry of consecutive patients presenting with symptomatic, acute VTE, we aimed to assess which factors are involved in making the choice of the drug that best fits the patient's risk profile in a large real-world setting of VTE patients. MATERIALS AND METHODS We investigated 4,866 VTE patients who took oral anticoagulants in the period between 2012 and April 2018 to prevent a new thromboembolic episode. RESULTS The large majority of patients who underwent thrombophilic screening, regardless of the results obtained, were prescribed direct oral anticoagulants rather than conventional anticoagulant therapy (p<0.001). During anticoagulation, bleeding events occurred more frequently in patients on conventional anticoagulant therapy (4.2%) than in those receiving direct oral anticoagulants (1.8%) and an increase in bleeding events was observed in patients who tested positive at the thrombophilic screening. Overall, a higher number of recurrent VTE was observed in patients not screened for thrombophilia (n=36; 1.7%) than in those screened (n=20; 0.7%; adjusted odds ratio: 2.2; 95% confidence interval: 1.2-4.1). DISCUSSION The present data confirm previous findings from other post-marketing registries and suggest that the choice of oral anticoagulation is strongly driven by patients' characteristics and VTE manifestations. Factors leading to the prescription of thrombophilic screening may identify a patient with a lower risk of VTE recurrence during anticoagulation.
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16
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Van Galen J, Pava L, Wright C, Elbadawi A, Hamer A, Chaturvedi A, Cameron SJ. Effect of platelet inhibitors on thrombus burden in patients with acute pulmonary embolism. Platelets 2020; 32:138-140. [PMID: 32141372 DOI: 10.1080/09537104.2020.1732329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Venous thromboembolism (VTE) whether provoked or not can be life-threatening due to an acute increase in load on the right ventricle (RV) from obstruction of the pulmonary artery (PA). Treatment for and prevention of VTE involves anti-thrombotic agents; more specifically, medications targeting the anticoagulation cascade. In spite of the widespread acceptance of anticoagulants in the treatment of VTE, there appears to be an ongoing belief that platelet reactivity contributes to thrombus burden in patients with acute pulmonary embolism (PE). This investigation of 398 patients presenting with acute PE evaluated whether anti-platelet medication use, which consisted mostly of aspirin therapy, at the time of presentation, affects PA thrombus burden, RV load, or short-term patient outcomes. We conclude that platelets may have been erroneously incriminated as direct thrombotic mediators in patients with acute PE since aspirin neither decreased PA thrombus burden, nor did aspirin improve short-term mortality following acute PE.
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Affiliation(s)
- Joseph Van Galen
- Department of Medicine, University of Virginia , Charlottesville, VA, USA
| | - Libia Pava
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Colin Wright
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch , Galveston, TX, USA
| | - Annelise Hamer
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA
| | - Abhishek Chaturvedi
- Department of Imaging Sciences, University of Rochester School of Medicine , Rochester, NY, USA
| | - Scott J Cameron
- Department of Medicine, University of Rochester School of Medicine , Rochester, NY, USA.,Heart Vascular and Thoracic Institute, Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation , Cleveland, OH, USA.,Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute , Cleveland, OH, USA
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17
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Costa F, Van Klaveren D, Feres F, James S, Räber L, Pilgrim T, Hong MK, Kim HS, Colombo A, Steg PG, Bhatt DL, Stone GW, Windecker S, Steyerberg EW, Valgimigli M. Dual Antiplatelet Therapy Duration Based on Ischemic and Bleeding Risks After Coronary Stenting. J Am Coll Cardiol 2020; 73:741-754. [PMID: 30784667 DOI: 10.1016/j.jacc.2018.11.048] [Citation(s) in RCA: 192] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Complex percutaneous coronary intervention (PCI) is associated with higher ischemic risk, which can be mitigated by long-term dual antiplatelet therapy (DAPT). However, concomitant high bleeding risk (HBR) may be present, making it unclear whether short- or long-term DAPT should be prioritized. OBJECTIVES This study investigated the effects of ischemic (by PCI complexity) and bleeding (by PRECISE-DAPT [PREdicting bleeding Complications in patients undergoing stent Implantation and SubsequEnt Dual AntiPlatelet Therapy] score) risks on clinical outcomes and on the impact of DAPT duration after coronary stenting. METHODS Complex PCI was defined as ≥3 stents implanted and/or ≥3 lesions treated, bifurcation stenting and/or stent length >60 mm, and/or chronic total occlusion revascularization. Ischemic and bleeding outcomes in high (≥25) or non-high (<25) PRECISE-DAPT strata were evaluated based on randomly allocated duration of DAPT. RESULTS Among 14,963 patients from 8 randomized trials, 3,118 underwent complex PCI and experienced a higher rate of ischemic, but not bleeding, events. Long-term DAPT in non-HBR patients reduced ischemic events in both complex (absolute risk difference: -3.86%; 95% confidence interval: -7.71 to +0.06) and noncomplex PCI strata (absolute risk difference: -1.14%; 95% confidence interval: -2.26 to -0.02), but not among HBR patients, regardless of complex PCI features. The bleeding risk according to the Thrombolysis In Myocardial Infarction scale was increased by long-term DAPT only in HBR patients, regardless of PCI complexity. CONCLUSIONS Patients who underwent complex PCI had a higher risk of ischemic events, but benefitted from long-term DAPT only if HBR features were not present. These data suggested that when concordant, bleeding, more than ischemic risk, should inform decision-making on the duration of DAPT.
