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Chang WT, Huang PS, Su LW, Liao CT, Siong Toh H, Chen YC, Chung‑Han H, Chen ZC, Hsu PC, Hong CS. Utility of the ACD-GENE-CLI Score in Asian Patients with Critical Limb Ischemia Undergoing Endovascular Interventions. J Atheroscler Thromb 2024; 31:572-586. [PMID: 38092392 PMCID: PMC11079481 DOI: 10.5551/jat.64326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 10/19/2023] [Indexed: 05/03/2024] Open
Abstract
AIMS Critical limb ischemia (CLI) is an emerging public health threat and lacks a reliable score for predicting the outcomes. The Age, Body Mass Index, Chronic Kidney Disease, Diabetes, and Genotyping (ABCD-GENE) risk score helps identify patients with coronary artery disease who have cytochrome P450 2C19 (CYP2C19) polymorphism-related drug resistance and are at risk for cardiovascular adverse events. However, its application to CLI remains unknown. In this study, we aim to validate a modified ACD-GENE-CLI score to improve the prediction of major adverse limb events (MALEs) in patients with CLI receiving clopidogrel. METHODS Patients with CLI receiving clopidogrel post-endovascular intervention were enrolled prospectively in two medical centers. Amputation and revascularization as MALEs were regarded as the outcomes. RESULTS A total of 473 patients were recruited, with a mean follow-up duration of 25 months. Except for obesity, old age, diabetes, chronic kidney disease (CKD), and CYP2C19 polymorphisms were significantly associated with MALEs. Using bootstrap regression analysis, we established a modified risk score (ACD-GENE-CLI) that included old age (≥ 65 years), diabetes, CKD, and CYP2C19 polymorphisms. At a cutoff value of 8, the ACD-GENE-CLI score was superior to the CYP2C19 deficiency only, and the conventional ABCD-GENE score in predicting MALEs (area under the curve: 0.69 vs. 0.59 vs. 0.67, p=0.01). The diagnostic ability of the ACD-GENE-CLI score was consistent in the external validation. Also, Kaplan-Meier curves showed that in CYP2C19 deficiency, the ABCD-GENE and ACD-GENE-CLI scores could all differentiate patients with CLI who are free from MALEs. CONCLUSIONS The modified ACD-GENE-CLI score could differentiate patients with CLI receiving clopidogrel who are at risk of MALEs. Further studies are required to generalize the utility of the score.
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Affiliation(s)
- Wei-Ting Chang
- School of Medicine and Doctoral Program of Clinical and Experimental Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-sen University, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Sen Huang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Li-Wei Su
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Te Liao
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Belgium
| | - Han Siong Toh
- Department of Intensive Care Medicine, Chi Mei Medical Centre, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yi-Chen Chen
- Department of Medical Research, Chi-Mei Medical Center, Tainan
| | - Ho Chung‑Han
- Department of Medical Research, Chi-Mei Medical Center, Tainan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
- Department of Internal Medicine, Faculty of Medicine, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chon-Seng Hong
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
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2
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Chang WT, Lin YW, Huang PS, Lin YC, Tseng SY, Chao TH, Chen ZC, Shih JY, Hong CS. Deletion of MicroRNA-21 Impairs Neovascularization Following Limb Ischemia: From Bedside to Bench. Front Cardiovasc Med 2022; 9:826478. [PMID: 35557515 PMCID: PMC9086398 DOI: 10.3389/fcvm.2022.826478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/31/2022] [Indexed: 12/14/2022] Open
Abstract
With an increasing prevalence, peripheral arterial disease (PAD), cause by atherosclerosis is a new threat to public health beyond coronary artery disease and involves aberrant vascular endothelial cell proliferation and angiogenesis. The degree of vascular remodeling is influenced by the processes described. MicroRNA-21 (miR-21) has been found to play a critical role in cellular functions, including angiogenesis. Nevertheless, the effect of miR-21 on endothelial cells in response to hypoxia is largely unknown. Using wild-type C57BL/6J and miR-21–/– mice, we compared the capability of angiogenesis in response to hindlimb hypoxic/ischemia. In an in vitro study, we further studied whether overexpression of miR-21 mitigates hypoxia-induced apoptosis and impaired angiogenesis. Also, we prospectively collected the sera of patients with limb ischemia and followed the clinical information, including major adverse limb events (MALEs). Using laser Doppler perfusion imaging and CD31 staining, compared with miR-21–/– mice, wild-type mice expressed a significantly higher capability of angiogenesis and less apoptosis following 28 days of hindlimb hypoxic/ischemic surgery. In our in vitro study, after 24 h of hypoxia, proliferation, migration, and tube formation were significantly impaired in cells treated with the miR-21 inhibitor but rescued by the miR-21 mimic. Mechanistically, by suppressing PTEN/PI3K/AKT, miR-21 promoted angiogenesis and suppressed apoptosis in endothelial cells post hypoxia. In patients with limb ischemia, the high expression of circulating miR-21 was associated with less subsequent MALE. Collectively, miR-21 could be a biomarker associated with the endogenous ability of angiogenesis and reflect subsequent MALE in patients. Additionally, abolishing miR-21 impairs angiogenesis and promotes apoptosis post limb ischemia. Further studies are required to elucidate the clinical applications of miR-21.
