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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024:ehae177. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [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] [Indexed: 09/04/2024] Open
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2
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Van Gelder IC, Rienstra M, Bunting KV, Casado-Arroyo R, Caso V, Crijns HJGM, De Potter TJR, Dwight J, Guasti L, Hanke T, Jaarsma T, Lettino M, Løchen ML, Lumbers RT, Maesen B, Mølgaard I, Rosano GMC, Sanders P, Schnabel RB, Suwalski P, Svennberg E, Tamargo J, Tica O, Traykov V, Tzeis S, Kotecha D. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2024:ehae176. [PMID: 39210723 DOI: 10.1093/eurheartj/ehae176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Ando K, Suwa S, Isawa T, Takenaka H, Ishikawa T, Yamada M, Wakatsuki T, Nozaki Y, Kitahara H, Kato R, Kawai R, Kobayashi Y, Ishii M, Goto Y, Ono K, Kimura T. Aspirin-Free Strategy for Percutaneous Coronary Intervention in Patients With Oral Anticoagulation: Prespecified Subgroup Analysis From the STOPDAPT-3 Trial. J Am Heart Assoc 2024; 13:e034201. [PMID: 39056346 DOI: 10.1161/jaha.123.034201] [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: 02/09/2024] [Accepted: 06/11/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND The effects of aspirin-free strategy on bleeding and cardiovascular events in patients undergoing percutaneous coronary intervention with oral anticoagulation (OAC) have not been fully elucidated. METHODS AND RESULTS We conducted the prespecified subgroup analysis based on the use of OAC, including vitamin K antagonist and direct oral anticoagulants, within 7 days before percutaneous coronary intervention in the STOPDAPT-3 (Short and Optimal Duration of Dual Antiplatelet Therapy-3) trial, which randomly compared prasugrel monotherapy (2984 patients) to dual antiplatelet therapy (DAPT) with prasugrel and aspirin (2982 patients) in patients with acute coronary syndrome or high bleeding risk. The coprimary end points were major bleeding events (Bleeding Academic Research Consortium types 3 or 5) and cardiovascular events (a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke) at 1 month. Among 5966 study patients, there were 530 patients (8.9%) with OAC (no aspirin: N=248, and DAPT: N=282) and 5436 patients (91.1%) without OAC (no aspirin: N=2736, and DAPT: N=2700). Regardless of the use of OAC, the effects of no aspirin compared with DAPT were not significant for the bleeding end point (OAC: 4.45% and 4.27%, hazard ratio [HR], 1.04 [95% CI, 0.46-2.35]; no-OAC: 4.47% and 4.75%, HR, 0.94 [95% CI, 0.73-1.20]; P for interaction=0.82), and for the cardiovascular end point (OAC: 4.84% and 3.20%, HR, 1.53 [95% CI, 0.64-3.62]; no-OAC: 4.06% and 3.74%, HR, 1.09 [95% CI 0.83-1.42]; P for interaction =0.46). CONCLUSIONS The no-aspirin strategy compared with the DAPT strategy failed to reduce major bleeding events irrespective of the use of OAC. There was a numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events in patients with OAC.
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Affiliation(s)
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology Hyogo College of Medicine Nishinomiya Japan
| | - Ko Yamamoto
- Department of Cardiology Kokura Memorial Hospital Kitakyusyu Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Kenji Ando
- Department of Cardiology Kokura Memorial Hospital Kitakyusyu Japan
| | - Satoru Suwa
- Department of Cardiology Juntendo University Shizuoka Hospital Izunokuni Japan
| | - Tsuyoshi Isawa
- Department of Cardiology Sendai Kousei Hospital Sendai Japan
| | | | - Tetsuya Ishikawa
- Department of Cardiology Dokkyo Medical University Saitama Medical Center Koshigaya Japan
| | - Minoru Yamada
- Division of Cardiology Shizuoka Saiseikai General Hospital Shizuoka Japan
| | - Tetsuzo Wakatsuki
- Department of Cardiovascular Medicine Tokushima University Hospital Tokushima Japan
| | - Yoichi Nozaki
- Department of Cardiovascular Medicine Hokko Memorial Hospital Sapporo Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine Chiba University Hospital Chiba Japan
| | - Ryuichi Kato
- Department of Cardiology Higashiyamato Hospital Higashiyamato Japan
| | - Ryoma Kawai
- Department of Cardiology Tenri Hospital Tenri Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center Japanese Red Cross Osaka Hospital Osaka Japan
| | - Mitsuru Ishii
- Department of Cardiology Kyoto Medical Center Kyoto Japan
| | - Yoshitaka Goto
- Department of Cardiology Fukuoka Wajiro Hospital Fukuoka Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine Kyoto University Kyoto Japan
| | - Takeshi Kimura
- Division of Cardiology Hirakata Kohsai Hospital Hirakata Japan
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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5
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Verburg A, Bor WL, Küçük IT, Henriques JPS, Vink MA, Ruifrok WPT, Plomp J, Heestermans TACM, Schotborgh CE, Vlaar PJ, Magro M, Rikken SAOF, van den Broek WWA, van Mieghem CAG, Cornelis K, Rosseel L, Dujardin KS, Vandeloo B, Vandendriessche T, Ferdinande B, van 't Hof AWJ, Tijssen JGP, Limbruno U, De Caterina R, Rubboli A, Angiolillo DJ, Adriaenssens T, Dewilde W, Ten Berg JM. Temporary omission of oral anticoagulation in atrial fibrillation patients undergoing percutaneous coronary intervention: rationale and design of the WOEST-3 randomised trial. EUROINTERVENTION 2024; 20:e898-e904. [PMID: 39007830 PMCID: PMC11228535 DOI: 10.4244/eij-d-24-00100] [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: 01/31/2024] [Accepted: 04/22/2024] [Indexed: 07/16/2024]
Abstract
The optimal antithrombotic management of atrial fibrillation (AF) patients who require oral anticoagulation (OAC) undergoing percutaneous coronary intervention (PCI) remains unclear. Current guidelines recommend dual antithrombotic therapy (DAT; OAC plus P2Y12 inhibitor - preferably clopidogrel) after a short course of triple antithrombotic therapy (TAT; DAT plus aspirin). Although DAT reduces bleeding risk compared to TAT, this is counterbalanced by an increase in ischaemic events. Aspirin provides early ischaemic benefit, but TAT is associated with an increased haemorrhagic burden; therefore, we propose a 30-day dual antiplatelet therapy (DAPT; aspirin plus P2Y12 inhibitor) strategy post-PCI, temporarily omitting OAC. The study aims to compare bleeding and ischaemic risk between a 30-day DAPT strategy following PCI and a guideline-directed therapy in AF patients requiring OAC. WOEST-3 (ClinicalTrials.gov: NCT04436978) is an investigator-initiated, international, open-label, randomised controlled trial (RCT). AF patients requiring OAC who have undergone successful PCI will be randomised within 72 hours after PCI to guideline-directed therapy (edoxaban plus P2Y12 inhibitor plus limited duration of aspirin) or a 30-day DAPT strategy (P2Y12 inhibitor plus aspirin, immediately discontinuing OAC) followed by DAT (edoxaban plus P2Y12 inhibitor). With a sample size of 2,000 patients, this trial is powered to assess both superiority for major or clinically relevant non-major bleeding and non-inferiority for a composite of all-cause death, myocardial infarction, stroke, systemic embolism or stent thrombosis. In summary, the WOEST-3 trial is the first RCT temporarily omitting OAC in AF patients, comparing a 30-day DAPT strategy with guideline-directed therapy post-PCI to reduce bleeding events without hampering efficacy.
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Affiliation(s)
- Ashley Verburg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Wilbert L Bor
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten A Vink
- Department of Cardiology, OLVG, Amsterdam, the Netherlands
| | | | - Jacobus Plomp
- Department of Cardiology, Tergooi MC, Blaricum, the Netherlands
| | | | | | - Pieter J Vlaar
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Sem A O F Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | | | | | | | - Liesbeth Rosseel
- Department of Cardiology, Algemeen Stedelijk Hospital, Aalst, Belgium
| | | | - Bert Vandeloo
- Department of Cardiology, University Hospital Brussels, Brussels, Belgium
| | | | - Bert Ferdinande
- Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium
| | - Arnoud W J van 't Hof
- Department of Cardiology, University Medical Centre Maastricht, Maastricht, the Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, the Netherlands
| | - Jan G P Tijssen
- Department of Clinical Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands
| | - Ugo Limbruno
- Cardioneurovascular Department, Azienda USL Toscana Sud Est, Grosseto, Italy
| | - Raffaele De Caterina
- Cardio-Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy and University of Pisa, Pisa, Italy
- Fondazione Villaserena per la Ricerca, Città Sant'Angelo, Italy
| | - Andrea Rubboli
- Department of Cardiology, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Tom Adriaenssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Willem Dewilde
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - Jurrien M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Centre Maastricht, Maastricht, the Netherlands
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6
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Gritti V, Pierini S, Ferlini M, Mauri S, Barbieri L, Castiglioni B, Lettieri C, Mircoli L, Mortara A, Nassiacos D, Oltrona Visconti L, Paggi A, Soriano F, Sponzilli C, Corsini A. Atrial fibrillation and ischemic heart disease: (un)solved therapeutic dilemma? Minerva Cardiol Angiol 2024; 72:225-236. [PMID: 37870421 DOI: 10.23736/s2724-5683.23.06275-0] [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: 10/24/2023]
Abstract
Concomitant presence of atrial fibrillation and coronary artery disease requiring percutaneous coronary intervention is a frequent occurrence. The choice of optimal antithrombotic therapy, in this context, is still challenging. To offer the best protection both in terms of stroke and stent thrombosis, triple therapy with oral anticoagulation and dual antiplatelet therapy would be required. Several drug combinations have been tested in recent years, including direct oral anticoagulants, with the aim of balancing ischemic and bleeding risk. Both pharmacokinetic aspects of the molecules and patient's characteristics should be analyzed in choosing oral anticoagulation. Then, as suggested by guidelines, triple therapy should start with a seven-day duration and the aim to prolong to thirty days in high thrombotic risk patients. Dual therapy should follow to reach twelve months after coronary intervention. Even not fully discussed by the guidelines, in order to balance ischemic and bleeding risk it should also be considered: 1) integrated assessment of coronary artery disease and procedural complexity of coronary intervention; 2) appropriateness to maintain the anticoagulant drug dosage indicated in technical data sheet; the lack of data on the suspension of antiplatelet drugs one year after percutaneous intervention; 3) the possibility of combination therapy with ticagrelor; and 4) the need to treat the occurrence of paroxysmal atrial fibrillation during acute coronary syndrome. With data provided clinician should pursue a therapy as personalized as possible, both in terms of drug choice and treatment duration, in order to balance ischemic and bleeding risk.
