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Kang J, Yun J, Park KW, Park M, Park S, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Angiolillo DJ, Urban P, Kim HS. Long-term outcomes of high bleeding risk patients undergoing percutaneous coronary intervention: a Korean nationwide registry. Eur Heart J 2024:ehae462. [PMID: 39042715 DOI: 10.1093/eurheartj/ehae462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 01/12/2024] [Accepted: 07/03/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND AND AIMS Patients with high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI) are at increased risk of not only bleeding, but also ischaemic events. This study aimed to determine the long-term relative risk of ischaemic and bleeding events in HBR patients. METHODS This study was a nationwide cohort study, based on the Korean National Health Insurance Review and Assessment Service database. Patients diagnosed with stable angina or acute coronary syndrome and those who underwent PCI in Korea between 2009 and 2018 were included in the analysis. According to the Academic Research Consortium HBR criteria, the total population was divided into HBR and non-HBR groups. The co-primary outcomes were major bleeding events and ischaemic (composite of cardiac death, myocardial infarction, and ischaemic stroke) events. RESULTS Among a total of 325 417 patients who underwent PCI, 66 426 patients (20.4%) had HBR. During the follow-up period, HBR patients had a higher risk for major bleeding events (23.9% vs. 8.9%, P < .001) and ischaemic events (33.8% vs. 14.4%, P < .001). However, the impact of HBR was significant for major bleeding events [hazard ratio (HR) 3.12, 95% confidence interval (CI) 3.04-3.21, P < .001] and for ischaemic events (HR 2.50, 95% CI 2.45-2.56, P < .001). The HBR group was also associated with a greater risk of all-cause mortality (HR 3.73, 95% CI 3.66-3.79, P < .001). The average annual rate of major bleeding events within the first year after PCI was 5.5% for a single major criterion, and 2.9% for a single minor criterion. CONCLUSIONS Among patients undergoing PCI, those with HBR were at increased long-term risk for both bleeding and ischaemic events, with a greater risk of mortality compared to non-HBR patients.
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Affiliation(s)
- Jeehoon Kang
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
- Department of Molecular Medicine and Biopharmaceutical Science, Seoul National University, Seoul, Republic of Korea
| | - Junpil Yun
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Kyung Woo Park
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Minae Park
- Data Science Team, Hanmi Pharm. Co., Ltd, Seoul, Republic of Korea
| | - Sojeong Park
- Data Science Team, Hanmi Pharm. Co., Ltd, Seoul, Republic of Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
| | - Philip Urban
- Hôpital de la Tour, 1 Ave Maillard, 1217 Geneva, Switzerland
| | - Hyo-Soo Kim
- Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
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2
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Fioretti V, Sperandeo L, Gerardi D, Di Fazio A, Stabile E. Antiplatelet Therapy for Elderly Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. J Clin Med 2024; 13:4229. [PMID: 39064269 PMCID: PMC11277659 DOI: 10.3390/jcm13144229] [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: 05/22/2024] [Revised: 07/08/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
The elderly represent an increasing proportion of patients presenting with acute coronary syndrome (ACS). Various data have shown that the benefits of percutaneous coronary revascularization are maintained in elderly patients presenting with ACS. Conversely, the management of antiplatelet therapy remains challenging and controversial, because older patients are usually at a high risk of both ischemia and bleeding. Moreover, the recommended ischemic and bleeding risk scores in patients with ACS were developed from studies with a low representation of older patients. New antiplatelet strategies have been developed, but their evidence in elderly patients is limited because they are usually underrepresented in randomized clinical trials due to their clinical complexity. The aim of this review is to summarize the different factors associated with increased ischemic and/or bleeding risk and the scientific evidence about the different antiplatelet strategies in elderly patients presenting with ACS and undergoing percutaneous coronary revascularization.
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Affiliation(s)
- Vincenzo Fioretti
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale “San Carlo”, 85100 Potenza, Italy
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy
| | - Luca Sperandeo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy
| | - Donato Gerardi
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale “San Carlo”, 85100 Potenza, Italy
| | - Aldo Di Fazio
- Regional Complex Intercompany Institute of Legal Medicine, Azienda Ospedaliera Regionale ”San Carlo”, 85100 Potenza, Italy;
| | - Eugenio Stabile
- Division of Cardiology, Cardiovascular Department, Azienda Ospedaliera Regionale “San Carlo”, 85100 Potenza, Italy
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3
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Simonetti F, Kastrati A. A Simple Bleeding Risk Score for the Complex Older Patient. Am J Cardiol 2024; 223:178-180. [PMID: 38697452 DOI: 10.1016/j.amjcard.2024.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Fiorenzo Simonetti
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany.
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4
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Cao D, Vranckx P, Valgimigli M, Sartori S, Angiolillo DJ, Bangalore S, Bhatt DL, Feng Y, Ge J, Hermiller J, Makkar RR, Neumann FJ, Saito S, Picon H, Toelg R, Maksoud A, Chehab BM, Choi JW, Campo G, De la Torre Hernandez JM, Krucoff MW, Kunadian V, Sardella G, Spirito A, Thiele H, Varenne O, Vogel B, Zhou Y, Windecker S, Mehran R. One- versus three-month dual antiplatelet therapy in high bleeding risk patients undergoing percutaneous coronary intervention for non-ST-segment elevation acute coronary syndromes. EUROINTERVENTION 2024; 20:e630-e642. [PMID: 38776146 PMCID: PMC11100501 DOI: 10.4244/eij-d-23-00658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/12/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND A short dual antiplatelet therapy (DAPT) duration has been proposed for patients at high bleeding risk (HBR) undergoing drug-eluting coronary stent (DES) implantation. Whether this strategy is safe and effective after a non-ST-segment elevation acute coronary syndrome (NSTE-ACS) remains uncertain. AIMS We aimed to compare the impact of 1-month versus 3-month DAPT on clinical outcomes after DES implantation among HBR patients with or without NSTE-ACS. METHODS This is a prespecified analysis from the XIENCE Short DAPT programme involving three prospective, international, single-arm studies evaluating the safety and efficacy of 1-month (XIENCE 28 USA and Global) or 3-month (XIENCE 90) DAPT among HBR patients after implantation of a cobalt-chromium everolimus-eluting stent. Ischaemic and bleeding outcomes associated with 1- versus 3-month DAPT were assessed according to clinical presentation using propensity score stratification. RESULTS Of 3,364 HBR patients (1,392 on 1-month DAPT and 1,972 on 3-month DAPT), 1,164 (34.6%) underwent DES implantation for NSTE-ACS. At 12 months, the risk of the primary endpoint of death or myocardial infarction was similar between 1- and 3-month DAPT in patients with (hazard ratio [HR] 1.09, 95% confidence interval [CI]: 0.71-1.65) and without NSTE-ACS (HR 0.88, 95% CI: 0.63-1.23; p-interaction=0.34). The key secondary endpoint of Bleeding Academic Research Consortium (BARC) Type 2-5 bleeding was consistently reduced in both NSTE-ACS (HR 0.57, 95% CI: 0.37-0.88) and stable patients (HR 0.84, 95% CI: 0.61-1.15; p-interaction=0.15) with 1-month DAPT. CONCLUSIONS Among HBR patients undergoing implantation of an everolimus-eluting stent, 1-month, compared to 3-month DAPT, was associated with similar ischaemic risk and reduced bleeding at 1 year, irrespective of clinical presentation.
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Affiliation(s)
- Davide Cao
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Pascal Vranckx
- Heart Centre Hasselt, Hasselt, Belgium and University of Hasselt, Hasselt, Belgium
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Bern University Hospital, Bern, Switzerland
| | - Samantha Sartori
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yihan Feng
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Junbo Ge
- Zhongshan Hospital Fudan University, Shanghai, China
| | - James Hermiller
- St Vincent's Medical Center of Indiana, Indianapolis, IN, USA
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | | | | - Ralph Toelg
- Segeberger Kliniken GmbH, Herzzentrum, Bad Segeberg, Germany
| | - Aziz Maksoud
- Kansas Heart Hospital, Wichita, KS, USA and University of Kansas School of Medicine, Wichita, KS, USA
| | | | - James W Choi
- Texas Health Presbyterian Hospital Dallas, Dallas, TX, USA
| | - Gianluca Campo
- Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | | | - Mitchell W Krucoff
- Duke University Medical Center, Durham, NC, USA and Duke Clinical Research Institute, Durham, NC, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Alessandro Spirito
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Leipzig, Germany and Leipzig Heart Institute, Leipzig, Germany
| | | | - Birgit Vogel
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kedhi E, Rroku A, Hermanides RS, Dambrink JH, Singh S, Berg JT, van Ginkel DJ, Hudec M, Amoroso G, Amat-Santos IJ, Andreas M, Teles RC, Bonnet G, Van Belle E, Conradi L, van Garsse L, Wojakowski W, Voudris V, Sacha J, Cervinka P, Lipsic E, Somi S, Nombela-Franco L, Postma S, Piayda K, De Luca G, Malinofski K, Modine T. TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and multivessel or advanced coronary disease: The transcatheter valve and vessels trial (TCW trial): Design and rationale. Am Heart J 2024; 270:86-94. [PMID: 38309610 DOI: 10.1016/j.ahj.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND Patients with severe aortic stenosis (AS) frequently present with concomitant obstructive coronary artery disease (CAD). In those, current guidelines recommend combined coronary artery bypass grafting (CABG) and surgical aortic valve replacement (SAVR) as the preferred treatment option, although this surgical approach is associated with a high rate of clinical events. Combined transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) with or without FFR have evolved as a valid alternative for cardiac surgery in patients with AS and multivessel or advanced CAD. To date, no dedicated trial has prospectively evaluated the outcomes of a percutaneous versus surgical treatment for patients with both severe AS and CAD. AIMS To investigate whether fractional-flow reserve (FFR)-guided PCI and TAVI is noninferior to combined CABG and SAVR for the treatment of severe AS and multivessel or advanced CAD. METHODS The Transcatheter Valve and Vessels (TCW) trial (clinicaltrial.gov: NCT03424941) is a prospective, randomized, controlled, open label, international trial. Patients ≥ 70 years with severe AS and multivessel (≥ 2 vessels) or advanced CAD, deemed feasible by the heart team for both; a full percutaneous or surgical treatment, will be randomised in a 1:1 fashion to either FFR-guided PCI followed by TAVI (intervention arm) vs. CABG and SAVR (control arm). The primary endpoint is a patient-oriented composite of all-cause mortality, myocardial infarction, disabling stroke, unscheduled clinically-driven target vessel revascularization, valve reintervention, and life threatening or disabling bleeding at 1 year. The TCW trial is powered for noninferiority, and if met, superiority will be tested. Assuming a primary endpoint rate of 30% in the CABG-SAVR arm, with a significance level α of 5%, a noninferiority limit delta of 15% and a loss to follow-up of 2%, a total of 328 patients are needed to obtain a power of 90%. The primary endpoint analysis is performed on an intention-to-treat basis. SUMMARY The TCW Trial is the first prospective randomized trial that will study if a less invasive percutaneous treatment for severe AS and concomitant advanced CAD (i.e., FFR-guided PCI-TAVI) is noninferior to the guidelines recommended approach (CABG-SAVR).