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Affiliation(s)
- Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan.,College of Medicine, Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Wen Lin
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Po-Sen Huang
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - You-Cheng Lin
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Shih-Ya Tseng
- Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, Taiwan
| | - Ting-Hsing Chao
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Jhih-Yuan Shih
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Chon-Seng Hong
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
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3
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Vogt JC, Manning PG, Sheikh O, Aronow HD, Chilton RJ, Cigarroa JE. The role of rivaroxaban for patients with atherosclerotic vascular disease in the modern era. Catheter Cardiovasc Interv 2021; 97:1221-1229. [PMID: 32638540 DOI: 10.1002/ccd.29089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/02/2020] [Accepted: 06/09/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Joshua C Vogt
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Patrick G Manning
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Omar Sheikh
- Division of Cardiology, UT Health San Antonio, San Antonio, Texas, USA
| | - Herbert D Aronow
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, Rhode Island, USA
| | - Robert J Chilton
- Division of Cardiology, UT Health San Antonio, San Antonio, Texas, USA
| | - Joaquin E Cigarroa
- Division of Cardiology, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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4
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Biagioni LC, Pereira L, Nasser F, Biagioni RB, Burihan MC, Wolosker N. Comparison between antegrade common femoral artery access and superficial femoral artery access in infrainguinal endovascular interventions. J Vasc Surg 2021; 74:763-770. [PMID: 33684479 DOI: 10.1016/j.jvs.2021.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 02/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antegrade access for infrainguinal endovascular intervention can be achieved through the common femoral artery (CFA) or superficial femoral artery (SFA). A few studies with small sample sizes have shown similar efficacy and safety for antegrade puncture of the CFA and SFA. In the present study, we analyzed the feasibility of SFA access and the occurrence of complications between SFA and CFA ipsilateral access in a broader cohort. METHODS In the present retrospective study, we analyzed data from 462 patients with peripheral arterial disease (PAD) who had undergone peripheral angioplasty from 2009 to 2016. The inclusion criteria were PAD at Rutherford stage 3 to 6 and use of an endovascular approach. Patients with coagulation disorders, those receiving anticoagulant therapy, cases with deployment of closure devices, cases with more than one access on the same limb, and patients with inadequate bed rest after the procedure were excluded. A systematic analysis of all patients' electronic medical records was performed to evaluate the demographic aspects and technical success and identify the possible complications associated with CFA and SFA access. RESULTS Of the 462 patients, 290 had undergone SFA puncture and 172, CFA puncture. The demographic evaluation of both groups revealed no differences between the two groups, except that more patients with diabetes were in the CFA group and more patients with dyslipidemia and an advanced clinical presentation were in the SFA group. First puncture access was successful in 99.7% of the SFA group and 96.5% of the CFA group (P = .01). The hematoma rate in the SFA and CFA groups was 20.3% and 11%, respectively (P = .01). The incidence of major bleeding and clinically relevant nonmajor bleeding was not significantly different between the two groups (P = .215). Only three patients had developed a pseudoaneurysm, two of whom were in the SFA group. Female sex (odds ratio [OR], 2.572; 95% confidence interval [CI], 1.520-4.354; P < .001] and older age (OR, 1.034; 95% CI, 1.009-1.059; P = .007) were associated with an increased hematoma rate. CONCLUSIONS SFA access was associated with a higher overall rate of hematoma compared with CFA access. However, no significant difference was found in the incidence of major bleeding between the two access sites. Planned SFA access should be considered as an alternative to CFA access.