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Affiliation(s)
- Valeria Gritti
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy -
| | - Simona Pierini
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Marco Ferlini
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - Silvia Mauri
- Cardiology and Coronary Unit, ASST Ovest Milanese, Milan, Italy
| | - Lucia Barbieri
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Luca Mircoli
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Mortara
- Department of Clinical Cardiology, Polyclinic of Monza, Monza, Monza-Brianza, Italy
| | - Daniele Nassiacos
- Unit of Cardiology and Cardiac Intensive Care, ASST Valle Olona, Saronno, Varese, Italy
| | | | - Anita Paggi
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Francesco Soriano
- Cardiothoracovascular Department, ASST Niguarda Hospital, Milan, Italy
| | | | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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7
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024; 47:714-770. [PMID: 38687179 DOI: 10.1111/pace.14920] [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: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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8
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Tern PJW, Yeo KK, Tan JWC, Chin CT, Tan RS, Yap J. Role of anticoagulation in non-ST-elevation myocardial infarction: a contemporary narrative review. Expert Rev Cardiovasc Ther 2024; 22:203-215. [PMID: 38739469 DOI: 10.1080/14779072.2024.2354243] [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: 12/06/2023] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Anticoagulants play a vital role as part of the antithrombotic therapy of myocardial infarction and are complementary to antiplatelet therapies. In the acute setting, the rationale for their use is to antagonize the ongoing clotting cascade including during percutaneous coronary intervention. Anticoagulation may be an important part of the longer-term antithrombotic strategy especially in patients who have other existing indications (e.g. atrial fibrillation) for their use. AREAS COVERED In this narrative review, the authors provide a contemporary summary of the anticoagulation strategies of patients presenting with NSTEMI, both in terms of anticoagulation during the acute phase as well as suggested antithrombotic regimens for patients who require long-term anticoagulation for other indications. EXPERT OPINION Patients presenting with non-ST-elevation myocardial infarction (NSTEMI) should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period for those medically managed or until percutaneous coronary intervention. Longer term management of NSTEMI for patients with an existing indication for long-term anticoagulation should comprise triple antithrombotic therapy of anticoagulant (preferably DOAC) with aspirin and clopidogrel for up to 1 month (typically 1 week or until hospital discharge), followed by DOAC plus clopidogrel for up to 1 year, and then DOAC monotherapy thereafter.
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Affiliation(s)
- Paul Jie Wen Tern
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jack Wei Chieh Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Ru San Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Jonathan Yap
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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10
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Hayek A, MacDonald BJ, Marquis-Gravel G, Bainey KR, Mansour S, Ackman ML, Cantor WJ, Turgeon RD. Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis. CJC Open 2024; 6:708-720. [PMID: 38846448 PMCID: PMC11150964 DOI: 10.1016/j.cjco.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024] Open
Abstract
Background Ongoing debate remains regarding optimal antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease. Methods We performed a systematic review and meta-analysis to synthesize randomized controlled trials (RCTs) comparing the following: (i) dual-pathway therapy (DPT; oral anticoagulant [OAC] plus antiplatelet) vs triple therapy (OAC and dual-antiplatelet therapy) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS), and (iii) OAC monotherapy vs DPT at least 1 year after PCI or ACS. Following a 2-stage process, we identified systematic reviews published between 2019 and 2022 on these 2 clinical questions, and we updated the most comprehensive search for additional RCTs published up to October 2022. Outcomes of interest were major adverse cardiovascular events (MACE), death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Results Based on 6 RCTs (n = 10,435), DPT reduced major bleeding (RR 0.62, 95% CI 0.52-0.73) and increased stent thrombosis (RR 1.55, 95% CI 1.02-2.36), vs triple therapy after PCI or medically-managed ACS, with no significant differences in MACE and death. In 2 RCTs (n = 2905), OAC monotherapy reduced major bleeding (RR 0.66, 95% CI 0.49-0.91) vs DPT in AF patients with remote PCI or ACS, with no significant differences in MACE or death. Conclusions In patients with AF and coronary artery disease, using less-aggressive antithrombotic treatment (DPT after PCI or ACS, and OAC alone after remote PCI or ACS) reduced major bleeding, with an increase in stent thrombosis with recent PCI. These results support a minimalist yet personalized antithrombotic strategy for these patients.
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Affiliation(s)
- Ahmad Hayek
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Margaret L. Ackman
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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11
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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12
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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13
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Bainey KR, Marquis-Gravel G, Belley-Côté E, Turgeon RD, Ackman ML, Babadagli HE, Bewick D, Boivin-Proulx LA, Cantor WJ, Fremes SE, Graham MM, Lordkipanidzé M, Madan M, Mansour S, Mehta SR, Potter BJ, Shavadia J, So DF, Tanguay JF, Welsh RC, Yan AT, Bagai A, Bagur R, Bucci C, Elbarouni B, Geller C, Lavoie A, Lawler P, Liu S, Mancini J, Wong GC. Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2024; 40:160-181. [PMID: 38104631 DOI: 10.1016/j.cjca.2023.10.013] [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: 09/17/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
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Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ricky D Turgeon
- University of British Columbia, St Paul's Hospital PHARM-HF Clinic, Vancouver, British Columbia, Canada
| | | | - Hazal E Babadagli
- Pharmacy Services, Alberta Health Services, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - David Bewick
- Division of Cardiology, Department of Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal, Research Center, Montréal Heart Institute, Montréal, Québec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jay Shavadia
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek F So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-François Tanguay
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T Yan
- Division of Cardiology, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Claudia Bucci
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Basem Elbarouni
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carol Geller
- University of Ottawa, Centretown Community Health Centre, Ottawa, Ontario, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - Patrick Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shuangbo Liu
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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14
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Liu D, Xue Z, Qi J, Yin L, Duan B, Wu L, Yang K, Gao B, Cao Q, Mi J. Risk factors for instent restenosis of sirolimus-coated stents in coronary intervention for patients with unstable angina. Sci Rep 2024; 14:2537. [PMID: 38291094 PMCID: PMC10827786 DOI: 10.1038/s41598-024-52567-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024] Open
Abstract
To investigate the instent restenosis rate of sirolimus-coated stents in percutaneous coronary intervention (PCI) and risk factors for in-stent restenosis, patients with unstable angina (UA) caused by coronary artery stenosis were enrolled, and all clinical and imaging data were analyzed. Among 143 enrolled patients with UA aged 35-83 (mean 60.9 ± 10.0) years enrolled, there were 114 (79.7%) male and 29 (20.3%) female patients. Arterial stenosis was present in one coronary artery in 6 (4.2%) patients, in two coronary arteries in 20 (14.0%) patients, in three arteries in 116 (81.1%), and in four coronary arteries in 1 (0.7%) patient. Stenting was successfully performed in all (100%) patients, and 181 stents were deployed. The quantitative flow ratio (QFR) was 0.92 ± 0.03 (range 0.84-0.96) immediately after stenting, and the TIMI was grade 3 in all patients. The diameter of the stents deployed ranged 2.25-4 mm (mean 3.04 ± 0.44) with a length ranging 10 mm to 104 mm (mean 32.73 ± 15.5). Follow-up angiography was performed in all patients with a duration of 1-92 (mean 15.0 ± 18.8) months. Instent restenosis ≥ 50% occurred in 25 (17.5%) patients. In univariate logistic regression analysis, significant (P < 0.05) risk factors for instent restenosis ≥ 50% were QFR (OR 0.036, 95% CI 0.13-0.97), stent diameter (OR 0.43, 95% CI 0.18-0.92), hypertension (OR 3.16, 95% CI 1.02-9.82), smoking (OR 0.31, 95% CI 0.11-0.89), and neutrophil count (OR 2.22, 95% CI 1.10-5.44). In multivariate analysis, QFR (OR 0.02, 95% CI 0.002-0.19), stent diameter (OR 0.06, 95% CI 0.005-0.59), hypertension (OR 6.75, 95% CI 1.83-35.72) and neutrophil count (OR 276.07, 95% CI 12.32-10,959.95) were significant (P < 0.05) independent risk factors for instent restenosis ≥ 50%. In conclusion, certain instent restenosis rates occurs after the sirolimus-eluted coronary stent deployment for the treatment of coronary artery stenosis in patients with UA, and quantitative flow ratio after stenting, stent diameter, hypertension, and neutrophil count are significant risk factors for instent restenosis of the sirolimus-coated stents in coronary intervention.
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Affiliation(s)
- Dongchao Liu
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Zheng Xue
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Jingxian Qi
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Liang Yin
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Bing Duan
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Lin Wu
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Kun Yang
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Bulang Gao
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Qinying Cao
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China
| | - Jie Mi
- Department of Cardiology, Shijiazhuang People's Hospital, 365 South Jianhua Street, Shijiazhuang, 050011, Hebei, China.