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Affiliation(s)
- Elvin Kedhi
- McGill University Health Center, Montreal, Quebec, Canada; Department of Cardiology and Structural Heart Disease, Medical University of Silesia, Katowice, Poland.
| | - Andi Rroku
- Department of Cardiology, Deutsches Herzzentrum der Charité, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Berlin, Germany
| | - Rik S Hermanides
- Isala Heart Center, Department of Cardiology, Zwolle, The Netherlands
| | - Jan Henk Dambrink
- Isala Heart Center, Department of Cardiology, Zwolle, The Netherlands
| | - Sandeep Singh
- Isala Heart Center, Department of Thoracic Surgery, Zwolle, The Netherlands
| | - Jurriën Ten Berg
- St.Antonius Ziekenhuis, Nieuwegein, The Netherlands and University Medical Center Maastricht, Maastricht, The Netherlands
| | - Dirk-Jan van Ginkel
- St.Antonius Ziekenhuis, Nieuwegein, The Netherlands and University Medical Center Maastricht, Maastricht, The Netherlands
| | | | - Giovanni Amoroso
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ignacio J Amat-Santos
- Centro de Investigación Biomdica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Rui Campante Teles
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | - Guillaume Bonnet
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, France
| | - Eric Van Belle
- CHU Lille, Department of Cardiology, Department of Interventional Cardiology for Coronary, Valves and Structural Heart Diseases, Institut Coeur Puomon, Inserm, U1011, Institut Pasteur de Lille, EGIG, Université de Lille, Lille, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Germany
| | - Leen van Garsse
- Department of Cardiothoracic Surgery, Radboud University Medical Centre, The Netherlands
| | - Wojtek Wojakowski
- Department of Cardiology and Structural Heart Disease, Medical Univ. Silesia, Katowice, Poland
| | - Vasileious Voudris
- Interventional Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Jerzy Sacha
- Department of Cardiology, University Hospital, Institute of Medical Sciences, University of Opole, Opole, Poland; Faculty of Physical Education and Physiotherapy, Opole University of Technology, Opole, Poland
| | - Pavel Cervinka
- Department of Cardiology, Krajska Zdravotni A.S., Masaryk Hospital and UJEP Usti nad Labem, Czech Republic
| | - Erik Lipsic
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Samer Somi
- Department of Cardiology, Haga Hospital, The Hague, The Netherlands
| | | | | | - Kerstin Piayda
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, Giessen, Germany
| | - Giuseppe De Luca
- Division of Clinical and Experimental Cardiology, AOU Sassari, University of Sassari, Sassari, Italy
| | - Krzysztof Malinofski
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland; Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Thomas Modine
- Medico-Surgical Department (Valvulopathies, Cardiac Surgery, Adult Interventional Cardiology), Hôpital Cardiologique de Haut-Lévèque, Bordeaux University Hospital, France
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6
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Bhagirath V, Kovalova T, Wang J, Xu L, Bangdiwala SI, O'Donnell M, Shoamanesh A, Bosch J, Coppolecchia R, Vaitsiakhovich T, Kleinjung F, Mundl H, Eikelboom J. Bleeding Risk Prediction in Patients Treated with Antithrombotic Drugs According to the Anatomic Site of Bleeding, Indication for Treatment, and Time Since Treatment Initiation. TH OPEN 2024; 8:e121-e131. [PMID: 38505564 PMCID: PMC10948265 DOI: 10.1055/a-2259-1134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/28/2024] [Indexed: 03/21/2024] Open
Abstract
Background Reasons for the relatively poor performance of bleeding prediction models are not well understood but may relate to differences in predictors for various anatomical sites of bleeding. Methods We pooled individual participant data from four randomized controlled trials of antithrombotic therapy in patients with coronary and peripheral artery diseases, embolic stroke of undetermined source (ESUS), or atrial fibrillation. We examined discrimination and calibration of models for any major bleeding, major gastrointestinal (GI) bleeding, and intracranial hemorrhage (ICH), according to the time since initiation of antithrombotic therapy, and indication for antithrombotic therapy. Results Of 57,813 patients included, 1,948 (3.37%) experienced major bleeding, including 717 (1.24%) major GI bleeding and 274 (0.47%) ICH. The model derived to predict major bleeding at 1 year from any site (c-index, 0.69, 95% confidence interval [CI], 0.68-0.71) performed similarly when applied to predict major GI bleeding (0.71, 0.69-0.74), but less well to predict ICH (0.64, 0.61-0.69). Models derived to predict GI bleeding (0.75, 0.74-0.78) and ICH (0.72, 0.70-0.79) performed better than the general major bleeding model. Discrimination declined over time since the initiation of antithrombotic treatment, stabilizing at approximately 2 years for any major bleeding and major GI bleeding and 1 year for ICH. Discrimination was best for the model predicting ICH in the ESUS population (0.82, 0.78-0.92) and worst for the model predicting any major bleeding in the coronary and peripheral artery disease population (0.66, 0.65-0.69). Conclusion Performance of risk prediction models for major bleeding is affected by site of bleeding, time since initiation of antithrombotic therapy, and indication for antithrombotic therapy.
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Affiliation(s)
- Vinai Bhagirath
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Tanya Kovalova
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shrikant I. Bangdiwala
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Martin O'Donnell
- Population Health Research Institute, Hamilton, Ontario, Canada
- University of Galway, Galway, Galway, Ireland
| | - Ashkan Shoamanesh
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | - John Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
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7
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Musto C, Paolucci L, Pivato CA, Testa L, Pacchioni A, Briguori C, Esposito G, Piccolo R, Lucisano L, De Luca L, Conrotto F, Sanz-Sanchez J, Cesario V, De Felice F, Latini AC, Regazzoli D, Sardella G, Indolfi C, Reimers B, Condorelli G, Stefanini G. One-Month Dual Antiplatelet Therapy in Patients With Chronic and Acute Coronary Syndromes Treated With Bioresorbable Polymer Everolimus-Eluting Stents. Am J Cardiol 2023; 207:170-178. [PMID: 37741107 DOI: 10.1016/j.amjcard.2023.08.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/19/2023] [Accepted: 08/20/2023] [Indexed: 09/25/2023]
Abstract
There is a paucity of data regarding the safety of a 1-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) presenting with acute coronary syndromes (ACS). We aimed to compare the clinical outcomes of patients at HBR with chronic coronary syndrome (CCS) or ACS treated with PCI using bioresorbable polymer everolimus-eluting stent (BP-EES) followed by 1-month DAPT. Patients at HBR who underwent PCI with BP-EES were prospectively enrolled in 10 Italian centers. All patients were treated with 1-month DAPT. In case of need for anticoagulation, patients received an oral anticoagulant in addition to a P2Y12 inhibitor for 1 month, followed by oral anticoagulation only after that. The primary end point was a composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis at 12 months. Overall, 263 patients (59.4%) with CCS and 180 patients (40.6%) with ACS were enrolled. No significant difference was evident between patients with CCS and ACS for the primary end point (4.3% vs 5.6%, respectively, p = 0.497) and for each isolated component. The risk for Bleeding Academic Research Consortium (BARC) type 1 to 5 or type 3 to 5 bleedings was also similar between patients with CCS and ACS (4.3% vs 5.2%, p = 0.677, and 1.6% vs 2.9%, p = 0.351, respectively). In conclusion, among HBR patients with ACS who underwent PCI with BP-EES, a 1-month DAPT strategy is associated with a similar risk of ischemic and bleeding events compared with those with CCS.
