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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [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] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [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] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Schaefer JK, Errickson J, Kong X, Ali MA, DeCamillo D, Edupuganti S, Haymart B, Kaatz S, Kline-Rogers E, Kozlowski JH, Krol GD, Sood SL, Froehlich JB, Barnes GD. Outcomes of direct oral anticoagulants with aspirin vs warfarin with aspirin: a registry-based cohort study. Res Pract Thromb Haemost 2024; 8:102449. [PMID: 38983902 PMCID: PMC11231707 DOI: 10.1016/j.rpth.2024.102449] [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: 12/30/2023] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 07/11/2024] Open
Abstract
Background For patients anticoagulated with direct oral anticoagulants (DOACs) or warfarin and on aspirin (ASA) for nonvalvular atrial fibrillation and/or venous thromboembolism, it is unclear if bleeding outcomes differ. Objectives To assess bleeding rates for ASA with DOACs vs warfarin and one another. Methods Registry-based cohort study of patients followed by a 6-center quality improvement collaborative in Michigan using data from 2009 to 2022. The study included adults on ASA with warfarin or DOACs for atrial fibrillation and/or venous thromboembolism without a recent myocardial infarction or heart valve replacement. Results After propensity matching by anticoagulant class, we compared 2 groups of 1467 patients followed for a median of 18.0 months. Any bleeding and nonmajor bleeding was increased with DOACs + ASA compared with warfarin + ASA (32.2 vs 27.8 and 27.1 vs 22.9 events/100 patient-years; relative risks [RRs], 1.1 and 1.2; 95% CIs, 1.1-1.2 and 1.1-1.3, respectively). After matching by drug, patients on apixaban + ASA vs warfarin + ASA had more bleeding (31.2 vs 27.8 events/100 patient-years; RR, 1.1; 95% CI, 1.0-1.2) and nonmajor bleeding but less major bleeding (3.8 vs 4.7 events/100 patient-years; RR, 0.8; 95% CI, 0.6-1.0) and emergency room visits for bleeding. Patients on rivaroxaban + ASA vs warfarin + ASA had more bleeding (39.3 vs 26.3 events/100 patient-years, RR, 1.5; 95% CI, 1.3-1.6), nonmajor bleeding, and thrombosis. Patients on apixaban + ASA vs rivaroxaban + ASA had significantly less bleeding (22.5 vs 39.3/100 patient-years; RR, 0.6; 95% CI, 0.5-0.7), nonmajor bleeding, major bleeding (2.1 vs 5.5 events/100 patient-years; RR, 0.4; 95% CI, 0.2-0.6), emergency room visits for bleeding, and thrombotic events. Conclusion Patients on DOAC + ASA without a recent myocardial infarction or heart valve replacement had more nonmajor bleeding but otherwise similar outcomes compared with warfarin + ASA. Patients treated with rivaroxaban + ASA experienced more adverse clinical events compared with warfarin + ASA or apixaban + ASA.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Josh Errickson
- Consulting for Statistics, Computing, and Analytics Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mona A Ali
- Department of Heart and Vascular Services, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Deborah DeCamillo
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Subhash Edupuganti
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jay H Kozlowski
- Huron Valley Sinai Hospital, Commerce Township, Michigan, USA
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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McGinigle KL. Peripheral Vascular Disease. Prim Care 2024; 51:83-93. [PMID: 38278575 DOI: 10.1016/j.pop.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Peripheral artery disease is most often caused by atherosclerosis. Arterial insufficiency from atherosclerotic blockages in the limbs can impair walking distance and put patients with severe disease at risk of limb loss. Management of the disease centers around early diagnosis, supervised exercise therapy and lifestyle modification, optimizing medical care (with the goal of reducing fatal cardiac and cerebrovascular events), and revascularization.
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Affiliation(s)
- Katharine L McGinigle
- Division of Vascular Surgery, School of Medicine, University of North Carolina at Chapel Hill, 3021 Burnett Womack Building, Campus Box 7212, Chapel Hill, NC 27599, USA.
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Fadaei MS, Fadaei MR, Kheirieh AE, Rahmanian-Devin P, Dabbaghi MM, Nazari Tavallaei K, Shafaghi A, Hatami H, Baradaran Rahimi V, Nokhodchi A, Askari VR. Niosome as a promising tool for increasing the effectiveness of anti-inflammatory compounds. EXCLI JOURNAL 2024; 23:212-263. [PMID: 38487088 PMCID: PMC10938253 DOI: 10.17179/excli2023-6868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/16/2024] [Indexed: 03/17/2024]
Abstract
Niosomes are drug delivery systems with widespread applications in pharmaceutical research and the cosmetic industry. Niosomes are vesicles of one or more bilayers made of non-ionic surfactants, cholesterol, and charge inducers. Because of their bilayer characteristics, similar to liposomes, niosomes can be loaded with lipophilic and hydrophilic cargos. Therefore, they are more stable and cheaper in preparation than liposomes. They can be classified into four categories according to their sizes and structures, namely small unilamellar vesicles (SUVs), large unilamellar vesicles (LUVs,), multilamellar vesicles (MLVs), and multivesicular vesicles (MVVs). There are many methods for niosome preparation, such as thin-film hydration, solvent injection, and heating method. The current study focuses on the preparation methods and pharmacological effects of niosomes loaded with natural and chemical anti-inflammatory compounds in kinds of literature during the past decade. We found that most research was carried out to load anti-inflammatory agents like non-steroidal anti-inflammatory drugs (NSAIDs) into niosome vesicles. The studies revealed that niosomes could improve anti-inflammatory agents' physicochemical properties, including solubility, cellular uptake, stability, encapsulation, drug release and liberation, efficiency, and oral bioavailability or topical absorption. See also the graphical abstract(Fig. 1).
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Affiliation(s)
- Mohammad Saleh Fadaei
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Reza Fadaei
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Emad Kheirieh
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pouria Rahmanian-Devin
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | | | - Abouzar Shafaghi
- Department of Pharmaceutical Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hooman Hatami
- Department of Pharmaceutics, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Nokhodchi
- Lupin Pharmaceutical Research Center, 4006 NW 124th Ave., Coral Springs, Florida, FL 33065, USA
- Pharmaceutics Research Laboratory, School of Life Sciences, University of Sussex, Brighton BN1 9QJ, UK
| | - Vahid Reza Askari
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
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Ji Y, Wang B, Wu G, Zhang Y, Wang Q, Zhou M. Comparison of rivaroxaban-based dual antithrombotic and antiplatelet therapies for symptomatic patients with lower-extremity peripheral artery disease post-revascularization: a retrospective cohort study. Ther Adv Chronic Dis 2023; 14:20406223231213262. [PMID: 38085917 PMCID: PMC10699158 DOI: 10.1177/20406223231213262] [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: 05/25/2023] [Accepted: 10/19/2023] [Indexed: 02/07/2024] Open
Abstract
Background Patients with symptomatic lower-extremity peripheral artery disease (LE-PAD) are prone to serious cardiovascular and limb events. Few studies have evaluated the effect of rivaroxaban-based dual antithrombotic therapy in high-risk patients with LE-PAD in Asian populations. Objectives To investigate the efficacy and safety of rivaroxaban-based dual antithrombotic therapy in symptomatic patients with LE-PAD. Design Retrospective cohort study. Methods This study included patients with LE-PAD treated at the Nanjing Drum Tower Hospital from 1 January 2018 to 31 December 2021. These participants were divided into antiplatelet (APT) or antiplatelet therapy combined with rivaroxaban (RAPT) groups. The efficacy outcomes in this study were the occurrence of major adverse cardiovascular events (MACE), including myocardial infarction, ischemic stroke, or death from cardiovascular causes, and major adverse limb events (MALE), including urgent revascularization, acute limb ischemia, and major amputation. The safety outcomes included major and clinically relevant non-major (CRNM) bleeding. Patients were followed up until the time of death or the end of the study (31 March 2023). Results We included 1144 patients with LE-PAD (APT: 502 patients; RAPT: 642 patients). The RAPT group had a lower risk of primary composite efficacy outcomes [hazard ratio (HR): 0.40] and a nonsignificant increase in major bleeding risk (HR: 2.33) than the APT group. The RATP group also had a significantly lower risk of secondary efficacy outcomes, including ischemic stroke (HR: 0.41), myocardial infarction (HR: 0.31), cardiovascular death (HR: 0.40), and MALE (HR: 0.65), than the APT group. The CRNM bleeding incidence varied between the two groups (HR: 3.96). Moreover, no significant interactions were observed between the subgroups and treatment groups in the composite efficacy analysis. Conclusion Rivaroxaban-based dual antithrombotic therapy significantly reduced the occurrence of MACE in patients with LE-PAD without increasing major bleeding events. High-risk patients benefited from the dual antithrombotic therapy.
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Affiliation(s)
- Ye Ji
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Baoyan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Guangyan Wu
- Department of Vascular Surgery, Medical School of Southeast University, Nanjing Drum Tower Hospital, Nanjing, China
| | - Yepeng Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Qing Wang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Min Zhou
- Department of Vascular Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
- Department of Vascular Surgery, Medical School of Southeast University, Nanjing Drum Tower Hospital, Nanjing, China
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, No. 321 Zhongshan Road, Nanjing, Jiangsu 210008, China
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Lee JH, Jeon HS, Lee JW, Youn YJ, Ahn SG, Kim H, Bae Y, Kim U, Ahn CM, Ko YG. Impact of guideline-directed medical therapy on 5-year mortality in patients with newly diagnosed peripheral artery disease. J Vasc Surg 2023; 78:1471-1478.e3. [PMID: 37597591 DOI: 10.1016/j.jvs.2023.08.103] [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: 03/14/2023] [Revised: 08/03/2023] [Accepted: 08/10/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Current guidelines recommend that patients with peripheral artery disease (PAD) should be treated with antithrombotic agents, renin-angiotensin-system blockers, and statins. However, the clinical impact of guideline-directed medical therapy (GDMT) on long-term mortality in patients with newly diagnosed PAD remains unclear. We aimed to investigate the prevalence of GDMT and evaluate 5-year mortality according to GDMT after PAD diagnosis. METHODS This retrospective cohort study, using nationwide health insurance claims data in Korea, included patients newly diagnosed with PAD between 2006 and 2015. GDMT was defined as the use of all drugs, including antithrombotic agents, renin-angiotensin-system blockers, and statins, within 3 months of PAD diagnosis. The primary endpoint was all-cause mortality. RESULTS We investigated 19,561 newly diagnosed patients with PAD without proven cardiovascular disease. Among the study population, 4378 patients (22.4%) were categorized in the GDMT and 15,183 (77.6%) in the non-GDMT groups. During the 5-year follow-up, GDMT showed a lower incidence of all-cause mortality than that of non-GDMT (2.8% vs 4.8%; adjusted hazard ratio, 0.329; 95% confidence interval, 0.257-0.421; P < .001). Even in the propensity-matched population, GDMT showed a lower mortality rate than non-GDMT (hazard ratio, 0.283; 95% confidence interval, 0.217-0.370; P < .001). As the number of guideline-recommended drugs increased, the mortality rate decreased proportionately. CONCLUSIONS After PAD diagnosis, GDMT was associated with a lower incidence of mortality regardless of proven cardiovascular disease. This retrospective analysis showed an insufficient prevalence of GDMT among patients with PAD in real-world practice.
