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Chandiramani R, Mehta A, Blumenthal RS, Williams MS. Should We Use Aspirin or P2Y 12 Inhibitor Monotherapy in Stable Ischemic Heart Disease? Curr Atheroscler Rep 2024:10.1007/s11883-024-01234-2. [PMID: 39243345 DOI: 10.1007/s11883-024-01234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE OF REVIEW To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks. RECENT FINDINGS It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient's risk profile.
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Affiliation(s)
| | - Adhya Mehta
- Department of Internal Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | | | - Marlene S Williams
- Department of Medicine, Division of Cardiology, The Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
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Wurtzel JGT, Lazar S, Askari S, Zhao X, Severa J, Ayombil F, Michael JV, Camire RM, McKenzie SE, Stalker TJ, Ma P, Goldfinger LE. Plasma growth factors maintain constitutive translation in platelets to regulate reactivity and thrombotic potential. Blood Adv 2024; 8:1550-1566. [PMID: 38163324 PMCID: PMC10982986 DOI: 10.1182/bloodadvances.2023011734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/14/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT Mechanisms of proteostasis in anucleate circulating platelets are unknown and may regulate platelet function. We investigated the hypothesis that plasma-borne growth factors/hormones (GFHs) maintain constitutive translation in circulating platelets to facilitate reactivity. Bio-orthogonal noncanonical amino acid tagging (BONCAT) coupled with liquid chromatography-tandem mass spectrometry analysis revealed constitutive translation of a broad-spectrum translatome in human platelets dependent upon plasma or GFH exposure, and in murine circulation. Freshly isolated platelets from plasma showed homeostatic activation of translation-initiation signaling pathways: phosphorylation of p38/ERK upstream kinases, essential intermediate MNK1/2, and effectors eIF4E/4E-BP1. Plasma starvation led to loss of pathway phosphorylation, but it was fully restored with 5-minute stimulation by plasma or GFHs. Cycloheximide or puromycin infusion suppressed ex vivo platelet GpIIb/IIIa activation and P-selectin exposure with low thrombin concentrations and low-to-saturating concentrations of adenosine 5'-diphosphate (ADP) or thromboxane analog but not convulxin. ADP-induced thromboxane generation was blunted by translation inhibition, and secondary-wave aggregation was inhibited in a thromboxane-dependent manner. Intravenously administered puromycin reduced injury-induced clot size in cremaster muscle arterioles, and delayed primary hemostasis after tail tip amputation but did not delay neither final hemostasis after subsequent rebleeds, nor final hemostasis after jugular vein puncture. In contrast, these mice were protected from injury-induced arterial thrombosis and thrombin-induced pulmonary thromboembolism (PE), and adoptive transfer of translation-inhibited platelets into untreated mice inhibited arterial thrombosis and PE. Thus, constitutive plasma GFH-driven translation regulates platelet G protein-coupled receptor reactivity to balance hemostasis and thrombotic potential.
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Affiliation(s)
- Jeremy G. T. Wurtzel
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Sophia Lazar
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Shayan Askari
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Xuefei Zhao
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Jenna Severa
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Francis Ayombil
- Division of Hematology and the Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - James V. Michael
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Rodney M. Camire
- Division of Hematology and the Raymond G. Perelman Center for Cellular and Molecular Therapeutics, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven E. McKenzie
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Timothy J. Stalker
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Peisong Ma
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Lawrence E. Goldfinger
- Division of Hematology, Department of Medicine, Cardeza Foundation for Hematologic Research, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Mihatov N, Kirtane AJ, Stoler R, Feldman R, Neumann FJ, Boutis L, Tahirkheli N, Kereiakes DJ, Toelg R, Othman I, Stein B, Allocco D, Windecker S, Yeh RW. Bleeding and Ischemic Risk Prediction in Patients With High Bleeding Risk (an EVOLVE Short DAPT Analysis). Am J Cardiol 2023; 207:370-379. [PMID: 37778226 DOI: 10.1016/j.amjcard.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/03/2023] [Accepted: 06/06/2023] [Indexed: 10/03/2023]
Abstract
The EVOLVE Short DAPT study demonstrated the safety of truncated dual antiplatelet therapy (DAPT) in patients with a high bleeding risk (HBR) treated with SYNERGY stent(s) (Boston Scientific Company, Marlborough, Massachusetts). In this population, bleeding and ischemic risk prediction may further inform DAPT decisions. This post hoc analysis of the EVOLVE Short DAPT study identified predictors of ischemic and bleeding events up to 15 months using Cox proportional hazard models. The predicted probabilities of bleeding were calculated using the Breslow method. Of 2,009 enrolled patients, 96.9% of the patients met at least 1 HBR criteria. At 15 months, the cumulative incidences of bleeding and ischemic events were 6.3% and 6.0%, respectively. The risk of bleeding was increased in patients who received oral anticoagulants (hazard ratio [HR] 2.24, 95% confidence interval [CI] 1.50 to 3.36, p <0.001) or had peripheral vascular disease (HR 1.61, 95% CI 1.01 to 2.56, p = 0.045). The risk of ischemic events was increased in patients with diabetes (HR 1.86, 95% CI 1.24 to 2.78, p <0.01) or congestive heart failure (HR 2.06, 95% CI 1.39 to 3.04, p <0.001). Renal insufficiency/failure was associated with both endpoints. There was a strong positive correlation between the predicted probability of ischemic and bleeding events (R = 0.77, p <0.001). In 617 patients with a predicted bleeding risk <4%, ischemic events predominated, and the ischemic and bleeding rates were higher in patients with a predicted bleeding risk ≥4%. Within an HBR cohort, specific characteristics identify patients at a higher risk for ischemic and separately, bleeding events. Increased bleeding risk is tied to increased ischemic risk. In conclusion, standardized risk models are needed to inform DAPT decisions in patients with a higher risk. Clinical Trial Registration: NCT02605447.