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Affiliation(s)
- Carmine Musto
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | - Luca Paolucci
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | - Carlo Andrea Pivato
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Testa
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, Milan, Italy
| | | | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Italy
| | | | - Leonardo De Luca
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Jorge Sanz-Sanchez
- Cardiology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain; Centro de Investigación Biomedica en Red (CIBERCV), Madrid, Spain
| | - Vincenzo Cesario
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | - Francesco De Felice
- Department of Cardiosciences, A.O. San Camillo-Forlanini Hospital, Rome, Italy
| | - Alessia Chiara Latini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | | | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
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8
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Oliva A, Cao D, Spirito A, Nicolas J, Pileggi B, Kamaleldin K, Vogel B, Mehran R. Personalized Approaches to Antiplatelet Treatment for Cardiovascular Diseases: An Umbrella Review. Pharmgenomics Pers Med 2023; 16:973-990. [PMID: 37941790 PMCID: PMC10629404 DOI: 10.2147/pgpm.s391400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/21/2023] [Indexed: 11/10/2023] Open
Abstract
Antiplatelet therapy is the cornerstone of antithrombotic prevention in patients with established atherosclerosis, since it has been proven to reduce coronary, cerebrovascular, and peripheral thrombotic events. However, the protective effect of antiplatelet agents is counterbalanced by an increase of bleeding events that impacts on patients' mortality and morbidity. Over the last years, great efforts have been made toward personalized antithrombotic strategies according to the individual bleeding and ischemic risk profile, aiming to maximizing the net clinical benefit. The development of risk scores, consensus definitions, and the new promising artificial intelligence tools, as well as the assessment of platelet responsiveness using platelet function and genetic testing, are now part of an integrated approach to tailored antithrombotic management. Moreover, novel strategies are available including dual antiplatelet therapy intensity and length modulation in patients undergoing myocardial revascularization, the use of P2Y12 inhibitor monotherapy for long-term secondary prevention, the implementation of parenteral antiplatelet agents in high-ischemic risk clinical settings, and combination of antiplatelet agents with low-dose factor Xa inhibitors (dual pathway inhibition) in patients suffering from polyvascular disease. This review summarizes the currently available evidence and provides an overview of the principal risk-stratification tools and antiplatelet strategies to inform treatment decisions in patients with cardiovascular disease.
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Affiliation(s)
- Angelo Oliva
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Cardio Center, Humanitas Research Hospital IRCCS Rozzano, Milan, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Brunna Pileggi
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Cardiopneumonology, Heart Institute of the University of Sao Paulo, Sao Paulo, Brazil
| | - Karim Kamaleldin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
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9
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Piccolo R, Calabrò P, Varricchio A, Baldi C, Napolitano G, De Simone C, Mauro C, Stabile E, Caiazzo G, Tesorio T, Boccalatte M, Tuccillo B, Bottiglieri G, Russolillo E, Di Lorenzo E, Carrara G, Cassese S, Leonardi S, Biscaglia S, Costa F, McFadden E, Heg D, Franzone A, Stefanini GG, Capodanno D, Esposito G. Rationale and design of the PARTHENOPE trial: A two-by-two factorial comparison of polymer-free vs biodegradable-polymer drug-eluting stents and personalized vs standard duration of dual antiplatelet therapy in all-comers undergoing PCI. Am Heart J 2023; 265:153-160. [PMID: 37572785 DOI: 10.1016/j.ahj.2023.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/14/2023]
Abstract
BACKGROUND Over the past few decades, percutaneous coronary intervention (PCI) has undergone significant advancements as a result of the combination of device-based and drug-based therapies. These iterations have led to the development of polymer-free drug-eluting stents. However, there is a scarcity of data regarding their clinical performance. Furthermore, while various risk scores have been proposed to determine the optimal duration of dual antiplatelet therapy (DAPT), none of them have undergone prospective validation within the context of randomized trials. DESIGN The PARTHENOPE trial is a phase IV, prospective, randomized, multicenter, investigator-initiated, assessor-blind study being conducted at 14 centers in Italy (NCT04135989). It includes 2,107 all-comers patients with minimal exclusion criteria, randomly assigned in a 2-by-2 design to receive either the Cre8 amphilimus-eluting stent or the SYNERGY everolimus-eluting stent, along with either a personalized or standard duration of DAPT. Personalized DAPT duration is determined by the DAPT score, which accounts for both bleeding and ischemic risks. Patients with a DAPT score <2 (indicating higher bleeding than ischemic risk) receive DAPT for 3 or 6 months for chronic or acute coronary syndrome, respectively, while patients with a DAPT score ≥2 (indicating higher ischemic than bleeding risk) receive DAPT for 24 months. Patients in the standard DAPT group receive DAPT for 12 months. The trial aims to establish the noninferiority between stents with respect to a device-oriented composite end point of cardiovascular death, target-vessel myocardial infarction, or clinically-driven target-lesion revascularization at 12 months after PCI. Additionally, the trial aims to demonstrate the superiority of personalized DAPT compared to a standard approach with respect to a net clinical composite of all-cause death, any myocardial infarction, stroke, urgent target-vessel revascularization, or type 2 to 5 bleeding according to the Bleeding Academic Research Consortium criteria at 24-months after PCI. SUMMARY The PARTHENOPE trial is the largest randomized trial investigating the efficacy and safety of a polymer-free DES with a reservoir technology for drug-release and the first trial evaluating a personalized duration of DAPT based on the DAPT score. The study results will provide novel insights into the optimizing the use of drug-eluting stents and DAPT in patients undergoing PCI.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Attilio Varricchio
- Division of Cardiology, P.O.S. Anna e SS. Madonna della Neve di Boscotrecase, Ospedali Riuniti Area Vesuviana, Naples, Italy
| | - Cesare Baldi
- Division of Interventional Cardiology, Cardiovascular and Thoracic Department, San Giovanni di Dio e Ruggi, Salerno, Italy
| | - Giovanni Napolitano
- Division of Cardiology, "San Giuliano" Hospital of Giugliano in Campania, Giugliano in Campania, Italy
| | - Ciro De Simone
- Division of Cardiology, Clinica Villa Dei Fiori, Acerra, Italy
| | - Ciro Mauro
- Division of Cardiology, Antonio Cardarelli Hospital, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy; Division of Cardiology, Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Gianluca Caiazzo
- Division of Cardiology, San Giuseppe Moscati Hospital, Aversa, Italy
| | - Tullio Tesorio
- Department of Invasive Cardiology, Clinica Montevergine, Mercogliano, Italy
| | - Marco Boccalatte
- Division of Cardiology, Ospedale Santa Maria delle Grazie, Pozzuoli, Italy
| | | | | | | | | | | | - Salvatore Cassese
- Division of Cardiology, Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sergio Leonardi
- Department of Molecular Medicine, University of Pavia, Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina, Italy
| | - Eugene McFadden
- Division of Cardiology, Cork University Hospital, Cork, Ireland
| | - Dik Heg
- Department of Clinical Research, CTU Bern, University of Bern, Bern, Switzerland
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Division of Cardiology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy.
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10
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D'Ascenzo F, Fabris E, DeGregorio C, Mittone G, De Filippo O, Wańha W, Leonardi S, Roubin SR, Chinaglia A, Truffa A, Huczek Z, Gaibazzi N, Ielasi A, Cortese B, Borin A, Pagliaro B, Núñez-Gil IJ, Ugo F, Marengo G, Barbieri L, Marchini F, Desperak P, Melendo-Viu M, Montalto C, Bianco M, Bruno F, Mancone M, Ferrandez-Escarabajal M, Morici N, Scaglione M, Tuttolomondo D, Gąsior M, Mazurek M, Gallone G, Campo G, Wojakowski W, Abu Assi E, Stefanini G, Sinagra G, de Ferrari GM. Forecasting the Risk of Heart Failure Hospitalization After Acute Coronary Syndromes: the CORALYS HF Score. Am J Cardiol 2023; 206:320-329. [PMID: 37734293 DOI: 10.1016/j.amjcard.2023.08.010] [Citation(s) in RCA: 1] [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: 04/15/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 09/23/2023]
Abstract
The present study aimed to identify patients at a higher risk of hospitalization for heart failure (HF) in a population of patients with acute coronary syndrome (ACS) treated with percutaneous coronary revascularization without a history of HF or reduced left ventricular (LV) ejection fraction before the index admission. We performed a Cox regression multivariable analysis with competitive risk and machine learning models on the incideNce and predictOrs of heaRt fAiLure After Acute coronarY Syndrome (CORALYS) registry (NCT04895176), an international and multicenter study including consecutive patients admitted for ACS in 16 European Centers from 2015 to 2020. Of 14,699 patients, 593 (4.0%) were admitted for the development of HF up to 1 year after the index ACS presentation. A total of 2 different data sets were randomly created, 1 for the derivative cohort including 11,626 patients (80%) and 1 for the validation cohort including 3,073 patients (20%). On the Cox regression multivariable analysis, several variables were associated with the risk of HF hospitalization, with reduced renal function, complete revascularization, and LV ejection fraction as the most relevant ones. The area under the curve at 1 year was 0.75 (0.72 to 0.78) in the derivative cohort, whereas on validation, it was 0.72 (0.67 to 0.77). The machine learning analysis showed a slightly inferior performance. In conclusion, in a large cohort of patients with ACS without a history of HF or LV dysfunction before the index event, the CORALYS HF score identified patients at a higher risk of hospitalization for HF using variables easily accessible at discharge. Further approaches to tackle HF development in this high-risk subset of patients are needed.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy.