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15
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Poirier CM, Carter AA, Kwan Y, Koo J, Westlund JM, Alkass F, Leblanc K. Experiences of Patients With Atrial Fibrillation With Combination Antithrombotic Therapy Post-Percutaneous Coronary Intervention. CJC Open 2023; 5:846-858. [PMID: 38020330 PMCID: PMC10679455 DOI: 10.1016/j.cjco.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/19/2023] [Indexed: 12/01/2023] Open
Abstract
Background Up to 30% of patients with atrial fibrillation (AF) have coronary artery disease, and many undergo percutaneous coronary intervention (PCI). In the setting of acute coronary syndrome with PCI, or high-risk elective PCI, Canadian AF guidelines recommend 1-30 days of acetylsalicylic acid, 1-12 months of clopidogrel, and oral anticoagulation (OAC) with doses that may change throughout the 12 months post-PCI. The complexity of these regimens may contribute to unplanned modifications (UPMs), increasing the risk of thrombosis and/or bleeding. We describe what happens to these patients and their antithrombotic therapy (ATT) after discharge. Methods Prospective follow-up was conducted of patients with AF requiring OAC who underwent PCI and were discharged on combination ATT. Patients were contacted at 1, 3, 6, and 12 months post-PCI. Results Sixty-five patients were enrolled, with data at any time point available for 61 of them (94%). Of these, 44 (68%) experienced at least one UPM to ATT. In total, 105 UPMs occurred. The most common UPM was an extended duration of P2Y12 inhibitor (23 instances; 22%). The most common UPM with acetylsalicylic acid was extended (11 instances; 11%) or shortened (11 instances; 11%) duration. Thirty-nine UPMs (37%) were related to OACs; 9 (23%) were related to warfarin, and 30 (77%) were related to direct OACs. Of all patients with at least one UPM, 33 (75%) experienced bleeding. Conclusions More than 2 in 3 patients with AF undergoing PCI experienced a UPM to their ATT. This study underscores the challenges of combination ATT for patients and clinicians alike, emphasizing the need for patient support after discharge.
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Affiliation(s)
- Caylie M Poirier
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
| | - Aleesa A Carter
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Yvonne Kwan
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
| | - Jessica Koo
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
| | - Jill M Westlund
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
| | - Fadi Alkass
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Kori Leblanc
- Pharmacy Department, University Health Network, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
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16
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Baldus S, Beyer-Westendorf J, Möllmann H, Rottbauer W, Beyerlein E, Goette A. Edoxaban in patients with non-valvular atrial fibrillation after percutaneous coronary intervention: ENCOURAGE-AF design. Sci Rep 2023; 13:18215. [PMID: 37880316 PMCID: PMC10600182 DOI: 10.1038/s41598-023-44345-7] [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: 05/30/2023] [Accepted: 10/06/2023] [Indexed: 10/27/2023] Open
Abstract
Approximately one fifth of patients diagnosed with atrial fibrillation (AF) undergo a percutaneous coronary intervention (PCI). Current guidelines recommend different combinations and durations of triple or dual antithrombotic therapy for these patients but data on the implementation of these recommendations in clinical routine are scarce. ENCOURAGE-AF is a prospective, non-interventional, non-comparative, multicentre study. Approximately 720 patients will be consecutively enrolled from 70 participating sites across Germany. Patients with non-valvular AF treated with edoxaban, who have undergone successful PCI, have no planned elective cardiac intervention during the study period, have capability, availability, and willingness for follow-up by telephone interview during the study, are aged ≥ 18 years with life expectancy ≥ 1 year, and provide written informed consent, will be included. Eligible patients will be enrolled between 4- and 72-h after completing a successful PCI. Duration of exposure to and dosing regimens of edoxaban, antiplatelet agents and other concomitant medications of interest will be monitored in line with the clinical practice. Physician- and patient-reported clinical events, adverse drug reactions, patient quality of life (EQ-5D-5L) and health resource utilisation (HRU) parameters will be evaluated at 30 days and 1-year post-PCI. The ENCOURAGE-AF non-interventional study will provide insights into the patterns of edoxaban usage in combination with antiplatelet treatment and other concomitant medications in AF patients with a successful PCI over a 1-year time period during routine clinical practice in Germany. The effectiveness and safety of edoxaban in this patient population, as well as patients' quality of life and HRU will be evaluated.Trial registration: Clinicaltrial.gov NCT04519944, registered on 20 August 2020.
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Affiliation(s)
- Stephan Baldus
- Heart Center of the University Hospital Cologne, University Hospital Cologne, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Cologne, Germany.
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17
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 661] [Impact Index Per Article: 661.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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18
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Bachorski W, Bychowski J, Gruchała M, Jaguszewski M. Two Approaches to Triple Antithrombotic Therapy in Patients with Acute Coronary Syndrome and Non-Valvular Atrial Fibrillation Treated with Percutaneous Coronary Intervention: Which Is More Efficient and Safer? Diagnostics (Basel) 2023; 13:3055. [PMID: 37835798 PMCID: PMC10572308 DOI: 10.3390/diagnostics13193055] [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: 08/15/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
INTRODUCTION Patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding and thromboembolic events. Thus, optimal treatment strategies in this challenging subset have been controversial. Herein, we aim to investigate different triple antithrombotic treatment (TAT) strategies in patients with ACS and AF after PCI. METHODS This was a retrospective, single-center study based on all consecutive patients with the diagnosis of ACS and AF treated with vitamin K antagonists (VKA) or non-vitamin K antagonist oral anticoagulants (NOAC) plus dual antiplatelet therapy using a P2Y12 inhibitor (clopidogrel) and aspirin (for 1 to 3 months) and observed for 12 months for major adverse cardiac events (MACE) and major or clinically relevant non-major bleeding incidents. RESULTS MACE occurred in 26.6% of patients treated with the VKA and 30.9% with NOAC (p = 0.659). Bleeding occurred in 7.8% of patients treated with VKA and 7.4% with NOAC (ns). CONCLUSIONS Among patients with ACS and AF who had undergone PCI, there was no significant difference in the risk of bleeding and ischemic events among those who received TAT with NOAC and VKA.
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Affiliation(s)
- Witold Bachorski
- Department of Cardiology, Medical University of Gdansk, M. Skłodowskiej-Curie 3a, 80-210 Gdansk, Poland
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19
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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20
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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21
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Chow JK, Bagai A, Tan MK, Har BJ, Yip AMC, Paniagua M, Elbarouni B, Bainey KR, Paradis JM, Maranda R, Cantor WJ, Eisenberg MJ, Dery JP, Madan M, Cieza T, Matteau A, Roth S, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh RC, Kim HH, Robinson SD, Daneault B, Chong AY, Le May MR, Ahooja V, Gregoire JC, Nadeau PL, Laksman Z, Heilbron B, Yung D, Minhas K, Bourgeois R, Overgaard CB, Bonakdar H, Logsetty G, Lavoie AJ, De LaRochelliere R, Mansour S, Spindler C, Yan AT, Goodman SG. Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program. J Cardiol 2023; 82:153-161. [PMID: 36931433 DOI: 10.1016/j.jjcc.2023.03.004] [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: 09/16/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
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Affiliation(s)
| | - Akshay Bagai
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Bryan J Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Basem Elbarouni
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | | | - Warren J Cantor
- University of Toronto, Toronto, Canada; Southlake Regional Health Centre, Newmarket, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Mina Madan
- University of Toronto, Toronto, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Alexis Matteau
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | - Sherryn Roth
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Scarborough Health Network, Toronto, Canada
| | | | | | | | - Ravi Tahiliani
- Central East Regional Cardiac Care Program, Oshawa, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Hahn Hoe Kim
- St. Mary's General Hospital, Kitchener-Waterloo, Canada
| | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, Canada
| | - Benoit Daneault
- Centre hospitalier Universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Canada
| | | | | | | | | | | | | | - Brett Heilbron
- University of British Columbia, Vancouver, Canada; St. Paul's Hospital, Vancouver, Canada
| | - Derek Yung
- Scarborough Health Network, Toronto, Canada
| | - Kunal Minhas
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Ronald Bourgeois
- Moncton Hospital, Dalhousie University Faculty of Medicine, Moncton, Canada
| | | | - Hamid Bonakdar
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Robert De LaRochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Samer Mansour
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | | | - Andrew T Yan
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada.
| | - Shaun G Goodman
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada.
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22
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Zeymer U, Toelg R, Wienbergen H, Hobbach HP, Cuneo A, Bekeredjian R, Ritter O, Hailer B, Hertting K, Hennersdorf M, Scholtz W, Lanzer P, Mudra H, Schwefer M, Schwimmbeck PL, Liebetrau C, Thiele H, Claas C, Riemer T, Zahn R. Current status of antithrombotic therapy and in-hospital outcomes in patients with atrial fibrillation undergoing percutaneous coronary intervention in Germany. Herz 2023; 48:134-140. [PMID: 35243515 DOI: 10.1007/s00059-022-05099-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Little is known about current patterns of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in clinical practice in Germany. METHODS The RIVA-PCI is a prospective, non-interventional, multicenter study with follow-up until hospital discharge including consecutive patients with AF undergoing PCI. RESULTS Between January 2018 and March 2020, 1636 patients (elective in 52.6%, non-ST elevation acute coronary syndrome [NSTE-ACS] in 39.3%, ST-elevation myocardial infarction in 8.2%) from 51 German hospitals were enrolled in the study. After PCI a dual antithrombotic therapy (DAT) consisting of OAC and a P2Y12 inhibitor was given to 66.0%, triple antithrombotic therapy (TAT) to 26.0%, dual antiplatelet therapy to 5.5%, and a mono-therapy to 2.5% of the patients. Non-vitamin K antagonist oral anticoagulants (NOACs) were given to 82.4% and vitamin K antagonists to 11.5% of the patients. In-hospital events included death in 12 cases (0.7%), myocardial infarction, stent thrombosis, and ischemic stroke in four (0.2%) patients each, while 2.8% of patients had bleeding complications. The recommended durations for DAT or TAT at discharge were 1 month (1.5%), 3 months (2.1%), 6 months (43.1%), and 12 months (45.6%), with a 6-month course of DAT (47.7%) most often recommended after elective PCI and a 12-month course of DAT (40.1%) after ACS. CONCLUSION The preferred therapy after PCI in patients with AF is DAT with a NOAC and clopidogrel. In-hospital ischemic and bleeding events were rare. The recommended durations for combination therapy vary considerably.