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Affiliation(s)
- Nino Mihatov
- New York-Presbyterian Hospital - Brooklyn Methodist & Weill Cornell Medical College, New York, New York; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Robert Stoler
- Baylor Scott & White Heart and Vascular Hospital, Dallas, Texas
| | - Robert Feldman
- MediQuest Research at AdventHealth Ocala, Ocala, Florida
| | | | - Loukas Boutis
- North Shore University Hospital, Manhasset, New York
| | | | - Dean J Kereiakes
- Lindner Center for Research and Education at Christ Hospital, Cincinnati, Ohio
| | - Ralph Toelg
- Heart Center Segeberger Kliniken, Bad Segeberg, Germany
| | - Islam Othman
- Duke University Health System, Durham, North Carolina
| | - Bernardo Stein
- Morton Plant Mease Healthcare System, Clearwater, Florida
| | | | - Stephan Windecker
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Robert W Yeh
- Beth Israel Deaconess Medical Center, Boston, Massachusetts; Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts.
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Lee J, Kim MJ, Kim M, Park J, Kim H, Cho S, Choi Y, Lee J, Kim JH, Cha SJ, Kim TO, Kang DY, Lee PH, Ahn JM, Park SJ, Park DW. Validation of Academic Research Consortium for High Bleeding Risk Definition in East-Asian Patients. JACC. ASIA 2023; 3:390-399. [PMID: 37323862 PMCID: PMC10261889 DOI: 10.1016/j.jacasi.2022.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 11/17/2022] [Indexed: 06/17/2023]
Abstract
Background Clinical applicability of the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in East-Asian patients receiving potent antiplatelet therapy for acute coronary syndromes (ACS) is still undetermined. Objectives The purpose of this study was to validate the ARC definition for HBR in East-Asian patients with ACS for invasive management. Methods We analyzed data from the TICAKOREA (Ticagrelor Versus Clopidogrel in Asian/Korean Patients With ACS Intended for Invasive Management) trial and randomly assigned 800 Korean ACS subjects to receive, in a 1:1 ratio, ticagrelor or clopidogrel. Patients were considered HBR if they met at least 1 major or 2 minor ARC-HBR criteria. The primary bleeding endpoint was Bleeding Academic Research Consortium 3 or 5 bleeding and the primary ischemic endpoint was a major adverse cardiovascular event (MACE) (a composite of cardiovascular death, myocardial infarction, or stroke) at 12 months. Results Among 800 randomized patients, 129 (16.3%) were categorized HBR patients. HBR patients, compared with non-HBR patients, had a higher incidence of Bleeding Academic Research Consortium 3 or 5 bleeding (10.0% vs 3.7%; HR: 2.98; 95% CI: 1.52-5.86; P < 0.001) and MACE (14.3% vs 6.1%; HR: 2.35; 95% CI: 1.35-4.10; P = 0.002). The relative treatment effect of ticagrelor or clopidogrel on primary bleeding and ischemic outcomes were different between each group. Conclusions This study validates the ARC-HBR definition in Korean ACS patients. Approximately 15% of patients qualified as HBR patients who were at increased risk not only for bleeding but also for thrombotic events. The clinical application of ARC-HBR to determine the relative effect of different antiplatelet regiments should be further investigated. (Safety and Efficacy of Ticagrelor Versus Clopidogrel in Asian/KOREAn Patients with Acute Coronary Syndromes Intended for Invasive Management [TICA KOREA]; NCT02094963).
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Affiliation(s)
- Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Mijin Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinsun Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hoyun Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suji Cho
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeonwoo Choi
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Joo Cha
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Oh Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Polimeni A, Sorrentino S, Spaccarotella C, Mongiardo A, Sabatino J, De Rosa S, Gori T, Indolfi C. Stent Thrombosis After Percutaneous Coronary Intervention: From Bare-Metal to the Last Generation of Drug-Eluting Stents. Interv Cardiol Clin 2022; 11:465-473. [PMID: 36243491 DOI: 10.1016/j.iccl.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Since their introduction in clinical practice in 1986, different types of coronary stents have been developed and become available for the treatment of coronary artery disease. Stent thrombosis (ST) is an uncommon but harmful complication after percutaneous coronary implantation, with a high occurrence of acute myocardial infarction and risk of mortality. Among several procedural and clinical predictors, the type of coronary stent is a strong determinant of ST. This article reviews the available evidence on the most used coronary stent types in the modern era and the related risk of ST.
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Affiliation(s)
- Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Tommaso Gori
- Kardiologie I, Zentrum für Kardiologie, University Medical Center Mainz, Deutsches Zentrum für Herz und Kreislauf Forschung, Langenbeckstraße 1, Standort Rhein-Main 55131, Germany
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Mediterranea Cardiocentro, Via Orazio, 2, Naples 80122, Italy.
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Okabe K, Miura K, Shima Y, Ikuta A, Taguchi Y, Takahashi K, Osakada K, Ohya M, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Comparison and Validation of Long-Term Bleeding Events for Academic Bleeding Risk (ARC-HBR) Criteria and Contemporary Risk Scores for Percutaneous Coronary Intervention With a Second-Generation Drug Eluting Stent. Circ J 2022; 86:1379-1387. [PMID: 35400715 DOI: 10.1253/circj.cj-21-0901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
BACKGROUND The Academic Research Consortium for High Bleeding Risk (ARC-HBR) defined a consensus clinical criterion for patients at HBR undergoing percutaneous coronary intervention (PCI). This study aimed to validate and compare the ARC-HBR criteria and the contemporary risk score for long-term bleeding outcomes using a cohort of patients undergoing PCI. METHODS AND RESULTS This study analyzed 3,410 patients who underwent PCI between 2010 and 2013. The endpoint was defined as incidence of The Bleeding Academic Research Consortium 3 or 5 bleeding events. In addition to ARC-HBR, this study validated the predictability of the Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score, Patterns of non-adherence to Anti-platelet Regimens In Stented patients (PARIS) bleeding score, and Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) bleeding scores for bleeding events. There was a trend toward an increase in bleeding events, as the risk score increased for all bleeding risk scores used in this study. The ARC-HBR criteria had higher diagnostic sensitivity for bleeding events than other bleeding risk scores. CONCLUSIONS Patients with a higher number of risk factors in each of the four bleeding risk scores had a higher risk of long-term bleeding events. In comparison to other contemporary risk scores, the ARC-HBR criteria were more sensitive in the identification of patients with bleeding events in the long-term.