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Affiliation(s)
- Jung-Hee Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Ho Sung Jeon
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Jun-Won Lee
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Young Jin Youn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Sung Gyun Ahn
- Department of Internal Medicine, Yonsei University, Wonju College of Medicine, Wonju, Korea
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Yoonjong Bae
- Department of Data Science, Hanmi Pharm. Co., Ltd, Seoul, Korea
| | - Ung Kim
- Division of Cardiology, Yeungnam University Medical Center, Daegu, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Nana P, Spanos K, Kouvelos G, Georgakopoulou VE, Lempesis IG, Trakas N, Sklapani P, Paterakis K, Fotakopoulos G, Brotis AG. Carotid artery stenting and endarterectomy surgery techniques: A 30‑year time‑lapse. MEDICINE INTERNATIONAL 2023; 3:61. [PMID: 38204583 PMCID: PMC10777268 DOI: 10.3892/mi.2023.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/30/2023] [Indexed: 01/12/2024]
Abstract
Carotid endarterectomy or carotid artery stenting (CAS), are the most important axes in carotid artery interventional management. A bibliometric analysis permits an easier access to the current literature trends and information to design future studies. The aim of the present study was to identify the knowledge routes on CAS and examine the research front on the topic. The search was interpreted in Scopus, from 1994 to 2023, and included only original articles and reviews. The BibTex format was used to download all citation and bibliographic data. The present analysis was conducted in two parts, a descriptive one and a network extraction process. Between 1994 and 2023, 34,503 references and 7,758 authors were recorded. The annual growth rate was 21.64%. The CAVATAS trial was the most cited article. As regards word trends, since 2017, trans-carotid stenting, risk factors and plaque characteristics are highlighted. CAS remains an area of high interest with a publication growth rate of >20% per year. As numerous questions remain to be answered, the need to determine the role of CAS may drive further research.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41221 Larissa, Greece
| | | | - Ioannis G. Lempesis
- Department of Pathophysiology, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Konstantinos Paterakis
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Alexandros G. Brotis
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
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Bierowski M, Galanis T, Majeed A, Mofid A. Peripheral Artery Disease: Overview of Diagnosis and Medical Therapy. Med Clin North Am 2023; 107:807-822. [PMID: 37541709 DOI: 10.1016/j.mcna.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Peripheral artery disease (PAD) affects approximately 230 million people worldwide and is associated with an increased risk of major adverse cardiovascular and limb events. Even though this condition is considered a cardiovascular equivalent, it remains an underrecognized and undertreated entity. Antiplatelet and statin therapy, along with smoking cessation, are the foundations of therapy to reduce adverse events but are challenging to fully implement in this patient population. Race and socioeconomic status also have profound impacts on PAD outcomes.
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Affiliation(s)
- Matthew Bierowski
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Taki Galanis
- Division Vascular Medicine, Jefferson Vascular Center, Sidney Kimmel Medical College, Philadelphia, PA, USA.
| | - Amry Majeed
- Internal Medicine, Thomas Jefferson University Hospital, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Alireza Mofid
- Vascular Surgery, Thomas Jefferson University Hospital, 111 South 11th Street, Suite 6210 Gibbon, Philadelphia, PA 19107, USA
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Parwani D, Ahmed MA, Mahawar A, Gorantla VR. Peripheral Arterial Disease: A Narrative Review. Cureus 2023; 15:e40267. [PMID: 37448414 PMCID: PMC10336185 DOI: 10.7759/cureus.40267] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Peripheral arterial disease (PAD) describes the partial or complete occlusion of blood flow in the distal arteries of the body. A decreased arterial patency may occur due to a reduction in the elasticity or diameter of the vessel. The goal of interventions is to decrease incidence and reduce complications by identifying and minimizing the primary causes. This paper discusses PAD affecting the aortoiliac, common femoral, and femoropopliteal arteries. In a significant portion of the population, PAD may lack usual symptoms such as limb pain, claudication, and diminished pulses. Imaging techniques become crucial to ensuring timely diagnosis, monitoring treatment effectiveness, and preventing recurrence. Duplex ultrasound (DUS) is a cheap and non-invasive preliminary technique to detect atherosclerotic plaques and grade arterial stenosis. Magnetic resonance angiography (MRA) provides the added advantage of minimizing artifacts. Digital subtraction angiography (DSA) remains the gold standard for grading the degree of stenosis but is only employed second-line to DUS or MRA due to the high dose of nephrotoxic contrast. Computed tomography angiography (CTA) is able to overcome the anatomical limitations of DUS and MRA and proves to be a suitable alternative to DSA in patients with renal disease. Preventative measures involve monitoring blood pressure, cholesterol levels, and tobacco usage. First-line treatment options include endovascular procedures as well as surgical interventions in cases of significant arterial involvement. Endovascular treatments involve the use of balloon angioplasty, drug-coated balloons, and drug-coated stents, to name a few, that serve as minimally invasive techniques to manage PAD. Surgical procedures, although more complex, are considered gold-standard treatment options for long and intricate lesions. Endovascular methods are generally preferred over surgical options as the complication risk is severely reduced and the rates of reintervention are comparable to surgical options.
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Affiliation(s)
- Divya Parwani
- Anatomical Sciences, St. George's University School of Medicine, St.George's, GRD
| | - Mohamed A Ahmed
- Anatomical Sciences, St. George's University School of Medicine, St. George's, GRD
| | - Anmol Mahawar
- Anatomical Sciences, St. George's University School of Medicine, St.George's, GRD
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Ferdinand KC, Sadik K, Browne R, Desai U, Lefebvre P, Lejeune D, Mahendran M, Laliberté F, Matay L, Armstrong DG. Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease. Adv Ther 2023; 40:1850-1866. [PMID: 36877443 PMCID: PMC10070216 DOI: 10.1007/s12325-023-02465-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/14/2023] [Indexed: 03/07/2023]
Abstract
INTRODUCTION Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States. METHODS Optum's de-identified Clinformatics® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models. RESULTS A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8 years vs. 74.2 years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI) = 1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI) = 1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD. CONCLUSIONS Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis.
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Affiliation(s)
| | - Kay Sadik
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | - Urvi Desai
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA.
| | | | | | | | | | - Lisa Matay
- Analysis Group, Inc., 111 Huntington Avenue, 14th Floor, Boston, MA, 02199, USA
| | - David G Armstrong
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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12
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Schaefer JK, Errickson J, Gu X, Alexandris-Souphis T, Ali MA, Haymart B, Kaatz S, Kline-Rogers E, Kozlowski JH, Krol GD, Shah V, Sood SL, Froehlich JB, Barnes GD. Assessment of an Intervention to Reduce Aspirin Prescribing for Patients Receiving Warfarin for Anticoagulation. JAMA Netw Open 2022; 5:e2231973. [PMID: 36121653 PMCID: PMC9486454 DOI: 10.1001/jamanetworkopen.2022.31973] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE For some patients receiving warfarin, adding aspirin (acetylsalicylic acid) increases bleeding risk with unclear treatment benefit. Reducing excess aspirin use could be associated with improved clinical outcomes. OBJECTIVE To assess changes in aspirin use, bleeding, and thrombosis event rates among patients treated with warfarin. DESIGN, SETTING, AND PARTICIPANTS This pre-post observational quality improvement study was conducted from January 1, 2010, to December 31, 2019, at a 6-center quality improvement collaborative in Michigan among 6738 adults taking warfarin for atrial fibrillation and/or venous thromboembolism without an apparent indication for concomitant aspirin. Statistical analysis was conducted from November 26, 2020, to June 14, 2021. INTERVENTION Primary care professionals for patients taking aspirin were asked whether an ongoing combination aspirin and warfarin treatment was indicated. If not, then aspirin was discontinued with the approval of the managing clinician. MAIN OUTCOMES AND MEASURES Outcomes were assessed before and after intervention for the primary analysis and before and after 24 months before the intervention (when rates of aspirin use first began to decrease) for the secondary analysis. Outcomes included the rate of aspirin use, bleeding, and thrombotic outcomes. An interrupted time series analysis assessed cumulative monthly event rates over time. RESULTS A total of 6738 patients treated with warfarin (3160 men [46.9%]; mean [SD] age, 62.8 [16.2] years) were followed up for a median of 6.7 months (IQR, 3.2-19.3 months). Aspirin use decreased slightly from a baseline mean use of 29.4% (95% CI, 28.9%-29.9%) to 27.1% (95% CI, 26.1%-28.0%) during the 24 months before the intervention (P < .001 for slope before and after 24 months before the intervention) with an accelerated decrease after the intervention (mean aspirin use, 15.7%; 95% CI, 14.8%-16.8%; P = .001 for slope before and after intervention). In the primary analysis, the intervention was associated with a significant decrease in major bleeding events per month (preintervention, 0.31%; 95% CI, 0.27%-0.34%; postintervention, 0.21%; 95% CI, 0.14%-0.28%; P = .03 for difference in slope before and after intervention). No change was observed in mean percentage of patients having a thrombotic event from before to after the intervention (0.21% vs 0.24%; P = .34 for difference in slope). In the secondary analysis, reducing aspirin use (starting 24 months before the intervention) was associated with decreases in mean percentage of patients having any bleeding event (2.3% vs 1.5%; P = .02 for change in slope before and after 24 months before the intervention), mean percentage of patients having a major bleeding event (0.31% vs 0.25%; P = .001 for change in slope before and after 24 months before the intervention), and mean percentage of patients with an emergency department visit for bleeding (0.99% vs 0.67%; P = .04 for change in slope before and after 24 months before the intervention), with no change in mean percentage of patients with a thrombotic event (0.20% vs 0.23%; P = .36 for change in slope before and after 24 months before the intervention). CONCLUSIONS AND RELEVANCE This quality improvement intervention was associated with an acceleration of a preexisting decrease in aspirin use among patients taking warfarin for atrial fibrillation and/or venous thromboembolism without a clear indication for aspirin therapy. Reductions in aspirin use were associated with reduced bleeding. This study suggests that an anticoagulation clinic-based aspirin deimplementation intervention can improve guideline-concordant aspirin use.
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Affiliation(s)
- Jordan K. Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Josh Errickson
- Consulting for Statistics, Computing, & Analytics Research, University of Michigan, Ann Arbor
| | - Xiaokui Gu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Tina Alexandris-Souphis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona A. Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Gregory D. Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Vinay Shah
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Suman L. Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B. Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D. Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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13
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P2Y12 Inhibitor Monotherapy is Associated with Superior Outcomes as Compared to Aspirin Monotherapy in Chronic Limb Threatening Ischemia. J Vasc Surg 2022; 76:1053-1059. [PMID: 35709863 DOI: 10.1016/j.jvs.2022.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/31/2022] [Accepted: 04/17/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Antiplatelet therapy is recommended in patients with Peripheral Arterial Disease (PAD) to reduce cardiovascular risk and improve outcomes. However, issues including the drug of choice and use of dual antiplatelet (DAPT) vs monotherapy remain unclear. This study aims to compare the impact of aspirin (ASA) monotherapy, P2Y12 monotherapy and DAPT on limb salvage (LS), amputation-free survival (AFS) and overall survival (OS) in patients undergoing lower extremity peripheral endovascular intervention (PVI) for chronic limb threatening ischemia (CLTI). METHODS The Vascular Quality Initiative PVI registry was used to identify index procedures completed for CLTI between 3/1/2010- 09/30/2017. Patients were categorized by antiplatelet use at the time of last follow-up. Patients not on antiplatelet therapy were compared with ASA, P2Y12 monotherapy and DAPT. Propensity score matched (PSM) samples were created for direct ASA vs P2Y12 and P2Y12 vs DAPT comparisons; veracity was confirmed by Chi-Square and Hosmer-Lemeshow. Kaplan Meier and Cox regression were performed for OS, AFS and LS. RESULTS 12,433 index PVI were completed for CLTI in 11,503 subjects in the pre-matched sample. Antiplatelet use at follow-up was: 12% none, 31% ASA, 14% P2Y12 and 43% DAPT. Median FU was 1389 days. P2Y12 monotherapy was associated with improved outcomes as compared to ASA monotherapy, OS (87.8% vs 85.5%, P=.026; Cox HR 0.82(0.68-0.98); P= .03), AFS (79.6% vs74.8%, P<.001; Cox HR 0.75(0.65-0.86); P < .001) and LS (89.5% vs 86.8%, P= .013; Cox HR 0 .74(0.60-0.91); P= .004). P2Y12 monotherapy and DAPT had comparable OS (87.8% vs 88.9%, P= .62; Cox HR 0.94(0.77-1.14); P= .50), AFS (79.6% vs 81.5%, P= .33; Cox HR 0.92(0.78-1.07); P= .28) and LS (91.7% vs 89.4, P=.03; Cox HR 0.80 (0.64-1.00); P= .06). CONCLUSIONS P2Y12 monotherapy was associated with superior overall survival (OS), amputation-free survival (AFS) and limb salvage (LS) as compared to ASA monotherapy, and comparable OS, LS and AFS to dual antiplatelet therapy (DAPT) in patients undergoing peripheral endovascular interventions for chronic limb threatening ischemia. P2Y12 monotherapy may be considered over ASA monotherapy and DAPT in CLTI patient, especially in patients at high bleeding risk.
