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Miyake K, Ikeda S, Sadachi Y, Sugimoto M, Furugori T, Kimura T, Yakushiji Y. Evolution of antiplatelet therapy in Japan for the management of cerebrovascular and cardiovascular disease: a survey using data from an insurance claims data information service. Expert Opin Pharmacother 2024:1-10. [PMID: 39290164 DOI: 10.1080/14656566.2024.2404108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 09/10/2024] [Accepted: 09/10/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND Non-cardioembolic ischemic stroke (NCIS) and ischemic heart disease (IHD) require secondary prevention with antiplatelet therapy (APT). We investigated APT prescription status for patients with NCIS and IHD. RESEARCH DESIGN AND METHODS This retrospective study utilized claims data from patients with NCIS and those who underwent percutaneous coronary intervention for IHD and received antiplatelet drugs. The study included Phases A (2015-2016), B (2017-2018), and C (2019-2020). We evaluated patient characteristics, APT prescription rates (dual [DAPT] and single [SAPT]), and prescriptions by NCIS subtype. RESULTS In the NCIS cohort, the initial DAPT prescription rate increased over time (Phase A: 14.9%, B: 19.2%, C: 28.0%), but decreased to 6% after 3 months. Subsequently, 25% of patients did not receive APT. For IHD, DAPT duration decreased over time, with 12-month prescription rates of 48.0%, 43.1%, and 32.6% for Phases A, B, and C, respectively. SAPT prescriptions, predominantly aspirin, increased, and use of P2Y12 inhibitors also rose. Few patients (10%) did not receive APT. CONCLUSIONS Shorter DAPT duration/earlier switching to SAPT for NCIS and IHD have gained acceptance in regional medical care. A higher proportion of NCIS vs IHD patients did not receive APT in the chronic phase. TRIAL REGISTRATION UMIN000052198.
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Affiliation(s)
- Kosuke Miyake
- Department of Neurology, Kansai Medical University, Hirakata, Japan
| | - Shuhei Ikeda
- Department of Neurology, Kansai Medical University, Hirakata, Japan
| | - Yu Sadachi
- Data Intelligence Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Masako Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Taketoshi Furugori
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd, Tokyo, Japan
| | - Yusuke Yakushiji
- Department of Neurology, Kansai Medical University, Hirakata, Japan
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2
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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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3
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Geisler T, Poli S, Huber K, Rath D, Aidery P, Kristensen SD, Storey RF, Ball A, Collet JP, Berg JT. Resumption of Antiplatelet Therapy after Major Bleeding. Thromb Haemost 2023; 123:135-149. [PMID: 35785817 DOI: 10.1055/s-0042-1750419] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Major bleeding is a common threat in patients requiring antiplatelet therapy. Timing and intensity with regard to resumption of antiplatelet therapy represent a major challenge in clinical practice. Knowledge of the patient's bleeding risk, defining transient/treatable and permanent/untreatable risk factors for bleeding, and weighing these against thrombotic risk are key to successful prevention of major adverse events. Shared decision-making involving various disciplines is essential to determine the optimal strategy. The present article addresses clinically relevant questions focusing on the most life-threatening or frequently occurring bleeding events, such as intracranial hemorrhage and gastrointestinal bleeding, and discusses the evidence for antiplatelet therapy resumption using individual risk assessment in high-risk cardiovascular disease patients.