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Affiliation(s)
- Koya Okabe
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Katsuya Miura
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Yuki Shima
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Akihiro Ikuta
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Yuya Taguchi
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Kotaro Takahashi
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Kohei Osakada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Masanobu Ohya
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Shunsuke Kubo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Hiroyuki Tanaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Yasushi Fuku
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital
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Baber U. Polymer-Based Versus Polymer-Free Stents in High Bleeding Risk Patients: Less Is Not Always More. JACC Cardiovasc Interv 2022; 15:1164-1166. [PMID: 35680196 DOI: 10.1016/j.jcin.2022.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Usman Baber
- University of Oklahoma Health Sciences Center, Department of Medicine, Cardiovascular Section, Oklahoma City, Oklahoma, USA.
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Wang HY, Dou KF, Guan C, Xie L, Huang Y, Zhang R, Yang W, Wu Y, Yang Y, Qiao S, Gao R, Xu B. New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study. Circ Cardiovasc Interv 2022; 15:e011536. [PMID: 35582961 DOI: 10.1161/circinterventions.121.011536] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate duration of dual antiplatelet therapy (DAPT) and risk-benefit ratio for long-term DAPT in patients with left main (LM) disease undergoing percutaneous coronary intervention remains uncertain. METHODS Four thousand five hundred sixty-one consecutive patients with stenting of LM disease at a single center from January 2004 to December 2016 were enrolled. Decision to discontinue or remain on DAPT after 12 months was left to an individualized decision-making based on treating physicians by weighing the patient's risks of ischemia versus bleeding and considering patient preference. The primary outcome was a composite of death, myocardial infarction, stent thrombosis, or stroke at 3 years. Key safety outcome was 3-year rate of Bleeding Academic Research Consortium 2, 3, or 5 bleeding. RESULTS Of 3865 patients free of ischemic and bleeding events at 12 months, 1727 (44.7%) remained on DAPT (mostly clopidogrel based [97.7%]) beyond 12 months after LM percutaneous coronary intervention. DAPT>12-month versus ≤12-month DAPT was associated with a significant reduced risk of 3-year primary outcome (2.6% versus 4.6%; adjusted hazard ratio: 0.59 [95% CI, 0.41-0.84]). The same trend was found for other ischemic end points: death (0.9% versus 3.0%; Plog-rank<0.001), cardiovascular death (0.5% versus 1.7%; Plog-rank=0.001), myocardial infarction (0.8% versus 1.9%; Plog-rank=0.005), and stent thrombosis (0.4% versus 1.1%; Plog-rank=0.017). The key safety end point was not significantly different between 2 regimens (1.8% versus 1.6%; adjusted hazard ratio: 1.07 [95% CI, 0.65-1.74]). The effect of DAPT>12 month on primary and key safety outcomes was consistent across clinical presentations, high bleeding risk, P2Y12 inhibitor, and LM bifurcation percutaneous coronary intervention approach. CONCLUSIONS In a large cohort of patients free from clinical events during the first year after LM percutaneous coronary intervention and at low apparent future bleeding risk, an individualized patient-tailored approach to longer duration (>12 month) of DAPT with aspirin plus a P2Y12 inhibitor (mostly clopidogrel) improved both composite and individual efficacy outcomes by reducing ischemic risk, without a concomitant increase in clinically relevant bleeding.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Ke-Fei Dou
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Changdong Guan
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunfei Huang
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Weixian Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yongjian Wu
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yuejin Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Shubin Qiao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Runlin Gao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Bo Xu
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
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9
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Montalto C, Munafò AR, Arzuffi L, Casula M, Mandurino-Mirizzi A, Costa F, Leonardi S, Visconti LO, Ferlini M. Validation of the ARC-HBR criteria in 68,874 patients undergoing PCI: A systematic review and meta-analysis. Hellenic J Cardiol 2022; 66:59-66. [PMID: 35550178 DOI: 10.1016/j.hjc.2022.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 02/26/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022] Open
Abstract
The Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria aims to stratify patients undergoing percutaneous coronary intervention (PCI) and are now recommended by international guidelines to stratify bleeding risk in clinical practice. We searched electronic databases from 2019 (ARC-HBR proposal) up to February 2021 for studies that reported the occurrence of major bleedings according to ARC-HBR status in patients undergoing PCI and pooled them as relative risk (RR) in a random-effect analysis. Only studies that reported events according to the number of times the ARC-HBR definition was met were included in a sensitivity analysis and RR for each stratum was calculated. Nine studies and 68,874 subjects were included in our analysis; 39.2% of them were at HBR and they had a significantly higher risk of major bleedings (RR: 2.70; 95% CI: 2.35-3.10; p<0.0001). The ARC-HBR definition also had a moderate discriminative power (pooled c-stat: 0.69; 95% CI: 0.61-0.75) while calibration was suboptimal with a tendency toward underpredicting bleeding events (pooled observed:expected ratio: 1.47; 95% CI: 0.82-2.60). Our sensitivity analysis included 5 studies and 46,712 patients and confirmed the incremental, additive power of the ARC-HBR when it is met multiple times. Finally, among baseline characteristics explored, only presenting with an acute coronary syndrome had a significant impact on the ARC-HBR predictive ability. The ARC-HBR definition is a useful clinical tool, but with a tendency towards underpredicting major bleedings and its predictive ability might be optimized by including the number of times the definition is met.
