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Sabouret P, Barbato E, Montalescot G, Biondi-Zoccai G, Manzo-Silberman S. Remembering our friend Jean-Philippe Collet: a giant in cardiology, a gentleman in life. Minerva Cardiol Angiol 2024; 72:329-331. [PMID: 38535986 DOI: 10.23736/s2724-5683.24.06559-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Pierre Sabouret
- Heart Institute and Action Group, Pitié-Salpétrière Hospital, Sorbonne University, Paris, France
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | - Gilles Montalescot
- ACTION Group, Sorbonne University, Institute of Cardiology (AP-HP), Pitié-Salpêtrière Hospital, Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Italy -
- Mediterranea Cardiocentro, Naples, Italy
| | - Stéphane Manzo-Silberman
- Heart Institute and Action Group, Pitié-Salpétrière Hospital, Sorbonne University, Paris, France
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2
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Hayek A, MacDonald BJ, Marquis-Gravel G, Bainey KR, Mansour S, Ackman ML, Cantor WJ, Turgeon RD. Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis. CJC Open 2024; 6:708-720. [PMID: 38846448 PMCID: PMC11150964 DOI: 10.1016/j.cjco.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024] Open
Abstract
Background Ongoing debate remains regarding optimal antithrombotic therapy in patients with atrial fibrillation (AF) and coronary artery disease. Methods We performed a systematic review and meta-analysis to synthesize randomized controlled trials (RCTs) comparing the following: (i) dual-pathway therapy (DPT; oral anticoagulant [OAC] plus antiplatelet) vs triple therapy (OAC and dual-antiplatelet therapy) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS), and (iii) OAC monotherapy vs DPT at least 1 year after PCI or ACS. Following a 2-stage process, we identified systematic reviews published between 2019 and 2022 on these 2 clinical questions, and we updated the most comprehensive search for additional RCTs published up to October 2022. Outcomes of interest were major adverse cardiovascular events (MACE), death, stent thrombosis, and major bleeding. We estimated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model. Results Based on 6 RCTs (n = 10,435), DPT reduced major bleeding (RR 0.62, 95% CI 0.52-0.73) and increased stent thrombosis (RR 1.55, 95% CI 1.02-2.36), vs triple therapy after PCI or medically-managed ACS, with no significant differences in MACE and death. In 2 RCTs (n = 2905), OAC monotherapy reduced major bleeding (RR 0.66, 95% CI 0.49-0.91) vs DPT in AF patients with remote PCI or ACS, with no significant differences in MACE or death. Conclusions In patients with AF and coronary artery disease, using less-aggressive antithrombotic treatment (DPT after PCI or ACS, and OAC alone after remote PCI or ACS) reduced major bleeding, with an increase in stent thrombosis with recent PCI. These results support a minimalist yet personalized antithrombotic strategy for these patients.
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Affiliation(s)
- Ahmad Hayek
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Margaret L. Ackman
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Parfrey S, Teh AW, Roberts L, Brennan A, Clark D, Duffy SJ, Ajani AE, Reid CM, Freeman M. The role of CHA2DS2-VASc score in evaluating patients with atrial fibrillation undergoing percutaneous coronary intervention. Coron Artery Dis 2021; 32:288-294. [PMID: 33394696 DOI: 10.1097/mca.0000000000000987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI). BACKGROUND The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated. METHODS The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups. RESULTS A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P < 0.001). High-risk patients were more likely to have renal impairment and multivessel disease. Increasing CHA2DS2-VASc score was associated with increased risk of stroke (0, 2, 6; P = 0.03). However, only 41.9% received anticoagulation, with no difference across the risk groups. When compared to low-risk, intermediate [HR 3.57; 95% confidence interval (CI), 1.28-9.92; P = 0.015] and high (hazard ratio 7.82; 95% CI, 2.88-21.24; P < 0.001) CHA2DS2-VASc scores were significant predictors of long-term mortality. CONCLUSIONS Higher CHA2DS2-VASc scores in patients with atrial fibrillation undergoing PCI are associated with significantly worse outcomes. Despite being high-risk, the patients in this cohort are likely undertreated with anticoagulation. Close clinical follow-up with greater utilization of anticoagulation and optimal medical therapy has the potential to improve long-term outcomes.