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Affiliation(s)
- Uwe Zeymer
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany. .,Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
| | - Ralph Toelg
- Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | | | | | | | | | | | - Birgit Hailer
- Katholische Kliniken Essen-Nord-West gGmbH, Essen, Germany
| | | | | | | | - Peter Lanzer
- Gesundheitszentrum Bitterfeld Wolfen, Bitterfeld, Germany
| | - Harald Mudra
- Städtisches Krankenhaus Neuperlach-München, München, Germany
| | | | | | | | - Holger Thiele
- Herzzentrum Leipzig und Universität Leipzig, Leipzig, Germany
| | - Christoph Claas
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Ralf Zahn
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany
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23
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [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: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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24
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One-Year Outcomes in Anticoagulated Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the Greek Antiplatelet Atrial Fibrillation Registry. J Cardiovasc Pharmacol 2023; 81:141-149. [PMID: 36410034 DOI: 10.1097/fjc.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/29/2022] [Indexed: 11/22/2022]
Abstract
ABSTRACT GReek-AntiPlatElet Atrial Fibrillation registry is a multicenter, observational, noninterventional study of atrial fibrillation patients undergoing percutaneous coronary intervention. Primary endpoint included clinically significant bleeding rate at 12 months between different antithrombotic regimens prescribed at discharge; secondary endpoints included major adverse cardiovascular events and net adverse clinical events. A total of 647 patients were analyzed. Most (92.9%) were discharged on novel oral anticoagulants with only 7.1% receiving the vitamin K antagonist. A little over half of patients (50.4%) received triple antithrombotic therapy (TAT)-mostly (62.9%) for ≤1 month-whereas the rest (49.6%) received dual antithrombotic therapy (DAT). Clinically significant bleeding risk was similar between TAT and DAT [Hazard ratio (HR) = 1.08; 95% confidence interval (CI), 0.66-1.78], although among TAT-receiving patients, the risk was lower in those receiving TAT for ≤1 month (HR = 0.50; 95% CI, 0.25-0.99). Anticoagulant choice (novel oral anticoagulant vs. vitamin K antagonist) did not significantly affect bleeding rates ( P = 0.258). Age, heart failure, leukemia/myelodysplasia, and acute coronary syndrome were associated with increased bleeding rates. Risk of major adverse cardiovascular events and net adverse clinical events was similar between ΤAT and DAT (HR = 1.73; 95% CI, 0.95-3.18, P = 0.075 and HR = 1.39; 95% CI, 0.93-2.08, P = 0.106, respectively). In conclusion, clinically significant bleeding and ischemic rates were similar between DAT and TAT, although TAT >1 month was associated with higher bleeding risk.
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25
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Szapáry L, Tornyos D, Kupó P, Lukács R, El Alaoui El Abdallaoui O, Komócsi A. Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:1036609. [PMID: 36568540 PMCID: PMC9773199 DOI: 10.3389/fcvm.2022.1036609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022] Open
Abstract
Background Despite numerous randomized clinical trials (RCT), data regarding the efficacy of antiplatelet and anticoagulant combinations are still conflicting. We aimed to analyze treatment options tested in various fields of cardiovascular prevention, regarding their efficacy and bleeding risk. Methods Systematic searches of electronic databases were conducted until June 2022. A component network meta-analysis was performed in R. Risk estimates across trials were pooled using random-effects model selecting risk ratio (RR) with 95% confidence intervals (95% CIs) as summary statistics. The primary endpoint of interest was the rate of major cardiac adverse events (MACE). Major bleeding events were assessed as main safety endpoint. Secondary outcomes included cardiovascular- and overall mortality, myocardial infarction (MI), stent thrombosis, and stroke. Results Fifteen studies randomizing 73,536 patients were identified. The MACE risk reflected heterogeneity among the anticoagulants with dabigatran and apixaban significantly reducing the risk of MACE (RR 0.56; 95% CI 0.39-0.80 and RR 0.75; 95% CI 0.58-0.98, respectively). Vitamin K antagonist (VKA), rivaroxaban, or edoxaban did not reduced of MACE while it was associated with a significant increase of bleeding risk (RR 1.66; 3.66, and 5.47, respectively). The direct anticoagulant (DOAC) dose reduction resulted in tendencies of fewer bleeding but higher MACE risk, while combination with aspirin was followed with increased risk for bleeding, however, remained non-significant in these cases. Conclusion Our meta-analysis supports that the ischemic-bleeding balance is different among direct-acting oral anticoagulants (DOACs) while this is not significantly affected by the dose reduction approaches. Long-term aspirin treatment as part of the anticoagulant and dual antiplatelet regimen provides no ischemic benefit but may increase bleeding risk. Systematic review registration [https://www.crd.york.ac.uk/prospero/], identifier [259703].
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26
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Matsuura Y, Moribayashi K, Kaikita K. Optimal Antithrombotic Therapy in Patients Undergoing Percutaneous Coronary Intervention: A Focused Review on High Bleeding Risk. J Atheroscler Thromb 2022; 29:1409-1420. [PMID: 35934784 PMCID: PMC9529379 DOI: 10.5551/jat.rv17066] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 11/11/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) is a therapeutic cornerstone to prevent stent thrombosis following percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, the longer the DAPT duration, the higher the incidence of bleeding and mortality. Since the advent of second-generation drug-eluting stents (DES), the continuous evolution of DES has reduced the thrombotic risk and allowed for a shorter DAPT duration. On the other hand, concerns on the elevated risk of bleeding during antithrombotic therapy have been further raised due to the growing number of elderly CAD patients with multiple comorbidities. The consequent debate topic over post-PCI antithrombotic therapy has shifted from simply reducing thrombotic risk to safely minimizing bleeding risk. Due to the significant impact of bleeding on clinical outcomes, including prognosis, current guidelines on antithrombotic therapy for CAD prioritize stratification of patients at a high bleeding risk (HBR) as the top consideration in determining post-PCI antithrombotic therapy. Achieving optimal antithrombotic therapy for each patient undergoing PCI requires a better understanding of the clinical variables constituting the balance of bleeding and thrombotic risk. This review highlights relevant evidence required to optimize antithrombotic therapy for HBR patients undergoing PCI.
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Affiliation(s)
- Yunosuke Matsuura
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kohei Moribayashi
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Koichi Kaikita
- Division of Cardiovascular Medicine and Nephrology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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27
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Lee SR, Jung JH, Choi EK, Lee SW, Kwon S, Park JS, Kang J, Han KD, Park KW, Oh S, Lip GYH. Net clinical benefit of antithrombotic therapy for atrial fibrillation patients with stable coronary artery disease. Front Cardiovasc Med 2022; 9:991293. [PMID: 36072876 PMCID: PMC9441665 DOI: 10.3389/fcvm.2022.991293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
Objectives To compare the net clinical benefit of oral anticoagulant (OAC) monotherapy to OAC plus single antiplatelet therapy (SAPT) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) at 1- and 3-year after percutaneous coronary intervention (PCI). Background It has not been studied whether the net clinical benefit of the antithrombotic treatment options differs depending on the elapsed time from the index PCI. Methods Using the Korean nationwide claims database, we included AF patients who underwent PCI from 2009 to 2019 and constructed two cohorts: 1- and 3-year after PCI. In each cohort, the baseline characteristics of two groups were balanced using propensity score weighting. Ischemic stroke, myocardial infarction, major bleeding, and composite clinical outcomes were analyzed. Results Among patients with 1-year after PCI, OAC monotherapy (n = 678), and OAC plus SAPT (n = 3,159) showed comparable results for all clinical outcomes. In patients with 3-year after PCI, OAC monotherapy (n = 1,038) and OAC plus SAPT (n = 2,128) showed comparable results for ischemic stroke and myocardial infarction, but OAC monotherapy was associated with a lower risk of composite clinical outcomes (HR 0.762, 95% CI 0.607–0.950), mainly driven by the reduction of major bleeding risk (HR 0.498, 95% CI 0.345–0.701). Conclusion Oral anticoagulant monotherapy may be a comparable choice for patients with AF and stable CAD compared to OAC plus SAPT. In patients with stable CAD more than 3-year after index PCI, OAC monotherapy would be a better choice, being associated with less major bleeding and a positive net clinical benefit.
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Affiliation(s)
- So-Ryoung Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jin-Hyung Jung
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Eue-Keun Choi,
| | - Seung-Woo Lee
- Department of Medical Statistics, College of Medicine, Catholic University of Korea, Seoul, South Korea
| | - Soonil Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Ji-Suck Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Gregory Y. H. Lip
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest and Heart Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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28
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Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 1). JACC. ASIA 2022; 2:395-411. [PMID: 36339361 PMCID: PMC9627863 DOI: 10.1016/j.jacasi.2022.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/09/2022] [Accepted: 05/27/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk of stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonist direct oral anticoagulant (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions when NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the recent decade, and a more sophisticated strategy for atrial fibrillation patients is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. This statement aimed to provide possible treatment option in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is the part 1 of the whole statement.