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Affiliation(s)
- Claudio Montalto
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy. https://twitter.com/MdMontalto
| | | | - Luca Arzuffi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Matteo Casula
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G. Martino", University of Messina, Messina, Italy. https://twitter.com/Costa_F_8
| | - Sergio Leonardi
- Department of Molecular Medicine, University of Pavia, Pavia, Italy; Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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10
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Iijima R, Kadota K, Nakao K, Nakagawa Y, Shite J, Yokoi H, Kozuma K, Tanabe K, Akasaka T, Shinke T, Ueno T, Hirayama A, Uemura S, Harada A, Kuroda T, Takita A, Murakami Y, Saito S, Nakamura M. Ischemic and Bleeding Events in PENDULUM Patients With High Bleeding Risk and High Platelet Reactivity. Circ J 2022; 86:763-771. [PMID: 34880154 DOI: 10.1253/circj.cj-21-0717] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The balance between thrombotic and bleeding risk is of great concern in high bleeding risk (HBR) patients. This study evaluated the relationship between perioperative antiplatelet reactivity and thrombotic and bleeding events in patients at HBR undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS In this post hoc analysis of the PENDULUM (Platelet rEactivity in patieNts with DrUg eLUting stent and balancing risk of bleeding and ischeMic event) registry, patients undergoing PCI were categorized as HBR or non-HBR, and stratified as having high platelet reactivity (HPR; P2Y12reaction unit [PRU] >208) or non-HPR (PRU ≤208). Cumulative incidences of cardiovascular and cerebrovascular events (Journal of the American College of Cardiology expert definitions) and bleeding events (Bleeding Academic Research Consortium criteria) were assessed 12 months after index PCI. The incidence of ischemic and bleeding events was ~3-fold higher in HBR vs. non-HBR patients. Thrombotic/ischemic events were significantly more common in the HPR subgroup in HBR patients (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11-2.28; P=0.012), but there was no difference in non-HBR patients. After adjustment for covariates, HPR in HBR patients remained an independent factor for thrombotic and ischemic events (HR: 1.69; 95% CI: 1.13-2.54; P=0.011), but not for bleeding events (HR: 1.56; 95% CI: 0.78-3.11; P=0.210). CONCLUSIONS Maintaining adequate PRU levels during PCI is an important factor in improving clinical outcomes, especially for HBR patients.
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Affiliation(s)
- Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Junya Shite
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Takafumi Ueno
- Department of Cardiovascular Medicine, Fukuoka Kinen Hospital
| | | | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | | | - Takeshi Kuroda
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Shigeru Saito
- Division of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
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11
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Comparison of original and modified Academic Research Consortium for High Bleeding Risk definitions in real-world practice. J Cardiol 2022; 80:155-161. [DOI: 10.1016/j.jjcc.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022]
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12
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Silverio A, Di Maio M, Buccheri S, De Luca G, Esposito L, Sarno G, Vecchione C, Galasso G. Validation of the academic research consortium high bleeding risk criteria in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis of 10 studies and 67,862 patients. Int J Cardiol 2022; 347:8-15. [PMID: 34774882 DOI: 10.1016/j.ijcard.2021.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/20/2021] [Accepted: 11/07/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND To assess the performance of the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in stratifying the risk of bleeding and ischaemic events after percutaneous coronary intervention (PCI). METHODS MEDLINE, COCHRANE, Web of Sciences, and SCOPUS were searched for studies aimed at validating the ARC-HBR criteria in patients treated with PCI. The primary outcome measure of this meta-analysis was major bleeding. RESULTS The analysis included 10 studies encompassing 67,862 patients undergoing PCI; the HBR definition was fulfilled in 44.7% of the cases. The risk of major bleeding was significantly higher in HBR vs. Non-HBR group (RR, 2.56, 95% CI 2.28-2.89). The average C-statistic was 0.64 (95% CI 0.60-0.68), indicating modest discrimination. The risk of intracranial hemorrhage, gastrointestinal bleeding, fatal bleeding, ischaemic stroke, cardiac death and all-cause death was higher in HBR vs. Non-HBR group. Despite a higher incidence of myocardial infarction and stent thrombosis in patients deemed at HBR, the rate of target lesion revascularization was comparable between groups (RR, 1.01, 95% CI 0.88-1.16). The mean effect size for the cumulative incidence of major bleeding exceeded the HBR cut-off value of 4% for all major criteria except one, and for two out of six minor criteria, namely age ≥ 75 years and moderate CKD. CONCLUSION The ARC-HBR definition identifies patients at higher risk of major bleeding and other adverse cardiovascular events after PCI. Almost all major criteria, but also two of the minor criteria, were individually associated with rates of major bleeding above 4% thus fulfilling the definition of major HBR criteria.
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Affiliation(s)
- Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Sergio Buccheri
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy
| | - Giovanna Sarno
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Carmine Vecchione
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy; Vascular Pathophysiology Unit, IRCCS Neuromed, Pozzilli, Isernia, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Salerno, Italy.
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13
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Sorrentino S, Salerno N, Leo I, Polimeni A, Sabatino J, Spaccarotella CAM, Mongiardo A, De Rosa S, Indolfi C. New antithrombotic strategies and coronary stent technologies for patients at high bleeding risk undergoing percutaneous coronary intervention. Curr Vasc Pharmacol 2021; 20:37-45. [PMID: 34370641 DOI: 10.2174/1570161119666210809163404] [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: 03/09/2021] [Revised: 05/11/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022]
Abstract
Patients at high bleeding risk (HBR) are a sizable part of the population undergoing percutaneous coronary intervention (PCI) and stent implantation. This population historically lacks standardized definition, thus limiting trial design, data generalizability, and clinical decision-making. To overcome this limitation the Academic Research Consortium (ARC) has recently released comprehensive guidelines defining HBR criteria for study design purpose and daily clinical practice. Furthermore, several risk scores have been developed aiming to discriminate HBR patients and support physicians for clinical decision making when faced with this complex subset of patients. Accordingly, the first part of this review article will explore guideline-recommended risk scoring as well as ARC-HBR criteria and their relative application for daily clinical practice. The second part of this review article will explore the complex interplay between risk of bleeding, and coronary thrombotic events in patients deemed at HBR. Indeed, several features that identify these patients, are also independent predictors of recurrent ischemic events, thus challenging revascularization strategies and optimal antithrombotic therapy. Accordingly, several clinical trials have been conducted to evaluate the safety and efficacy of the new generation of coronary platforms and different antithrombotic strategies for HBR patients to minimize both ischemic and bleeding events. Accordingly, in this part we discuss current guidelines, trials and observational data evaluating antithrombotic strategies and stent technologies for patients at HBR.