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14
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Lüscher TF, Davies A, Beer JH, Valgimigli M, Nienaber CA, Camm JA, Baumgartner I, Diener HC, Konstantinides SV. Towards personalized antithrombotic management with drugs and devices across the cardiovascular spectrum. Eur Heart J 2022; 43:940-958. [PMID: 34624084 DOI: 10.1093/eurheartj/ehab642] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 05/06/2021] [Accepted: 09/01/2021] [Indexed: 01/10/2023] Open
Abstract
Intravascular thrombus formation and embolization are among the most frequent events leading to a number of cardiovascular conditions with high morbidity and mortality. The underlying causes are stasis of the circulating blood, genetic and acquired coagulation disorders, and reduced antithrombotic or prothrombotic properties of the vascular wall (Virchow's triad). In the venous system, intravascular thrombi can cause venous thrombosis and pulmonary and even peripheral embolism including ischaemic stroke [through a patent foramen ovale (PFO)]. Thrombi in the left atrium and its appendage or ventricle form in the context of atrial fibrillation and infarction, respectively. Furthermore, thrombi can form on native or prosthetic aortic valves, within the aorta (in particular at sites of ulcers, aortic dissection, and abdominal aneurysms), and in cerebral and peripheral arteries causing stroke and critical limb ischaemia, respectively. Finally, thrombotic occlusion may occur in arteries supplying vital organs such the heart, brain, kidney, and extremities. Thrombus formation and embolization can be managed with anticoagulants and devices depending on where they form and embolize and on patient characteristics. Vitamin K antagonists are preferred in patients with mechanical valves, while novel oral anticoagulants are first choice in most other cardiovascular conditions, in particular venous thromboembolism and atrial fibrillation. As anticoagulants are associated with a risk of bleeding, devices such as occluders of a PFO or the left atrial appendage are preferred in patients with an increased bleeding risk. Platelet inhibitors such as aspirin and/or P2Y12 antagonists are preferred in the secondary prevention of coronary artery disease, stroke, and peripheral artery disease either alone or in combination depending on the clinical condition. A differential and personalized use of anticoagulants, platelet inhibitors, and devices is recommended and reviewed in this article.
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Affiliation(s)
- Thomas F Lüscher
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - Juerg H Beer
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Valgimigli
- CardioCentro, Lugano, Switzerland.,University of Bern, Bern, Switzerland
| | - Christoph A Nienaber
- Royal Brompton & Harefield Hospitals, Heart Division, Guy Scadding Building, Dovehouse Street, Imperial College, London SW3 6LY, UK
| | - John A Camm
- St. Georges University and Imperial College, London, UK
| | | | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Duisburg-Essen, Germany
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15
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Abd Ur Rehman M, Kassem A, Akram H, Almughalles SA, Ahmad S. Sometimes a punch is needed to get started: A case of complete aortic occlusion with complete heart block rescued with percussion pacing. Clin Case Rep 2022; 10:e05424. [PMID: 35154730 PMCID: PMC8822258 DOI: 10.1002/ccr3.5424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/20/2021] [Accepted: 12/11/2021] [Indexed: 11/13/2022] Open
Abstract
Complete heart block (CHB) is defined as the complete absence of atrioventricular conduction. Electrical pacing is the treatment of choice. We present a case of CHB which is interesting not only due to being a diagnostic dilemma in the emergency department but also for its management and the final diagnosis.
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Affiliation(s)
| | - Ahmed Kassem
- Emergency MedicineHamad Medical CorporationDohaQatar
| | - Hina Akram
- Department of Public HealthQatar UniversityDohaQatar
| | | | - Shabbir Ahmad
- Emergency MedicineHamad Medical CorporationDohaQatar
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16
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Manolis AA, Manolis TA, Melita H, Mikhailidis DP, Manolis AS. Update on Cilostazol: A Critical Review of Its Antithrombotic and Cardiovascular Actions and Its Clinical Applications. J Clin Pharmacol 2021; 62:320-358. [PMID: 34671983 DOI: 10.1002/jcph.1988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/17/2021] [Indexed: 12/17/2022]
Abstract
Cilostazol, a phosphodiesterase III inhibitor, has vasodilating and antiplatelet properties with a low rate of bleeding complications. It has been used over the past 25 years for improving intermittent claudication in patients with peripheral artery disease (PAD). Cilostazol also has demonstrated efficacy in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease. In addition to its antithrombotic and vasodilating actions, cilostazol also inhibits vascular smooth muscle cell proliferation via phosphodiesterase III inhibition, thus mitigating restenosis. Accumulated evidence has shown that cilostazol, due to its "pleiotropic" effects, is a useful, albeit underutilized, agent for both coronary artery disease and PAD. It is also potentially useful after ischemic stroke and is an alternative in those who are allergic or intolerant to classical antithrombotic agents (eg, aspirin or clopidogrel). These issues are herein reviewed together with the pharmacology and pharmacodynamics of cilostazol. Large studies and meta-analyses are presented and evaluated. Current guidelines are also discussed, and the spectrum of cilostazol's actions and therapeutic applications are illustrated.
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Affiliation(s)
| | | | | | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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17
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Bae JS, Ahn JH, Jang JY, Cho SY, Kang MG, Kim KH, Park HW, Koh JS, Park Y, Hwang SJ, Kwak CH, Hwang JY, Tantry US, Gurbel PA, Jeong YH. The Impact of platelet-fibrin clot strength on occurrence and clinical outcomes of peripheral artery disease in patients with significant coronary artery disease. J Thromb Thrombolysis 2021; 50:969-981. [PMID: 32279217 DOI: 10.1007/s11239-020-02103-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with peripheral artery disease (PAD) have shown the increased risk of cardiovascular (CV) morbidity and mortality. This study sought to evaluate the impact of clot strength on prevalence and major adverse CV events (MACE) of PAD in high-risk patients. We enrolled patients undergoing percutaneous coronary intervention (PCI) (n = 1667) with available platelet-fibrin clot strength [thrombin-induced maximal amplitude (MAthrombin) measured by thromboelastography] and inflammation [high sensitivity C-reactive protein (hs-CRP)]. PAD was defined with abnormal ankle-brachial index (≤ 0.9 or > 1.4). MACE was defined as a composite of CV death, myocardial infarction or stroke. PAD was observed in 201 patients (12.1%). In the multivariate analysis, high clot strength [MAthrombin ≥ 68 mm: odds ratio (OR) 1.70, 95% confidence interval (CI) 1.20 to 2.41, p = 0.003] and enhanced inflammation (hs-CRP ≥ 3.0 mg/L: OR 2.30, 95% CI 1.56 to 3.41, p < 0.001) were associated with PAD occurrence. During the follow-up post-PCI (median, 25 months), MACE was more frequently occurred in patients with vs. without PAD (18.7% vs. 6.4% at 3 years; hazard ratio 1.72, 95% CI 1.03 to 2.87, p = 0.039). Furthermore, combined presence of PAD and high clot strength significantly increased the risk of MACE. In conclusion, this study is the first to show the impact of clot strength on prevalence and clinical outcomes of PAD in coronary artery disease patients undergoing PCI. Whether antithrombotic strategy according to level of this biomarker can improve clinical outcomes in PAD patients deserves the further study.
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Affiliation(s)
- Jae Seok Bae
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Jeong Yoon Jang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Sang Young Cho
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Min Gyu Kang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Kye-Hwan Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Seok-Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Choong Hwan Kwak
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, 11 Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea. .,Institute of the Health Sciences, Gyeongsang National University, Jinju, Republic of Korea.
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18
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Debus ES, Nehler MR, Govsyeyev N, Bauersachs RM, Anand SS, Patel MR, Fanelli F, Capell WH, Brackin T, Hinterreiter F, Krievins D, Nault P, Piffaretti G, Svetlikov A, Jaeger N, Hess CN, Sillesen HH, Conte M, Mills J, Muehlhofer E, Haskell LP, Berkowitz SD, Hiatt WR, Bonaca MP. Effect of Rivaroxaban and Aspirin in Patients with Peripheral Artery Disease Undergoing Surgical Revascularization: Insights from the VOYAGER PAD Trial. Circulation 2021; 144:1104-1116. [PMID: 34380322 DOI: 10.1161/circulationaha.121.054835] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Patients with peripheral artery disease (PAD) requiring lower extremity revascularization (LER) are at high risk of adverse limb and cardiovascular events. VOYAGER PAD demonstrated that rivaroxaban significantly reduced this risk. The efficacy and safety of rivaroxaban has not been described in patients who underwent surgical LER. Methods: The VOYAGER PAD trial randomized patients with PAD after surgical and endovascular LER to rivaroxaban 2.5mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. The primary endpoint was a composite of acute limb ischemia, major vascular amputation, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding. International Society on Thrombosis and Haemostasis (ISTH) bleeding was a secondary safety outcome. All efficacy and safety outcomes were adjudicated by a blinded independent committee. Results: Of the 6564 randomized, 2185 (33%) underwent surgical LER and 4379 (67%) endovascular. Compared to placebo, rivaroxaban reduced the primary endpoint consistently regardless of LER method (p-interaction 0.43). Following surgical LER, the primary efficacy outcome occurred in 199 (18.4%) patients in the rivaroxaban group and 242 (22.0%) patients in the placebo group with a cumulative incidence at 3 years of 19.7% and 23.9%, respectively (HR 0.81, 95% CI 0.67 - 0.98; p=0.026). In the overall trial, TIMI major bleeding and ISTH major bleeding were increased with rivaroxaban. There was no heterogeneity for TIMI major bleeding (p-interaction 0.17) or ISTH major bleeding (p-interaction 0.73) based on LER approach. Following surgical LER, the principal safety outcome occurred in 11 (1.0%) patients in the rivaroxaban group and 13 (1.2%) patients in the placebo group; 3-year cumulative incidence 1.3% and 1.4% respectively (HR 0.88, 95% CI 0.39-1.95; p=0.75) Among surgical patients, the composite of fatal bleeding or intracranial hemorrhage (p=0.95) and postprocedural bleeding requiring intervention (p=0.93) were not significantly increased. Conclusions: The efficacy of rivaroxaban is associated with a benefit in surgical LER patients. While bleeding was increased with rivaroxaban plus aspirin, the incidence was low, with no significant increase in fatal bleeding, intracranial hemorrhage or postprocedural bleeds requiring intervention. Clinical Trial Registration: URL: https://clinicaltrials.gov Unique Identifier: NCT02504216.
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Affiliation(s)
- E Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Mark R Nehler
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Nicholas Govsyeyev
- CPC Clinical Research, Aurora, CO; Department of Surgery, Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Darmstadt, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC
| | - Fabrizio Fanelli
- Vascular and Interventional Radiology Department, Careggi University Hospital, University of Florence, Florence, Italy
| | - Warren H Capell
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO
| | | | - Franz Hinterreiter
- Department for Vascular Surgery KH BHB Linz, Seilerstätte 2, 4020, Austria
| | | | - Patrice Nault
- Vascular and Endovascular Surgery, McGill University Montreal, Canada
| | - Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Alexei Svetlikov
- The I.I. Mechnikov North-Western State Medical University, Department of Cardio-Vascular surgery, St-Petersburg, Russia
| | | | - Connie N Hess
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Henrik H Sillesen
- Department of Vascular Surgery, Rigshospitalet, Institute of Clinical Medicine, University of Copenhagen, Denmark
| | - Michael Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Joseph Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX
| | | | | | - Scott D Berkowitz
- Thrombosis Group Head, Clinical Development, Bayer U.S., Whippany, NJ
| | - William R Hiatt
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO; Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO
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Ge H, Song B, Wang X, Zhu Y, Huang Y, Huang W, Zhu Y. Comparison of digital subtraction angiography combined arterial thrombectomy versus simple arterial thrombectomy in the treatment of acute lower limb ischemia. BMC Surg 2021; 21:313. [PMID: 34266428 PMCID: PMC8281668 DOI: 10.1186/s12893-021-01297-x] [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: 12/24/2020] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aimed to compare the clinical efficacy of digital subtraction angiography (DSA) combined arterial thrombectomy versus simple arterial thrombectomy in the treatment of acute lower limb ischemia (ALI). METHODS This retrospective cohort study collected the clinical data from 124 patients (128 affected lower limbs) with ALI who underwent emergency surgery from March 2010 to November 2019. Patients were consecutively divided into Group A and Group B. Patients in Group A underwent simple arterial thrombectomy via the Fogarty catheterization. Patients in Group B underwent arterial thrombectomy, and the DSA was performed during the surgery. The differences in the success rate of primary surgery, the second intervention rate, and the amputation/mortality rate within 30-days after surgery were compared. RESULTS In Group A, 4 of 70 limbs (5.7%) were amputated, 54 of 70 limbs (77.1%) had improved blood flow, 14 of 70 limbs (20.0%) received a second intervention, and 3 of 68 patients (4.4%) died within 30 days. In Group B, 1 of 58 limbs (1.7%) was amputated, 56 of 58 limbs (96.6%) had improved blood flow, 3 of 58 limbs (5.2%) received a second intervention, and 2 of 56 patients (3.5%) died within 30-days. The success rate of primary surgery, the second intervention rate, and the amputation rate of Group B were significantly lower than Group A (P < 0.05). CONCLUSION Arterial thrombectomy combined with DSA may effectively improve the clinical efficacy of patients with ALI.