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Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Division of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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29
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Garg A, Rout A, Farhan S, Waxman S, Giustino G, Tayal R, Abbott JD, Huber K, Angiolillo DJ, Rao SV. Dual antiplatelet therapy duration after percutaneous coronary intervention using drug eluting stents in high bleeding risk patients: A systematic review and meta-analysis. Am Heart J 2022; 250:1-10. [PMID: 35436504 DOI: 10.1016/j.ahj.2022.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Optimal dual antiplatelet therapy (DAPT) duration in patients at high bleeding risk (HBR) is not fully defined. We aimed to compare the safety and effectiveness of short-term DAPT (S-DAPT) with longer duration DAPT (L-DAPT) after percutaneous coronary intervention (PCI) with drug eluting stents (DES) in patients at HBR. METHODS We searched for studies comparing S-DAPT (≤3 months) followed by aspirin or P2Y 12 inhibitor monotherapy against L-DAPT (6-12 months) after PCI in HBR patients. Primary end points of interest were major bleeding and myocardial infarction (MI). Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. RESULTS Six randomized trials and 3 propensity-matched studies (n = 16,848) were included in the primary analysis. Compared with L-DAPT (n = 8,422), major bleeding was lower with S-DAPT (n = 8,426) [OR 0.68; 95% CI 0.51-0.89] whereas MI did not differ significantly between the 2 groups [1.16; 0.94-1.44]. There were no significant differences in risks of death, stroke or stent thrombosis (ST) between S-DAPT and L-DAPT groups. These findings were consistent when propensity-matched studies were analysed separately. Finally, there was a numerically higher, albeit statistically non-significant, ST in the S-DAPT arm of patients without an indication for OAC [1.98; 0.86-4.58]. CONCLUSIONS Among HBR patients undergoing current generation DES implantation, S-DAPT reduces bleeding without an increased risk of death or MI compared with L-DAPT. More research is needed to (1) evaluate risks of late ST after 1 to 3 months DAPT among patients with high ischemic and bleeding risks, (2) defining the SAPT of choice after 1 to 3 months DAPT.
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Affiliation(s)
- Aakash Garg
- Division of Cardiology, Brown University, Providence, RI.
| | - Amit Rout
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Serdar Farhan
- Division of Cardiology, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Sergio Waxman
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ
| | - Gennaro Giustino
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Raj Tayal
- Division of Cardiology, Valley Hospital, Ridgewood, NJ
| | | | - Kurt Huber
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
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Kitahara H, Tateishi K, Shiko Y, Inaba Y, Kobayashi Y, Inoue T. Comparison of short-term clinical outcomes between low-dose prasugrel and clopidogrel as part of triple antithrombotic therapy in patients requiring oral anticoagulant therapy and percutaneous coronary intervention. PLoS One 2022; 17:e0272140. [PMID: 35901007 PMCID: PMC9333269 DOI: 10.1371/journal.pone.0272140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 07/13/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Triple antithrombotic therapy, including dual antiplatelet therapy and oral anticoagulant (OAC), is recommended for a short-term period after percutaneous coronary intervention (PCI) in patients requiring anticoagulation therapy. The purpose of this study was to compare in-hospital clinical outcomes between low-dose prasugrel (3.75 mg/day) and clopidogrel, as part of triple antithrombotic therapy, using a large database in Japan. METHODS Patients with ischemic heart disease who underwent PCI between January 2015 and December 2019, and were prescribed triple therapy with aspirin, a P2Y12 inhibitor (clopidogrel or low-dose prasugrel), and OAC (direct oral anticoagulant: DOAC or vitamin K antagonist: VKA), were selected from the Diagnosis Procedure Combination database. The primary outcome was in-hospital mortality. The secondary outcomes were myocardial infarction, ischemic stroke, bleeding stroke, gastrointestinal bleeding, and blood transfusion. RESULTS Overall, 5,777 patients were eligible in this analysis. The patients were divided into 4 subgroups according to the type of P2Y12 inhibitor and OAC: clopidogrel/DOAC (n = 1,628), clopidogrel/VKA (n = 1,334), prasugrel/DOAC (n = 1,607), and prasugrel/VKA (n = 1,208). There was no significant difference in the incidence of death and gastrointestinal bleeding among the 4 subgroups. The prasugrel/DOAC group had significantly lower incidence of MI (OR 0.566, 95% CI 0.348-0.921). The incidence of ischemic stroke was significantly lower in the prasugrel/DOAC group (OR 0.701, 95% CI 0.502-0.979), and significantly higher in the clopidogrel/VKA group (OR 1.680, 95% CI 1.273-2.216). Need for blood transfusion was less frequent in the prasugrel/DOAC group (OR 0.729, 95% CI 0.598-0.890), and more frequent in both the clopidogrel/VKA group (OR 1.424, 95% CI 1.187-1.708) and the prasugrel/VKA group (OR 1.633, 95% CI 1.367-1.950). CONCLUSIONS Combination of low-dose prasugrel and DOAC was associated with lower incidence of MI, ischemic stroke, and blood transfusion. Low-dose prasugrel may be feasible as part of triple therapy in patients undergoing PCI.
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Affiliation(s)
- Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yusuke Inaba
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takahiro Inoue
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
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Zwart B, Bor WL, de Veer AJWM, Mahmoodi BK, Kelder JC, Lip GY, Bhatt DL, Cannon CP, ten Berg JM. A novel risk score to identify the need for triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a post hoc analysis of the RE-DUAL PCI trial. EUROINTERVENTION 2022; 18:e292-e302. [PMID: 35105533 PMCID: PMC9912964 DOI: 10.4244/eij-d-21-00165] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Current guidelines recommend treating atrial fibrillation (AF) patients who undergo percutaneous coronary intervention (PCI) with triple antithrombotic therapy (TAT) for up to one month in patients at high thrombotic risk. It is unclear how to select these high-risk patients. AIMS The aim of this study was to identify patients at high thrombotic risk who might benefit from TAT over double antithrombotic therapy (DAT). METHODS This study was a post hoc subanalysis of the RE-DUAL PCI trial. A Cox proportional hazards model was built by stepwise selection of plausible predictor variables for a composite ischaemic endpoint, defined as cardiovascular death, myocardial infarction (MI), stent thrombosis (ST) or ischaemic stroke. The effect of TAT versus DAT was calculated for those patients with the highest proportion of predicted thrombotic risk. A simplified risk score was constructed based on beta-coefficients. RESULTS For 209 patients (7.7%) the composite ischaemic endpoint occurred during the first year. The simplified risk score contained six variables. In patients with a score ≥5 (n=154, 5.7%), a significant reduction in the composite of MI and ST was observed with TAT versus DAT (6.3% vs 21.0%, p=0.041), without a penalty in terms of bleeding. In patients at low thrombotic risk, a significant increase in bleeding was observed without a reduction of ischaemic events. CONCLUSIONS Our findings support the use of DAT in the majority of patients. A small subgroup of patients might benefit from TAT and we propose a novel clinical risk score to select these patients.
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Affiliation(s)
- Bastiaan Zwart
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | | | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deepak L. Bhatt
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Cannon
- Heart & Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jurriën Maria ten Berg
- Dept. of Cardiology, St Antonius Hospital Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
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Bor WL, de Veer AJW, Olie RH, Rikken SA, Chan Pin Yin DR, Herrman JPR, Vrolix M, Meuwissen M, Vandendriessche T, van Mieghem C, Magro M, Bennaghmouch N, Hermanides R, Adriaenssens T, Dewilde WJ, ten Berg JM. Dual versus triple antithrombotic therapy after percutaneous coronary intervention: the prospective multicentre WOEST 2 Study. EUROINTERVENTION 2022; 18:e303-e313. [PMID: 35370126 PMCID: PMC9980408 DOI: 10.4244/eij-d-21-00703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND For patients on oral anticoagulants (OAC) undergoing percutaneous coronary intervention (PCI), European guidelines have recently changed their recommendations to dual antithrombotic therapy (DAT; P2Y12 inhibitor and OAC) without aspirin. AIMS The prospective WOEST 2 registry was designed to obtain contemporary real-world data on antithrombotic regimens and related outcomes after PCI in patients with an indication for OAC. METHODS In this analysis, we compare DAT (P2Y12 inhibitor and OAC) to triple antithrombotic therapy (TAT; aspirin, P2Y12 inhibitor, and OAC) on thrombotic and bleeding outcomes after one year. Clinically relevant bleeding was defined as Bleeding Academic Research Consortium classification (BARC) grade 2, 3, or 5; major bleeding as BARC grade 3 or 5. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause mortality, myocardial infarction, stent thrombosis, ischaemic stroke, and transient ischaemic attack. RESULTS A total of 1,075 patients were included between 2014 and 2021. Patients used OAC for atrial fibrillation (93.6%) or mechanical heart valve prosthesis (4.7%). Non-vitamin K oral anticoagulants (NOAC) were prescribed in 53.1% and vitamin K antagonists in 46.9% of patients. At discharge, 60.9% received DAT, and 39.1% TAT. DAT was associated with less clinically relevant and similar major bleeding (16.8% vs 23.4%; p<0.01 and 7.6% vs 7.7%, not significant), compared to TAT. The difference in MACCE between the two groups was not statistically significant (12.4% vs 9.7%; p=0.17). Multivariable adjustment and propensity score matching confirmed these results. CONCLUSIONS Dual antithrombotic therapy is associated with a substantially lower risk of clinically relevant bleeding without a statistically significant penalty in ischaemic events.