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Affiliation(s)
- Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nadia Salerno
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Isabella Leo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | | | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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14
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Patel NJ, Heuser RR. The death knell of bare metal stents: The Cobra stent's encouraging results with short-term antiplatelet therapy. Catheter Cardiovasc Interv 2021; 98:55-56. [PMID: 34219370 DOI: 10.1002/ccd.29813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Nachiket J Patel
- Divison of Cardiology, University of Arizona College of Medicine, Phoenix, Arizona, USA.,Cardiovascular and Arrhythmia Institute, Mesa, Arizona, USA
| | - Richard R Heuser
- Divison of Cardiology, University of Arizona College of Medicine, Phoenix, Arizona, USA.,Vascular Heart and Lung Associates, Mesa, Arizona, USA
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15
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Marquis-Gravel G, Urban P, Copt S, Capodanno D, Pocock S, Sadozai Slama S, Stoll HP, Tanguay JF, Mehran R, Leon MB, Rao S, Morice MC, Krucoff MW. Drug-coated stents versus bare metal stents in Academic Research Consortium-defined high bleeding risk patients. EUROINTERVENTION 2021; 17:240-247. [PMID: 32830645 PMCID: PMC9724924 DOI: 10.4244/eij-d-20-00749] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND More effective and progressively safer generations of drug-elut-ing stents (DES) have replaced bare metal stents (BMS) in rou-tine clinical practice. However, patients considered to be at high bleeding risk (HBR) have traditionally been underrepresented in pivotal DES trials. AIMS The aim of this study was to model the safety and effectiveness of drug-coated stents (DCS) versus BMS in HBR patients according to the Academic Research Consortium (ARC) criteria. METHODS Participants from the LEADERS FREE (LF) and LEADERS FREE II (LFII) studies were pooled into one data set. Participants were treated with 30 days of DAPT. The primary safety (composite of cardiac death, myocardial infarction, or stent thrombosis) and effectiveness (target lesion revascularisation) endpoints were compared between DCS and BMS in the subgroup of patients satisfying the ARC-HBR definition using propensity-score modelling. RESULTS From the 3,635 participants included in the combined LF and LFII data set, 2,898 (79.7%) satisfied the ARC-HBR criteria (DCS: 1,923; BMS: 975). The primary safety endpoint occurred in 184 (9.8%) and in 132 (13.8%) participants in the DCS and BMS groups, respectively (adjusted HR 0.72, 95% CI: 0.57-0.91; p=0.006). The risk of the primary effectiveness endpoint was also significantly lower with DCS (6.2%) versus BMS (8.8%) (adjusted HR 0.70, 95% CI: 0.52-0.94; p=0.016). The safety and effectiveness of DCS versus BMS were consistent according to ARC-HBR status (p for interaction=0.206 and 0.260, respectively). CONCLUSIONS DCS are safer and more effective than BMS in an ARC-defined HBR population.
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Affiliation(s)
| | | | | | - Davide Capodanno
- Cardiovascular Department, Ferrarotto Hospital, University of Catania, and ETNA Foundation, Catania, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Jean-François Tanguay
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, and the Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Martin B. Leon
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Sunil Rao
- Duke Clinical Research Institute, Durham, NC, USA,Duke University School of Medicine, Durham, NC, USA
| | - Marie-Claude Morice
- Ramsay Générale de Santé - Institut Cardiovasculaire Paris Sud, Massy, France
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16
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Miura K, Shima Y, Okabe K, Taguchi Y, Ikuta A, Takahashi K, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Academic Research Consortium for High Bleeding Risk Definitions for Early, Late, and Very Late Bleeding Events. Circ J 2021; 85:797-805. [PMID: 33853992 DOI: 10.1253/circj.cj-21-0120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The validity of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definitions of early (<1 year), late (1-4 years), and very late (>4 years) bleeding events is unknown. METHODS AND RESULTS This study was performed on patients (n=3,453) implanted with second-generation drug-eluting stents (DES) between 2010 and 2013. Data on all criteria of the ARC-HBR definition were collected retrospectively. The primary endpoint was Bleeding Academic Research Consortium Type 3 or 5 bleeding events; the ischemic endpoint was a composite of cardiac death, myocardial infarction, and ischemic stroke. The mean follow-up period was 7.5 years. Compared with non-high bleeding risk (HBR) patients, HBR patients (n=1,840; 53.3%) had an increased risk of the primary endpoint (early events, 3.6% vs. 0.5% [P<0.0001]; late events, 5.3% vs. 2.5% [P<0.0001]; very late events, 5.5% vs. 2.1% [P<0.0001]) and of ischemic events during follow-up. The discrimination ability of the ARC-HBR definition for late and very late bleeding events was comparable to that of early bleeding events (C statistics 0.679, 0.621, and 0.620, respectively) with high negative predictive value (96.6%, 95.1%, and 93.1%, respectively). Multivariate analysis revealed the different effects of individual criteria on bleeding events in each follow-up period. CONCLUSIONS The ARC-HBR definition consistently identified patients at risk of long-term bleeding and ischemic events after second-generation DES implantation.