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Affiliation(s)
- Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls-University Tuebingen, Tuebingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Dominik Rath
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Parwez Aidery
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Tuebingen, Germany
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Alex Ball
- Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne Université, Paris, France
| | - Jurriën Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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4
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Garg A, Rout A, Farhan S, Waxman S, Giustino G, Tayal R, Abbott JD, Huber K, Angiolillo DJ, Rao SV. Dual antiplatelet therapy duration after percutaneous coronary intervention using drug eluting stents in high bleeding risk patients: A systematic review and meta-analysis. Am Heart J 2022; 250:1-10. [PMID: 35436504 DOI: 10.1016/j.ahj.2022.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 03/11/2022] [Accepted: 04/12/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Optimal dual antiplatelet therapy (DAPT) duration in patients at high bleeding risk (HBR) is not fully defined. We aimed to compare the safety and effectiveness of short-term DAPT (S-DAPT) with longer duration DAPT (L-DAPT) after percutaneous coronary intervention (PCI) with drug eluting stents (DES) in patients at HBR. METHODS We searched for studies comparing S-DAPT (≤3 months) followed by aspirin or P2Y 12 inhibitor monotherapy against L-DAPT (6-12 months) after PCI in HBR patients. Primary end points of interest were major bleeding and myocardial infarction (MI). Random-effects meta-analyses were performed to calculate odds ratios with 95% CIs. RESULTS Six randomized trials and 3 propensity-matched studies (n = 16,848) were included in the primary analysis. Compared with L-DAPT (n = 8,422), major bleeding was lower with S-DAPT (n = 8,426) [OR 0.68; 95% CI 0.51-0.89] whereas MI did not differ significantly between the 2 groups [1.16; 0.94-1.44]. There were no significant differences in risks of death, stroke or stent thrombosis (ST) between S-DAPT and L-DAPT groups. These findings were consistent when propensity-matched studies were analysed separately. Finally, there was a numerically higher, albeit statistically non-significant, ST in the S-DAPT arm of patients without an indication for OAC [1.98; 0.86-4.58]. CONCLUSIONS Among HBR patients undergoing current generation DES implantation, S-DAPT reduces bleeding without an increased risk of death or MI compared with L-DAPT. More research is needed to (1) evaluate risks of late ST after 1 to 3 months DAPT among patients with high ischemic and bleeding risks, (2) defining the SAPT of choice after 1 to 3 months DAPT.
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Affiliation(s)
- Aakash Garg
- Division of Cardiology, Brown University, Providence, RI.
| | - Amit Rout
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Serdar Farhan
- Division of Cardiology, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Sergio Waxman
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ
| | - Gennaro Giustino
- Division of Cardiology, University of Louisville, Louisville, KY
| | - Raj Tayal
- Division of Cardiology, Valley Hospital, Ridgewood, NJ
| | | | - Kurt Huber
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Sunil V Rao
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC
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5
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Yokoi H, Oda E, Kaneko K, Matsubayashi K. Duration and clinical outcome of dual antiplatelet therapy after percutaneous coronary intervention: a retrospective cohort study using a medical information database from Japanese hospitals. Cardiovasc Interv Ther 2022; 37:465-474. [PMID: 35141843 PMCID: PMC9197891 DOI: 10.1007/s12928-021-00833-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 12/09/2021] [Indexed: 01/01/2023]
Abstract
In this real-world, retrospective cohort study of 9753 patients in Japan prescribed dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI), we investigated DAPT duration and determined factors associated with early DAPT discontinuation and with event rates in patients who discontinued DAPT. The study period was April 1, 2012–March 31, 2018; endpoints comprised composite efficacy [death, myocardial infarction (MI), and stroke] and bleeding (intracranial, gastrointestinal, and requiring transfusion) endpoints. Overall, 68.8% of patients were continuing DAPT at 3 months post-PCI. Patients without major efficacy or safety events within 3 months after index PCI were included in a landmark analysis set (LAS; n = 7056), and categorized as DAPT ≥ 3 months (continuation) versus < 3 months (discontinuation). In the two LAS analysis groups, there was no difference in the composite bleeding endpoint (P = 0.067), although the incidence of the composite efficacy endpoint was higher in the discontinuation group (P < 0.001). In multivariate regression analysis, age ≥ 75 years, minor bleeding after PCI, history of cerebral infarction, history of cerebral or gastrointestinal bleeding, atrial fibrillation, dialysis, and anticoagulant use after PCI were associated with early DAPT discontinuation. Acute coronary syndrome, history of MI, kidney disorder, and anticoagulant use after PCI were associated with the composite efficacy endpoint in the discontinuation group. In conclusion, early DAPT discontinuation is more likely in patients at high bleeding risk, but may influence the occurrence of ischemic events in these patients. Determination of DAPT duration should take into account potential ischemic risk, even in patients at high bleeding risk.