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Affiliation(s)
- Willem Lambertus Bor
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | | | - Renske H. Olie
- Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sem A.O.F. Rikken
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | | | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | | | - Carlos van Mieghem
- Cardiovascular Research Center Aalst, OLV Clinic, Aalst, Belgium,Department of Cardiology, AZ Groeninge, Kortrijk, Belgium
| | - Michael Magro
- Department of Cardiology, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Naoual Bennaghmouch
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Rick Hermanides
- Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Jurriën Maria ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands,Cardiovascular Research Institute Maastricht (CARIM), School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, the Netherlands
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Zhang L, Tian Y, Ren H, Zhu A, Dong L, Wang X, Han X. Effect of PCI Standardized Telephone Follow-Up Service Mode on Out-of-Hospital Complications, Rehospitalization Rate, and Quality of Life of Discharged Patients with Acute Coronary Syndrome after PCI. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4319887. [PMID: 35912146 PMCID: PMC9334068 DOI: 10.1155/2022/4319887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 12/04/2022]
Abstract
Objective To explore the effect of percutaneous coronary intervention (PCI) standardized telephone follow-up service mode on out-of-hospital complications, rehospitalization rate, and life quality of discharged acute coronary syndrome (ACS) patients after PCI. Methods From August 2020 to March 2022, 218 ACS patients who were discharged after PCI were included. The controls accepted routine nursing care, and the researches accepted PCI standardized telephone follow-up service mode. The nursing satisfaction, rehospitalization rate, out-of-hospital complication rate, blood lipid level, and life quality score were taken as the comparisons. Results The nursing satisfaction of study group (100.00%) was significantly higher than that of control group (88.07%). The rehospitalization rate was dramatically lower in the study group (3/109; 2.75%) than in the control group (25/109; 22.94%) (P < 0.05). In addition, compared with the control group, the incidence of complications (acute myocardial infarction and angina pectoris) was significantly reduced in the study group outside the hospital (P < 0.05). The blood lipid levels of TCHO, TG, LDL-C, and HDL-C were lower in the study group than in the controls. Further, after nursing, the quality of life score of the two groups was both decreased with a higher quality of life score in the study group (P < 0.05). Conclusion The application of PCI standardized telephone follow-up service mode in discharged patients with acute coronary syndrome after PCI can reduce out-of-hospital complications and rehospitalization rate and improve blood lipid level and life quality.
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Affiliation(s)
- Luyan Zhang
- Patients Pay a Return Visit Department, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Yaling Tian
- Patients Pay a Return Visit Department, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Hong Ren
- Performance Management Section, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Aihong Zhu
- CCU, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Li Dong
- Department of Geriatrics, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Xiuqin Wang
- Patients Pay a Return Visit Department, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
| | - Xiaoyu Han
- CCU, The First Hospital of Qinhuangdao, Qinhuangdao 066000, China
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Management of Oral Anticoagulation and Antiplatelet Therapy in Post-Myocardial Infarction Patients with Acute Ischemic Stroke with and without Atrial Fibrillation. J Clin Med 2022; 11:jcm11133894. [PMID: 35807178 PMCID: PMC9267324 DOI: 10.3390/jcm11133894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/01/2022] [Accepted: 07/01/2022] [Indexed: 02/04/2023] Open
Abstract
The association between atrial fibrillation (AF), acute coronary syndrome (ACS), and stroke is a complex scenario in which the assessment of both thrombotic and hemorrhagic risk is necessary for scheduling an individually tailored therapeutic plan. Recent clinical trials investigating new antithrombotic drugs and dual and triple pathways in high-risk cardiovascular patients have revealed a new therapeutic scenario. In this paper, we review the burden of ischemic stroke (IS) in patients post-myocardial infarction with and without atrial fibrillation and the possible therapeutic strategies from a stroke point of view.
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Galli M, Angiolillo DJ. Dual versus triple antithrombotic therapy for atrial fibrillation-ACS/PCI: One size does not fit all. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:152-154. [PMID: 35750592 DOI: 10.1016/j.carrev.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States.
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Rowland B, Batty JA, Mehran R, Kunadian V. Triple Antiplatelet Therapy and Combinations with Oral Anticoagulants after Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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De Luca L, Rubboli A, Lettino M, Tubaro M, Leonardi S, Casella G, Valente S, Rossini R, Sciahbasi A, Natale E, Trambaiolo P, Navazio A, Cipriani M, Corda M, De Nardo A, Francese GM, Napoletano C, Tizzani E, Nardi F, Roncon L, Caldarola P, Riccio C, Gabrielli D, Oliva F, Massimo Gulizia M, Colivicchi F. ANMCO position paper on antithrombotic treatment of patients with atrial fibrillation undergoing intracoronary stenting and/or acute coronary syndromes. Eur Heart J Suppl 2022; 24:C254-C271. [PMID: 35663586 PMCID: PMC9155223 DOI: 10.1093/eurheartj/suac020] [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] [Indexed: 11/16/2022]
Abstract
Patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with or without acute coronary syndromes (ACS) represent a subgroup with a challenging pharmacological management. Indeed, if on the one hand, antithrombotic therapy should reduce the risk related to recurrent ischaemic events and/or stent thrombosis; on the other hand, care must be taken to avoid major bleeding events. In recent years, several trials, which overall included more than 12 000 patients, have been conducted demonstrating the safety of different therapeutic combinations of oral antiplatelet and anticoagulant agents. In the present ANMCO position paper, we propose a decision-making algorithm on antithrombotic strategies based on scientific evidence and expert consensus to be adopted in the periprocedural phase, at the time of hospital discharge, and in the long-term follow-up of patients with AF undergoing PCI with/without ACS.
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Affiliation(s)
- Leonardo De Luca
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Andrea Rubboli
- Cardiology, Cardiovascular Department, Ospedale S. Maria delle Croci, Ravenna, Italy
| | - Maddalena Lettino
- Department of Cardiology, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Marco Tubaro
- CCU, Intensive and Interventional Cardiology Department, P.O. San Filippo Neri, Roma, Italy
| | - Sergio Leonardi
- University of Pavia and IRCCS S. Matteo Foundation General Hospital, Pavia, Italy
| | - Gianni Casella
- Cardiology Department, Ospedale Maggiore, Azienda USL di Bologna, Bologna, Italy
| | - Serafina Valente
- Cardio-Thoracic Department, A.O.U. Senese, Ospedale Santa Maria alle Scotte, Siena, Italy
| | - Roberta Rossini
- Emergency Department and Critical Areas, Azienda Ospedaliera Santa Croce e Carle, Cuneo, Italy
| | | | - Enrico Natale
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Paolo Trambaiolo
- Cardiology Department, Ospedale Sandro Pertini, ASL RM2, Roma, Italy
| | - Alessandro Navazio
- Hospital Cardiology Department, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Manlio Cipriani
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Marco Corda
- Cardiology Department, Azienda Ospedaliera G. Brotzu, Cagliari, Italy
| | - Alfredo De Nardo
- Cardiology-ICU Department, Ospedale Civile “G. Jazzolino”, Vibo Valentia, Italy
| | - Giuseppina Maura Francese
- Cardiology Department, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Cosimo Napoletano
- Cardiology-ICU Department—Cath Lab, Presidio Ospedaliero “G. Mazzini”, Teramo, Italy
| | | | - Federico Nardi
- Cardiology Department, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | - Loris Roncon
- Cardiology Department, Ospedale Santa Maria della Misericordia, Rovigo, Italy
| | | | - Carmine Riccio
- Follow-up of the Post-Acute Patient, Cardio-Vascular Department, AORN Sant'Anna and San Sebastiano, Caserta, Italy
| | - Domenico Gabrielli
- Cardiology, Department of Cardio-Thoraco-Vascular, Azienda Ospedaliera San Camillo Forlanini, Circonvallazione Gianicolense, 87, 00152 Roma, Italy
| | - Fabrizio Oliva
- Cardiology 2-Heart Failure and Transplants, Dipartimento Cardiotoracovascolare “A. De Gasperis”, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, Presidio Ospedaliero San Filippo Neri, ASL Roma 1, Roma, Italy
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Real world prescribing practices of apixaban or rivaroxaban lead-in doses for the treatment of venous thromboembolism in hospitalized patients. J Thromb Thrombolysis 2022; 54:219-229. [PMID: 35381944 DOI: 10.1007/s11239-022-02641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
The oral factor Xa inhibitors (OFXAi) apixaban and rivaroxaban are increasingly utilized for the treatment of venous thromboembolism (VTE) with recommended initial higher dose 7- and 21-day lead-in regimens, respectively. In patients receiving initial parenteral anticoagulation, it remains unknown if the full recommended higher dose OFXAi lead-in regimens are warranted, or if days can be subtracted. We aimed to describe when clinicians may deviate from recommended lead-in durations and evaluate clinical outcomes in these scenarios. This is a retrospective, observational study of patients 18 years or older who were treated with rivaroxaban or apixaban for acute pulmonary embolism (PE) or symptomatic proximal deep vein thrombosis (DVT) that received parenteral anticoagulation for at least 24 h before transitioning to the OFXAi. Among our cohort of 171 patients with acute VTE who received parenteral anticoagulation for a median of 48 h, 134 (78%) were prescribed a full OFXAi lead-in and 37 (22%) were prescribed a reduced lead-in. Patients in the reduced lead-in group were older with more cardiac comorbidities and antiplatelet use. There were four recurrent thromboembolic events within 3 months, two in the reduced lead-in group and two in the full lead-in group (5% vs. 2%, p = 0.206). Bleeding within 3 months occurred in 9 (5%) patients, with 6 events occurring in the reduced lead-in group and 3 events in the full lead-in group (16% vs. 2%, p = 0.004). Prescribing patterns of OFXAi lead-in therapy duration are variable in patients receiving initial parenteral anticoagulation. Larger cohorts are needed to better define the safety and efficacy of lead-in reduction.