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Affiliation(s)
- Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital
| | - Koya Okabe
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuya Taguchi
- Department of Cardiology, Kurashiki Central Hospital
| | - Akihiro Ikuta
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
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17
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Saito Y, Kobayashi Y. Academic Research Consortium Definition of High Bleeding Risk in Clinical Practice - Validation and Beyond. Circ J 2021; 85:806-807. [PMID: 33853999 DOI: 10.1253/circj.cj-21-0192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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18
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Zhang J, Qiu M, Na K, Ma S, Jiang Z, Li J, Li Y, Han Y. Impact of 6- versus 12-month dual antiplatelet therapy on clinical prognosis in patients with high bleeding risk: Insights from the 4-year results of the I LOVE IT 2 study. Catheter Cardiovasc Interv 2021; 97 Suppl 2:1025-1031. [PMID: 33645914 DOI: 10.1002/ccd.29588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To explore the impact of 6- versus 12-month dual antiplatelet therapy (DAPT) on the clinical prognosis of high bleeding risk (HBR) patients. BACKGROUND The optimal DAPT duration after percutaneous coronary intervention (PCI) in HBR patients is unclear. METHODS This study is a post hoc analysis of the 4-year clinical follow-up results of the I LOVE IT 2 study. Prevalence and prognosis of HBR patients were explored, and clinical outcomes of HBR patients who underwent 6- versus 12-month DAPT were compared. The primary outcome was Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding. The secondary outcomes were BARC type 2-5 bleeding and net clinical adverse events (NACE), defined as a composite of all-cause death, myocardial infarction (MI), ischemia-driven revascularization, stroke, stent thrombosis, or any bleeding events. RESULTS HBR occurred in 440 of 2,737 patients (16.0%). HBR patients were associated with a higher risk of BARC type 3 or 5 bleeding (2.95 vs. 1.52%, p = .03), NACE (31.82 vs. 25.99%, p = .01), all-cause death (5.68 vs. 3.13%, p = .008) and stroke (9.09 vs. 3.83%, p < .001) than non-HBR patients at 4 years. There were no significant differences in BARC type 3 or 5 bleeding (3.07 vs. 2.76%, p = 1.00) or NACE rate (31.9 vs. 33.8%, p = .72) between patients who underwent 6- and 12-month DAPT. CONCLUSIONS HBR patients are at a higher risk of long-term bleeding and ischemic events than non-HBR patients. The safety and efficacy of 6- and 12-month DAPT were comparable in HBR patients.
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Affiliation(s)
- Jiaoyang Zhang
- Postgraduate Training Base of the General Hospital of Northern Theater Command, Jinzhou Medical University, Jinzhou, China.,Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zaixin Jiang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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19
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Hioki H, Kozuma K, Kinoshita Y, Nanasato M, Ito Y, Yamaguchi J, Shiode N, Hibi K, Tanabe K, Ako J, Morino Y, Hirohata A, Sonoda S, Nakagawa Y, Okada H, Nakagami T, Takamisawa I, Ando K, Abe M, Ikari Y. Ischemic/bleeding event after short dual-antiplatelet therapy in patients with high bleeding risk: Sub-analysis of the MODEL U-SES study. J Cardiol 2021; 78:107-113. [PMID: 33875313 DOI: 10.1016/j.jjcc.2021.03.015] [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: 12/16/2020] [Revised: 02/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI). METHODS We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated. RESULTS Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y12 inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR. CONCLUSION In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y12 inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events.
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Affiliation(s)
- Hirofumi Hioki
- Division of Cardiology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
| | - Ken Kozuma
- Division of Cardiology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan.
| | | | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Yoshiaki Ito
- Department of Cardiology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuo Shiode
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Junya Ako
- Department of Cardiology, Kitazato University Hospital, Sagamihara, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Morioka, Japan
| | - Atsushi Hirohata
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Shinjo Sonoda
- Department of Cardiology, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Hisayuki Okada
- Department of Cardiology, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Takuo Nakagami
- Department of Cardiology, Omihachiman Community Medical Center, Omihachiman, Japan
| | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University Hospital, Isehara, Japan
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20
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Hu YC, Yao WJ, Jin DX, Zhang JX, Wang L, Zhang R, Xu JH, Cong HL. Bivalirudin in patients undergoing percutaneous coronary intervention and independent predictors of postoperative adverse events in these patients: A real world retrospective study. Medicine (Baltimore) 2021; 100:e25003. [PMID: 33725878 PMCID: PMC7969278 DOI: 10.1097/md.0000000000025003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT The efficacy and safety of bivalirudin in percutaneous coronary intervention (PCI) has always been a hot topic in perioperative antithrombotic therapy, but there are still some controversies. So studies are needed to provide more evidence, especially the real world study which includes patients excluded from previous RCT studys. Our study aimed to investigate these information and analyze the independent predictors of postoperative adverse events.A retrospective study enrolled 1416 patients underwent PCI in Tianjin Chest Hospital from May 2016 to October 2017. The incidence of stent-thrombosis and net clinical adverse events, including all-cause death, myocardial infarction, stroke, urgent target-vessel revascularization and bleeding, were followed up for 30 days and 1 year. Logistic regression and COX regression were respectively used to analyze independent predictors of bleeding events within 30-days, and independent predictors of Major adverse cardiovascular and cerebrovascular events (MACCE) in patients with stent implantation within 1-year.Seven hundred six patients were treated with bivalirudin while 710 with unfractionated heparin (UFH). The proportions of diabetes, hypertension, anemia, myocardial-infarction history, PCI history, moderate-to-severe renal-impairment, gastrointestinal-bleeding history in the bivalirudin group were significantly higher (P < .05). Women, anemia were independent risk factors for bleeding within 30-days (P < .05). Among 682 patients with stent implantation in bivalirudin group, anemia, Body Mass Index (BMI) >25 kg/m2, KILLIP ≥2, ejection fraction (EF) <45%, eGFR <60 ml/minutes were independent risk factors for MACCE, while Statins, proton pump inhibitor (PPI) were independent protective factors for MACCE with-in 1-year (P < .05).Bivalirudin have good anticoagulant effect and lower bleeding risk during PCI, especially in patients with higher bleeding risk. In patients treated with bivalirudin, female, anemia were independent predictors of bleeding within 30-days, BMI >25 kg/m2, anemia, KILLIP ≥2, EF <45%, eGFR <60 ml/minutes were independent risk factors and Statins, PPI were independent protective factors of MACCE within 1-year.