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Affiliation(s)
| | - Andrew W Teh
- Department of Cardiology, Box Hill Hospital
- Department of Cardiology, Austin Hospital
| | | | - Angela Brennan
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
| | - David Clark
- Department of Cardiology, Austin Hospital
- University of Melbourne
| | - Stephen J Duffy
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- Department of Cardiovascular Medicine, Alfred Hospital
| | - Andrew E Ajani
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- University of Melbourne
- Department of Cardiology, Royal Melbourne Hospital
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics (CCRE), Monash University
- John Curtain Distinguished Professor Director, Centre for Clinical Research and Education Director, WAHTN Clinical Trials and Data Management Centre, Curtain University, Perth, Western Australia, Australia
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Capodanno D, Di Maio M, Greco A, Bhatt DL, Gibson CM, Goette A, Lopes RD, Mehran R, Vranckx P, Angiolillo DJ. Safety and Efficacy of Double Antithrombotic Therapy With Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e017212. [PMID: 32805186 PMCID: PMC7660808 DOI: 10.1161/jaha.120.017212] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 06/18/2020] [Indexed: 02/06/2023]
Abstract
Background The optimal antithrombotic therapy for patients with atrial fibrillation undergoing percutaneous coronary intervention is a topic of debate. We aimed at defining the efficacy and safety of double antithrombotic therapy with single antiplatelet therapy (SAPT) plus a non-vitamin K antagonist oral anticoagulant (NOAC) against triple antithrombotic therapy with dual antiplatelet therapy (DAPT) added to a vitamin K antagonist (VKA), illustrating the pooled cumulative distribution of events, the ranking of different NOACs tested in NOAC+SAPT combination strategies, and the state of the current evidence in the field. Methods and Results Randomized controlled trials meeting the inclusion criteria were identified. The primary efficacy end point was the composite of trial-defined major adverse cardiac events. The primary safety end point was clinically significant bleeding. Secondary end points were the components of primary end points. Trial-level pairwise and Bayesian network meta-analyses, reconstructed Kaplan-Meier analyses, and trial sequential analysis were performed. Four randomized controlled trials (10 969 patients) were included. No differences were found in terms of major adverse cardiac events (hazard ratio [HR], 1.07; 95% CI, 0.94-1.22), and the NOAC+SAPT strategy showed a lower rate of clinically significant bleeding compared with VKA + DAPT (HR, 0.56; 95% CI, 0.39-0.80). These results were consistent in reconstructed Kaplan-Meier analyses. In the Bayesian network meta-analysis, different NOACs displayed diverse risk-benefit profiles. Trial sequential analyses suggest that the evidence for the similarity in major adverse cardiac events compared with VKA + DAPT and the bleeding risk reduction observed with NOAC+SAPT is likely to be conclusive. Conclusions NOAC+SAPT does not increase the risk of major adverse cardiac events and reduces the risk of bleeding compared with VKA + DAPT in AF patients undergoing percutaneous coronary intervention. Various NOACs may have different risk-benefit profiles in combination strategies. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42020151089.