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Affiliation(s)
- Hiroyoshi Yokoi
- Cardiovascular Medicine Center, Fukuoka Sanno Hospital, 3-6-45 Momochihama, Sawara-ku, Fukuoka, 814-0001, Japan. .,International University of Health and Welfare, Tochigi, Japan.
| | - Eisei Oda
- StatLink Medical Statistics Consulting Service, Tokyo, Japan
| | - Kazuki Kaneko
- EBM Unit, Medical Data Vision Co., Ltd., Tokyo, Japan
| | - Kenta Matsubayashi
- Clinical Development Department II, Daiichi Sankyo Co., Ltd., Tokyo, Japan
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6
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Russo JJ, Yan AT, Pocock SJ, Brieger D, Owen R, Sundell KA, Bagai A, Granger CB, Cohen MG, Yasuda S, Nicolau JC, Brandrup-Wognsen G, Westermann D, Simon T, Goodman SG. Determinants of long-term dual antiplatelet therapy use in post myocardial infarction patients: Insights from the TIGRIS registry. J Cardiol 2021; 79:522-529. [PMID: 34857432 DOI: 10.1016/j.jjcc.2021.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patterns of dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI) have not been well studied. METHODS TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 24 countries), observational study of patients 1 to 3 years post-MI. We sought to identify the prevalence and determinants of DAPT use ≥1 year post-MI in patients enrolled in TIGRIS. We used multivariable logistic regression to identify determinants of DAPT use at 396 days post-MI (365 days plus a 31day overrun period to account for intended DAPT discontinuation at 1 year). Patients treated with an oral anticoagulant were excluded. RESULTS Of 7708 patients (median age 67 years, women 25%, ST-elevation MI 50%), 39% and 16% were on DAPT at 396 days and 5 years post-MI, respectively. DAPT use at 396 days post-MI was more prevalent in patients <65 years of age, treated with percutaneous coronary intervention (versus coronary artery bypass grafting or medical therapy), and with multivessel disease or a history of angina. Additional clinical determinants of ischemic and/or bleeding events following MI (diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independently associated with DAPT use at 396 days. There were geographic variations in the use of DAPT at 396 days (p<0.001), with the lowest use in Europe and the highest in Asia and Australia. CONCLUSION In a contemporary patient cohort, DAPT use beyond 1 year post MI was prevalent and associated with patient and index event characteristics. There were marked geographical variations in DAPT use beyond 1 year post MI.
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Affiliation(s)
- Juan J Russo
- University of Ottawa Heart Institute, Ottawa, Canada
| | - Andrew T Yan
- St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Stuart J Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David Brieger
- Concord Hospital, University of Sydney, Sydney, Australia
| | - Ruth Owen
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Akshay Bagai
- St Michael's Hospital, University of Toronto, Toronto, Canada
| | | | | | - Satoshi Yasuda
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas sHCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | | | | | - Tabassome Simon
- Assistance Publique-Hôpitaux de Paris (APHP), UPMC-Paris 06 University, Paris, France
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Toronto, Canada.