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Affiliation(s)
- Yue-cheng Hu
- Department of Cardiology, Tianjin Chest Hospital
| | - Wei-jie Yao
- NHC Key Laboratory of Hormones and Development, Tianjin Key Laboratory of Metabolic Diseases, Chu Hsien-I Memorial Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Dong-xia Jin
- Department of Cardiology, Tianjin Chest Hospital
| | | | - Le Wang
- Department of Cardiology, Tianjin Chest Hospital
| | - Rui Zhang
- Department of Cardiology, Tianjin Chest Hospital
| | - Jing-han Xu
- Department of Cardiology, Tianjin Chest Hospital
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21
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Impact of renal function in high bleeding risk patients undergoing percutaneous coronary intervention: a patient-level stratified analysis from four post-approval studies. J Thromb Thrombolysis 2021; 52:419-428. [PMID: 33709255 DOI: 10.1007/s11239-020-02321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/21/2022]
Abstract
Data on ischemic and bleeding outcomes after percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients with chronic kidney disease (CKD) are scarce. We aimed to evaluate the association between CKD and ischemic and bleeding outcomes in HBR patients who underwent PCI. Among 10,502 patients in the four post-approval registries evaluating patients undergoing PCI, 2,300 patients presented with at least one major or two minor ARC-HBR criteria. CKD was defined as eGFR < 60 mL/min/1.73 m2. These HBR patients were divided into 3 groups: eGFR < 30 mL/min/1.73 m2 defined as severe CKD (N = 221), eGFR 30- < 60 mL/min/1.73 m2 defined as moderate CKD (N = 970), eGFR ≥ 60 mL/min/1.73 m2 defined as no CKD (N = 1,109). The primary endpoint was the composite of cardiac death, myocardial infarction, or stent thrombosis, and the safety endpoint was major bleeding up to 4-year follow-up. HBR patients with CKD were more often female and had higher rates of comorbidities compared to those without CKD. Reduced renal function was associated with higher rates of the primary endpoint (severe CKD vs. moderate CKD vs. no CKD: 30.2% vs. 12.5% vs. 9.1%, P < 0.01) as well as major bleeding (10.3% vs. 8.9% vs. 6.4%, P = 0.03). After adjustment, severe CKD and moderate CKD in HBR patients remained independent predictors for the primary endpoint (HR [95%CI] 2.84 [1.94-4.16], P < 0.01, 1.48 [1.10-2.00], P < 0.01) compared to those with no CKD. However, decreased renal function was no longer significantly associated with major bleeding after adjustment. In conclusions, in HBR patients undergoing PCI, CKD has an important impact on major ischemic events after PCI.
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22
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Hashimoto R, Numasawa Y, Yokokura S, Daigo K, Sakata S, Imaeda S, Hitomi Y, Sato K, Taruoka A, Haginiwa S, Kojima H, Tanaka M, Kuno T, Kodaira M. Prevalence of the Academic Research Consortium high bleeding risk criteria in patients undergoing endovascular therapy for peripheral artery disease in lower extremities. Heart Vessels 2021; 36:1350-1358. [PMID: 33651134 DOI: 10.1007/s00380-021-01813-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
The Academic Research Consortium (ARC) recently published a definition of patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. However, the prevalence of the ARC-HBR criteria in patients undergoing endovascular therapy (EVT) for peripheral artery disease in lower extremities has not been thoroughly investigated. This study sought to investigate the prevalence and impact of the ARC-HBR criteria in patients undergoing EVT. We analyzed 277 consecutive patients who underwent their first EVT from July 2011 to September 2019. We applied the full ARC-HBR criteria to the study population. The primary end point was a composite outcome of all-cause mortality, Bleeding Academic Research Consortium 3 or 5 bleeding, and lower limb amputation within 12 months of EVT. Among the 277 patients, 193 (69.7%) met the ARC-HBR criteria. HBR patients had worse clinical outcomes compared with non-HBR patients at 12 months after EVT, including a higher incidence of the composite primary outcome (19.2% vs. 3.6%, p < 0.001) and all-cause death (7.8% vs. 0%, p = 0.007). In a multivariate Cox proportional hazards regression analysis, presence of the ARC-HBR criteria [hazard ratio (HR) 4.15, 95% confidence interval (CI) 1.25-13.80, p = 0.020], body mass index (HR 1.13, 95% CI 1.01-1.27, p = 0.042), diabetes mellitus (HR 2.70, 95% CI 1.28-5.69, p = 0.009), hyperlipidemia (HR 0.41, 95% CI 0.21-0.80, p = 0.009), and infrapopliteal lesions (HR 3.51, 95% CI 1.63-7.56, p = 0.001) were independent predictors of the primary composite outcome. Approximately 70% of Japanese patients undergoing EVT met the ARC-HBR criteria, and its presence was strongly associated with adverse outcomes within 12 months of EVT.
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Affiliation(s)
- Ryota Hashimoto
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Cardiovascular Medicine, Dokkyo Medical University Hospital, Mibu, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.
| | - Souichi Yokokura
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Kyohei Daigo
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Shingo Sakata
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Shohei Imaeda
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Yasuhiro Hitomi
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Kazuki Sato
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Akira Taruoka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Sho Haginiwa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Hidenori Kojima
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Makoto Tanaka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Cardiology, McGill University, Montreal, Canada
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23
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Affiliation(s)
- Giuseppe Gargiulo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, Via S. Pansini 5, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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24
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Ribeiro HB, Valim LR. DAPT: Ischemic versus bleeding risk-between Scylla and Charybdis. Int J Cardiol 2020; 328:81-82. [PMID: 33358835 DOI: 10.1016/j.ijcard.2020.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Henrique Barbosa Ribeiro
- Heart Institute (InCor), University of São Paulo, São Paulo, Brazil; Samaritano Paulista Hospital, São Paulo, Brazil.
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25
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Shima Y, Miura K, Shimada T, Ohya M, Murai R, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Impact of ischemic risk factors on long-term outcomes in patients with and without high bleeding risk. Int J Cardiol 2020; 326:12-18. [PMID: 33152414 DOI: 10.1016/j.ijcard.2020.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
Background The current guidelines have recommended to shorten the dual antiplatelet therapy duration in patients at high bleeding risk (HBR) to minimize the bleeding complications. The impact of ischemic risk factors (IRF) on long-term ischemic events in patients with and without HBR after percutaneous coronary intervention remains unclear. Methods The study population comprised 1219 patients who were treated with everolimus-eluting stents between 2010 and 2011. The mean follow-up period was 2996 ± 433 days. HBR was defined as set by the Academic Research Consortium. IRF was defined as high-risk features of stent-driven recurrent ischemic events endorsed in the 2017 European Society of Cardiology Guidelines. Major bleeding was defined as the occurrence of Bleeding Academic Research Consortium type 3 or 5 bleeding. Primary ischemic events included myocardial infarction, definite stent thrombosis, and cardiac death. Results The 1219 patients were divided into two groups: 614 patients at HBR (HBR group) and 605 patients at no HBR (non-HBR group). The rate of IRF patients was significantly higher in the HBR group than in the non-HBR group (81.4% versus 47.6%, P < 0.001). The cumulative rate of ischemic events in the HBR group was significantly higher in IRF patients than in non-IRF patients (21.0% versus 7.0%, log rank P < 0.001), whereas that in the non-HBR group was not significantly different between IRF and non-IRF patients (10.1% versus 6.3%, log rank P = 0.09). Conclusions More than 80% of HBR patients treated with everolimus-eluting stents were at IRF. A combination of HBR and IRF may increase the risk of long-term ischemic events.