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Affiliation(s)
- Davide Capodanno
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Marco Di Maio
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
- Division of CardiologyDepartment of Translational Medical SciencesUniversity of Campania "Luigi Vanvitelli"NaplesItaly
| | - Antonio Greco
- Division of CardiologyA.O.U. Policlinico "G. Rodolico ‐ S. Marco"University of CataniaItaly
| | - Deepak L. Bhatt
- Department of MedicineBrigham and Women’s Hospital and Harvard Medical SchoolBostonMA
| | - C. Michael Gibson
- Cardiovascular DivisionDepartment of MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA
| | - Andreas Goette
- Atrial Fibrillation NetworkMunsterGermany
- Cardiology and Intensive Care MedicineSt Vincenz‐HospitalPaderbornGermany
- Working Group of Molecular ElectrophysiologyUniversity Hospital MagdeburgMagdeburgGermany
| | | | - Roxana Mehran
- Cardiovascular InstituteMount Sinai Medical CenterIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Pascal Vranckx
- Jessa ZiekenhuisFaculty of Medicine and Life Sciences at the Hasselt UniversityHasseltBelgium
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Non-Vitamin K Oral Anticoagulants (NOAC) Versus Vitamin K Antagonists (VKA) for Atrial Fibrillation with Elective or Urgent Percutaneous Coronary Intervention: A Meta-Analysis with a Particular Focus on Combination Type. J Clin Med 2020; 9:jcm9041120. [PMID: 32295160 PMCID: PMC7230168 DOI: 10.3390/jcm9041120] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/03/2020] [Accepted: 04/07/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Our study aims to perform a meta-analysis of benefits and risks associated with the use of non-vitamin K oral anticoagulants (NOAC) versus vitamin K antagonists (VKA) in patients with a percutaneous coronary intervention (PCI) with a particular focus on the combination type: dual vs. dual antithrombotic therapy (DAT: NOAC + single antiplatelet therapy (SAPT) vs. DAT: VKA + SAPT), dual vs. triple antithrombotic therapy (DAT: NOAC + SAPT vs. TAT: VKA + dual antiplatelet therapy (DAPT)) or triple vs. triple antithrombotic therapy (TAT: NOAC+DAPT vs. TAT: VKA+DAPT). METHODS PubMed, EMBASE, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens. Four randomized studies (n = 10.969; PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, and ENTRUST-AF PCI) were included. The primary outcome was the composite of major bleeding defined by the International Society on Thrombosis and Hemostasis (ISTH) and clinically relevant bleeding requiring medical intervention (CRNM). Secondary outcomes included all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and stent thrombosis (ST). RESULTS Combination strategies with NOACs were associated with reduced risk of major bleeding events across different combination strategies as compared to VKA, with the most significant risk reduction when DAT was compared with TAT, namely DAT with NOAC + SAPT was associated with a 37% relative risk reduction (RRR) of major bleeding events as compared to TAT with VKA + DAPT (RR 0.63; 95% CI, 0.50-0.80). The reduction of major bleeding risks is a class effect of NOACs. Combination strategies of NOACs vs. VKAs resulted in a comparable risk of MACE, MI, stroke, ST, or death. CONCLUSIONS Antithrombotic combinations of NOACs (as DAT or TAT) are safer than VKAs with respect to bleeding risk and result in a satisfactory efficacy with no increase of ischemic or thrombotic events in patients undergoing PCI.
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Capodanno D. Triple antithrombotic therapy after ACS and PCI in patients on chronic oral anticoagulation: update. Heart 2018; 104:1976-1983. [PMID: 29695514 DOI: 10.1136/heartjnl-2017-312228] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero-Universitaria "Policlinico-Vittorio Emanuele", Catania, Italy.,Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
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7
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Sherwood MW, Cyr DD, Jones WS, Becker RC, Berkowitz SD, Washam JB, Breithardt G, Fox KAA, Halperin JL, Hankey GJ, Singer DE, Piccini JP, Nessel CC, Mahaffey KW, Patel MR. Use of Dual Antiplatelet Therapy and Patient Outcomes in Those Undergoing Percutaneous Coronary Intervention: The ROCKET AF Trial. JACC Cardiovasc Interv 2017; 9:1694-702. [PMID: 27539689 DOI: 10.1016/j.jcin.2016.05.039] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 05/04/2016] [Accepted: 05/19/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The authors assessed the use of dual antiplatelet therapy (DAPT) and outcomes in patients undergoing percutaneous coronary intervention (PCI) during the ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation). BACKGROUND The frequency, patterns, and outcomes when adding DAPT to non-vitamin K antagonist oral anticoagulants in the setting of PCI in patients with AF are largely unknown. METHODS The study population included all patients in the treatment group of the ROCKET AF trial divided by the receipt of PCI during follow-up. Clinical characteristics, PCI frequency, and rates of DAPT were reported. Clinical outcomes were adjudicated independently as part of the trial. RESULTS Among 14,171 patients, 153 (1.1%) underwent PCI during a median 806 days of follow-up. Patients treated with rivaroxaban were significantly less likely to undergo PCI compared with warfarin-treated patients (61 vs. 92; p = 0.01). Study drug was continued during PCI in 81% of patients. Long-term DAPT (≥30 days) was used in 37% and single antiplatelet therapy in 34%. A small number switched from DAPT to monotherapy within 30 days of PCI (n = 19 [12.3%]) and 15% of patients received no antiplatelet therapy after PCI. Rates of stroke/systemic embolism and major bleeding events were high in post-PCI patients (4.5/100 patient-years and 10.2/100 patient-years) in both treatment groups. CONCLUSIONS In patients with AF at moderate to high risk for stroke, PCI occurred in <1% per year. DAPT was used in a variable manner, with the majority of patients remaining on study drug after PCI. Rates of both thrombotic and bleeding events were high after PCI, highlighting the need for studies to determine the optimal antithrombotic therapy.