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Affiliation(s)
- Luisa Ciucci Biagioni
- Vascular, Endovascular, and Vascular Doppler Department, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil.
| | - Leticia Pereira
- Vascular, Endovascular, and Vascular Doppler Department, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
| | - Felipe Nasser
- Vascular, Endovascular, and Vascular Doppler Department, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil; Division of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Rodrigo Bruno Biagioni
- Vascular, Endovascular, and Vascular Doppler Department, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
| | - Marcelo Calil Burihan
- Vascular, Endovascular, and Vascular Doppler Department, Hospital Santa Marcelina, São Paulo, São Paulo, Brazil
| | - Nelson Wolosker
- Division of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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5
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González-Juanatey JR, Almendro-Delia M, Cosín-Sales J, Bellmunt-Montoya S, Gómez-Doblas JJ, Riambau V, García-Moll X, García-Alegría J, Hernández JL, Lozano FS, Suarez Fernández C. Residual risk reduction opportunities in patients with chronic coronary syndrome. Role of dual pathway inhibition. Expert Rev Clin Pharmacol 2021; 13:695-706. [PMID: 32434452 DOI: 10.1080/17512433.2020.1772056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In this review, the role of the rivaroxaban-plus-aspirin approach (dual pathway inhibition - DPI) in patients with chronic coronary syndrome (CCS) and to perform practical recommendations about its use was updated. AREAS COVERED The contents of this review were proposed in an expert meeting. To identify relevant articles, a systematic search of Medline/Embase was performed (to July 2019), using the key words 'rivaroxaban', 'vascular dose', 'COMPASS' and 'coronary artery disease' in the search strategy. EXPERT OPINION Despite current antithrombotic strategies (single/dual antiplatelet therapy) have decreased rates of recurrent cardiovascular events among patients with CCS, residual risk remains unacceptably high. The COMPASS trial showed in CCS patients that compared with aspirin 100 mg rivaroxaban 2.5 mg bid plus aspirin 100 mg reduced the risk of major cardiac events, cardiovascular hospitalization and mortality, without an increase of intracranial or fatal bleedings. Importantly, residual risk with the rivaroxaban plus aspirin approach was lower than with different dual antiplatelet therapy regimens. The rivaroxaban plus aspirin strategy is of particular benefit in patients with CCS and high-risk cardiovascular feature (i.e. ≥2 vascular beds, heart failure, renal insufficiency, peripheral artery disease, previous stroke or diabetes) and should be considered in these populations.
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Affiliation(s)
- José R González-Juanatey
- Cardiology and Intensive Cardiac Care Department, CIBERCV, University Hospital Santiago de Compostela , Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital , Seville, Spain
| | - Juan Cosín-Sales
- Cardiology Department, Hospital Arnau de Vilanova, Facultad de Medicina, Universidad CEU-Cardenal Herrena , Valencia, Spain
| | - Sergi Bellmunt-Montoya
- Vascular Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | | | - Vincent Riambau
- Vascular Surgery Division, CardioVascular Institute Hospital Clinic University of Barcelona , Barcelona, Spain
| | | | | | - José Luis Hernández
- Internal Medicine Department, Hospital Marqués de Valdecilla-IDIVAL, Universidad de Cantabria , Santander, Spain
| | - Francisco S Lozano
- Department of Vascular Surgery, Hospital Clínico de Salamanca , Salamanca, Spain
| | - Carmen Suarez Fernández
- Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid , Madrid, Spain
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6