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Caterina DeGregorio
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Gianluca Mittone
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Alessandra Chinaglia
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | | | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Alfonso Ielasi
- U.O. di Cardiologia Clinica ed Interventistica, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Bernardo Cortese
- Cardiovascular Research Team, San Carlo Clinic, Milano, Italy; Fondazione Ricerca e Innovazione Cardiovascolare, Milano, Italy
| | - Andrea Borin
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | | | - Iván J Núñez-Gil
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Fabrizio Ugo
- Division of Cardiology, Ospedale Sant'Andrea di Vercelli, Vercelli, Italy
| | - Giorgio Marengo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy; Departement of Informatica, University of Turin, Turin, Italy
| | - Lucia Barbieri
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy; Division of Cardiology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; University of Milan, Milan, Italy
| | - Federico Marchini
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Piotr Desperak
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | - Claudio Montalto
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Matteo Bianco
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Turin, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Massimo Mancone
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | | | - Nuccia Morici
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Scaglione
- Division of Cardiology, Ospedale Cardinal G. Massaia, Asti, Italy
| | | | - Mariusz Gąsior
- Departement of Informatica, University of Turin, Turin, Italy
| | - Maciej Mazurek
- 1st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Guglielmo Gallone
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | | | - Emad Abu Assi
- Hospital Universitario Álvaro Cunqueiro, Vigo, Spain
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Gaetano Maria de Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, Turin, Italy
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11
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van der Sangen NMR, Küçük IT, Sivanesan S, Appelman Y, Ten Berg JM, Verburg A, Azzahhafi J, Arkenbout EK, Kikkert WJ, Pisters R, Jukema JW, Arslan F, van 't Hof A, Ilhan M, Hoebers LP, van der Schaaf RJ, Damman P, Woudstra P, van de Hoef TP, Bax M, Anthonio RL, Polad J, Adriaenssens T, Dewilde W, Zivelonghi C, Laanmets P, Majas R, Dijkgraaf MGW, Claessen BEPM, Henriques JPS. Less bleeding by omitting aspirin in non-ST-segment elevation acute coronary syndrome patients: Rationale and design of the LEGACY study. Am Heart J 2023; 265:114-120. [PMID: 37517430 DOI: 10.1016/j.ahj.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Early aspirin withdrawal, also known as P2Y12-inhibitor monotherapy, following percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) can reduce bleeding without a trade-off in efficacy. Still the average daily bleeding risk is highest during the first months and it remains unclear if aspirin can be omitted immediately following PCI. METHODS The LEGACY study is an open-label, multicenter randomized controlled trial evaluating the safety and efficacy of immediate P2Y12-inhibitor monotherapy versus dual antiplatelet therapy (DAPT) for 12 months in 3,090 patients. Patients are randomized immediately following successful PCI for NSTE-ACS to 75-100 mg aspirin once daily versus no aspirin. The primary hypothesis is that immediately omitting aspirin is superior to DAPT with respect to major or minor bleeding defined as Bleeding Academic Research Consortium type 2, 3, or 5 bleeding, while maintaining noninferiority for the composite of all-cause mortality, myocardial infarction and stroke compared to DAPT. CONCLUSIONS The LEGACY study is the first randomized study that is specifically designed to evaluate the impact of immediately omitting aspirin, and thus treating patients with P2Y12-inhibitor monotherapy, as compared to DAPT for 12 months on bleeding and ischemic events within 12 months following PCI for NSTE-ACS.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Shabiga Sivanesan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands; Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands
| | - Ashley Verburg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E Karin Arkenbout
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Tergooi Hospital, Hilversum, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Fatih Arslan
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Arnoud van 't Hof
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Mustafa Ilhan
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Loes P Hoebers
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), University Medical Center Maastricht, Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medical Center, Heerlen, The Netherlands
| | | | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pier Woudstra
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Matthijs Bax
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Rutger L Anthonio
- Department of Cardiology, Treant Zorggroep, Scheper Hospital, Emmen, The Netherlands
| | - Jawed Polad
- Department of Cardiology, Jeroen Bosch Ziekenhuis, Hertogenbosch, The Netherlands
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Willem Dewilde
- Department of Cardiology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Carlo Zivelonghi
- Department of Cardiology, HartCentrum, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Peep Laanmets
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Risko Majas
- Department of Cardiology, North Estonia Medical Center Foundation, Tallinn, Estonia
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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12
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Capodanno D, Greco A. Short Dual Antiplatelet Therapy in High Bleeding Risk Patients: 1 Month or 3 Months? JACC Cardiovasc Interv 2023; 16:2511-2513. [PMID: 37804285 DOI: 10.1016/j.jcin.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/29/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy.
| | - Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco," University of Catania, Catania, Italy
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13
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Piccolo R, Avvedimento M, Canonico ME, Gargiulo P, Paolillo R, Conti V, Dal Piaz F, Filippelli A, Morisco C, Simonetti F, Leone A, Marenna A, Bruzzese D, Gargiulo G, Stabile E, Di Serafino L, Franzone A, Cirillo P, Esposito G. Platelet Inhibition with Ticagrelor 60 mg Versus 90 mg Twice Daily in Elderly Patients with Acute Coronary Syndrome: Rationale and Design of the PLINY THE ELDER Trial. Cardiovasc Drugs Ther 2023; 37:1031-1038. [PMID: 35048203 DOI: 10.1007/s10557-021-07302-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Elderly status is steadily increasing among patients with acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) with aspirin and a potent P2Y12 receptor inhibitor is the cornerstone of treatment to prevent recurrent thrombotic complications in patients with ACS. However, DAPT in older patients is challenged by a concurrent heightened risk of ischemia and bleeding. The aim of this study is to evaluate the pharmacodynamic and pharmacokinetic profile of a lower dose of ticagrelor (60 mg twice daily) among elderly patients during the early phase of ACS. STUDY DESIGN PLINY THE ELDER (PLatelet INhibition with two different doses of potent P2y12 inhibitors in THE ELDERly population) (NCT04739384) is a prospective, randomized, open-label, crossover trial to evaluate the non-inferiority of a lower dose of ticagrelor (60 mg twice daily) compared with a standard dose (90 mg twice daily) among elderly patients with ACS undergoing percutaneous coronary intervention (PCI). A total of 50 patients, aged 75 years or more, with indication to potent P2Y12 receptor inhibitors will be randomized within 3 days from PCI for the index ACS. Patients with indication to oral anticoagulant therapy, treatment with glycoprotein IIb/IIIa inhibitors, or active bleeding will be excluded. The primary endpoint is platelet reactivity determined by P2Y12 reaction units (PRU) (VerifyNow, Accumetrics, San Diego, CA, USA) after treatment with ticagrelor 60 or 90 mg twice daily for 14 days. Secondary endpoints will include other pharmacodynamic tests of ADP-induced aggregation (light transmittance aggregometry and multiple electrode aggregometry) and determination of pharmacokinetic profile (plasma levels of ticagrelor and its metabolite AR-C124910XX) by high performance liquid chromatography-tandem mass spectrometry. CONCLUSIONS The PLINY THE ELDER trial will determine whether a lower dose of ticagrelor confers non-inferior platelet inhibition compared with the standard dose in the early phase of ACS among elderly patients undergoing PCI, informing future clinical investigation.
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Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy.
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Valeria Conti
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Fabrizio Dal Piaz
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Baronissi, SA, Italy
- Department of Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni Di Dio E Ruggi d'Aragona", Salerno, Italy
| | - Carmine Morisco
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Alessandra Marenna
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Dario Bruzzese
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Eugenio Stabile
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, University of Naples Federico II, Naples, Italy
- UNESCO Chair On Health Education and Sustainable Development, University of Naples Federico II, Naples, Italy
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14
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Calabrò P, Gragnano F. Bleeding in Patients Undergoing PCI and TAVR: Combining Coronary and Valve Procedures Raises New Challenges. JACC Cardiovasc Interv 2023; 16:2165-2168. [PMID: 37704302 DOI: 10.1016/j.jcin.2023.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano," Caserta, Italy.
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy; Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano," Caserta, Italy
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15
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Mo R, Wang HY, Yang YM, Zhang H, Suo N, Wang JY. Implications of bleeding on subsequent cardiovascular events in patients with atrial fibrillation after acute coronary syndrome or PCI. Thromb Res 2023; 229:243-251. [PMID: 37591154 DOI: 10.1016/j.thromres.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 06/22/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
INTRODUCTION The association between bleeding and subsequent major adverse cardiac and cerebrovascular events (MACCE) remains poorly characterized. We aimed to evaluate the impact of hemorrhagic events in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI). MATERIALS AND METHODS A total of 1877 consecutive patients with AF and ACS or undergoing PCI were prospectively recruited. The primary endpoint was MACCE, including all-cause death, myocardial infarction, ischemic stroke, systemic embolism or ischemia-driven revascularization during follow-up. Post-discharge bleeding was graded according to TIMI criteria. Associations between bleeding and subsequent MACCE were examined using time-dependent multivariate Cox regression after adjusting for baseline covariates and the time from bleeding. RESULTS During a median follow-up of 34.2 months, 341 (18.2 %) had TIMI major or minor bleeding events, of whom 86 (25.2 %) also experienced MACCE. The risk of MACCE was significantly higher in patients with bleeding than those without (8.85 % versus 6.99 % per patient-year; HR, 1.568, 95 % CI, 1.232-1.994). In patients who had both bleeding and MACCE, 65.1 % (56 of 86) bleeding events occurred first. Temporal gradients in MACCE risk after major bleeding was highest within 30 days (HRadj, 23.877; 95 % CI, 12.810-44.506) and remained significant beyond 1 year (HRadj, 3.640; 95 % CI, 1.278-10.366). Minor bleeding was associated with increased risk of MACCE within 1 year. CONCLUSIONS In patients with AF and ACS or PCI, major and minor bleeding were associated with subsequent MACCE with time-dependency. Our findings may aid in better defining net clinical benefit of optimal antithrombotic therapy.