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Affiliation(s)
| | - Derek D Cyr
- Duke Clinical Research Institute, Durham, North Carolina
| | - W Schuyler Jones
- Duke Clinical Research Institute, Durham, North Carolina; Duke Heart Center, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Jeffrey B Washam
- Duke Heart Center, Duke University School of Medicine, Durham, North Carolina
| | | | - Keith A A Fox
- University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jonathan L Halperin
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Graeme J Hankey
- School of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia
| | - Daniel E Singer
- Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina; Duke Heart Center, Duke University School of Medicine, Durham, North Carolina
| | | | | | - Manesh R Patel
- Duke Clinical Research Institute, Durham, North Carolina; Duke Heart Center, Duke University School of Medicine, Durham, North Carolina
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Capodanno D. Oral antithrombotic therapy after acute coronary syndromes: “dual antiplatelet” or “dual pathway”? EUROINTERVENTION 2017; 13:773-775. [DOI: 10.4244/eijv13i7a112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Colombo A, Giannini F, Briguori C. Should We Still Have Bare-Metal Stents Available in Our Catheterization Laboratory? J Am Coll Cardiol 2017; 70:607-619. [PMID: 28750704 DOI: 10.1016/j.jacc.2017.05.057] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/21/2017] [Accepted: 05/26/2017] [Indexed: 12/17/2022]
Abstract
The introduction of bare-metal stents (BMS) has represented a major advancement over plain old balloon angioplasty in the management of coronary artery disease. However, the high rates of target lesion revascularization associated with use of BMS have led to the development of drug-eluting stents, which require prolonged dual antiplatelet therapy due to the increased risk of late and very late stent thrombosis. The improvements in newer-generation drug-eluting stents have translated into better safety and efficacy compared with earlier generation and BMS, thus allowing shorter dual antiplatelet therapy duration. Here, we aim to provide reasons as to why we still need BMS in our cardiac catheterization laboratory.
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Affiliation(s)
- Antonio Colombo
- Unit of Cardiovascular Interventions, Istituto Di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy.
| | - Francesco Giannini
- Unit of Cardiovascular Interventions, Istituto Di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Briguori
- Unit of Cardiovascular Interventions, Istituto Di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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Pelliccia F, Rollini F, Marazzi G, Greco C, Gaudio C, Angiolillo DJ, Rosano G. New oral anticoagulants and dual antiplatelet therapy: Focus on apixaban. Int J Cardiol 2016; 225:154-158. [PMID: 27723533 DOI: 10.1016/j.ijcard.2016.09.125] [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: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
Abstract
The combination of AF and coronary artery disease not only is a common clinical setting, it is also a complex setting to deal with anticoagulation and antiplatelet therapy, and it is associated with significantly higher mortality rates. Unfortunately, there are no sufficient data available to optimally guide clinical practice in such settings. This review focuses specifically on newer oral anticoagulants (NOACs) associated with dual antiplatelet therapy (DAPT) in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). There are no randomized studies comparing vitamin K antagonists and NOACs in patients with AF undergoing PCI either for acute coronary syndromes or for stable patients, i.e. those patients who have an indication to receive DAPT. Moreover, new antiplatelet agents such as ticagrelor and prasugrel have entered the market for acute coronary syndromes. So far, there are no large-scale randomized studies published evaluating these newer antiplatelet agents in patients with AF receiving either vitamin K antagonists or NOACs, adding to the uncertainty on how to use these antithrombotics in combination when both coronary artery disease (unstable or stable patients) and AF converge in a given patient. The lack of large outcome trials and the large number of possible combinations are reflected in the wide variety of practices in the real world. To date, given the lack of data, watchfulness when using NOACs as component of DAPT or triple oral antithrombotic therapy is warranted.