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De Filippo O, Piroli F, Bruno F, Bocchino PP, Saglietto A, Franchin L, Angelini F, Gallone G, Alabed S, Gasparini M, Ahmad M, De Ferrari GM, D'Ascenzo F. De-escalation of dual antiplatelet therapy for patients with acute coronary syndrome after percutaneous coronary intervention: a network meta-analysis of randomised controlled trials. Hippokratia 2021. [DOI: 10.1002/14651858.cd014813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ovidio De Filippo
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Francesco Piroli
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Francesco Bruno
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Andrea Saglietto
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Luca Franchin
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine; University of Turin; Turin Italy
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease; University of Sheffield; Sheffield UK
| | - Mauro Gasparini
- Dipartimento di Scienze Matematiche (DISMA); Giuseppe Luigi Lagrange, Politecnico di Torino; Torino Italy
| | - Mahmood Ahmad
- Department of Cardiology; Royal Free Hospital, Royal Free London NHS Foundation Trust; London UK
| | | | - Fabrizio D'Ascenzo
- Department of Internal Medicine; Division of Cardiology, University of Turin; Turin Italy
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8
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Ayoub A, Ayinapudi K, Al-Ogaili A, Panhwar MS, Dakkak W, LeJemtel T. Toward Brief Dual Antiplatelet Therapy and P2Y12 Inhibitors for Monotherapy After PCI. Am J Cardiovasc Drugs 2021; 21:153-163. [PMID: 32780215 DOI: 10.1007/s40256-020-00430-0] [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] [Indexed: 11/27/2022]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention remains a controversial topic. The European Society of Cardiology and the American College of Cardiology/American Heart Association recommend at least 6 and 12 months of DAPT after PCI in patients with stable coronary artery disease or acute coronary syndrome, respectively. Although prolonging DAPT duration reduces ischemic events, it is associated with higher rates of bleeding and possible fatal outcomes. The DAPT score can be an important tool to identify patients who may still benefit from prolonged therapy. Nevertheless, several recent randomized controlled trials showed that shortening DAPT duration from 12 to 1-3 months reduces bleeding rates without significantly increasing ischemic event rates. These trials also suggested replacing acetylsalicylic acid (aspirin) with P2Y12 inhibitors after short-term DAPT. We review and compare past and present studies regarding DAPT and analyze the evidence favoring a short DAPT duration and the long-term single antiplatelet agent of choice.
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Affiliation(s)
- Ali Ayoub
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA.
| | - Karnika Ayinapudi
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Ahmed Al-Ogaili
- Department of Cardiology, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, USA
| | - Muhammad Siyab Panhwar
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
| | - Wael Dakkak
- Department of Medicine, Southern Illinois University, Springfield, IL, USA
| | - Thierry LeJemtel
- Tulane University Heart and Vascular Institute, 1415 Tulane Ave, New Orleans, LA, 70112, USA
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9
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Langer G, Gartlehner G, Schwingshackl L, Töws I, Meerpohl JJ. GRADE-Leitlinien: 17. Beurteilung des Bias-Risikos durch fehlende Endpunkt-Daten im Evidenzkörper. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2020; 149:73-81. [PMID: 32122800 DOI: 10.1016/j.zefq.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To provide GRADE guidance for assessing risk of bias across an entire body of evidence consequent on missing data for systematic reviews of both binary and continuous outcomes. STUDY DESIGN AND SETTING Systematic survey of published methodological research, iterative discussions, testing in systematic reviews, and feedback from the GRADE Working Group. RESULTS Approaches begin with a primary meta-analysis using a complete case analysis followed by sensitivity meta-analyses imputing, in each study, data for those with missing data, and then pooling across studies. For binary outcomes, we suggest use of "plausible worst case" in which review authors assume that those with missing data in treatment arms have proportionally higher event rates than those followed successfully. For continuous outcomes, imputed mean values come from other studies within the systematic review and the standard deviation (SD) from the median SDs of the control arms of all studies. CONCLUSIONS If the results of the primary meta-analysis are robust to the most extreme assumptions viewed as plausible, one does not rate down certainty in the evidence for risk of bias due to missing participant outcome data. If the results fail to prove robust to plausible assumptions, one would rate down certainty in the evidence for risk of bias.