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Affiliation(s)
- Ran Mo
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China.; National Center for Neurological Disorders, No. 45 Changchun Street, Xicheng District, Beijing, 100053, China
| | - Hao-Yu Wang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.; State Key Laboratory of Cardiovascular Disease, No.167 North Lishi Road, Xicheng District, Beijing, China.; National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Yan-Min Yang
- State Key Laboratory of Cardiovascular Disease, No.167 North Lishi Road, Xicheng District, Beijing, China.; National Clinical Research Center of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China.; Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China..
| | - Han Zhang
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Ni Suo
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
| | - Jing-Yang Wang
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 North Lishi Road, Xicheng District, Beijing, China
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16
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van der Sangen NMR, Azzahhafi J, Chan Pin Yin DRPP, Rayhi S, van Weede VM, Walhout RJ, Tjon Joe Gin M, Pisters R, Nicastia DM, Langerveld J, Vlachojannis GJ, van Bommel RJ, Appelman Y, Henriques JPS, Ten Berg J, Kikkert W. Impact of recurrent ischaemic and bleeding events on quality of life in patients with acute coronary syndrome: Insights from the FORCE-ACS registry. Open Heart 2023; 10:e002405. [PMID: 37527905 PMCID: PMC10394548 DOI: 10.1136/openhrt-2023-002405] [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] [Received: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVE Patients with acute coronary syndrome (ACS) remain at high risk for recurrent ischaemic and bleeding events during follow-up. Our study aimed to quantify and compare the impact of these adverse events on quality of life (QoL). METHODS Data from patients with ACS prospectively enrolled in the FORCE-ACS registry between January 2015 and December 2019 were used for this study. The primary ischaemic and bleeding events of interest were hospital readmission for ACS and Bleeding Academic Research Consortium type 2 or 3 bleeding during 12 months follow-up. QoL was measured using the EQ-5D Visual Analogue Scale (VAS) score and the 12-item Short Form Survey version 2 derived Physical Component Summary (PCS) and Mental Health Component Summary (MCS) scores at 12 months follow-up. RESULTS In total, 3339 patients (mean age 66.8 years, 27.9% women) were included. During follow-up, ischaemic events occurred in 202 patients (6.0%) and bleeding events in 565 patients (16.9%). After adjustment for demographic and clinical characteristics, ischaemic events remained independently associated with lower QoL regardless of metric used. Bleeding was also independently associated with lower EQ-5D VAS and PCS scores, but not with a lower MCS score. The QoL decrement associated with ischaemic events was numerically larger than the decrement associated with bleeding. CONCLUSIONS Ischaemic and bleeding events remain prevalent and are independently associated with lower QoL at 12 months follow-up in patients previously admitted for ACS. The incidence and impact of these adverse events should be considered when balancing individual ischaemic and bleeding risks.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jaouad Azzahhafi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Senna Rayhi
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Victoria M van Weede
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ronald J Walhout
- Department of Cardiology, Hospital Gelderse Vallei, Ede, The Netherlands
| | | | - Ron Pisters
- Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Jorina Langerveld
- Department of Cardiology, Rivierenland Hospital, Tiel, The Netherlands
| | | | | | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiology, Maastricht UMC+, Maastricht, The Netherlands
| | - Wouter Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Department of Cardiology, Tergooi MC, Hilversum, The Netherlands
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17
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van der Sangen NMR, Claessen BEPM, Küçük IT, den Hartog AW, Baan J, Beijk MAM, Delewi R, van de Hoef TP, Knaapen P, Lemkes JS, Marques KM, Nap A, Verouden NJW, Vis MM, de Winter RJ, Kikkert WJ, Appelman Y, Henriques JPS. Single antiplatelet therapy directly after percutaneous coronary intervention in non-ST-segment elevation acute coronary syndrome patients: the OPTICA study. EUROINTERVENTION 2023; 19:63-72. [PMID: 36734020 PMCID: PMC10173755 DOI: 10.4244/eij-d-22-00886] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early P2Y12 inhibitor monotherapy has emerged as a promising alternative to 12 months of dual antiplatelet therapy following percutaneous coronary intervention (PCI). AIMS In this single-arm pilot study, we evaluated the feasibility and safety of ticagrelor or prasugrel monotherapy directly following PCI in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS Patients received a loading dose of ticagrelor or prasugrel before undergoing platelet function testing and subsequent PCI using new-generation drug-eluting stents. The stent result was adjudicated with optical coherence tomography in the first 35 patients. Ticagrelor or prasugrel monotherapy was continued for 12 months. The primary ischaemic endpoint was the composite of all-cause mortality, myocardial infarction, definite or probable stent thrombosis or stroke within 6 months. The primary bleeding endpoint was Bleeding Academic Research Consortium type 2, 3 or 5 bleeding within 6 months. RESULTS From March 2021 to March 2022, 125 patients were enrolled, of whom 75 ultimately met all in- and exclusion criteria (mean age 64.5 years, 29.3% women). Overall, 70 out of 75 (93.3%) patients were treated with ticagrelor or prasugrel monotherapy directly following PCI. The primary ischaemic endpoint occurred in 3 (4.0%) patients within 6 months. No cases of stent thrombosis or spontaneous myocardial infarction occurred. The primary bleeding endpoint occurred in 7 (9.3%) patients within 6 months. CONCLUSIONS This study provides first-in-human evidence that P2Y12 inhibitor monotherapy directly following PCI for NSTE-ACS is feasible, without any overt safety concerns, and highlights the need for randomised controlled trials comparing direct P2Y12 inhibitor monotherapy with the current standard of care.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jan Baan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jorrit S Lemkes
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Koen M Marques
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Niels J W Verouden
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - M Marije Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jose P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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18
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Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, Hoang Trinh K, O'Hara G, Rodés-Cabau J. Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives. Circ Cardiovasc Interv 2023; 16:e012812. [PMID: 37192309 DOI: 10.1161/circinterventions.122.012812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Pedro Cepas-Guillén
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Xavier Freixa
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Eduardo Flores-Umanzor
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
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19
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Cao D, Gragnano F. Clopidogrel Monotherapy After 1-Month DAPT in Diabetic Patients Undergoing PCI: Is Less Always More? JACC Cardiovasc Interv 2023; 16:32-35. [PMID: 36599585 DOI: 10.1016/j.jcin.2022.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 10/23/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Davide Cao
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Caserta, Italy; Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy.
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20
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Capodanno D, Angiolillo DJ. Timing, Selection, Modulation, and Duration of P2Y 12 Inhibitors for Patients With Acute Coronary Syndromes Undergoing PCI. JACC Cardiovasc Interv 2023; 16:1-18. [PMID: 36599574 DOI: 10.1016/j.jcin.2022.10.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/03/2022] [Accepted: 10/10/2022] [Indexed: 01/04/2023]
Abstract
Dual antiplatelet therapy with aspirin and the oral P2Y12 inhibitor clopidogrel as the cornerstone of treatment for patients with an acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) was firstly established in 2001. Soon thereafter, the newer-generation P2Y12 inhibitors prasugrel and ticagrelor became commercially available. The clinical management of ACS patients undergoing PCI has evolved significantly in the last 2 decades, with a shift toward more rapid invasive management, broader use of drug-eluting stents, and the increasing recognition that major bleeding due to antiplatelet therapy is detrimental. In this ever-changing scenario, numerous studies have addressed 4 main questions regarding P2Y12 inhibition in ACS patients undergoing PCI: timing, selection, modulation, and duration. This paper reviews the latest evidence surrounding these topical questions, with a focus on efficacy and safety data, practice guidelines, and residual areas of uncertainty.
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Affiliation(s)
- Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico "Gaspare Rodolico - San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA.
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21
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Oliva A, Castiello DS, Franzone A, Condorelli G, Colombo A, Esposito G, Stefanini GG, Piccolo R. P2Y12 Inhibitors Monotherapy in Patients Undergoing Complex vs Non-Complex Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Trials. Am Heart J 2023; 255:71-81. [PMID: 36220356 DOI: 10.1016/j.ahj.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/03/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Monotherapy with P2Y12 inhibitors (P2Y12i) is emerging as alternative strategy to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). However, early withdrawal of aspirin as part of P2Y12i monotherapy regimens may pose concerns in high-risk patients, such as those undergoing complex PCI. Our aim was to evaluate the efficacy and safety of P2Y12i monotherapy after a short course of DAPT (1-3-month) compared with standard DAPT (≥12-month) according to PCI complexity. METHODS We performed a meta-analysis of randomized trials using random effects models to combine hazard ratios (HRs) with 95% confidence intervals (CIs). Within-trial interactions were pooled to estimate heterogeneity between complex and noncomplex PCI strata. The study protocol was registered in the PROSPERO (CRD42021291027). RESULTS We identified 5 trials including 31,627 patients, of whom 8,328 (26.3%) underwent complex PCI. P2Y12i monotherapy compared with standard DAPT was associated with a similar risk of all-cause death, stent thrombosis, and stroke, with no evidence for interaction between complex and noncomplex PCI. We found heterogeneity in the treatment effect of P2Y12i monotherapy vs standard DAPT with respect to myocardial infarction (P-interaction = 0.027). Compared with standard DAPT, P2Y12i monotherapy decreased the risk of myocardial infarction in complex PCI (HR 0.77, 95%CI 0.60-0.99, P = .042), but not in noncomplex PCI patients (HR 1.09, 95%CI 0.90-1.30, P = .382). The risk of major bleeding was significantly reduced by P2Y12i monotherapy with a consistent treatment effect (P-interaction = 0.699) in both complex and noncomplex PCI strata. CONCLUSIONS Patients undergoing complex PCI may derive more benefit and less harm from P2Y12i monotherapy after early aspirin withdrawal compared with standard DAPT.