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Affiliation(s)
| | - Fabiana Rollini
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, United States
| | | | - Cesare Greco
- Department 'Attilio Reale', Sapienza University, Rome, Italy
| | - Carlo Gaudio
- Department 'Attilio Reale', Sapienza University, Rome, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
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Antiplatelet and Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Coronary Stenting. Interv Cardiol Clin 2016; 6:91-117. [PMID: 27886825 DOI: 10.1016/j.iccl.2016.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Stroke prevention is the main priority in the management cascade of atrial fibrillation. Most patients require long-term oral anticoagulation (OAC) and may require percutaneous coronary intervention. Prevention of recurrent cardiac ischemia and stent thrombosis necessitate dual antiplatelet therapy (DAPT) for up to 12 months. Triple antithrombotic therapy with OAC plus DAPT of shortest feasible duration is warranted, followed by dual antithrombotic therapy of OAC and antiplatelet agent, and OAC alone after 12 months. Because of elevated risk of hemorrhagic complications, new-generation drug-eluting stents, lower-intensity OAC, radial access, and routine use of gastric protection with proton pump inhibitors are recommended.
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Koskinas KC, Räber L, Zanchin T, Pilgrim T, Stortecky S, Hunziker L, Blöchlinger S, Billinger M, Gartwyl F, Moro C, Moschovitis A, Jüni P, Heg D, Windecker S. Duration of Triple Antithrombotic Therapy and Outcomes Among Patients Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2016; 9:1473-83. [DOI: 10.1016/j.jcin.2016.04.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 12/22/2022]
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13
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De Caterina R, Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Collet JP, Halvorsen S, Huber K, Jespersen J, Kristensen SD, Lip GYH, Morais J, Rasmussen LH, Ricci F, Sibbing D, Siegbahn A, Storey RF, Ten Berg J, Verheugt FWA, Weitz JI. Oral anticoagulants in coronary heart disease (Section IV). Position paper of the ESC Working Group on Thrombosis - Task Force on Anticoagulants in Heart Disease. Thromb Haemost 2016; 115:685-711. [PMID: 26952877 DOI: 10.1160/th15-09-0703] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Accepted: 01/29/2016] [Indexed: 11/05/2022]
Abstract
Until recently, vitamin K antagonists (VKAs) were the only available oral anticoagulants evaluated for long-term treatment of patients with coronary heart disease (CHD), particularly after an acute coronary syndrome (ACS). Despite efficacy in this setting, VKAs are rarely used because they are cumbersome to administer. Instead, the more readily manageable antiplatelet agents are the mainstay of prevention in ACS patients. This situation has the potential to change with the introduction of non-VKA oral anticoagulants (NOACs), which are easier to administer than VKAs because they can be given in fixed doses without routine coagulation monitoring. The NOACs include dabigatran, which inhibits thrombin, and apixaban, rivaroxaban and edoxaban, which inhibit factor Xa. Apixaban and rivaroxaban were evaluated in phase III trials for prevention of recurrent ischaemia in ACS patients, most of whom were also receiving dual antiplatelet therapy with aspirin and clopidogrel. Although at the doses tested rivaroxaban was effective and apixaban was not, both agents increased major bleeding. The role for the NOACs in ACS management, although promising, is therefore complicated, because it is uncertain how they compare with newer antiplatelet agents, such as prasugrel, ticagrelor or vorapaxar, and because their safety in combination with these other drugs is unknown. Ongoing studies are also now evaluating the use of NOACs in non-valvular atrial fibrillation patients, where their role is established, with coexistent ACS or coronary stenting. Focusing on CHD, we review the results of clinical trials with the NOACs and provide a perspective on their future incorporation into clinical practice.