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Affiliation(s)
- Gero Langer
- Martin-Luther-Universität Halle-Wittenberg, Medizinische Fakultät, Institut für Gesundheits- und Pflegewissenschaft, Halle (Saale), Deutschland.
| | - Gerald Gartlehner
- Department für Evidenzbasierte Medizin und Evaluation, Donau-Universität Krems, Krems, Österreich
| | - Lukas Schwingshackl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, 79110 Freiburg, Deutschland
| | - Ingrid Töws
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
| | - Joerg J Meerpohl
- Institut für Evidenz in der Medizin, Universitätsklinikum und Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland; Cochrane Deutschland, Cochrane Deutschland Stiftung, 79110 Freiburg, Deutschland
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10
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Núñez Gil IJ, Elizondo A, Gradari S, Villablanca PA, Bueno H, Feltes G, Quirós A, Ramakrishna H, Boshra L, Fernandez Ortiz A. Meta-Analysis Design and Results in Real Life: Problem Solvers or Detour to Maze. A Critical Review of Meta-Analysis of DAPT Randomized Controlled Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:897-906. [DOI: 10.1016/j.carrev.2018.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/03/2018] [Accepted: 10/17/2018] [Indexed: 01/10/2023]
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Zhao B, Li Z, Wang Y, Ma X, Wang X, Wang X, Liu J, Huang Y, Zhang J, Li L, Hu X, Jiang J, Qu S, Chai Q, Song M, Yang X, Bao T, Fei Y. Manual or electroacupuncture as an add-on therapy to SSRIs for depression: A randomized controlled trial. J Psychiatr Res 2019; 114:24-33. [PMID: 31015098 DOI: 10.1016/j.jpsychires.2019.04.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 01/23/2023]
Abstract
Selective serotonin reuptake inhibitors (SSRIs) are first-line antidepressants, however, only around 60% of patients could benefit from them. Acupuncture is supported by insufficient evidence to help with symptom relieving and SSRIs tolerance. This pragmatic randomized controlled trial compared SSRIs alone versus SSRIs together with manual acupuncture (MA) or electroacupuncture (EA) in moderate to severe depressed patients. Patients were randomly allocated to receive MA + SSRIs (161), EA + SSRIs (160), or SSRIs alone (156) for six weeks, and then followed up for another four weeks. The primary outcome was response rate of the 17-item Hamilton Depression Scale (HAMD-17) at 6th week. The secondary outcomes were HAMD-17 (remission rate, early onset rate, total score), Self-Rating Depression Scale (SDS: total score), Clinical Global Impression (CGI), Rating Scale for Side Effects (SERS: total and domain scores), number of patients with adjusted dosage of SSRIs and adverse events (AEs). Both MA + SSRIs and EA + SSRIs were significantly better than SSRIs at 6th week on HAMD-17 response rate (RR = 1.21, 95% CI 1.04, 1.42, P = 0.013; RR = 1.27, 95% CI 1.09, 1.48, P = 0.0014), HAMD-17 early onset rate (P < 0.0001), HAMD-17 and SDS total scores (P < 0.05), CGI (P < 0.01), SERS total score (P < 0.01), number of patients with increased dosage of SSRIs (P < 0.01). For HAMD-17 remission rate, EA + SSRIs was significantly higher than SSRIs (P = 0.0083), while MA + SSRIs showed no significant difference at 6th week (P = 0.092). No unintended acupuncture-related severe AE was observed. This study identified that both MA and EA showed beneficial effects in addition to SSRIs alone in patients with moderate to severe depression, and were well tolerated. Clinical trials registration: ChiCTR-TRC-08000297.