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Affiliation(s)
- Hongwei Ge
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Bin Song
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Xin Wang
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Yunfeng Zhu
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Yiming Huang
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Weibin Huang
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China
| | - Yongbin Zhu
- Department of Vascular Surgery, The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Tianning District, Changzhou, 213003, Jiangsu, China.
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20
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Luan TMB, Bang HT, Tan NM, Thang LV, Danh NVT, Cuong LT, Long LP, Vy TT. Catheter-directed intra-arterial thrombolysis in the treatment of acute thrombosis of below-the-knee arteries. Radiol Case Rep 2021; 16:2086-2090. [PMID: 34158899 PMCID: PMC8203573 DOI: 10.1016/j.radcr.2021.05.012] [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: 04/29/2021] [Revised: 05/01/2021] [Accepted: 05/01/2021] [Indexed: 11/15/2022] Open
Abstract
Selecting treatment options in acute arterial thrombosis of the lower extremity, which threatens limb viability, is still a challenge for vascular surgeons. Early restoration of blood flow is crucial and is conducted by surgical thrombectomies or endovascular procedures, depending on patient condition. Catheter-directed thrombolysis with or without percutaneous mechanical thrombectomy for acute limb ischemia has been widely implemented from the early 1990s. Here, we present 2 cases of acute thrombosis of below-the-knee arteries, where we successfully saved the involved limbs using catheter-directed thrombolysis and thrombus aspiration.
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Affiliation(s)
- Tran Minh Bao Luan
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam.,Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Ho Tat Bang
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam.,Department of Health Organization and Management, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Minh Tan
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam
| | - Luong Viet Thang
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam
| | - Nguyen Vo Tan Danh
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Lam Thao Cuong
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam.,Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Le Phi Long
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam
| | - Tran Thanh Vy
- Thoracic and Vascular Department, University Medical Center HCMC, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang Street, District 5, Ho Chi Minh City 72714, Vietnam.,Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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21
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Filopei J, Bondarsky EE, Ehrlich M, Islam M, Bajpayee G, Pang D, Shujaat A, Rowland J, Steiger DJ. Reducing length of stay with the direct oral anti-coagulants in low and intermediate risk pulmonary embolism: a single center experience. J Thromb Thrombolysis 2021; 50:399-407. [PMID: 31997255 DOI: 10.1007/s11239-020-02045-3] [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] [Indexed: 10/25/2022]
Abstract
Direct oral anti-coagulants (DOACs) reduce hospital length-of-stay (LOS) in patients with acute pulmonary embolism (PE) in clinical trials. There is a paucity of literature describing real world utility of DOACs, particularly in intermediate-risk patients. To evaluate if the utilization of DOACs vs. non-DOACs in acute PE patients, reduces LOS without a difference in safety in patients defined as low and intermediate-risk of mortality by the European Society of Cardiology. This was a retrospective cohort study of prospectively collected data from a single center registry of consecutive adult outpatients diagnosed with acute PE who survived to hospital discharge. Primary outcome was median hospital LOS. Secondary outcomes were 30-day readmission, survival, and incidence of major and minor bleeding. There were 307 outpatients admitted with acute PE 88 (28.7%) low-risk, 213 (69.4%) intermediate-risk, and 6 (2.0%) high-risk. Two hundred and twenty-six (73.6%) received a DOAC. There was a statistically significant shorter median LOS in all patients treated with a DOAC (2.9 days, IQR 1.8-4.7) vs non-DOAC (4.9 days, IQR 3-8.9) (Generalized Linear Model p < 0.001). There was a shorter median LOS between intermediate-risk patients treated with a DOAC (3.6 days, IQR 2-5.8) vs non-DOAC (5, IQR 3-9). There was no difference in 30-day readmission, survival, or bleeding complications in both cohorts. There was a reduction in LOS in low and intermediate risk patients treated with a DOAC without a difference in 30-day safety and efficacy. Treating acute PE patients with DOACs including intermediate-risk patients, compared to conventional anticoagulation, may facilitate early discharge, and potentially reduce hospital costs.
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Affiliation(s)
- Jason Filopei
- Division of Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Eric E Bondarsky
- Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NYU Langone, 301 East 17th Street, Suite 550, New York, NY, 10003, USA.
| | - Madeline Ehrlich
- Division of Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Marjan Islam
- Divisions of Pulmonary and Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, USA
| | - Gargi Bajpayee
- Division of Cardiovascular Disease, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Daniel Pang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adil Shujaat
- Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Rowland
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David J Steiger
- Division of Pulmonary Critical Care and Sleep Medicine, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY, USA
- Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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22
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Schaefer JK, Errickson J, Li Y, Kong X, Alexandris-Souphis T, Ali MA, Decamillo D, Haymart B, Kaatz S, Kline-Rogers E, Kozlowski JH, Krol GD, Shankar SR, Sood SL, Froehlich JB, Barnes GD. Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication. JAMA Intern Med 2021; 181:817-824. [PMID: 33871544 PMCID: PMC8056309 DOI: 10.1001/jamainternmed.2021.1197] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE It is unclear how many patients treated with a direct oral anticoagulant (DOAC) are using concomitant acetylsalicylic acid (ASA, or aspirin) and how this affects clinical outcomes. OBJECTIVE To evaluate the frequency and outcomes of prescription of concomitant ASA and DOAC therapy for patients with atrial fibrillation (AF) or venous thromboembolic disease (VTE). DESIGN, SETTING, AND PARTICIPANTS This registry-based cohort study took place at 4 anticoagulation clinics in Michigan from January 2015 to December 2019. Eligible participants were adults undergoing treatment with a DOAC for AF or VTE, without a recent myocardial infarction (MI) or history of heart valve replacement, with at least 3 months of follow-up. EXPOSURES Use of ASA concomitant with DOAC therapy. MAIN OUTCOMES AND MEASURES Rates of bleeding (any, nonmajor, major), rates of thrombosis (stroke, VTE, MI), emergency department visits, hospitalizations, and death. RESULTS Of the study cohort of 3280 patients (1673 [51.0%] men; mean [SD] age 68.2 [13.3] years), 1107 (33.8%) patients without a clear indication for ASA were being treated with DOACs and ASA. Two propensity score-matched cohorts, each with 1047 patients, were analyzed (DOAC plus ASA and DOAC only). Patients were followed up for a mean (SD) of 20.9 (19.0) months. Patients taking DOAC and ASA experienced more bleeding events compared with DOAC monotherapy (26.0 bleeds vs 31.6 bleeds per 100 patient years, P = .01). Specifically, patients undergoing combination therapy had significantly higher rates of nonmajor bleeding (26.1 bleeds vs 21.7 bleeds per 100 patient years, P = .02) compared with DOAC monotherapy. Major bleeding rates were similar between the 2 cohorts. Thrombotic event rates were also similar between the cohorts (2.5 events vs 2.3 events per 100 patient years for patients treated with DOAC and ASA compared with DOAC monotherapy, P = .80). Patients were more often hospitalized while undergoing combination therapy (9.1 vs 6.5 admissions per 100 patient years, P = .02). CONCLUSION AND RELEVANCE Nearly one-third of patients with AF and/or VTE who were treated with a DOAC received ASA without a clear indication. Compared with DOAC monotherapy, concurrent DOAC and ASA use was associated with increased bleeding and hospitalizations but similar observed thrombosis rate. Future research should identify and deprescribe ASA for patients when the risk exceeds the anticipated benefit.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Josh Errickson
- Consulting for Statistics, Computing, & Analytics Research, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Tina Alexandris-Souphis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona A Ali
- Department of Heart and Vascular Services, Beaumont Hospital, Royal Oak, Michigan
| | - Deborah Decamillo
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jay H Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Sahana R Shankar
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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23
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Kawatani Y, Mochizuki T, Hori T. Traumatic brachial artery injury successfully treated with a stent-graft: A case report. Asian Cardiovasc Thorac Ann 2021; 30:586-588. [PMID: 34034504 DOI: 10.1177/02184923211019850] [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] [Indexed: 11/16/2022]
Abstract
There are few reports on brachial artery injury treated with stent-grafts. A 69-year-old man presented with a crush injury to the left upper arm. Enhanced computed tomography revealed left humerus fracture and disruption of the blood flow of the brachial artery along with paresis of the forearm. Following external fixation of the fracture, we performed endovascular therapy for brachial artery injury. Using real-time ultrasound imaging guidance, the injured lesion was crossed by the wire, and Viabahn endoprosthesis was placed in the left brachial artery. Hemostasis was achieved, and blood flow to the forearm was restored. Subsequently, the paresis improved.
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Affiliation(s)
- Yohei Kawatani
- Department of Cardiovascular Surgery, Kamagaya General Hospital, Kamagaha-Shi, Japan
| | - Takeshi Mochizuki
- Department of Orthopedic Surgery, Kamagaya General Hospital, Kamagaha-Shi, Japan
| | - Takaki Hori
- Department of Cardiovascular Surgery, Kamagaya General Hospital, Kamagaha-Shi, Japan
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24
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Nowrouzi-Sohrabi P, Tabrizi R, Hessami K, Shabani-Borujeni M, Hosseini-Bensenjan M, Rezaei S, Jalali M, Keshavarz P, Ahmadizar F. The effects of beraprost sodium on renal function and cardiometabolic profile in patients with diabetes mellitus: a systematic review and meta-analysis of clinical trials. Int Urol Nephrol 2021; 54:111-120. [PMID: 34019221 DOI: 10.1007/s11255-021-02887-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE This systematic review and meta-analysis aimed to assess renal function and cardiometabolic biomarkers after treatment with beraprost sodium in patients with diabetes mellitus. METHODS We systemically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library up to August 2020. Statistical heterogeneities were computed using Cochrane's Q test and I2 test. A fixed- or random-effects model was used to calculate the weighted mean difference (WMD) and corresponding 95% confidence intervals (CI). RESULTS From 341citations, seven trials were included into our meta-analysis. Our findings demonstrated that beraprost sodium intake significantly decreased blood urea nitrogen (BUN) (WMD = -5.62, 95% CI [-8.49, -2.74], P < 0.001) and cystatin C (WMD = -0.57, 95% CI [-0.68, -0.46], P < 0.001). Beraprost sodium intake had no significant effect on fasting blood sugar (FBS), hemoglobin A1c (HbA1c), cholesterol (TC), triglycerides (TG), HDL-C, LDL-C, systolic blood pressure (SBP), diastolic blood pressure (DBP), and creatinine (Cr) in patients with diabetes receiving beraprost sodium in comparison with the controls. CONCLUSION Our meta-analysis revealed that beraprost sodium administration significantly decreased BUN and cystatin C levels in patients with diabetes. However, no significant effect was observed on the cardiometabolic profile.
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Affiliation(s)
- Peyman Nowrouzi-Sohrabi
- Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran. .,Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Kamran Hessami
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Shabani-Borujeni
- Faculty of Pharmacy, Department of Clinical Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Shahla Rezaei
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Nutrition Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Jalali
- Nutrition Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pedram Keshavarz
- Department of Radiology, Medical Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fariba Ahmadizar
- Department of Epidemiology, Erasmus MC-University Medical Center, Rotterdam, Netherlands
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25
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Ramanan B, Jeon-Slaughter H, Chen X, Kashyap VS, Kirkwood ML, Timaran CH, Modrall JG, Tsai S. Impact of Dual Antiplatelet Therapy after Lower Extremity Revascularization for Chronic Limb Threatening Ischemia (CLTI). J Vasc Surg 2021; 74:1327-1334. [PMID: 34023428 DOI: 10.1016/j.jvs.2021.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The optimal antiplatelet regimen after lower extremity revascularization in patients with chronic limb threatening ischemia (CLTI) is unknown since current recommendations are based on extrapolation of data from trials in coronary artery disease and stroke. METHODS We identified all patients undergoing an elective lower extremity revascularization for CLTI in the Vascular Quality Initiative registry discharged on a mono antiplatelet agent (MAPT) or dual antiplatelet therapy (DAPT). RESULTS From 2003 to 2018, 50,890 patients underwent revascularization procedures for CLTI, and were discharged on MAPT or DAPT. Of these, 33,781 patients underwent endovascular therapy (EVT) and 17,109 patients underwent open surgery (OS) procedures. The rate of major amputation at 30 days in the target limb in the EVT group was 0.3% and 0.4% in the OS group (P=.22). On Kaplan Meier analyses, patients on MAPT at discharge had a higher risk 1-year major amputation compared to DAPT after EVT but not after OS procedures. Patients on MAPT had lower overall survival and amputation free survival (AFS) at 30 days and 1 year compared to DAPT after both EVT and OS. At 1 year, the MAPT group was at higher risk for target lesion re-intervention after EVT compared to the DAPT group (15.9% vs. 13%, P= .0012). There was no significant difference in thrombosis at 1 year between MAPT and DAPT groups either after EVT (3.9% vs. 3.7%; P = .3048) or OS (3.1% vs. 3.2%; P= .2893). On cox regression analysis, DAPT was associated with improved survival but not major amputation after both EVT and OS. CONCLUSIONS In CLTI patients, DAPT at the time of discharge has a positive impact on AFS and overall survival after both EVT and OS as well as target lesion re-intervention after EVT. DAPT was not associated with a positive impact on major amputation after either EVT or OS.