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Affiliation(s)
- Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G. Martino," University of Messina, Messina, Italy; Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - David Van Klaveren
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lorenz Räber
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea and Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy and Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Philippe Gabriel Steg
- FACT, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Université Paris-Diderot, Bichat Hospital, Paris, France
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Stephan Windecker
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland
| | - Ewout W Steyerberg
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Bern, Switzerland.
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18
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Olivieri O, Turcato G, Moruzzi S, Castagna A, Girelli D, Pizzolo F, Friso S, Sandri M, Bassi A, Martinelli N. Not Just Arterial Damage: Increased Incidence of Venous Thromboembolic Events in Cardiovascular Patients With Elevated Plasma Levels of Apolipoprotein CIII. J Am Heart Assoc 2020; 8:e010973. [PMID: 30646800 PMCID: PMC6497332 DOI: 10.1161/jaha.118.010973] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Apolipoprotein CIII (apo CIII) is a crucial player in triglyceride‐rich lipoprotein metabolism, but may also act pleiotropically, provoking inflammatory responses and stimulating coagulation. Elevated apoCIII plasma levels have been associated with increased activity of coagulation factors. Since these features of prothrombotic diathesis are linked with venous thromboembolism (VTE), we hypothesized that apo CIII plays a role in VTE. Methods and Results We recorded nonfatal VTE events in 1020 patients (age 63.3±11.4 years; 29.1% women) with or without coronary artery disease (79.1% with coronary artery disease and 20.9% without coronary artery disease) during a long follow‐up. Complete plasma lipid and apolipoproteins were available for all patients. Forty‐five patients (4.4%) experienced nonfatal VTE events during a median follow‐up period of 144 months. Apo CIII plasma concentration at enrollment was higher in patients with VTE compared with patients without VTE (12.2 [95% CI, 11.10–13.5] mg/dL vs 10.6 [95% CI, 10.4–10.9] mg/dL, respectively; P=0.011). Patients with apo CIII levels above the median value (10.6 mg/dL) exhibited an increased risk of VTE (incidence rate, 6.0 [95% CI, 4.0–8.0] vs 1.8 [95% CI, 0.7–2.9] VTE events/1000 person‐years; unadjusted hazard ratio [HR], 3.42 [95% CI, 1.73–6.75]; P<0.001). This association was confirmed after adjustment for sex, age, coronary artery disease diagnosis, body mass index, hypertension, and anticoagulant treatment at enrollment (HR, 2.66; 95% CI, 1.31–5.37 [P=0.007]), with inclusion of lipid parameters in the Cox model (HR, 3.74; 95% CI, 1.24–11.33 [P=0.019]), and even with exclusion of patients who died at follow‐up (HR, 3.92; 95% CI, 1.68–9.14 [P=0.002]) or patients taking anticoagulants (HR, 3.39; 95% CI, 1.72–6.69 [P<0.001]). Conclusions Our results suggest that high plasma apo CIII concentrations may predict an increased risk of VTE in patients with cardiovascular disease.