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Affiliation(s)
- Bingcong Zhao
- Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, 100029, China; Capital Medical University, Beijing Hospital of Traditional Chinese Medicine, Department of Acupuncture and Moxibustion, Beijing Key Laboratory of Acupuncture Neuromodulation, Beijing, 100010, China
| | - Zhigang Li
- Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, 100029, China
| | - Yuanzheng Wang
- (c)Peking University First Hospital, Department of Integrative TCM and Western Medicine, Beijing, 100034, China
| | - Xuehong Ma
- (d)Dongfang Hospital, The Second Clinical Medical College of Beijing University of Chinese Medicine, Department of Acupuncture & Moxibustion, Beijing, 100078, China
| | - Xiangqun Wang
- (e)Peking University Sixth Hospital, Department of Psychiatry, Beijing, 100191, China
| | - Xueqin Wang
- Peking University Sixth Hospital, Peking University Institute of Mental Health, NHC Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders (Peking University Sixth Hospital), Beijing, 100191, China
| | - Jianping Liu
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Yong Huang
- Southern Medical University, TCM School, Guangzhou, 510515, China
| | - Jianbin Zhang
- The Second Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Provincial Second Chinese Medicine Hospital, The Acuology Department, Nanjing, 210017, China
| | - Liqin Li
- Sixth Hospital of Baotou, Department of Psychiatry, Baotou, 014060, China
| | - Xiaoyang Hu
- University of Southampton, Aldermoor Health Centre, Primary Care and Population Sciences, Southampton, SO16 5ST, United Kingdom
| | - Jinfeng Jiang
- Nanjing University of Chinese Medicine, Key Laboratory of Acupuncture and Medicine Research of Minister of Education, Nanjing, 210023, China
| | - Shanshan Qu
- Southern Medical University, TCM School, Guangzhou, 510515, China
| | - Qianyun Chai
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China
| | - Meng Song
- Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, 100029, China
| | - Xinjing Yang
- Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, 100029, China
| | - Tuya Bao
- Beijing University of Chinese Medicine, School of Acupuncture-Moxibustion and Tuina, Beijing, 100029, China.
| | - Yutong Fei
- Beijing University of Chinese Medicine, Centre for Evidence-Based Chinese Medicine, Beijing, 100029, China.
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Yin SHL, Xu P, Wang B, Lu Y, Wu QY, Zhou ML, Wu JR, Cai JJ, Sun X, Yuan H. Duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent: systematic review and network meta-analysis. BMJ 2019; 365:l2222. [PMID: 31253632 PMCID: PMC6595429 DOI: 10.1136/bmj.l2222] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of standard term (12 months) or long term (>12 months) dual antiplatelet therapy (DAPT) versus short term (<6 months) DAPT after percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DESIGN Systematic review and network meta-analysis. DATA SOURCES Relevant studies published between June 1983 and April 2018 from Medline, Embase, Cochrane Library for clinical trials, PubMed, Web of Science, ClinicalTrials.gov, and Clinicaltrialsregister.eu. REVIEW METHODS Randomised controlled trials comparing two of the three durations of DAPT (short term, standard term, and long term) after PCI with DES were included. The primary study outcomes were cardiac or non-cardiac death, all cause mortality, myocardial infarction, stent thrombosis, and all bleeding events. RESULTS 17 studies (n=46 864) were included. Compared with short term DAPT, network meta-analysis showed that long term DAPT resulted in higher rates of major bleeding (odds ratio 1.78, 95% confidence interval 1.27 to 2.49) and non-cardiac death (1.63, 1.03 to 2.59); standard term DAPT was associated with higher rates of any bleeding (1.39, 1.01 to 1.92). No noticeable difference was observed in other primary endpoints. The sensitivity analysis revealed that the risks of non-cardiac death and bleeding were further increased for ≥18 months of DAPT compared with short term or standard term DAPT. In the subgroup analysis, long term DAPT led to higher all cause mortality than short term DAPT in patients implanted with newer-generation DES (1.99, 1.04 to 3.81); short term DAPT presented similar efficacy and safety to standard term DAPT with acute coronary syndrome (ACS) presentation and newer-generation DES placement. The heterogeneity of pooled trials was low, providing more confidence in the interpretation of results. CONCLUSIONS In patients with all clinical presentations, compared with short term DAPT (clopidogrel), long term DAPT led to higher rates of major bleeding and non-cardiac death, and standard term DAPT was associated with an increased risk of any bleeding. For patients with ACS, short term DAPT presented similar efficacy and safety with standard term DAPT. For patients implanted with newer-generation DES, long term DAPT resulted in more all cause mortality than short term DAPT. Although the optimal duration of DAPT should take personal ischaemic and bleeding risks into account, this study suggested short term DAPT could be considered for most patients after PCI with DES, combining evidence from both direct and indirect comparisons. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018099519.