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Affiliation(s)
- Bala Ramanan
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | | | - Xiaofei Chen
- Department of Statistical Science, Southern Methodist University, Dallas, Texas
| | - Vikram S Kashyap
- Vascular Center, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Melissa L Kirkwood
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Carlos H Timaran
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J Gregory Modrall
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shirling Tsai
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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26
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Abstract
PURPOSE OF REVIEW In under a year, coronavirus disease 2019 (COVID-19) has taken the lives of hundreds of thousands of Americans, leaving millions of survivors in its wake. The enormous number of people who survived acute illness but continue to have symptoms has highlighted the need for standardized evaluation of the post-COVID-19 patient. This review, based on the current literature and our experience, aims to guide the care of patients who have survived COVID-19. RECENT FINDINGS The literature on this topic is rapidly expanding and covers both pulmonary and nonpulmonary complications of COVID-19. Pulmonary complications include dyspnea with normoxia, organizing pneumonia and pulmonary fibrosis. Nonpulmonary complications include neurologic, cardiac, and thromboembolic disease. Special consideration should be taken for COVID-19 survivors of intensive care. SUMMARY The current review outlines the major clinical findings in post-COVID-19 patients and provides a guidelines to the evaluation and management of prolonged symptoms.
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27
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Targeting Uremic Toxins to Prevent Peripheral Vascular Complications in Chronic Kidney Disease. Toxins (Basel) 2020; 12:toxins12120808. [PMID: 33419312 PMCID: PMC7765928 DOI: 10.3390/toxins12120808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/14/2020] [Accepted: 12/16/2020] [Indexed: 12/24/2022] Open
Abstract
Chronic kidney disease (CKD) exhibits progressive kidney dysfunction and leads to disturbed homeostasis, including accumulation of uremic toxins, activated renin-angiotensin system, and increased oxidative stress and proinflammatory cytokines. Patients with CKD are prone to developing the peripheral vascular disease (PVD), leading to poorer outcomes than those without CKD. Cumulative evidence has showed that the synergy of uremic milieu and PVD could exaggerate vascular complications such as limb ischemia, amputation, stenosis, or thrombosis of a dialysis vascular access, and increase mortality risk. The role of uremic toxins in the pathogenesis of vascular dysfunction in CKD has been investigated. Moreover, growing evidence has shown the promising role of uremic toxins as a therapeutic target for PVD in CKD. This review focused on uremic toxins in the pathophysiology, in vitro and animal models, and current novel clinical approaches in reducing the uremic toxin to prevent peripheral vascular complications in CKD patients.
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28
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Hiatt WR, Bonaca MP, Patel MR, Nehler MR, Debus ES, Anand SS, Capell WH, Brackin T, Jaeger N, Hess CN, Pap AF, Berkowitz SD, Muehlhofer E, Haskell L, Brasil D, Madaric J, Sillesen H, Szalay D, Bauersachs R. Rivaroxaban and Aspirin in Peripheral Artery Disease Lower Extremity Revascularization. Circulation 2020; 142:2219-2230. [DOI: 10.1161/circulationaha.120.050465] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background:
The VOYAGER PAD trial (Vascular Outcomes Study of ASA Along With Rivaroxaban in Endovascular or Surgical Limb Revascularization for Peripheral Artery Disease) demonstrated superiority of rivaroxaban plus aspirin versus aspirin to reduce major cardiac and ischemic limb events after lower extremity revascularization. Clopidogrel is commonly used as a short-term adjunct to aspirin after endovascular revascularization. Whether clopidogrel modifies the efficacy and safety of rivaroxaban has not been described.
Methods:
VOYAGER PAD was a phase 3, international, double-blind, placebo-controlled trial in patients with symptomatic PAD undergoing lower extremity revascularization randomized to rivaroxaban 2.5 mg twice daily plus 100 mg aspirin daily or rivaroxaban placebo plus aspirin. The primary efficacy outcome was a composite of acute limb ischemia, major amputation of a vascular cause, myocardial infarction, ischemic stroke, or cardiovascular death. The principal safety end point was TIMI (Thrombolysis in Myocardial Infarction) major bleeding, with International Society on Thrombosis and Haemostasis major bleeding a secondary safety outcome. Clopidogrel use was allowed at the discretion of the investigator for up to 6 months after the qualifying revascularization.
Results:
Of the randomized patients, 3313 (50.6%) received clopidogrel for a median duration of 29.0 days. Over 3 years, the hazard ratio for the primary outcome of rivaroxaban versus placebo was 0.85 (95% CI, 0.71–1.01) with clopidogrel and 0.86 (95% CI, 0.73–1.01) without clopidogrel without statistical heterogeneity (
P
for interaction=0.92). Rivaroxaban resulted in an early apparent reduction in acute limb ischemia within 30 days (hazard ratio, 0.45 [95% CI, 0.14–1.46] with clopidogrel; hazard ratio, 0.48 [95% CI, 0.22–1.01] without clopidogrel;
P
for interaction=0.93). Compared with aspirin, rivaroxaban increased TIMI major bleeding similarly regardless of clopidogrel use (
P
for interaction=0.71). With clopidogrel use >30 days, rivaroxaban was associated with more International Society on Thrombosis and Haemostasis major bleeding within 365 days (hazard ratio, 3.20 [95% CI, 1.44–7.13]) compared with shorter durations of clopidogrel (
P
for trend=0.06).
Conclusions:
In the VOYAGER PAD trial, rivaroxaban plus aspirin reduced the risk of adverse cardiovascular and limb events with an early benefit for acute limb ischemia regardless of clopidogrel use. The safety of rivaroxaban was consistent regardless of clopidogrel use but with a trend for more International Society on Thrombosis and Haemostasis major bleeding with clopidogrel use >30 days than with a shorter duration. These data support the addition of rivaroxaban to aspirin after lower extremity revascularization regardless of concomitant clopidogrel, with a short course (≤30 days) associated with less bleeding.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02504216.
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Affiliation(s)
- William R. Hiatt
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
- University of Colorado School of Medicine, Division of Cardiology, Anschutz Medical Campus, Aurora (W.R.H., M.P.B., C.N.H.)
| | - Marc P. Bonaca
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
- University of Colorado School of Medicine, Division of Cardiology, Anschutz Medical Campus, Aurora (W.R.H., M.P.B., C.N.H.)
| | - Manesh R. Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University Medical Center, Durham, NC (M.R.P.)
| | - Mark R. Nehler
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
- Department of Surgery (M.R.N.), University of Colorado School of Medicine, Aurora
| | - Eike Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery–Angiology–Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany (E.S.D.)
| | - Sonia S. Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, ON, Canada (S.S.A.)
| | - Warren H. Capell
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
- Department of Medicine, Division of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora (W.H.C.)
| | - Taylor Brackin
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
| | - Nicole Jaeger
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
| | - Connie N. Hess
- CPC Clinical Research, Aurora, CO (W.R.H., M.P.B., M.R.N., W.H.C., T.B., N.J., C.N.H.)
- University of Colorado School of Medicine, Division of Cardiology, Anschutz Medical Campus, Aurora (W.R.H., M.P.B., C.N.H.)
| | - Akos F. Pap
- Bayer AG, Research & Development, Wuppertal, Germany (A.F.P., E.M.)
| | | | - Eva Muehlhofer
- Bayer AG, Research & Development, Wuppertal, Germany (A.F.P., E.M.)
| | - Lloyd Haskell
- Janssen Research and Development, Raritan, NJ (L.H.)
| | - David Brasil
- FELUMA–Faculdade de Ciencias Medicas de Minas Gerais School of Medicine, Belo Horizonte, Brazil (D.B.)
| | - Juraj Madaric
- Department of Angiology, Comenius University and National Cardiovascular Institute, Bratislava, Slovakia (J.M.)
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Institute of Clinical Medicine, University of Copenhagen, Denmark(H.S.)
| | - David Szalay
- McMaster University, Hamilton, ON, Canada (D.S.)
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Germany (R.B.)
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29
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Glotzer OS, Rojas E, Bouchard DR, Hill SS, Harad FT, Zhang Z, Bowser KE. Carotid Restenosis Following Endarterectomy in Patients Managed With Single Antiplatelet Therapy Versus Dual Antiplatelet Therapy. Vasc Endovascular Surg 2020; 55:209-215. [PMID: 33252022 DOI: 10.1177/1538574420975908] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Antiplatelet therapy is a cornerstone in the management of carotid artery disease following carotid endarterectomy (CEA). There is a paucity of data regarding the effect of dual antiplatelet therapy (DAPT) on restenosis rates. METHODS A retrospective review of patients who underwent CEA from January 1, 2007 to December 31, 2013 was performed at a single center. Study groups consisted of subjects who received DAPT and those who received single antiplatelet therapy (SAPT) following CEA. Restenosis was evaluated by carotid duplex. Severity and timing of restenosis, postoperative complications, and reinterventions were compared between study groups. RESULTS Between January 1, 2007 and December 31, 2013, 1453 patients underwent CEA. The SAPT group consisted of 245 patients and the DAPT group consisted of 1208 patients. No difference in restenosis was identified between groups at less than 6 weeks (6.5% vs. 11.7% 50-79% stenosis, 0% vs. 2.2% 80-99% stenosis, 2.2% vs. 0.6% occlusion, p = 0.368), and 6 weeks to 2 years (20.6% vs. 17.9% 50-79% stenosis, 1.1% vs. 1.0% 80-99% stenosis, 1.6% vs. 0.4% occlusion, p = 0.242). A higher rate of restenosis in SAPT was found greater than 2 years from surgery (68.4% vs. 82.4% <50% stenosis, 29.9% vs. 16.1% 50-79% stenosis, 0% vs. 0.6% 80-99% stenosis, 1.7% vs. 0.9% occlusion p = 0.004). This finding persisted on multivariable analysis with 31.6% of the SAPT group showing >50% stenosis vs. 17.6% of the DAPT group (adjusted OR 0.48, 95% CI 0.30-0.76, p = 0.002). In a propensity matched-population, 32.7% of the SAPT group demonstrated restenosis vs. 13.7% of the DAPT group (adjusted OR 0.35, 95% CI 0.16-0.77, p = 0.009). There was no difference in the need for reintervention between study groups (DAPT 3.8% vs SAPT 3.3%, p = 0.684). CONCLUSION Following CEA, patients on DAPT exhibited lower rates of late restenosis. Despite this finding, a clinical difference in reintervention was not found during this study period.
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Affiliation(s)
- Owen S Glotzer
- Division of Vascular Surgery, 5973Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA
| | - Elianne Rojas
- Division of Vascular Surgery, 6429Stanford University Medical Center, Stanford, CA, USA
| | | | - Susanna S Hill
- Division of Vascular Surgery, 5973Albany Medical Center Hospital, Albany Medical College, Albany, NY, USA
| | - F Todd Harad
- The Heart and Vascular Center, 5973Christiana Care Health System, Newark, DE, USA
| | - Zugui Zhang
- The Heart and Vascular Center, 5973Christiana Care Health System, Newark, DE, USA
| | - Kathryn E Bowser
- The Heart and Vascular Center, 5973Christiana Care Health System, Newark, DE, USA
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Zavgorodnyaya D, Knight TB, Daley MJ, Teixeira PG. Antithrombotic therapy for postinterventional management of peripheral arterial disease. Am J Health Syst Pharm 2020; 77:269-276. [PMID: 31930282 DOI: 10.1093/ajhp/zxz315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Evidence on the use of antithrombotic pharmacotherapy in patients undergoing revascularization of lower extremities for symptomatic peripheral arterial disease (PAD) is reviewed. SUMMARY Individuals with PAD can experience leg pain, intermittent claudication, critical limb ischemia, and acute limb ischemia. In such patients, revascularization may be indicated to improve the quality of life and to prevent amputations. Antithrombotic therapy is often intensified in the postrevascularization period to prevent restenosis of the index artery and to counteract the prothrombotic state induced by the intervention. Therapeutic modalities include dual antiplatelet therapy (DAPT), anticoagulation, a combination of antiplatelet and anticoagulation therapy, and addition of cilostazol to single antiplatelet therapy. Subgroup analyses of data from randomized clinical trials provided low-quality evidence for the use of DAPT in patients with a below-knee prosthetic bypass graft and anticoagulation for those with a venous bypass graft. Cilostazol, when added to aspirin therapy, has been shown to prevent index vessel reocclusion after an endovascular intervention in patients at low risk for thrombosis in several small randomized trials. CONCLUSION There is a considerable paucity of high-quality evidence on the optimal antithrombotic regimen for patients undergoing lower extremity revascularization, with no particular therapy shown to consistently improve patient outcomes. The decision to initiate intensified antithrombotic therapy should include a close examination of its risk-benefit profile. The demonstrated benefit of such treatment is restricted to the prevention of index artery reocclusion, while an increased risk of bleeding may lead to significant morbidity and mortality.