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Espinola-Klein C. When and How to Combine Antiplatelet and Anticoagulant Drugs? Hamostaseologie 2022; 42:73-79. [PMID: 35196733 DOI: 10.1055/a-1724-4922] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Antiplatelet and anticoagulant drugs work at different places in the coagulation system. Antiplatelet drugs are usually indicated in patients with atherosclerosis. Anticoagulant drugs are mostly used in patients with atrial fibrillation, venous thromboembolism, or technical heart valves. In some clinical situations, combination of antiplatelet and anticoagulant therapy can be indicated. The most recent situations are a more intensive antithrombotic therapy for risk reduction in patients with atherosclerosis and temporary addition of antiplatelet drugs in patients with indication for long-term anticoagulation. Temporary combination of antiplatelet and anticoagulant drugs is usually necessary after coronary intervention in patients with atrial fibrillation. In patients with high-risk atherosclerosis, the combination of low-dose rivaroxaban and aspirin reduces major adverse cardiovascular events (myocardial infarction, stroke, cardiovascular death) and major adverse limb events. But every combination of antiplatelet and antithrombotic drugs can increase bleeding risk. Therefore, a careful assessment of thrombotic versus bleeding risk is necessary for each patient.
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Affiliation(s)
- Christine Espinola-Klein
- Center of Cardiology, Cardiology III - Angiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
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40
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Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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41
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Harskamp RE, Fanaroff AC, Lopes RD, Wojdyla DM, Goodman SG, Thomas LE, Aronson R, Windecker S, Mehran R, Granger CB, Alexander JH. Antithrombotic Therapy in Patients With Atrial Fibrillation After Acute Coronary Syndromes or Percutaneous Intervention. J Am Coll Cardiol 2022; 79:417-427. [DOI: 10.1016/j.jacc.2021.11.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/24/2021] [Indexed: 12/30/2022]
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Fanaroff AC, Lopes RD. The role of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Prog Cardiovasc Dis 2021; 69:11-17. [PMID: 34883097 DOI: 10.1016/j.pcad.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin plus clopidogrel forms the backbone of secondary prevention in patients with acute coronary syndromes (ACS) or who undergo percutaneous coronary intervention (PCI), but in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is superior to antiplatelet therapy for the prevention of stroke and systemic embolism. Patients with AF who undergo PCI or have an ACS event therefore have an indication for both OAC and DAPT, so-called triple antithrombotic therapy. However, observational analyses have shown that the annual rate of major bleeding on triple therapy exceeds 10%. For this reason, five major randomized clinical trials have compared double antithrombotic therapy with OAC and a P2Y12 inhibitor versus triple therapy in patients with AF who underwent PCI or had an ACS event. Each of the trials showed that double antithrombotic therapy reduced the rate of major and clinically relevant non-major bleeding compared with triple therapy and was non-inferior for prevention of ischemic events, including cardiovascular death, myocardial infarction, or stroke. In the one trial that directly compared warfarin with a non-vitamin K antagonist oral anticoagulant (NOAC), apixaban reduced the rate of major or clinically relevant non-major bleeding compared with warfarin and was non-inferior with respect to prevention of ischemic events. As a result of these trials, consensus guidelines recommend that patients with AF who undergo PCI or have an ACS event should be treated with triple antithrombotic therapy (OAC + P2Y12 inhibitor + aspirin) for 7 days or less, followed by double antithrombotic therapy (OAC + P2Y12 inhibitor) for 6 to 12 months.
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Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Renato D Lopes
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Durham, NC, United States of America.
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43
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Research on the Health Literacy Status and Compliance Behavior of Patients with Acute Coronary Syndrome. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:9648708. [PMID: 34790257 PMCID: PMC8592731 DOI: 10.1155/2021/9648708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/06/2021] [Accepted: 10/30/2021] [Indexed: 11/21/2022]
Abstract
This study is aimed at assessing the current status of ACS patients' health literacy and medication compliance, analyzing the relationship between the two, and providing ideas for clinically improving the medication compliance of ACS patients and preventing the recurrence of cardiovascular events. ACS patients need long-term medication to prevent vascular restenosis after surgery, and bad living habits and mood swings will affect postoperative recovery, so clinical interventions are needed to help patients establish a healthy lifestyle. The effect of conventional care is not ideal. Therefore, this paper uses regression analysis to analyze the correlation between the health literacy status of ACS patients and the compliance behavior, combines the investigation and experiment to perform regression analysis and uses mathematical statistics to process data. The connection between health literacy level and compliance behavior is discovered via a study, providing a point of reference for future research.
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44
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Darius H. [Dual antiplatelet therapy after acute coronary syndrome or percutaneous coronary intervention: with what and for how long?]. Internist (Berl) 2021; 62:1243-1252. [PMID: 34633479 DOI: 10.1007/s00108-021-01189-5] [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: 09/24/2021] [Indexed: 10/20/2022]
Abstract
Thrombotic complications following coronary interventions (PCI) used to be frequent specifically in acute coronary syndrome (ACS) patients. In recent years complication rates have significantly fallen due to improved stent technology, catheterisation techniques and intravascular visualisation. Therefore, the shortest necessary duration of dual antiplatelet therapy (DAPT) comprising aspirin and a P2Y12 inhibitor is constantly the subject of scientific investigations in order to avoid bleeding complications without allowing ischemic complications to occur. A DAPT duration of 12 months after PCI and ACS was accepted as a standard. Meanwhile a highly individualized approach in terms of therapy duration and choice of drugs that takes the patient's individual bleeding and ischemic risk into account is being practised. Prolonged DAPT (>12 months) is currently recommended for patients post myocardial infarction with a low bleeding risk, at high ischemic risk due to coronary triple vessel disease, following a high risk coronary intervention with an unsatisfactory result or a personal history of prior stent thrombosis. Alternatively, instead of prolonged DAPT, dual-pathway antithrombotic therapy of aspirin plus rivaroxaban (2.5 mg bid) is recommended to prevent future strokes, critical limb ischemia and to reduce mortality in cases with multiregional atherosclerosis. In the meantime, reduced-duration DAPT of 3-6 months is being recommended for most patients. Recent data show that in patients with a high bleeding risk, a DAPT treatment period of 4 weeks may be sufficient with a markedly reduced rate of bleeding and without evidence for more ischemic events. Following the early termination of DAPT, continuing antithrombotic monotherapy with the P2Y12 inhibitor ticagrelor may be indicated to prevent further ischemic events without the risk of bleeding complications comparable to DAPT.
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Affiliation(s)
- Harald Darius
- Klinik für Kardiologie, Angiologie, Nephrologie und konservative Intensivmedizin, Vivantes Klinikum Neukölln, Rudower Str. 48, 12351, Berlin, Deutschland.
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45
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Smits PC, Frigoli E, Tijssen J, Jüni P, Vranckx P, Ozaki Y, Morice MC, Chevalier B, Onuma Y, Windecker S, Tonino PAL, Roffi M, Lesiak M, Mahfoud F, Bartunek J, Hildick-Smith D, Colombo A, Stankovic G, Iñiguez A, Schultz C, Kornowski R, Ong PJL, Alasnag M, Rodriguez AE, Moschovitis A, Laanmets P, Heg D, Valgimigli M. Abbreviated Antiplatelet Therapy in Patients at High Bleeding Risk With or Without Oral Anticoagulant Therapy After Coronary Stenting: An Open-Label, Randomized, Controlled Trial. Circulation 2021; 144:1196-1211. [PMID: 34455849 PMCID: PMC8500374 DOI: 10.1161/circulationaha.121.056680] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear.
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Affiliation(s)
- Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands (P.C.S.)
| | - Enrico Frigoli
- Clinical Trial Unit, University of Bern, Switzerland (E.F., D.H.)
| | - Jan Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, The Netherlands (J.T.).,ECRI, Rotterdam, The Netherlands (J.T.)
| | - Peter Jüni
- University of Toronto, Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Canada (P.J.)
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium (P.V.).,Faculty of Medicine and Life Sciences, Hasselt University, Belgium (P.V.)
| | - Yukio Ozaki
- Department of Cardiology, School of Medicine, Fujita Health University, Toyoake, Japan (Y. Ozaki)
| | | | - Bernard Chevalier
- Ramsay Générale de Santé, Interventional Cardiology Department, Institut Cardiovasculaire Paris Sud, Massy, France (B.C.)
| | | | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Switzerland (S.W.)
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands (P.A.L.T.)
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, Switzerland (M.R.)
| | - Maciej Lesiak
- First Department of Cardiology, University of Medical Sciences, Poznan, Poland (M.L.)
| | - Felix Mahfoud
- Department of Cardiology, Angiology, Intensive Care Medicine, Saarland University, Homburg, Germany (F.M.)
| | - Jozef Bartunek
- Cardiovascular Center, OLV Hospital, Aalst, Belgium (J.B.)
| | - David Hildick-Smith
- Brighton and Sussex University Hospitals NHS Trust, United Kingdom (D.H.-S.)
| | - Antonio Colombo
- Unit of Cardiovascular Interventions, IRCCS San Raffaele Scientific Institute, Milan, Italy (A.C.)
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, and Faculty of Medicine, University of Belgrade (G.S.)
| | | | - Carl Schultz
- Department of Cardiology, Royal Perth Hospital Campus, University of Western Australia (C.S.)
| | - Ran Kornowski
- Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Israel (R.K.)
| | | | - Mirvat Alasnag
- Department of Cardiology, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia (M.A.)
| | - Alfredo E Rodriguez
- Cardiac Unit Otamendi Hospital, Buenos Aires School of Medicine Cardiovascular Research Center, Argentina (A.E.R.)
| | | | - Peep Laanmets
- North-Estonia Medical Centre Foundation, Tallinn (P.L.)
| | - Dik Heg
- Clinical Trial Unit, University of Bern, Switzerland (E.F., D.H.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana, Lugano, Switzerland (M.V.)
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46
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Verstraete A, Herregods MC, Verbrugghe P, Lamberigts M, Vanassche T, Meyns B, Oosterlinck W, Rega F, Adriaenssens T, Van Hoof L, Keuleers S, Vandenbriele C, Sinnaeve P, Janssens S, Dubois C, Meuris B, Verhamme P. Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement. Front Cardiovasc Med 2021; 8:702780. [PMID: 34422930 PMCID: PMC8375148 DOI: 10.3389/fcvm.2021.702780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.