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Affiliation(s)
- Raffaele De Caterina
- Raffaele De Caterina, MD, PhD, Institute of Cardiology, "G. d'Annunzio" University - Chieti, Ospedale SS. Annunziata, Via dei Vestini, 66013 Chieti, Italy, E-mail:
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Byrne RA, Joner M, Kastrati A. Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Grüntzig Lecture ESC 2014. Eur Heart J 2015; 36:3320-31. [PMID: 26417060 PMCID: PMC4677274 DOI: 10.1093/eurheartj/ehv511] [Citation(s) in RCA: 377] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022] Open
Abstract
Modern-day stenting procedures leverage advances in pharmacotherapy and device innovation. Patients treated with contemporary antiplatelet agents, peri-procedural antithrombin therapy and new-generation drug-eluting stents (DES) have excellent outcomes over the short to medium term. Indeed, coupled with the reducing costs of these devices in most countries there remain very few indications where patients should be denied treatment with standard-of-care DES therapy. The two major causes of stent failure are stent thrombosis (ST) and in-stent restenosis (ISR). The incidence of both has reduced considerably in recent years. Current clinical registries and randomized trials with broad inclusion criteria show rates of ST at or <1% after 1 year and ∼0.2-0.4% per year thereafter; rates of clinical ISR are 5% respectively. Angiographic surveillance studies in large cohorts show rates of angiographic ISR of ∼10% with new-generation DES. The advent of high-resolution intracoronary imaging has shown that in many cases of late stent failure neoatherosclerotic change within the stented segment represents a final common pathway for both thrombotic and restenotic events. In future, a better understanding of the pathogenesis of this process may translate into improved late outcomes. Moreover, the predominance of non-stent-related disease as a cause of subsequent myocardial infarction during follow-up highlights the importance of lifestyle and pharmacological interventions targeted at modification of the underlying disease process. Finally, although recent developments focus on strategies which circumvent the need for chronically indwelling stents--such as drug-coated balloons or fully bioresorbable stents-more data are needed before the wider use of these therapies can be advocated.
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Affiliation(s)
- Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, Munich, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, Munich, Germany DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Coronary stent selection and optimal course of dual antiplatelet therapy in patients at high bleeding or thrombotic risk. Curr Opin Cardiol 2015; 30:325-32. [DOI: 10.1097/hco.0000000000000185] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Htun NM, Peter K. Non-vitamin K antagonist oral anticoagulants (NOACs) in the cardiac catherisation laboratory: Friends or Foes? Thromb Haemost 2015; 114:214-6. [PMID: 25995026 DOI: 10.1160/th15-04-0298] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/10/2015] [Indexed: 11/05/2022]
Affiliation(s)
| | - K Peter
- Prof. Karlheinz Peter, Baker IDI Heart and Diabetes Institute, PO Box 6492, Melbourne, Victoria 3004, Australia, Tel.:+61 3 8532 1490, Fax: +61 3 8532 1100, E-mail:
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Rohla M, Weiss TW, Wojta J, Niessner A, Huber K. Double or triple antithrombotic combination therapy in patients who need anticoagulation and antiplatelet therapy in parallel. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:191-7. [DOI: 10.1093/ehjcvp/pvv014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 03/16/2015] [Indexed: 01/28/2023]
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Windecker S. Standards of care: The EAPCI, guidelines and consensus documents. EUROINTERVENTION 2015; 10:1022-3. [DOI: 10.4244/eijv10i9a175] [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]
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Serruys PW. Positioning consensus for guidance. EUROINTERVENTION 2015; 10:1013-4. [DOI: 10.4244/eijv10i9a173] [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]
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