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Affiliation(s)
- Daria Zavgorodnyaya
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tamara B Knight
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Ascension Seton, Austin, TX
| | - Mitchell J Daley
- Department of Pharmacy, Dell Seton Medical Center at the University of Texas, Ascension Seton, Austin, TX
| | - Pedro G Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, the University of Texas at Austin, Austin, TX
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Sapelkin SV, Kuznetsov MR. [Current concepts of anticoagulant and antiplatelet therapy in patients with vascular pathology]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:16-26. [PMID: 33063748 DOI: 10.33529/angi02020305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The routine practice of a vascular surgeon is invariably associated with decreasing the risk of adverse cardiovascular events in patients presenting with either arterial or venous pathology. Antithrombotic therapy is one of the key approaches used to achieve this purpose. However, a wide variety of modern drugs inhibiting platelet aggregation and agents blocking the coagulation cascade, as well as their combinations makes the selection of the most appropriate treatment for a particular patient quite a difficult task. The choice should carefully be made taking into consideration the nosology, aetiology, accompanying diseases and therapy thereof, as well as the balance of the risk of ischaemic and haemorrhagic complications. Therefore, availability of modern antithrombotic drugs favourably contributing to a more personified approach to treatment is of utmost importance. Thus, for example, rivaroxaban, an anticoagulant belonging to the class of direct-acting oral factor Xa inhibitors, provides a possibility to select an optimal dosage and regimen for a particular patient with arterial or vascular pathology in practice of a cardiovascular surgeon.
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Affiliation(s)
- S V Sapelkin
- Vascular Surgery Department, National Medical Research Centre named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia
| | - M R Kuznetsov
- Department of Faculty Surgery #1, Pirogov Russian National Research Medical University of the RF Ministry of Public Health, Moscow, Russia
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Gresele P, Paciullo F, Migliacci R. Antithrombotic treatment of asymptomatic carotid atherosclerosis: a medical dilemma. Intern Emerg Med 2020; 15:1169-1181. [PMID: 32405817 DOI: 10.1007/s11739-020-02347-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/15/2020] [Indexed: 12/24/2022]
Abstract
Carotid artery atherosclerosis (CAAS) is a common finding in asymptomatic subjects evaluated for cardiovascular (CV)-risk stratification. Besides the careful control of CV-risk factors, antithrombotic agents, and in particular aspirin, may be considered for primary prevention in patients at CV-risk. However, there is strong controversy on the use of aspirin in primary prevention. Even if several studies confirmed the association between CAAS and CV-events, CAAS is not universally recognized as an independent risk factor and the choice to use aspirin as primary prevention in these patients remains a medical dilemma. Here we review the available evidence on the prognostic value of asymptomatic CAAS for major CV-events and on the utility of antithrombotic agents in this population. We conclude that the detection of asymptomatic CAAS can not be considered as a direct indication to carry out primary prophylaxis with antithrombotic drugs, and the choice to use aspirin should be made only after the careful estimate of the individual's CV-and hemorrhagic risk.
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Affiliation(s)
- Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Strada Vicinale Via Delle Corse, S. Andrea della Fratte, 06132, Perugia, Italy.
| | - Francesco Paciullo
- Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Strada Vicinale Via Delle Corse, S. Andrea della Fratte, 06132, Perugia, Italy
| | - Rino Migliacci
- Division of Internal Medicine, Ospedale Della Valdichiana "S. Margherita", Cortona, Italy
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Ruehl M, Lynch AM, O'Toole TE, Morris B, Rush J, Couto CG, Hmelo S, Sonnenshein S, Butler A, Guillaumin J. Outcome and treatments of dogs with aortic thrombosis: 100 cases (1997-2014). J Vet Intern Med 2020; 34:1759-1767. [PMID: 33463770 PMCID: PMC7517508 DOI: 10.1111/jvim.15874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 07/21/2020] [Accepted: 07/30/2020] [Indexed: 01/30/2023] Open
Abstract
Background Aortic thrombosis (ATh) is an uncommon condition in dogs, with limited understanding of risks factors, outcomes, and treatments. Objectives/Hypothesis To describe potential risk factors, outcome, and treatments in dogs with ATh. Animals Client‐owned dogs with a diagnosis of ATh based on ultrasonographic or gross necropsy examination. Method Multicentric retrospective study from 2 academic institutions. Results One hundred dogs were identified. Anti‐thrombin diagnosis, 35/100 dogs were nonambulatory. The dogs were classified as acute (n = 27), chronic (n = 72), or unknown (n = 1). Fifty‐four dogs had at least one comorbidity thought to predispose to ATh, and 23 others had multiple comorbidities. The remaining 23 dogs with no obvious comorbidities were classified as cryptogenic. Concurrent illnesses potentially related to the development of ATh included protein‐losing nephropathy (PLN) (n = 32), neoplasia (n = 22), exogenous corticosteroid administration (n = 16), endocrine disease (n = 13), and infection (n = 9). Dogs with PLN had lower antithrombin activity than those without PLN (64% and 82%, respectively) (P = .04). Sixty‐five dogs were hospitalized with 41 subsequently discharged. Sixteen were treated as outpatient and 19 euthanized at admission. In‐hospital treatments varied, but included thrombolytics (n = 12), alone or in combination with thrombectomy (n = 9). Fifty‐seven dogs survived to discharge. Sixteen were alive at 180 days. Using regression analysis, ambulation status at the time of presentation was significantly correlated with survival‐to‐discharge (P < .001). Conclusions/Clinical Importance Dogs with ATh have a poor prognosis, with nonambulatory dogs at the time of presentation having worse outcome. Although the presence of comorbid conditions associated with hypercoagulability is common, an underlying cause for ATh was not always identified.
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Affiliation(s)
| | - Alex M Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Therese E O'Toole
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts, USA
| | - Bari Morris
- VCA Shoreline Veterinary Referral and Emergency Center, Shelton, Connecticut, USA
| | - John Rush
- Department of Clinical Sciences, Cummings School of Veterinary Medicine at Tufts University, North Grafton, Massachusetts, USA
| | | | | | | | - Amy Butler
- Critical Consults, LLC, Pittsburgh, Pennsylvania, USA
| | - Julien Guillaumin
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA
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Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
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Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
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Belkin N, Stoecker JB, Jackson BM, Damrauer SM, Glaser J, Kalapatapu V, Golden MA, Wang GJ. Effects of dual antiplatelet therapy on graft patency after lower extremity bypass. J Vasc Surg 2020; 73:930-939. [PMID: 32777321 DOI: 10.1016/j.jvs.2020.06.127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Current guidelines recommend single-agent antiplatelet therapy for patients with symptomatic peripheral artery disease and consideration of dual antiplatelet therapy (DAPT) after surgical revascularization. The objective of this study was both to explore prescribing patterns of single antiplatelet therapy vs DAPT after lower extremity bypass surgery and to investigate the effects of antiplatelet therapy on bypass graft patency. METHODS A retrospective analysis of prospectively collected nonemergent infrainguinal lower extremity bypass operations entered in the national Vascular Quality Initiative (2003-2018) with captured long-term follow-up was performed. Patients discharged on aspirin monotherapy or DAPT were identified. Linear regression investigated temporal trends in antiplatelet use. Multivariable Cox regression investigated predictors of primary, primary assisted, and secondary patency. RESULTS Of the 13,020 patients investigated, 52.2% were discharged on aspirin monotherapy and 47.8% on DAPT. The proportion of patients discharged on DAPT increased from 10.6% in 2003 to 60.6% in 2018 (P < .001). The DAPT cohort was younger, had higher rates of medical (hypertension, diabetes, congestive heart failure, chronic obstructive pulmonary disease) and atherosclerotic (coronary artery disease, prior coronary artery bypass graft or percutaneous coronary intervention, prior lower extremity intervention) comorbidities, and had higher risk bypass procedures (more distal targets, prior inflow bypass procedure, prosthetic conduit use). Multivariable Cox regression analysis did not show any difference between the DAPT and aspirin cohorts in primary patency (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.88-1.10; P = .78), primary assisted patency (HR, 0.93; 95% CI, 0.80-1.07; P = .30), or secondary patency (HR, 0.88; 95% CI, 0.74-1.06; P = .18). On subgroup analysis based on bypass conduit, DAPT was found to have a protective effect on patency only in the prosthetic bypass cohort (primary patency: HR, 0.81 [95% CI, 0.66-1.00; P = .05]; primary assisted patency: HR, 0.74 [95% CI, 0.58-0.94; P = .01]; and secondary patency: HR, 0.60 [95% CI, 0.44-0.82; P < .001]). No patency differences were observed on adjusted subgroup analysis for the other bypass conduits. CONCLUSIONS A significant and increasing proportion of patients are discharged on DAPT after lower extremity bypass revascularization. These patients represent a higher risk cohort with more medical comorbidities and higher risk bypass features. After controlling for these differences, DAPT therapy had no beneficial effect on overall bypass graft patency or major adverse limb events. However, on subgroup analysis, DAPT was associated with improved bypass graft patency in patients receiving prosthetic bypass conduits. Further study is warranted to investigate optimal duration of DAPT therapy and its possible bleeding complications in prosthetic bypass patients.
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Affiliation(s)
- Nathan Belkin
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | - Jordan B Stoecker
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Scott M Damrauer
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Julia Glaser
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Venkat Kalapatapu
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Michael A Golden
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
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Abola MTB, Golledge J, Miyata T, Rha SW, Yan BP, Dy TC, Ganzon MSV, Handa PK, Harris S, Zhisheng J, Pinjala R, Robless PA, Yokoi H, Alajar EB, Bermudez-delos Santos AA, Llanes EJB, Obrado-Nabablit GM, Pestaño NS, Punzalan FE, Tumanan-Mendoza B. Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee. J Atheroscler Thromb 2020; 27:809-907. [PMID: 32624554 PMCID: PMC7458790 DOI: 10.5551/jat.53660] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 11/01/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD. OBJECTIVES The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD. METHODOLOGY A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique. RESULTS A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.