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Frank U, Nikol S, Belch J, Boc V, Brodmann M, Carpentier PH, Chraim A, Canning C, Dimakakos E, Gottsäter A, Heiss C, Mazzolai L, Madaric J, Olinic DM, Pécsvárady Z, Poredoš P, Quéré I, Roztocil K, Stanek A, Vasic D, Visonà A, Wautrecht JC, Bulvas M, Colgan MP, Dorigo W, Houston G, Kahan T, Lawall H, Lindstedt I, Mahe G, Martini R, Pernod G, Przywara S, Righini M, Schlager O, Terlecki P. ESVM Guideline on peripheral arterial disease. VASA 2019; 48:1-79. [DOI: 10.1024/0301-1526/a000834] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Moll F, Baumgartner I, Jaff M, Nwachuku C, Tangelder M, Ansel G, Adams G, Zeller T, Rundback J, Grosso M, Lin M, Mercur MF, Minar E. Edoxaban Plus Aspirin vs Dual Antiplatelet Therapy in Endovascular Treatment of Patients With Peripheral Artery Disease: Results of the ePAD Trial. J Endovasc Ther 2019; 25:158-168. [PMID: 29552984 PMCID: PMC5862321 DOI: 10.1177/1526602818760488] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose: To report a randomized study that investigated the safety (risk of major bleeds) and potential efficacy of edoxaban, an oral anticoagulant that targets the major components of arterial thrombi, to prevent loss of patency following endovascular treatment (EVT). Methods: Between February 2012 and June 2014, 203 patients who underwent femoropopliteal EVT were randomized to receive aspirin plus edoxaban or aspirin plus clopidogrel for 3 months in the Edoxaban in Peripheral Arterial Disease (ePAD) study (ClinicalTrials.gov identifier NCT01802775). Randomization assigned 101 patients (mean age 68.0±10.4 years; 67 men) to the edoxaban group and 102 patients (mean age 66.7±8.6 years; 78 men) to the clopidogrel group. The primary safety endpoint was bleeding as classified by the TIMI (Thrombolysis in Myocardial Infarction) criteria and ISTH (International Society of Thrombosis and Hemostasis) criteria; the efficacy endpoint was the rate of restenosis/reocclusion. Results: There were no major or life-threatening bleeding events in the edoxaban group, while there were 2 major and 2 life-threatening bleeding events in the clopidogrel group by the TIMI criteria. By the ISTH classification, there was 1 major and 1 life-threatening bleeding event vs 5 major and 2 life-threatening bleeding events, respectively [relative risk (RR) 0.20, 95% confidence interval (CI) 0.02 to 1.70]. The bleeding risk was not statistically different with either treatment when assessed by TIMI or ISTH. Following 6 months of observation, there was a lower incidence of restenosis/reocclusion with edoxaban compared with clopidogrel (30.9% vs 34.7%; RR 0.89, 95% CI 0.59 to 1.34, p=0.643). Conclusion: These results suggest that patients who have undergone EVT have similar risks for major and life-threatening bleeding events with edoxaban and aspirin compared with clopidogrel and aspirin. The incidence of restenosis/reocclusion events, while not statistically different, was lower with edoxaban and aspirin, but an adequately sized trial will be needed to confirm these findings.
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Affiliation(s)
- Frans Moll
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Iris Baumgartner
- 2 Cardiovascular Research Cluster, Universität Bern, Switzerland
| | - Michael Jaff
- 3 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Marco Tangelder
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Gary Ansel
- 5 Vascular Services, Ohio Health Heart & Vascular Physicians, Columbus, OH, USA
| | - George Adams
- 6 Cardiovascular and Peripheral Vascular Research, Rex Hospital University of North Carolina Health System, Raleigh, NC, USA
| | - Thomas Zeller
- 7 Department of Angiology, Universitäts Herzzentrum, Bad Krozingen, Germany
| | - John Rundback
- 8 Interventional Institute, Holy Name Medical Center, Teaneck, NJ, USA
| | | | - Min Lin
- 4 Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | | | - Erich Minar
- 9 Internal Medicine, Medical University Vienna, Austria
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Parvar SL, Fitridge R, Dawson J, Nicholls SJ. Medical and lifestyle management of peripheral arterial disease. J Vasc Surg 2019; 68:1595-1606. [PMID: 30360849 DOI: 10.1016/j.jvs.2018.07.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/21/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Peripheral arterial disease (PAD) is a global health issue associated with impaired functional capacity and elevated risk of major adverse cardiovascular events (MACEs). With changing risk factor profiles and an aging population, the burden of disease is expected to increase. This review considers evidence for the noninvasive management of PAD and makes clinical recommendations accordingly. METHODS A comprehensive literature review was performed to examine the evidence for smoking cessation, exercise therapy, antiplatelet therapy, anticoagulant therapy, antihypertensive therapy, lipid-lowering therapy, and glycemic control in diabetes for patients with PAD. RESULTS Nicotine replacement, bupropion, and varenicline are safe and more effective than placebo in