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Affiliation(s)
- Oliviero Olivieri
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | | | | | - Annalisa Castagna
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Domenico Girelli
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Francesca Pizzolo
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Simonetta Friso
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Marco Sandri
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
| | - Antonella Bassi
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy.,3 Laboratory of Clinical Chemistry and Hematology University Hospital of Verona Italy
| | - Nicola Martinelli
- 1 Unit of Internal Medicine Department of Medicine University of Verona Italy
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19
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Prandoni P. Is there a link between venous and arterial thrombosis? A reappraisal. Intern Emerg Med 2020; 15:33-36. [PMID: 31773560 DOI: 10.1007/s11739-019-02238-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Whether there is a link between venous and arterial thrombotic disorders is still a matter of debate. They share common risk factors, such as old age, male sex and obesity. Endothelial dysfunction and inflammation are likely to play a role in determining the simultaneous involvement of the two vascular compartments. Unlike subclinical atherosclerosis, symptomatic complications of atherosclerosis such as myocardial infarction, ischemic stroke and atrial fibrillation are likely to predict the subsequent development of venous thromboembolic (VTE) complications. Patients with VTE, especially those with apparently unprovoked episodes, have a definitely increased risk of subsequent arterial thrombotic disorders. Drugs that reduce the risk of arterial thrombosis are likely to reduce the risk of venous thrombosis and vice versa. In particular, the direct oral anticoagulants have recently been shown to reduce the risk of both vascular disorders. In conclusion, recent evidence provides compelling evidence in support of the link between venous and arterial thrombosis. Future studies are needed to clarify the nature of this association, to assess its extent, and to evaluate its implications for clinical practice.
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Affiliation(s)
- Paolo Prandoni
- Arianna Foundation On Anticoagulation, Via P. Fabbri 1/3, 40138, Bologna, Italy.
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20
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Frydman GH, Boyer EW, Nazarian RM, Van Cott EM, Piazza G. Coagulation Status and Venous Thromboembolism Risk in African Americans: A Potential Risk Factor in COVID-19. Clin Appl Thromb Hemost 2020; 26:1076029620943671. [PMID: 32702995 PMCID: PMC7383642 DOI: 10.1177/1076029620943671] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/16/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 infection (COVID-19) is known to induce severe inflammation and activation of the coagulation system, resulting in a prothrombotic state. Although inflammatory conditions and organ-specific diseases have been shown to be strong determinants of morbidity and mortality in patients with COVID-19, it is unclear whether preexisting differences in coagulation impact the severity of COVID-19. African Americans have higher rates of COVID-19 infection and disease-related morbidity and mortality. Moreover, African Americans are known to be at a higher risk for thrombotic events due to both biological and socioeconomic factors. In this review, we explore whether differences in baseline coagulation status and medical management of coagulation play an important role in COVID-19 disease severity and contribute to racial disparity trends within COVID-19.
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MESH Headings
- Black or African American/genetics
- Anemia, Sickle Cell/blood
- Anemia, Sickle Cell/ethnology
- Anticoagulants/therapeutic use
- Betacoronavirus
- Blood Proteins/analysis
- Blood Proteins/genetics
- COVID-19
- Clinical Trials as Topic
- Comorbidity
- Coronavirus Infections/blood
- Coronavirus Infections/complications
- Coronavirus Infections/ethnology
- Factor VIII/analysis
- Female
- Fibrin Fibrinogen Degradation Products/analysis
- Genetic Association Studies
- Genetic Predisposition to Disease
- Healthcare Disparities
- Humans
- Lupus Erythematosus, Systemic/blood
- Lupus Erythematosus, Systemic/ethnology
- Male
- Pandemics
- Patient Selection
- Pneumonia, Viral/blood
- Pneumonia, Viral/complications
- Pneumonia, Viral/ethnology
- Polymorphism, Single Nucleotide
- Prevalence
- Renal Insufficiency, Chronic/blood
- Renal Insufficiency, Chronic/ethnology
- Risk Factors
- SARS-CoV-2
- Social Determinants of Health
- Socioeconomic Factors
- Thrombophilia/blood
- Thrombophilia/drug therapy
- Thrombophilia/ethnology
- Thrombophilia/etiology
- Venous Thromboembolism/blood
- Venous Thromboembolism/ethnology
- Venous Thromboembolism/etiology
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- Galit H. Frydman
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Edward W. Boyer
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | | | | | - Gregory Piazza
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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