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Affiliation(s)
- Angelo Oliva
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Domenico S Castiello
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Naples, Italy
| | - Gianluigi Condorelli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Naples, Italy
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Cardio Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Napoli, Naples, Italy.
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22
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Sun Y, Feng L, Li X, Wang Z, Gao R, Wu Y. In-hospital major bleeding in patients with acute coronary syndrome medically treated with dual anti-platelet therapy: Associated factors and impact on mortality. Front Cardiovasc Med 2022; 9:878270. [DOI: 10.3389/fcvm.2022.878270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveMajor bleeding is associated with poor hospital prognosis in patients with acute coronary syndrome (ACS). Despite its clinical importance, there are limited studies on the incidence and risk factors for major bleeding in ACS patients with dual anti-platelet therapy (DAPT) without access to revascularization.MethodsWe analyzed data from 19,186 patients on DAPT after ACS with no access to revascularization from Clinical Pathway for Acute Coronary Syndrome in China Phase 3 (CPACS-3) cohort, which was conducted from 2011 to 2014. Major bleeding included intracranial hemorrhage, clinically significant bleeding, or bleeding requiring blood transfusion. Factors associated with in-hospital major bleeding were assessed using Poisson regressions with generalized estimating equations to account for the clustering effect.ResultsA total of 75 (0.39%) patients experienced major bleeding during hospitalization. Among subtypes of ACS, 0.65% of patients with STEMI, 0.33% with NSTEMI, and 0.13% with unstable angina had in-hospital major bleeding (p < 0.001). The patients who experienced major bleeding had a longer length of stay (median 12 vs. 9 days, p = 0.011) and a higher all-cause in-hospital death rate (22.7 vs. 3.7%, p < 0.001). Multivariable analysis showed advancing age (RR = 1.52 for every 10 years increase, 95% CI: 1.13, 2.05), impaired renal function (RR = 1.79, 95% CI: 1.10, 2.92), use of fibrinolytic drugs (RR = 2.93, 95% CI: 1.55, 5.56), and severe diseases other than cardiovascular and renal diseases (RR = 5.56, 95% CI: 1.10, 28.07) were associated with increased risk of major bleeding, whereas using renin–angiotensin system inhibitors (RR = 0.54, 95% CI: 0.36, 0.81) was associated with decreased risk of major bleeding. These independent factors together showed good predictive accuracy with an AUC of 0.788 (95% CI: 0.734, 0.841).ConclusionAmong ACS patients on DAPT, advancing age, impaired renal function, thrombolytic treatment, and severe comorbidities were independently associated with a higher risk of in-hospital major bleeding.
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Greco A, Mauro MS, Capodanno D, Angiolillo DJ. P2Y12 Inhibitor Monotherapy: Considerations for Acute and Long-Term Secondary Prevention Post-PCI. Rev Cardiovasc Med 2022; 23:348. [PMID: 39077128 PMCID: PMC11267341 DOI: 10.31083/j.rcm2310348] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 07/31/2024] Open
Abstract
Following percutaneous coronary intervention (PCI), an initial course of dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor ( P2Y 12 -i) is recommended to minimize the risk of thrombotic complications. After the initial period of DAPT, antiplatelet monotherapy, usually consisting of aspirin, is administered for long-term secondary prevention. However, over the last few years there has been accruing evidence on P2Y 12 -i monotherapy, both in the acute (i.e., post-PCI; after a brief period of DAPT, transitioning to monotherapy before six or 12 months in patients with chronic or acute coronary syndrome, respectively) and chronic (i.e., long-term secondary prevention; after completion of six or 12 months of DAPT, in patients with chronic or acute coronary syndrome, respectively) settings. In aggregate, most studies of short DAPT with transition to P2Y 12 -i monotherapy showed a reduced risk of bleeding complications, without any significant increase in ischemic events as compared to standard DAPT. On the other hand, the evidence on long-term P2Y 12 -i monotherapy is scarce, but results from a randomized trial showed that clopidogrel monotherapy outperformed aspirin monotherapy in terms of net benefit, ischemic events and bleeding. Antiplatelet therapy is also recommended for patients undergoing PCI and with an established indication for long-term oral anticoagulation (OAC). In this scenario, a brief period of triple therapy (i.e., aspirin, P2Y 12 -i and OAC) is followed by a course of dual antithrombotic therapy (usually with P2Y 12 -i and OAC) and ultimately by lifelong OAC alone. European and American guidelines have been recently updated to provide new recommendations on antithrombotic therapy, including the endorsement of P2Y 12 -i monotherapy in different settings. However, some areas of uncertainty still remain and further randomized investigations are ongoing to fulfil current gaps in knowledge. In this review, we assess the current knowledge and evidence on P2Y 12 -i monotherapy for the early and long-term secondary prevention in patients undergoing PCI, and explore upcoming research and future directions in the field.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico “G. Rodolico – San Marco”, 95125 Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Lahu S, Presch A, Ndrepepa G, Menichelli M, Valina C, Hemetsberger R, Witzenbichler B, Bernlochner I, Joner M, Xhepa E, Hapfelmeier A, Kufner S, Rifatov N, Sager HB, Mayer K, Kessler T, Laugwitz KL, Richardt G, Schunkert H, Neumann FJ, Sibbing D, Angiolillo DJ, Kastrati A, Cassese S. Ticagrelor or Prasugrel in Patients With Acute Coronary Syndrome and High Bleeding Risk. Circ Cardiovasc Interv 2022; 15:e012204. [PMID: 36256695 DOI: 10.1161/circinterventions.122.012204] [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: 01/10/2023]
Abstract
BACKGROUND The relative efficacy and safety of more potent P2Y12 inhibitors in patients with acute coronary syndrome and high bleeding risk (HBR) undergoing percutaneous coronary intervention remains unclear. We aimed to study the treatment effect of ticagrelor and prasugrel in percutaneous coronary intervention patients presenting with acute coronary syndrome and HBR. METHODS This post hoc analysis of the ISAR-REACT 5 trial (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5) included patients with acute coronary syndrome undergoing percutaneous coronary intervention, randomized to ticagrelor or prasugrel, in whom HBR was defined as per Academic Research Consortium criteria. The primary (efficacy) end point was the composite of all-cause death, myocardial infarction, or stroke. The secondary (safety) end point was Bleeding Academic Research Consortium type 3 to 5 bleeding. Outcomes were assessed 12 months after randomization. RESULTS Out of the 3239 patients included in this analysis, 486 fulfilled the criteria for Academic Research Consortium-HBR definition (HBR group; ticagrelor, n=230 and prasugrel, n=256), while 2753 did not (non-HBR group; ticagrelor, n=1375 and prasugrel, n=1378). Compared with the non-HBR group, the HBR group had a higher risk for the primary (hazard ratio [HR]=3.57 [95% CI, 2.79-4.57]; P<0.001) and secondary end point (HR=2.94 [2.17-3.99]; P<0.001). In the HBR group, the primary (HR=1.09 [0.73-1.62]) and secondary (HR=1.18 [0.67-2.08]) end points were not significantly different between patients assigned to ticagrelor and prasugrel. In the non-HBR group, the primary end point (HR=1.62 [1.19-2.20]) occurred more frequently in patients assigned to ticagrelor as compared to patients assigned to prasugrel, without difference in safety (HR=1.08 [0.74-1.58]). There was no significant treatment allocation-by-HBR status interaction with respect to the primary (P for interaction=0.12) or secondary (P for interaction=0.80) end points. CONCLUSIONS In patients with acute coronary syndrome undergoing percutaneous coronary intervention, HBR status increased both ischemic and bleeding risk without significant impact on the relative efficacy and safety of either ticagrelor or prasugrel. These results warrant confirmation in larger cohorts. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Antonia Presch
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Gjin Ndrepepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | | | - Christian Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Rayyan Hemetsberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Austria (R.H.)
| | | | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Michael Joner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Erion Xhepa
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute for AI and Informatics in Medicine, Germany (A.H.)
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Germany (A.H.)
| | - Sebastian Kufner
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Nonglag Rifatov
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Hendrik B Sager
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Katharina Mayer
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
| | - Thorsten Kessler
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Karl-Ludwig Laugwitz
- Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum rechts der Isar, Munich, Germany (I.B., K.-L.L.)
| | - Gert Richardt
- Heart Center Bad Segeberg, Segeberger Kliniken GmbH, Bad Segeberg, Germany (G.R.)
| | - Heribert Schunkert
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg - Bad Krozingen, Standort Bad Krozingen, Germany (C.V., F.-J.N.)
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (D.S.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Adnan Kastrati
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany (S.L., I.B., M.J., H.B.S., T.K., L.L., H.S., A.K.)
| | - Salvatore Cassese
- Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technische Universität München, Germany (S.L., A.P., G.N., M.J., E.X., S.K., N.R., H.B.S., K.M., T.K., H.S., A.K., S.C.)