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Affiliation(s)
- Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan.
| | - Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takenobu Shimada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Syunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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26
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Goel R, Cao D, Chandiramani R, Roumeliotis A, Blum M, Bhatt DL, Angiolillo DJ, Ge J, Seth A, Saito S, Krucoff M, Kozuma K, Makkar RM, Bangalore S, Wang L, Koo K, Neumann F, Hermiller J, Stefanini G, Valgimigli M, Mehran R. Comparative influence of bleeding and ischemic risk factors on diabetic patients undergoing percutaneous coronary intervention with everolimus‐eluting stents. Catheter Cardiovasc Interv 2020; 98:1111-1119. [DOI: 10.1002/ccd.29314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/18/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
- Department of Biomedical Sciences Humanitas University Milan Italy
| | - Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Anastasios Roumeliotis
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Moritz Blum
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular Center Harvard Medical School Boston Massachusetts
| | | | - Junbo Ge
- Zhongshan Hospital Fudan University Shanghai China
| | - Ashok Seth
- Fortis Escorts Heart Institute New Delhi India
| | | | | | - Ken Kozuma
- Division of Cardiology Teikyo University Tokyo Japan
| | | | - Sripal Bangalore
- Department of Cardiovascular Diseases New York University‐Langone Medical Center New York City New York
| | | | - Kai Koo
- Abbott Vascular Santa Clara California
| | - Franz‐Josef Neumann
- Department of Cardiology and Angiology II University Heart Center Freiburg Bad Krozingen Germany
| | - James Hermiller
- Division of Cardiovascular Medicine St Vincent Heart Center of Indiana Indianapolis Indiana
| | - Giulio Stefanini
- Department of Biomedical Sciences Humanitas University Milan Italy
| | - Marco Valgimigli
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York City New York
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27
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Marquis-Gravel G, Ohman EM. Towards a better standard for defining high bleeding risk patients: can we now translate this into a better practice? Eur Heart J 2020; 41:3750-3752. [PMID: 33099277 DOI: 10.1093/eurheartj/ehaa699] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - E Magnus Ohman
- Duke Program for Advanced Coronary Disease, Duke Clinical Research Institute and Duke University Medical Center, Durham, NC, USA
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28
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Polimeni A, Sorrentino S, Spaccarotella C, Mongiardo A, Sabatino J, De Rosa S, Gori T, Indolfi C. Stent Thrombosis After Percutaneous Coronary Intervention: From Bare-Metal to the Last Generation of Drug-Eluting Stents. Cardiol Clin 2020; 38:639-647. [PMID: 33036724 DOI: 10.1016/j.ccl.2020.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Since their introduction in clinical practice in 1986, different types of coronary stents have been developed and become available for the treatment of coronary artery disease. Stent thrombosis (ST) is an uncommon but harmful complication after percutaneous coronary implantation, with a high occurrence of acute myocardial infarction and risk of mortality. Among several procedural and clinical predictors, the type of coronary stent is a strong determinant of ST. This article reviews the available evidence on the most used coronary stent types in the modern era and the related risk of ST.
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Affiliation(s)
- Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Annalisa Mongiardo
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy
| | - Tommaso Gori
- Kardiologie I, Zentrum für Kardiologie, University Medical Center Mainz, Deutsches Zentrum für Herz und Kreislauf Forschung, Langenbeckstraße 1, Standort Rhein-Main 55131, Germany
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Research Center for Cardiovascular Diseases, "Magna Graecia" University, Viale Europa, Catanzaro 88100, Italy; Mediterranea Cardiocentro, Via Orazio, 2, Naples 80122, Italy.
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29
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Miura K, Shimada T, Ohya M, Murai R, Amano H, Kubo S, Tada T, Tanaka H, Fuku Y, Goto T, Kadota K. Prevalence of the Academic Research Consortium for High Bleeding Risk Criteria and Prognostic Value of a Simplified Definition. Circ J 2020; 84:1560-1567. [PMID: 32669530 DOI: 10.1253/circj.cj-20-0395] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been suggested as the standard definition of HBR. However, the prevalence of individual criteria and their prognostic value for long-term bleeding events after percutaneous coronary intervention are scarcely studied.Methods and Results:The study population comprised 1,193 patients treated with everolimus-eluting stents between 2010 and 2011. Data on all 17 major and minor criteria of the ARC-HBR definition were retrospectively collected, and applied to this study population. Major bleeding was defined as the occurrence of a BARC type 3 or 5 bleeding event. A simplified definition was developed by excluding the low-frequency criterion, and the prognostic value was assessed by a receiver-operating characteristic curve. Mean follow-up was 2,996±433 days and there were 656 HBR patients (55.0%). The cumulative incidence of major bleeding was significantly higher in the HBR group than in the non-HBR group (16.2% vs. 5.7% at 8 years, P<0.001). The frequencies of 6 of the 17 criteria were less than 1%. The prognostic value of the simplified definition made by excluding these 6 criteria for major bleeding was comparable to that of the original (c-statistic=0.598 and 0.600, P=0.08). CONCLUSIONS Some risk criteria of the ARC-HBR definition are observed infrequently. Our simplified definition identified patients with long-term bleeding risk as successfully as the original definition.
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Affiliation(s)
- Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital
| | - Hidewo Amano
- Department of Cardiology, Kurashiki Central Hospital
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
| | - Tsuyoshi Goto
- Department of Cardiology, Kurashiki Central Hospital
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