achieving smoking abstinence. Wherever it is practical and available, supervised exercise therapy is ideal treatment for intermittent claudication. Alternatively, step-monitored exercise can increase walking performance and the participant's compliance with less staff supervision. Clopidogrel is preferable to aspirin alone for all patients. However, small studies support the use of dual antiplatelet therapy after revascularization to improve limb outcomes. More recently, the addition of low-dose rivaroxaban to aspirin alone was proven to be more effective in reducing MACEs without a significant increase in major bleeding. However, the exact role of direct oral anticoagulant therapy in the management of PAD is still being understood. Evidence is emerging for more intensive blood pressure and lipid-lowering therapy than traditional targets. Whereas research in PAD is limited, there is clinical scope for an individualized approach to these risk factors. The management of diabetes remains challenging as glycemic control has not been demonstrated to improve macrovascular outcomes. Any potential impact of glycemic control on microvascular disease needs to be weighed against the risks of hypoglycemia. Sodium-glucose cotransporter 2 inhibitors appear to reduce MACEs, although caution is advised, given the increased incidence of lower limb amputation in clinical trials of canagliflozin. CONCLUSIONS Medical and lifestyle management of PAD should aim to improve functional outcomes and to reduce MACEs. Smoking cessation counseling or pharmacotherapy is recommended, although new strategies are needed. Whereas supervised exercise therapy is ideal, there can be barriers to clinical implementation. Other initiatives are being used as an alternative to walking-based supervised exercise therapy. More studies are required to investigate the role of intensive glycemic, blood pressure, and dyslipidemia control in patients with PAD. Overall, a multifactorial approach is recommended to alter the natural history of this condition.
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Affiliation(s)
- Saman L Parvar
- Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia.
| | - Robert Fitridge
- Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joseph Dawson
- Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia; Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen J Nicholls
- Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
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Diener HC, Aisenberg J, Ansell J, Atar D, Breithardt G, Eikelboom J, Ezekowitz MD, Granger CB, Halperin JL, Hohnloser SH, Hylek EM, Kirchhof P, Lane DA, Verheugt FWA, Veltkamp R, Lip GYH. Choosing a particular oral anticoagulant and dose for stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J 2018; 38:852-859. [PMID: 26848149 DOI: 10.1093/eurheartj/ehv643] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 11/09/2015] [Indexed: 01/05/2023] Open
Abstract
Patients with atrial fibrillation (AF) have a high risk of stroke and mortality, which can be considerably reduced by oral anticoagulants (OAC). Recently, four non-vitamin-K oral anticoagulants (NOACs) were compared with warfarin in large randomized trials for the prevention of stroke and systemic embolism. Today's clinician is faced with the difficult task of selecting a suitable OAC for a patient with a particular clinical profile or a particular pattern of risk factors and concomitant diseases. We reviewed analyses of subgroups of patients from trials of vitamin K antagonists vs. NOACs for stroke prevention in AF with the aim to identify patient groups who might benefit from a particular OAC more than from another. In the first of a two-part review, we discuss the choice of NOAC for stroke prevention in the following subgroups of patients with AF: (i) stable coronary artery disease or peripheral artery disease, including percutaneous coronary intervention with stenting and triple therapy; (ii) cardioversion, ablation and anti-arrhythmic drug therapy; (iii) mechanical valves and rheumatic valve disease, (iv) patients with time in therapeutic range of >70% on warfarin; (v) patients with a single stroke risk factor (CHA2DS2VASc score of 1 in males, 2 in females); and (vi) patients with a single first episode of paroxysmal AF. Although there are no major differences in terms of efficacy and safety between the NOACs for some clinical scenarios, in others we are able to suggest that particular drugs and/or doses be prioritized for anticoagulation.