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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26
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Krucoff MW, Cao D, Mehran R. ARC-HBR criteria and TAVR: not all high bleeding risk patients look alike. EUROINTERVENTION 2022; 18:448-449. [PMID: 35983744 PMCID: PMC10241261 DOI: 10.4244/eij-e-22-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/21/2023]
Affiliation(s)
- Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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27
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van der Sangen NM, Küçük IT, Ten Berg JM, Beijk MA, Delewi R, den Hartog AW, Appelman Y, Verouden NJ, Kikkert WJ, Henriques JP, Claessen BE. P2Y 12-inhibitor monotherapy after coronary stenting: are all P2Y 12-inhibitors equal? Expert Rev Cardiovasc Ther 2022; 20:637-645. [PMID: 35916833 DOI: 10.1080/14779072.2022.2104248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION P2Y12-inhibitor monotherapy following 1-3 months of dual antiplatelet therapy (DAPT) reduces (major) bleeding without an apparent increase in ischemic events and has therefore emerged as an alternative to 6-12 months of DAPT following percutaneous coronary intervention (PCI). However, there are important differences between the available P2Y12-inhibitors (clopidogrel, prasugrel, and ticagrelor) as agents of choice for P2Y12-inhibitor monotherapy. AREAS COVERED This review critically appraises the evidence for P2Y12-inhibitor monotherapy after PCI using either clopidogrel, prasugrel, or ticagrelor. Furthermore, we discuss ongoing trials and future directions for research. EXPERT OPINION P2Y12-inhibitor monotherapy following 1-3 months of DAPT is an alternative to 6-12 months of DAPT following PCI. Ticagrelor may be considered the current preferred option due to its reliable effect on platelet reactivity and its predominant use in clinical trials. Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but more research into prasugrel monotherapy is warranted. Alternatively, clopidogrel can be used, although there are concerns of high platelet reactivity, especially when genotyping and/or platelet function testing are not used. Future research will need to address the minimal duration of DAPT before switching to P2Y12-inhibitor monotherapy and what the optimal antithrombotic therapy beyond 12 months is.
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Affiliation(s)
- Niels Mr van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Marcel Am Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Jw Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - José Ps Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bimmer Epm Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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28
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Simonsson M, Alfredsson J, Szummer K, Jernberg T, Ueda P. Association of Ischemic and Bleeding Events With Mortality Among Patients in Sweden With Recent Acute Myocardial Infarction Receiving Antithrombotic Therapy. JAMA Netw Open 2022; 5:e2220030. [PMID: 36036452 PMCID: PMC9425148 DOI: 10.1001/jamanetworkopen.2022.20030] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 Antithrombotic treatment after myocardial infarction (MI) should be individualized based on the patient's risk of ischemic and bleeding events. Uncertainty remains regarding the relative prognostic importance of the 2 types of events, and further study would be useful. OBJECTIVES To compare the association of ischemic vs bleeding events with mortality in patients with a recent MI and assess whether the relative mortality risk for the 2 types of events has changed over the past 2 decades. DESIGN, SETTING, AND PARTICIPANTS A cohort study based on nationwide registers in Sweden, 2012-2017, was conducted. Data were analyzed between July 2021 and May 2022. Patients with MI who were discharged alive with antithrombotic therapy (antiplatelet therapy or oral anticoagulation) were included in the analysis. MAIN OUTCOMES AND MEASURES The incidence of a first ischemic event (hospitalization for MI or ischemic stroke) or bleeding event (hospitalization with bleeding) up to 1 year after discharge and the mortality risk up to 1 year after each type of event were assessed. Cox proportional hazards regression models were used to estimate adjusted hazard ratios (aHRs) for 1-year mortality after an ischemic and bleeding event vs no event, and after an ischemic vs bleeding event. Adjusted HRs for mortality after ischemic vs bleeding events were compared among patients discharged in 1997-2000, 2001-2011, and 2012-2017. RESULTS Of 86 736 patients discharged after MI in 2012-2017 (median age, 71 [IQR, 62-80] years; 57 287 [66.0%] men), 4039 individuals experienced a first ischemic event (5.7 per 100 person-years) and 3399 experienced a first bleeding event (4.8 per 100 person-years). The mortality rate was 46.2 per 100 person-years after an ischemic event and 27.1 per 100 person-years after a bleeding event. The aHR for 1-year mortality vs no event was 4.16 (95% CI, 3.91-4.43) after an ischemic event and 3.43 (95% CI, 3.17-3.71) after a bleeding event. When the 2 types of events were compared, the aHR was 1.27 (95% CI, 1.15-1.40) for an ischemic vs bleeding event. There was no statistically significant difference in the aHR of an ischemic vs bleeding event in 1997-2000, 2001-2011, and 2012-2017. CONCLUSIONS AND RELEVANCE In this nationwide cohort study of patients with a recent MI, postdischarge ischemic events were more common and associated with higher mortality risk compared with bleeding events.
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Affiliation(s)
- Moa Simonsson
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet, Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
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29
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Galli M, Laborante R, Andreotti F, Vergallo R, Montone RA, Iaconelli A, Trani C, Burzotta F, Crea F, D’Amario D. Bleeding Complications in Patients Undergoing Percutaneous Coronary Intervention. Rev Cardiovasc Med 2022; 23:286. [PMID: 39076646 PMCID: PMC11266963 DOI: 10.31083/j.rcm2308286] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 07/31/2024] Open
Abstract
Percutaneous coronary intervention (PCI) is considered a relatively safe procedure associated with low rates of complications, but is inevitably associated with short and mid-to-long term increased bleeding risk. Besides the short term risk associated with the arterial access to perform PCI, enhanced bleeding risk persists for several months, given the need for antithrombotic therapy to prevent procedure-related thrombotic complications as well as ischemic recurrences. Bleeding is a powerful harbinger of adverse outcomes. This awareness has fuelled intense research on bleeding reduction strategies, including new PCI devices and techniques as well as new medications and antithrombotic regimens. We here review the mechanisms and prevalence of bleeding in PCI patients, discuss the available evidence from a practical point of view, and explore future perspectives on how to treat and prevent bleeding complications in these patients.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiology, Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Antonio Iaconelli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
| | - Domenico D’Amario
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS , 00168 Rome, Italy
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30
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Hu CK, Cai RP, He L, He SR, Liao JY, Su Q. A Nomogram model for predicting the occurrence of no-reflow phenomenon after percutaneous coronary intervention using the lncRNA TUG1/miR-30e/ NPPB biomarkers. J Thorac Dis 2022; 14:2158-2168. [PMID: 35813727 PMCID: PMC9264104 DOI: 10.21037/jtd-22-481] [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: 03/28/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
Background Studies have shown that percutaneous coronary intervention (PCI) is considered as the essential therapeutic strategy for the patients with ST-segment elevation myocardial infarction (STEMI). However; no-reflow could still occur in a few patients after PCI. Studies have reported that biomarkers related to no-reflow pathogenetic components could play a prognostic role in the prediction phenomenon. Hence, this study explored the establishment of nomogram model for predicting the occurrence of no-reflow phenomenon after PCI using the lncRNA TUG1/miR-30e/NPPB biomarkers in patients with STEMI after PCI. Methods In this observational study, a total of 76 STEMI patients who underwent emergency PCI between January 2018 and December 2021were included. The patients after PCI, were divided into reflow (n=44) and no-reflow groups (n=32). The demographic, environmental and clinical risk factors were assessed and analysed between the groups. Quantitative RT-PCR was used to detect TUG1, miR-30e, and NPPB messenger RNA (mRNA) expression levels in the plasma of patients after PCI. Bioinformatic methods were used to predict the interaction of the plasma TUG1/miR-30e/NPPB axis. The risk factors in the no-reflow group were screened using a logistic-regression analysis, and a nomogram prediction model was constructed and validated. Subsequently, a gene set enrichment analysis revealed the function of lncRNA TUG1. Results Plasma lncRNA TUG1 and NPPB were more highly expressed and miR-30e was more lowly expressed in the no-reflow group than the normal-reflow group (P<0.001). A negative correlation was observed between lncRNA TUG1 and miR-30e, and between miR-30e and NPPB. However, a positive correlation was observed between lncRNA TUG1 and NPPB mRNA. The bioinformatics analysis predicted multiple binding sites on the lncRNA TUG1 and miR-30e. LncRNA TUG1 [odds ratio (OR): 0.163, 95% confidence interval (CI): 0.021–0.944] and hs-CRP (OR: 2.151, 95% CI: 1.536–3.974) found to be as independent predictors. The C-index of this prediction model was 0.982 (95% CI: 0.956–1.000). Conclusions TUG1 could function as an effective biomarker for no-reflow among patients with STEMI after PCT and the proposed nomogram may provide information for individualized treatment in patients with STEMI.