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Affiliation(s)
- Maria Teresa B Abola
- Department of Clinical Research, Philippine Heart Center and University of the Philippines College of Medicine, Metro Manila, Philippines
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, and Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Seung-Woon Rha
- Dept of Cardiology, Internal Medicine, College of Medicine, Korea University; Cardiovascular Center, Korea University Guro Hospital, Seoul, South Korea
| | - Bryan P Yan
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
| | - Timothy C Dy
- The Heart Institute, Chinese General Hospital and Medical Center, Manila, Philippines
| | | | | | - Salim Harris
- Neurovascular and Neurosonology Division, Neurology Department, Universitas Indonesia, Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | | | | | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital; International University of Health and Welfare, Fukuoka, Japan
| | - Elaine B Alajar
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital; University of the Philippines College of Medicine, Manila, Philippines
| | | | - Elmer Jasper B Llanes
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines Philippine General Hospital, Manila, Philippines
| | | | - Noemi S Pestaño
- Section of Cardiology, Department of Internal Medicine, Manila Doctors Hospital, Manila, Philippines
| | - Felix Eduardo Punzalan
- Division of Cardiology, Department of Medicine, College of Medicine, University of the Philippines; Philippine General Hospital, Manila, Philippines
| | - Bernadette Tumanan-Mendoza
- Department of Clinical Epidemiology, University of the Philippines College of Medicine, Manila, Philippines
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Ionova Y, Ashenhurst J, Zhan J, Nhan H, Kosinski C, Tamraz B, Chubb A. CYP2C19 Allele Frequencies in Over 2.2 Million Direct-to-Consumer Genetics Research Participants and the Potential Implication for Prescriptions in a Large Health System. Clin Transl Sci 2020; 13:1298-1306. [PMID: 32506666 PMCID: PMC7719394 DOI: 10.1111/cts.12830] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/08/2020] [Indexed: 01/03/2023] Open
Abstract
Understanding the prevalence of clinically relevant pharmacogenetic variants using large unselected populations is critical for gauging the potential clinical impact of widespread preemptive pharmacogenetic testing. To this end, we assessed the frequencies and ethnic distribution of the three most common CYP2C19 alleles (*2, *3, and *17) in 2.29 million direct-to-consumer genetics research participants (23andMe, Sunnyvale, CA). The overall frequencies of *2, *3, and *17 were 15.2%, 0.3%, and 20.4%, respectively, but varied by ethnicity. The most common variant diplotypes were *1/*17 at 26% and *1/*2 at 19.4%. The less common *2/*17, *17/*17, and *2/*2 genotypes occurred at 6.0%, 4.4%, and 2.5%, respectively. Overall, 58.3% of participants had at least one increased-function or no-function CYP2C19 allele. To better understand how this high frequency might impact a real patient population, we examined the prescription rates (Rx) of high-pharmacogenetic-risk medications metabolized by CYP2C19 using the University of California at San Francisco (UCSF) health system's anonymized database of over 1.25 million patients. Between 2012 and 2019, a total of 151,068 UCSF patients (15.8%) representing 5 self-reported ethnicities were prescribed one or more high-pharmacogenetic-risk CYP2C19 medications: proton pump inhibitors (145,243 Rx), three selective serotonin reuptake inhibitor antidepressants (54,463 Rx), clopidogrel (14,376 Rx), and voriconazole (2,303 Rx).
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Affiliation(s)
- Yelena Ionova
- School of Pharmacy, University of California, San Francisco, California, USA
| | | | | | - Hoang Nhan
- 23andMe, Inc., Sunnyvale, California, USA
| | | | - Bani Tamraz
- School of Pharmacy, University of California, San Francisco, California, USA
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Abstract
Распространенность заболеваний периферических артерий (ЗПА) во всем мире достигает порядка 200 миллионов человек. Самым частым клиническим проявлением ЗПА является перемежающая хромота, возникающая вследствие недостаточного кровоснабжения пораженной конечности. В настоящем обзоре литературы обобщены и систематизированы последние достижения в области диагностики и лечения пациентов с перемежающей хромотой. Тщательный сбор анамнеза и физикальное обследование являются первоочередными мероприятиями для установления предварительного диагноза и направлены на дифференциацию сосудистых и нейрогенных причин перемежающей хромоты. Лодыжечно-плечевой индекс относится к наиболее часто используемым методам скрининга и диагностики ЗПА. Основу лечения составляют четыре взаимодополняющих подхода: немедикаментозное и лекарственное лечение для купирования симптомов хронической ишемии, фармакотерапия для вторичной профилактики сердечно-сосудистых осложнений, открытая или эндоваскулярная реваскуляризация для увеличения дистанции безболевой ходьбы. Недавнее исследование COMPASS продемонстрировало преимущества комбинированного применения 2,5 мг ривароксабана дважды в день и аспирина в части снижения уровня неблагоприятных сердечно-сосудистых событий, при этом отмечался более высокий риск геморрагических осложнений. На сегодняшний день цилостазол является единственным препаратом, обладающим доказанной терапевтической эффективностью в отношении перемежающей хромоты. Программы лечебной физкультуры под наблюдением врача либо в домашних условиях способствуют улучшению коллатерального кровообращения и увеличивают дистанцию ходьбы без боли. Назначение высоких доз статинов и антитромбоцитарных препаратов абсолютно обосновано всем пациентам с ЗПА. Ингибиторы ангиотензин-превращающего фермента обеспечивают дополнительное снижение кардиоваскулярных рисков, в особенности у пациентов с сахарным диабетом и артериальной гипертензией.
The prevalence of peripheral artery disease (PAD) worldwide reaches about 200 million people. The most frequent clinical manifestation of PAD is intermittent claudication, which occurs due to insufficient blood supply to the affected limb. This literature review summarizes and systematizes recent advances in the diagnosis and treatment of patients with intermittent claudication.Thorough case history collection and physical examination are the primary measures for making a preliminary diagnosis, which is aimed at differentiating the vascular and neurogenic causes of intermittent claudication. The ankle-shoulder index is one of the most commonly used methods for screening and diagnosing PAD. The basis of treatment consists of four complementary approaches: non-pharmacological and pharmacological treatment for the relief of symptoms of chronic ischemia, pharmacotherapy for the secondary prevention of cardiovascular complications, open or endovascular revascularization to increase the distance of pain-free walking. A recent COMPASS study demonstrated the benefits of combining 2.5 mg of rivaroxaban twice daily with aspirin in reducing adverse cardiovascular events, however there was a higher risk of hemorrhagic complications. Today, cilostazol is the only drug with proven therapeutic effectiveness against intermittent claudication. Physical therapy programs under the supervision of a doctor or at home help to improve collateral blood circulation and increase the walking distance without pain. The administration of high doses of statins and antiplatelet drugs is absolutely justified in all patients with PAD. Angiotensin converting enzyme inhibitors provide an additional reduction in cardiovascular risks, especially in patients with diabetes and hypertension.
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Qureshi MI, Li HL, Ambler GK, Wong KHF, Dawson S, Chaplin K, Cheng HY, Hinchliffe RJ, Twine CP. Antiplatelet and Anticoagulant Use in Randomised Trials of Patients Undergoing Endovascular Intervention for Peripheral Arterial Disease: Systematic Review and Narrative Synthesis. Eur J Vasc Endovasc Surg 2020; 60:77-87. [PMID: 32265113 DOI: 10.1016/j.ejvs.2020.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/16/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Randomised trials of new devices for peripheral arterial endovascular intervention are published regularly. The evidence for which antiplatelet and/or anticoagulant (antithrombotic) therapy to use after an intervention is lacking. The aim of this systematic review was to examine the antithrombotic regimens in randomised trials for peripheral arterial endovascular intervention to understand choices made and trends with time or type of device. METHODS Data sources were the Medline, Embase, and Cochrane Library databases. Randomised trials including participants with peripheral arterial disease undergoing any endovascular arterial intervention were included. Trial methods were assessed to determine whether an antithrombotic protocol had been specified, its completeness, and the agent(s) prescribed. Antithrombotic therapy protocols were classed as peri-procedural (preceding and during intervention), immediate post-procedural (up to 30 days following intervention), and maintenance post-procedural (therapy continuing beyond 30 days). RESULTS Ninety-four trials were included in narrative synthesis. Study quality was low. None of the trials justified their antithrombotic therapy protocol. Only 29% of trials had complete peri-procedural antithrombotic protocols, and 34% had complete post-procedural protocols. In total, 64 different peri-procedural protocols, and 51 separate post-procedural protocols were specified. Antiplatelet monotherapy and unfractionated heparin were the most common regimen choices in the peri-procedural setting, and dual antiplatelet therapy (55%) was most commonly utilised post procedure. Over time there has been an increasing tendency to use dual therapy (p < .001). This corresponds with the introduction of newer technologies and trials focussed on below knee intervention. CONCLUSION Randomised trials comparing different types of peripheral endovascular arterial intervention have a high level of heterogeneity in their antithrombotic regimens. Antiplatelet therapy needs to be standardised in trials comparing endovascular technologies to reduce potential confounding. To do this, an independent randomised trial specifically examining antiplatelet therapy following peripheral arterial endovascular intervention is needed.
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Affiliation(s)
- Mahim I Qureshi
- North Bristol NHS Trust, Bristol, UK; Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hang L Li
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Graeme K Ambler
- North Bristol NHS Trust, Bristol, UK; Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kitty H F Wong
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sarah Dawson
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hung-Yuan Cheng
- Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robert J Hinchliffe
- North Bristol NHS Trust, Bristol, UK; Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK
| | - Christopher P Twine
- North Bristol NHS Trust, Bristol, UK; Bristol Centre for Surgical Research, Bristol Medical School, University of Bristol, Bristol, UK.
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Ellison PL, Holman N, Wallace K, Cote GA, Elmunzer BJ, Brock AS. Multimodal intervention for avoiding inappropriate cessation of aspirin prior to outpatient endoscopy. Endosc Int Open 2020; 8:E708-E716. [PMID: 32490153 PMCID: PMC7247888 DOI: 10.1055/a-1134-4813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/14/2019] [Indexed: 11/01/2022] Open
Abstract
Background and study aims Existing guidelines recommend continuation of aspirin therapy prior to outpatient endoscopic procedures, as it reduces peri-procedural cardiovascular events and is not associated with an increased risk of bleeding. Despite this, many patients at our institution inappropriately alter their aspirin prior to endoscopy. We sought to identify why this occurs and implement an intervention that could reduce improper aspirin alteration. Patients and methods All adult patients undergoing outpatient endoscopy at the Medical University of South Carolina were administered a survey querying demographics, aspirin use, endoscopic procedure, thromboembolic risk factors, and pre-procedural aspirin alteration, if any. An intervention involving revised written and verbal instructions as well as an automated voicemail aimed at ensuring patients adhere to guidelines was then undertaken. The same survey was administered after the intervention to assess for improved adherence. Results A total of 240 patients from the initial survey reported daily aspirin use, of which 114 (47.5 %) inappropriately altered aspirin therapy. A total of 182 patients from the post-intervention survey reported daily aspirin use, of which 66 (36.3 %) inappropriately altered aspirin therapy. This was a statistically significant reduction ( P = 0.04), which included adjustments for age, sex, procedure type, and thromboembolic risk. Conclusions A high proportion of patients at our institution inappropriately alter aspirin therapy prior to outpatient endoscopy. The reasons for this behavior include patient self-direction, misguidance from staff, and instruction from other physicians. This alteration can be reduced significantly through an intervention that educates both patients and staff on continuation of aspirin therapy prior to outpatient endoscopy.
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Affiliation(s)
- Parker L. Ellison
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Nathan Holman
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Kristin Wallace
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Gregory A. Cote
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - B. Joseph Elmunzer
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Andrew S. Brock
- Department of Internal Medicine and the Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, United States
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Coll PP, Roche V, Olsen JS, Voit JH, Bowen E, Kumar M. The Prevention of Cardiovascular Disease in Older Adults. J Am Geriatr Soc 2020; 68:1098-1106. [DOI: 10.1111/jgs.16353] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/09/2020] [Accepted: 01/10/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Patrick P. Coll
- Department of Family MedicineUniversity of Connecticut Health Center Farmington Connecticut
- Center on AgingUniversity of Connecticut Health Center Farmington Connecticut
| | - Vivyenne Roche
- Division of Geriatrics, Department of Internal MedicineUT Southwestern Medical Center Dallas Texas
| | - Jaclyn S. Olsen
- Center on AgingUniversity of Connecticut Health Center Farmington Connecticut
| | - Jessica H. Voit
- Division of Geriatrics, Department of Internal MedicineUT Southwestern Medical Center Dallas Texas
| | - Emily Bowen
- Division of Geriatrics, Department of Internal MedicineUT Southwestern Medical Center Dallas Texas
| | - Manish Kumar
- Center on AgingUniversity of Connecticut Health Center Farmington Connecticut
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gupta A, Lee MS, Gupta K, Kumar V, Reddy S. A Review of Antithrombotic Treatment in Critical Limb Ischemia After Endovascular Intervention. Cardiol Ther 2019; 8:193-209. [PMID: 31630320 PMCID: PMC6828854 DOI: 10.1007/s40119-019-00153-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Indexed: 12/14/2022] Open
Abstract
Endovascular intervention is often used to treat critical limb ischemia (CLI). Post-intervention treatment with antiplatelet and/or anticoagulant therapy has reduced morbidity and mortality due to cardiovascular complications. The purpose of this review is to shed light on the various pharmacologic treatment protocols for treating CLI following endovascular procedures. We reviewed the literature comparing outcomes after antithrombotic treatment for patients with CLI. We characterized antithrombotic therapies into three categories: (1) mono-antiplatelet therapy (MAPT) vs. dual antiplatelet therapy (DAPT), (2) MAPT vs. antiplatelet (AP) + anticoagulant (AC) therapy, and (3) AC vs. AP + AC therapy. Relevant results and statistics were extracted to determine differences in the rates of the following outcomes: (1) re-stenosis, (2) occlusion, (3) target limb revascularization (TLR), (4) major amputation, (5) major adverse cardiac events, (6) all-cause death, and (7) bleeding. Studies suggest that DAPT reduces post-surgical restenosis, TLR, and amputation for diabetic patients, without increasing major bleeding incidences, compared to MAPT. Also, AP + AC therapy provides overall superior efficacy, with no difference in bleeding incidences, compared to antiplatelet alone. Additionally, the effects were significant for restenosis, limb salvage, survival rates, and cumulative rate of above ankle amputation or death. These results suggest that treatment with DAPT and AP + AC might provide better outcomes than MAPT following the endovascular intervention for CLI, and that the ideal treatment may be related to the condition of the individual patient. However, the studies were few and heterogenous with small patient populations. Therefore, further large controlled studies are warranted to confirm these outcomes.