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Affiliation(s)
| | | | - Jack Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, USA
| | - Dan Atar
- Division of Medicine, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
| | - Günter Breithardt
- Division of Rhythmology, Department of Cardiovascular Medicine, Hospital of the University Münster, Münster, Germany
| | - John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael D Ezekowitz
- Cardiovascular Research Foundation, New York, NY, USA.,Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, PA, USA.,Lankenau Medical Center, Wynnewood, PA, USA
| | | | - Jonathan L Halperin
- Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J. W. Goethe University, Frankfurt, Germany
| | - Elaine M Hylek
- Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, SWBH and UHB NHS Trusts, Birmingham, UK.,Department of Cardiovascular Medicine, Hospital of the University of Münster, Münster, Germany
| | - Deirdre A Lane
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | | | | | - Gregory Y H Lip
- University of Birmingham, Birmingham, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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10
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Lee KH, Joung B, Lee SR, Hwang YM, Park J, Baek YS, Park YM, Park JK, Park HC, Park HW, Lee YS, Choi KJ. 2018 KHRS Expert Consensus Recommendation for Oral Anticoagulants Choice and Appropriate Doses: Specific Situation and High Risk Patients. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.110] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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11
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Olinic DM, Tataru DA, Homorodean C, Spinu M, Olinic M. Antithrombotic treatment in peripheral artery disease. VASA 2018; 47:99-108. [DOI: 10.1024/0301-1526/a000676] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract. This review treats antithrombotic use for peripheral arterial disease (PAD). In asymptomatic patients, there are no scientific data to support single antiplatelet therapy (SAPT) for primary prophylaxis. In symptomatic PAD, SAPT with aspirin or clopidogrel is indicated. The efficacy of aspirin is controversial. Clopidogrel may be preferred over aspirin. Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but lowers the risk of ischaemic stroke. In symptomatic PAD, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding. DAPT with ticagrelor 60 mg b. i. d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of SAPT or DAPT with aspirin and/or clopidogrel, reduces the risk of acute limb ischaemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints – total mortality and cardiovascular mortality. Therefore, this association shows the strongest evidence for secondary prevention of symptomatic PAD patients. In PAD patients undergoing percutaneous peripheral interventions, at least four weeks of DAPT with aspirin and clopidogrel is recommended after infrainguinal stent implantation. Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available. Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures. The strategy includes use of unfractioned heparin, bivalirudin or enoxaparin. Vitamin K antagonists may be considered after autologous vein infrainguinal bypass.
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Affiliation(s)
- Dan-Mircea Olinic
- Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Dan Alexandru Tataru
- Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Calin Homorodean
- Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihail Spinu
- Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maria Olinic
- Medical Clinic no. 1, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Stephan D, Cordeanu EM, Mirea C, Faller A, Lejay A, Gaertner S. Place of non-vitamin K antagonist oral anticoagulants in anticoagulant-antiplatelet combinations in peripheral artery disease. Arch Cardiovasc Dis 2016; 109:634-640. [PMID: 27692662 DOI: 10.1016/j.acvd.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 12/21/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants are becoming increasingly important in the prophylaxis and treatment of thrombosis in atrial fibrillation and venous thromboembolism. Antiplatelets are widely prescribed in the primary and secondary prevention of cardiac and vascular diseases. There are potentially numerous situations where anticoagulants and antiplatelets may be combined; these combinations have been explored in coronary artery disease, and some have been included in updated recommendations. Is it legitimate to transpose these recommendations to the management of peripheral artery disease? The specific characteristics of the treated vessels, the stents used, the respective frequencies of stent thrombosis and its effect on the target organ are probably different, and explain why opinions differ. However, because of a lack of evidence, empirical behaviours are being established without scientific validation. This review of the literature details the situations in which combinations of an anticoagulant and an antiplatelet have been explored in peripheral artery disease. We discuss the issue of antithrombotic combinations in stable peripheral artery disease and for vascular or endovascular surgery.
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Affiliation(s)
- Dominique Stephan
- Services des maladies vasculaires, de l'hypertension et de pharmacologie clinique, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France.
| | - Elena-Mihaela Cordeanu
- Services des maladies vasculaires, de l'hypertension et de pharmacologie clinique, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
| | - Corina Mirea
- Services des maladies vasculaires, de l'hypertension et de pharmacologie clinique, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
| | - Alix Faller
- Services des maladies vasculaires, de l'hypertension et de pharmacologie clinique, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
| | - Anne Lejay
- Service de chirurgie vasculaire et de transplantation rénale, CHRU de Strasbourg, 67091 Strasbourg, France
| | - Sébastien Gaertner
- Services des maladies vasculaires, de l'hypertension et de pharmacologie clinique, CHRU de Strasbourg, BP 426, 67091 Strasbourg, France
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Abstract
Antiplatelet agents are recommended for the reduction of major adverse cardiovascular events among all patients with symptomatic peripheral artery disease. However, the optimal antiplatelet regimen and duration of therapy in peripheral artery disease (PAD) remains unclear, largely due to limited and conflicting data in this patient population. This article reviews current data on antithrombotic therapy in PAD and discusses the implications of this data for current practice and future research.
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Affiliation(s)
- T Raymond Foley
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Stephen W Waldo
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- VA Eastern Colorado Healthcare System and Division of Cardiology, University of Colorado, Denver, CO, USA
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