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Affiliation(s)
- Chen-Kai Hu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Ru-Ping Cai
- Department of Cardiology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Lei He
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Shi-Rong He
- Department of Cardiology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Jun-Yu Liao
- Department of Cardiology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Qiang Su
- Department of Cardiology, Affiliated Hospital of Guilin Medical University, Guilin, China
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31
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Lee P, Brennan A, Dinh D, Stub D, Lefkovits J, Reid CM, Zomer E, Chin K, Liew D. The cost-effectiveness of radial access percutaneous coronary intervention: A propensity-score matched analysis of Victorian data. Clin Cardiol 2022; 45:435-446. [PMID: 35191069 PMCID: PMC9019896 DOI: 10.1002/clc.23798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 11/15/2022] Open
Abstract
Background Despite evidence of the comparative benefits of transradial access percutaneous coronary intervention (PCI) over transfemoral access, its uptake remains highly varied across Australia. Few studies have explored the implications of the choice of access site during PCI from the perspective of the Australian healthcare setting. We, therefore, performed a cost‐effectiveness analysis of radial versus femoral access PCI. Methods Data from the Victorian Cardiac Outcomes Registry (VCOR) were used to inform our economic analyses. Patients treated through either radial or femoral access PCI were propensity score‐matched using the inverse probability weighted (IPW) method, and the incidence of major bleeding and all‐cause mortality in the cohort was used to inform an economic model comprising a hypothetical sample of 1000 patients. Costs and utility data were drawn from published sources. The economic evaluation adopted the perspective of the Australian healthcare system. Results Among a cohort of 1000 patients over 1 year, there were 19 fewer deaths, and six fewer episodes of nonfatal major bleeding in the radial group compared to the femoral group. Total cost savings attributed to radial access was AUD $1 214 688. Hence, from a health economic point of view, radial access PCI was dominant over femoral access PCI. Sensitivity analyses supported the robustness of these findings. Conclusions Radial access is associated with improved patient outcomes and considerably lower costs relative to femoral access PCI. Our findings support radial access being the preferred approach for PCI across a variety of indications in Australia.
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Affiliation(s)
- Peter Lee
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Diem Dinh
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Cardiology Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Cardiology Department, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, Western Australia, Australia
| | - Ella Zomer
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ken Chin
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Laudani C, Greco A, Occhipinti G, Ingala S, Calderone D, Scalia L, Agnello F, Legnazzi M, Mauro MS, Rochira C, Buccheri S, Mehran R, James S, Angiolillo DJ, Capodanno D. Short Duration of DAPT Versus De-Escalation After Percutaneous Coronary Intervention for Acute Coronary Syndromes. JACC Cardiovasc Interv 2022; 15:268-277. [PMID: 35144783 DOI: 10.1016/j.jcin.2021.11.028] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of this study was to compare short dual antiplatelet therapy (DAPT) and de-escalation in a network meta-analysis using standard DAPT as common comparator. BACKGROUND In patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI), shortening DAPT and de-escalating to a lower potency regimen mitigate bleeding risk. These strategies have never been randomly compared. METHODS Randomized trials of DAPT modulation strategies in patients with ACS undergoing PCI were identified. All-cause death was the primary outcome. Secondary outcomes included net adverse cardiovascular events (NACE), major adverse cardiovascular events, and their components. Frequentist and Bayesian network meta-analyses were conducted. Treatments were ranked on the basis of posterior probability. Sensitivity analyses were performed to explore sources of heterogeneity. RESULTS Twenty-nine studies encompassing 50,602 patients were included. The transitivity assumption was fulfilled. In the frequentist indirect comparison, the risk ratio (RR) for all-cause death was 0.98 (95% CI: 0.68-1.43). De-escalation reduced the risk for NACE (RR: 0.87; 95% CI: 0.70-0.94) and increased major bleeding (RR: 1.54; 95% CI: 1.07-2.21). These results were consistent in the Bayesian meta-analysis. De-escalation displayed a >95% probability to rank first for NACE, myocardial infarction, stroke, stent thrombosis, and minor bleeding, while short DAPT ranked first for major bleeding. These findings were consistent in node-split and multiple sensitivity analyses. CONCLUSIONS In patients with ACS undergoing PCI, there was no difference in all-cause death between short DAPT and de-escalation. De-escalation reduced the risk for NACE, while short DAPT decreased major bleeding. These data characterize 2 contemporary strategies to personalize DAPT on the basis of treatment objectives and risk profile.
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Affiliation(s)
- Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Salvatore Ingala
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dario Calderone
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Lorenzo Scalia
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Marco Legnazzi
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Sergio Buccheri
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy.
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33
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Córdoba-Soriano JG, Gutiérrez-Díez A, Del Blanco BG, Núñez J, Amat-Santos IJ, Oteo JF, Romaguera R, Gallardo-López A, Lozano Ruíz-Poveda F, Baello P, Aguar P, Jerez-Valero M, Jiménez-Díaz VA, Serra B, Cascon JD, Morales-Ponce FJ, Portero-Portaz JJ, Melehi El Assali D, Cerrato-García P, Jiménez-Mazuecos J. Bioactive or Drug Eluting Stents in 75 years or older patients: The BIODES-75 Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:114-120. [DOI: 10.1016/j.carrev.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 11/27/2022]
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34
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Wang X, Zhao G, Zhou M, Ma C, Ge J, Huo Y, Smith SC, Fonarow GC, Hao Y, Liu J, Morgan L, Gong W, Yan Y, Liu J, Zhao D, Han Y, Nie S. Trends in Bleeding Events Among Patients With Acute Coronary Syndrome in China, 2015 to 2019: Insights From the CCC-ACS Project. Front Cardiovasc Med 2021; 8:769165. [PMID: 34966795 PMCID: PMC8710688 DOI: 10.3389/fcvm.2021.769165] [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: 09/01/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Major bleeding is a common complication following treatment for an acute coronary syndrome (ACS) and is associated with increased mortality. We aimed to explore the temporal trend of bleeding events in relation to changes of therapeutic strategies among patients hospitalized for ACS in China. Methods: The CCC-ACS project (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) is a collaborative initiative of the American Heart Association and the Chinese Society of Cardiology. We analyzed 113,567 ACS patients from 241 hospitals in China from 2015 to 2019. Major bleeding was defined as intracranial bleeding, retroperitoneal bleeding, a decline in hemoglobin levels ≥3 g/dL, transfusion with overt bleeding, bleeding requiring surgical intervention, and fatal bleeding. Kruskal-Wallis test was used to examine the trend of major bleeding over time. Results: The rate of in-hospital major bleeding decreased from 6.3% in 2015 to 4.7% in 2019 (unadjusted OR = 0.74, 95% CI: 0.68-0.80, and P < 0.001). The relative changes were consistent across almost all subgroups including patients with NSTE-ACS and STEMI, although the trend was more pronounced in NSTE-ACS patients. The decrease in bleeding was accompanied by a decrease in use of GP IIb/IIIa inhibitors and parenteral anticoagulation therapy during hospitalization. The annual reduced risk of bleeding (OR = 0.91, 95% CI: 0.89-0.93) was attenuated after stepwise adjusting for baseline characteristics and antithrombotic treatments (OR = 0.95, 95% CI: 0.93-0.97), but did not change after adjusting for invasive treatment (OR = 0.95, 95% CI: 0.93-0.97). Conclusions: There was a temporal reduction in in-hospital bleeding among Chinese ACS patients during the last 5 years, which was associated with more evidence-based use of antithrombotic therapies. Clinical Trial Registration: https://www.clinicaltrials.gov, identifier: NCT02306616.
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Affiliation(s)
- Xiao Wang
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guanqi Zhao
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Mengge Zhou
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junbo Ge
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, United States
| | - Gregg C. Fonarow
- Divisions of Cardiology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, New York, NY, United States
| | - Wei Gong
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yan Yan
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yaling Han
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Shaoping Nie
- Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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35
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Walking the Line with Ticagrelor: Meta-Analysis Comparing the Safety and Efficacy of Ticagrelor Monotherapy after a Short Course of Ticagrelor-Based Dual Antiplatelet Therapy versus Standard Therapy in Complex Percutaneous Coronary Intervention. J Clin Med 2021; 10:jcm10235506. [PMID: 34884208 PMCID: PMC8658113 DOI: 10.3390/jcm10235506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/17/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
(1) Shorter-duration dual antiplatelet therapy (DAPT) followed by single antiplatelet therapy has been shown to significantly reduce bleeding events while preserving anti-ischemic effects in patients undergoing conventional percutaneous coronary interventions (PCI). Whether this strategy is also safe and effective in complex PCI remains elusive; (2) A systematic search of randomized controlled trials comparing a short course of ticagrelor-based DAPT versus standard DAPT in patients undergoing complex PCI was performed; (3) Of 10,689 studies screened, 3 were identified for a total of 4176 participants on ticagrelor monotherapy after a short course of ticagrelor-based DAPT, and 4209 on standard DAPT. The pooled analysis revealed no difference in the outcomes of major bleeding, myocardial infarction, definite or probable stent thrombosis and ischemic stroke. A significant reduction in the risk of cardiovascular death (incidence rate ratio (IRR) 0.52; 95% CI 0.28–0.96; p = 0.04), all-cause death (IRR 0.65; 95% CI 0.49–0.86; p = 0.003), and any bleeding events (IRR 0.62; 95% CI 0.47–0.81; p < 0.001) was seen in the shorter DAPT group; (4) Among patients undergoing complex PCI, ticagrelor monotherapy after a short course of ticagrelor-based DAPT significantly reduced bleeding risk without increasing ischemic risk. More data are needed to definitively explain mortality benefits.
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O’Donoghue M, Patel S. Walking the tightrope between ischaemia and bleeding. EUROINTERVENTION 2021; 17:527-529. [PMID: 34554092 PMCID: PMC9707433 DOI: 10.4244/eijv17i7a93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Michelle O’Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, 60 Fenwood Rd, 7th Floor, Boston, MA 02115, USA
| | - Siddharth Patel
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
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