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Affiliation(s)
- Amol Gupta
- Heart, Vascular & Leg Center, Bakersfield, CA, USA.
| | - Michael S Lee
- Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Kush Gupta
- Kasturba Medical College, Mangalore, India
| | - Vinod Kumar
- Heart, Vascular & Leg Center, Bakersfield, CA, USA
| | - Sarath Reddy
- Division of Cardiology, The Brooklyn Hospital Center, Brooklyn, NY, USA
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Meini S, Dentali F, Melillo E, de Donato G, Mumoli N, Mazzone A. Prostanoids for Critical Limb Ischemia: A Clinical Review and Consideration of Current Guideline Recommendations. Angiology 2019; 71:226-234. [PMID: 31769315 DOI: 10.1177/0003319719889273] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
For many years, the only pharmacological option for patients with critical limb ischemia (CLI) unsuitable for revascularization has been prostanoids; however, some recent guidelines have become very restrictive regarding their use. We review the available evidence on the use of prostanoids and analyze the guideline positions as well as the possible reasons for changes over time. In most placebo-controlled trials and meta-analyses, prostanoids showed a significant effect in improving rest pain, promoting ulcer healing and reducing major amputations. Results for iloprost were especially consistent. Different prostanoid drugs have different evidence of efficacy, thus using a generic term "prostanoids" is misleading. Unfortunately, the available evidence is often of low quality and probably not sufficient to support an extensive use of prostanoids in all patients, and further high-quality randomized trials are needed. Consequently, some recent guidelines do not recommend treatment with prostanoids in this setting. However, in our opinion, pending definitive evidence, patients with CLI who have a viable limb in whom revascularization is unfeasible or has a poor chance of success, without alternative to amputation, may benefit from treatment with iloprost, balancing harms and benefits in each case.
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Affiliation(s)
- Simone Meini
- Internal Medicine Unit, Santa Maria Annunziata Hospital, Florence, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Elio Melillo
- Cardiothoracic and Vascular Department, Angiology Unit, University of Pisa, Pisa, Italy
| | | | - Nicola Mumoli
- Internal Medicine Department, ASST Ovest Milanese Magenta, Legnano, Italy
| | - Antonino Mazzone
- Internal Medicine Department, ASST Ovest Milanese Magenta, Legnano, Italy
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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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Gupta A, Lee MS, Gupta K, Kumar V, Reddy S. The Impact of Antithrombotic Regimens on Clinical Outcomes After Endovascular Intervention and Bypass Surgery for Infrapopliteal Artery Disease. Cardiol Res 2019; 10:255-267. [PMID: 31636793 PMCID: PMC6785292 DOI: 10.14740/cr937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 09/12/2019] [Indexed: 11/29/2022] Open
Abstract
Endovascular intervention and bypass surgery are the main options of treatments for infrapopliteal artery disease. Although post-intervention treatment with antiplatelet (AP) and/or anticoagulant (AC) drugs has reduced morbidity and mortality rates from cardiovascular complications; the ideal antithrombotic treatment regimen is unknown. The aim of this review was to compare the efficacy and safety of various anticoagulation and/or AP therapy regimens in patients undergoing below-knee endovascular treatment for infrapopliteal artery disease. We reviewed published literature in PubMed and Google Scholar, and Cochrane, evaluating efficacy and safety outcomes after antithrombotic treatment following endovascular intervention or bypass surgery in patients with infrapopliteal artery disease. We extracted relevant efficacy and safety data with related statistics from each study. We found that AP treatment should be administered to patients receiving endovascular therapy or bypass. We did not find superior effects for dual AP treatment (DAPT) over mono-AP therapy (MAPT) for endovascular intervention or bypass surgery with venous graft, suggesting that MAPT suffices for these groups. Also, aspirin + clopidogrel was effective over aspirin alone for prosthetic, but not venous graft, albeit higher non-severe bleeding incidences, suggesting a potential benefit of this regime for below-knee prosthetic graft. AP + AC yielded superior results compared to AP following endovascular procedure and bypass surgery, suggesting the potential benefit of this regime in the absence of contraindications. More prospective studies with large number of patients are warranted to identify the best treatment for infrapopliteal artery diseases.
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Affiliation(s)
- Amol Gupta
- Heart, Vascular & Leg Center, Bakersfield, CA, USA
| | - Michael S Lee
- Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Kush Gupta
- Kasturba Medical College, Mangalore, India
| | - Vinod Kumar
- Heart, Vascular & Leg Center, Bakersfield, CA, USA
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Anand SS, Eikelboom JW, Dyal L, Bosch J, Neumann C, Widimsky P, Avezum AA, Probstfield J, Cook Bruns N, Fox KA, Bhatt DL, Connolly SJ, Yusuf S. Rivaroxaban Plus Aspirin Versus Aspirin in Relation to Vascular Risk in the COMPASS Trial. J Am Coll Cardiol 2019; 73:3271-3280. [DOI: 10.1016/j.jacc.2019.02.079] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/19/2019] [Accepted: 02/26/2019] [Indexed: 12/27/2022]
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 69:e71-e126. [PMID: 27851992 DOI: 10.1016/j.jacc.2016.11.007] [Citation(s) in RCA: 438] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bulvas M, Sommerová Z, Vaněk I, Weiss J. Prospective Single-Arm Trial of Endovascular Mechanical Debulking as Initial Therapy in Patients With Acute and Subacute Lower Limb Ischemia: One-Year Outcomes. J Endovasc Ther 2019; 26:291-301. [PMID: 30955402 PMCID: PMC6537139 DOI: 10.1177/1526602819840697] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purpose: To report the results of a prospective, single-arm study to
establish whether the initial treatment of acute or subacute limb ischemia (ALI
and SLI, respectively) can be accomplished successfully using endovascular
mechanical debulking of the target vessels to avoid the risks associated with
thrombolysis and/or open surgery. Materials and Methods: From April
2009 to April 2015, 316 consecutive patients (mean age 70.9±12 years; 184 men)
with ALI (202, 63.9%) or SLI (114, 36.1%) were enrolled; the only exclusion
criterion was irreversible ischemia. The ALI group included 146 (72.3%)
participants with category IIb ischemia and 56 (27.7%) with category IIa.
Critical limb ischemia was diagnosed in 74 (64.9%) of the 114 patients with SLI.
Target occlusions of thrombotic (n=256) or embolic (n=60) origin were located in
the femoropopliteal segment (n=231), prosthetic or venous femoropopliteal bypass
grafts (n=75), and the aortoiliac segment (n=35). The mean occlusion length was
22.9±14.8 cm. Results: The overall technical success (residual
stenosis ≤30%) was 100% after debulking and adjunctive techniques (aspiration,
dilation, stenting) at the level of the target lesions. No open surgical or
thrombolytic modalities were necessary to bypass or recanalize the target
vessels, and no death occurred in association with target occlusion therapy.
Additional infrapopliteal interventions were performed in 195 (61.7%) patients
(adjunctive thrombolysis in 29) to treat acute, subacute, and chronic lesions.
Minor complications directly related to the debulking procedure occurred in 26
(8.2%) patients. Serious complications occurred in 11 (3.5%) patients, including
hemorrhage in 8 (2.5%) patients (associated with infrapopliteal thrombolysis in
5). At 30 days, primary and secondary patency rates were 94.3% and 97.2%,
respectively; mortality was 0.3% (1 fatal intracranial hemorrhage after
adjunctive thrombolysis). Of 229 patients eligible for 1-year follow-up,
amputation-free survival was estimated to be 87.4% in 199 patients with
available data. Conclusion: In this all-comers study, mechanical
debulking with the Rotarex alone or with adjunctive techniques is feasible as a
primary therapy for occluded supratibial vessels in patients with ALI or
SLI.
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Affiliation(s)
- Miroslav Bulvas
- 1 Cardiocenter, Third Faculty of Medicine, Charles University, and Department of Surgery, Division of Interventional Angiology, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Zuzana Sommerová
- 2 Department of Internal Medicine 2, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Ivan Vaněk
- 1 Cardiocenter, Third Faculty of Medicine, Charles University, and Department of Surgery, Division of Interventional Angiology, University Hospital Královské Vinohrady, Prague, Czech Republic
| | - Jiří Weiss
- 1 Cardiocenter, Third Faculty of Medicine, Charles University, and Department of Surgery, Division of Interventional Angiology, University Hospital Královské Vinohrady, Prague, Czech Republic
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Schaefer JK, Li Y, Gu X, Souphis NM, Haymart B, Kline-Rogers E, Almany SL, Kaatz S, Kozlowski JH, Krol GD, Sood SL, Froehlich JB, Barnes GD. Association of Adding Aspirin to Warfarin Therapy Without an Apparent Indication With Bleeding and Other Adverse Events. JAMA Intern Med 2019; 179:533-541. [PMID: 30830172 PMCID: PMC6450296 DOI: 10.1001/jamainternmed.2018.7816] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE It is not clear how often patients receive aspirin (acetylsalicylic acid) while receiving oral anticoagulation with warfarin sodium without a clear therapeutic indication for aspirin, such as a mechanical heart valve replacement, recent percutaneous coronary intervention, or acute coronary syndrome. The clinical outcomes of such patients treated with warfarin and aspirin therapy compared with warfarin monotherapy are not well defined to date. OBJECTIVE To evaluate the frequency and outcomes of adding aspirin to warfarin for patients without a clear therapeutic indication for combination therapy. DESIGN, SETTING, AND PARTICIPANTS A registry-based cohort study of adults enrolled at 6 anticoagulation clinics in Michigan (January 1, 2010, to December 31, 2017) who were receiving warfarin therapy for atrial fibrillation or venous thromboembolism without documentation of a recent myocardial infarction or history of valve replacement. EXPOSURE Aspirin use without therapeutic indication. MAIN OUTCOMES AND MEASURES Rates of any bleeding, major bleeding events, emergency department visits, hospitalizations, and thrombotic events at 1, 2, and 3 years. RESULTS Of the study cohort of 6539 patients (3326 men [50.9%]; mean [SD] age, 66.1 [15.5] years), 2453 patients (37.5%) without a clear therapeutic indication for aspirin were receiving combination warfarin and aspirin therapy. Data from 2 propensity score-matched cohorts of 1844 patients were analyzed (warfarin and aspirin vs warfarin only). At 1 year, patients receiving combination warfarin and aspirin compared with those receiving warfarin only had higher rates of overall bleeding (cumulative incidence, 26.0%; 95% CI, 23.8%-28.3% vs 20.3%; 95% CI, 18.3%-22.3%; P < .001), major bleeding (5.7%; 95% CI, 4.6%-7.1% vs 3.3%; 95% CI, 2.4%-4.3%; P < .001), emergency department visits for bleeding (13.3%; 95% CI, 11.6%-15.1% vs 9.8%; 95% CI, 8.4%-11.4%; P = .001), and hospitalizations for bleeding (8.1%; 6.8%-9.6% vs 5.2%; 4.1%-6.4%; P = .001). Rates of thrombosis were similar, with a 1-year cumulative incidence of 2.3% (95% CI, 1.6%-3.1%) for those receiving combination warfarin and aspirin therapy compared with 2.7% (95% CI, 2.0%-3.6%) for those receiving warfarin alone (P = .40). Similar findings persisted during 3 years of follow-up as well as in sensitivity analyses. CONCLUSIONS AND RELEVANCE Compared with warfarin monotherapy, receipt of combination warfarin and aspirin therapy was associated with increased bleeding and similar observed rates of thrombosis. Further research is needed to better stratify which patients may benefit from aspirin while anticoagulated with warfarin for atrial fibrillation or venous thromboembolism; clinicians should be judicious in selecting patients for combination therapy.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Xiaokui Gu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Nicole M Souphis
- College Student, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Steven L Almany
- Department of Internal Medicine, Beaumont Health, Oakland University School of Medicine, Royal Oak, Michigan
| | - Scott Kaatz
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jay H Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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