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Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marie Lamberigts
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Siegmund Keuleers
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Sinnaeve
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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47
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Yoon GS, Kim SH, Kang SH, Yoon CH, Cho YS, Youn TJ, Chae IH. Prognosis of Atrial Fibrillation Patients Undergoing PCI According to Anticoagulants and Antiplatelet Agents. J Clin Med 2021; 10:jcm10153370. [PMID: 34362151 PMCID: PMC8348599 DOI: 10.3390/jcm10153370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/24/2021] [Accepted: 07/25/2021] [Indexed: 11/16/2022] Open
Abstract
There are limited data evaluating conformation of antithrombotic therapy usage to the guideline recommendations. We investigated clinical trends and prognoses of patients with atrial fibrillation (AF) according to anticoagulants and antiplatelet agents beyond 1 year after percutaneous coronary intervention (PCI). We analyzed the records of patients with AF who underwent PCI using the Korean National Health Insurance Service database. The primary endpoint was a composite of major adverse cardiac events (MACE). The safety outcome was bleeding complications. Of 4193 participants, 81.6% received antiplatelet therapy, whereas 27.3% had oral anticoagulant (OAC)-based therapy at 18 months after PCI. The dominant therapy was dual antiplatelet therapy (37.2%), and only 3.3% of participants had OAC monotherapy. At the 1-year follow-up, the incidence of MACE was significantly lower among those receiving a combination of OAC and single antiplatelet therapy (SAPT) than among those receiving OAC monotherapy (4.78% vs. 9.42%, p = 0.017). Bleeding complication events (5.01% vs. 5.80%, p = 0.587) did not differ between the groups. In clinical practice, most patients with AF who underwent PCI continued to receive antiplatelet agents beyond 1-year post-PCI. OAC with SAPT seemed to be more effective than OAC monotherapy, without a difference in safety.
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Affiliation(s)
- Gwang-Seok Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
| | - Sun-Hwa Kim
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
| | - Si-Hyuck Kang
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
| | - Chang-Hwan Yoon
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
- Correspondence: ; Tel.: +82-31-787-7052; Fax: +82-31-787-4052
| | - Young-Seok Cho
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
| | - Tae-Jin Youn
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
| | - In-Ho Chae
- Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam-si 13620, Korea; (G.-S.Y.); (S.-H.K.); (S.-H.K.); (Y.-S.C.); (T.-J.Y.); (I.-H.C.)
- Department of Internal Medicine, Seoul National University, Seoul 03087, Korea
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48
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Gill K, Servati N, Flahive J, Fraielli K. Safety and Efficacy of Triple Therapy With Ticagrelor or Prasugrel Versus Clopidogrel After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction. J Cardiovasc Pharmacol Ther 2021; 26:625-629. [PMID: 34236915 DOI: 10.1177/10742484211031436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients on dual antiplatelet therapy following percutaneous coronary intervention often have indications for concomitant oral anticoagulation, known as triple antithrombotic therapy. Majority of literature evaluating triple antithrombotic therapy fails to adequately represent patients with ST-elevation myocardial infarction and those prescribed potent P2Y12 inhibitors, ticagrelor or prasugrel. The purpose of this study was to evaluate the safety and efficacy of triple antithrombotic regimens containing ticagrelor or prasugrel versus clopidogrel after percutaneous coronary intervention in the setting of ST-elevation myocardial infarction. METHODS This was a single-center, retrospective cohort trial. The primary endpoint was net adverse clinical event, defined as the primary efficacy endpoint of death, myocardial infarction, or cerebrovascular accident and the primary safety endpoint of any bleeding event. RESULTS Between October 2017 and October 2019, a total of 65 patients with ST-elevation myocardial infarction were initiated on triple therapy. Forty-six patients were included in the primary analysis, of which 26 were discharged on triple antithrombotic therapy with clopidogrel and 20 discharged on potent P2Y12 inhibitors (ticagrelor or prasugrel). The primary endpoint occurred in 27% of the clopidogrel group and 40% of the potent P2Y12 inhibitor group (P = 0.35). Bleeding occurred in 23% of the clopidogrel group and 35% of the potent P2Y12 inhibitor group (P = 0.37). CONCLUSIONS This small cohort study suggests, in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention, the net adverse clinical event rate does not differ between clopidogrel and potent P2Y12 inhibitors in the setting of triple antithrombotic therapy. The results of this exploratory analysis warrant confirmation in a larger, randomized study.
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Affiliation(s)
- Kristina Gill
- Department of Pharmacy, 3354UMass Memorial Medical Center, Worcester, MA, USA.,12262University of Massachusetts Medical School, Worcester, MA, USA
| | - Nicholas Servati
- Department of Pharmacy, 3354UMass Memorial Medical Center, Worcester, MA, USA
| | - Julie Flahive
- Biostatistics and Health Services Research, 12262University of Massachusetts Medical School, Worcester, MA, USA
| | - Kyle Fraielli
- Department of Pharmacy, 3354UMass Memorial Medical Center, Worcester, MA, USA
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49
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Zhao S, Hong X, Cai H, Liu M, Li B, Ma P. Antithrombotic Management for Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention or With Acute Coronary Syndrome: An Evidence-Based Update. Front Cardiovasc Med 2021; 8:660986. [PMID: 34262952 PMCID: PMC8273244 DOI: 10.3389/fcvm.2021.660986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/27/2021] [Indexed: 12/13/2022] Open
Abstract
Combined antithrombotic regimens for atrial fibrillation (AF) patients with coronary artery disease, particularly for those who have acute coronary syndrome (ACS) and/or are undergoing percutaneous coronary intervention (PCI), presents a great challenge in the real-world clinical scenario. Conventionally, a triple antithrombotic therapy (TAT), which consists of combined oral anticoagulant therapy to prevent systemic embolism or stroke along with dual antiplatelet therapy to prevent coronary arterial thrombosis (CAT), is used. However, TAT has been associated with a significantly increased risk of bleeding. With the emergence of non-vitamin K antagonist oral anticoagulants (NOACs), randomized controlled trials have demonstrated a better risk-to-benefit ratio of dual antithrombotic therapy (DAT) in combination of a NOAC and with a P2Y12 inhibitor than vitamin K antagonist-based TAT. The results of these studies have impacted the recommendations of current international guidelines, which favor a DAT with a NOAC and P2Y12 inhibitor (especially clopidogrel) in this clinical setting. Additionally, aspirin can be administered during the periprocedural period, while the treatment duration of TAT should be as short as possible. In this article, we summarize the up-to-date evidence regarding antithrombotic regimens for AF patients with PCI or ACS, with a specific focus on the optimal approach and critical discussions of key scientific data and future developments for antithrombotic management in these patients.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Xuejiao Hong
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Haixia Cai
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Mingzhou Liu
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Bing Li
- Department of General Practice, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
| | - Peizhi Ma
- Department of Pharmacy, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, School of Clinical Medicine, Henan University, Zhengzhou, China
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50
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Benz AP, Johansson I, Dewilde WJM, Lopes RD, Mehran R, Sartori S, Sarafoff N, Yasuda S, McIntyre WF, Healey JS, Shoamanesh A, Eikelboom JW, Connolly SJ. Antiplatelet Therapy in Patients with Atrial Fibrillation: A Systematic Review and Metaanalysis of Randomized Trials. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:648-659. [PMID: 34142118 DOI: 10.1093/ehjcvp/pvab044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022]
Abstract
AIMS To systematically assess the effects of antiplatelets on clinical outcomes in patients with atrial fibrillation (AF), treated and not treated with oral anticoagulation. METHODS AND RESULTS We searched MEDLINE, Embase and CENTRAL from inception until September 2020. From 5,446 citations, we selected randomized trials allocating patients with AF to antiplatelet therapy vs. control. We applied random-effects models for meta-analysis and assessed potential effect modification with background anticoagulation use. Eighteen trials including 21,518 participants met our prespecified eligibility criteria. In 10 studies without background anticoagulation, antiplatelets reduced all-cause stroke (486/6,165 [events/patients] vs. 621/6,061; risk ratio [RR] 0.77, 95% confidence interval [CI] 0.69-0.86, I2=0%). In 8 studies with background anticoagulation, there was a signal for an increase in all-cause stroke with antiplatelets (97/4,608 vs. 72/4,684; RR 1.33, 95% CI 0.98-1.79, I2=0%), p-value for interaction < 0.001. A similar pattern emerged for ischaemic stroke. Irrespective of background anticoagulation use, antiplatelets increased major bleeding (509/10,402 vs. 328/10,496; RR 1.54, 95% CI 1.35-1.77, I2=0%) and intracranial Haemorrhage (107/10,221 vs. 65/10,232; RR 1.64, 95% CI 1.20-2.24, I2=0%), and reduced myocardial infarction (201/9,679 vs. 260/9,751; RR 0.79, 95% CI 0.65-0.94, I2=0%), all p-values for interaction ≥ 0.36. Antiplatelets did not affect mortality (1,221/10,299 vs. 1,211/10,287; RR 1.02, 95% CI 0.89-1.17, I2=29%), p-value for interaction = 0.23. CONCLUSIONS In patients with AF not receiving oral anticoagulation, antiplatelet therapy modestly reduced stroke. There was a corresponding signal for harm when used on top of anticoagulation. Irrespective of background anticoagulation use, antiplatelet therapy significantly increased bleeding, moderately reduced myocardial infarction and did not affect mortality.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Isabelle Johansson
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States
| | - Nikolaus Sarafoff
- Deutsches Herzzentrum München, Klinik für Herz-und Kreislauferkrankungen, Technische Universität Munich, Germany
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - William F McIntyre
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
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