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Affiliation(s)
- Shang-He-Lin Yin
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Peng Xu
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Bian Wang
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Yao Lu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Qiao-Yu Wu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Meng-Li Zhou
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Jun-Ru Wu
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Jing-Jing Cai
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xin Sun
- Chinese Evidence-based Medicine Centre and CREAT Group, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University and Collaborative Innovation Centre, Chengdu, Sichuan, China
| | - Hong Yuan
- Center of Clinical Pharmacology, Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
- Department of Cardiology, Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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De-escalation of anti-platelet therapy in patients with acute coronary syndromes undergoing percutaneous coronary intervention: a narrative review. Chin Med J (Engl) 2019; 132:197-210. [PMID: 30614864 PMCID: PMC6365275 DOI: 10.1097/cm9.0000000000000047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACS) and in those undergoing percutaneous coronary intervention (PCI). In current clinical situation, availability of different oral P2Y12 inhibitors (clopidogrel, prasugrel, and ticagrelor) has enabled physicians to switch among therapies owing to specific clinical scenarios. Although optimum time, loading dose and interval of transition between P2Y12 inhibitors is still controversial and needs further evidence, switching between oral inhibitors frequently occurs in clinical practice for several reasons. Data sources: This review was based on data in articles published in PubMed up to June 2018, with the following keywords “antiplatelet therapy”, “ACS”, “PCI”, “ticagrelor”, and “clopidogrel”. Study selection: Original articles and critical reviews on de-escalation strategy in ACS patients after PCI were selected. References of the retrieved articles were also screened to search for potentially relevant papers. Results: Safety concerns associated with switching between antiplatelet agents, has prompted the use of clopidogrel for patients with ACS especially after PCI as a de-escalation strategy. Practical considerations for de-escalating therapies in patients with ACS such as reducing dose of P2Y12 inhibitors or shortening duration of DAPT (followed by aspirin or P2Y12 receptor inhibitor monotherapy) as potential options are yet to be standardized and validated. Conclusions: Current review will provide an overview of the pharmacology of common P2Y12 inhibitors, definitions of de-escalation and different de-escalating strategies and its outcomes, along with possible direction to be explored in de-escalation.
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Lugo LM, Ferreiro JL. Dual antiplatelet therapy after coronary stent implantation: Individualizing the optimal duration. J Cardiol 2018; 72:94-104. [DOI: 10.1016/j.jjcc.2018.03.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 01/06/2023]
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Gargiulo G, Valgimigli M, Capodanno D, Bittl JA. State of the art: duration of dual antiplatelet therapy after percutaneous coronary intervention and coronary stent implantation - past, present and future perspectives. EUROINTERVENTION 2018; 13:717-733. [PMID: 28844033 DOI: 10.4244/eij-d-17-00468] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Evidence from studies published more than 10 years ago suggested that patients receiving first-generation drug-eluting stents (DES) needed dual antiplatelet therapy (DAPT) for at least 12 months. Current evidence from randomised controlled trials (RCT) reported within the past five years suggests that patients with stable ischaemic heart disease who receive newer-generation DES need DAPT for a minimum of three to six months. Patients who undergo stenting for an acute coronary syndrome benefit from DAPT for at least 12 months, but a Bayesian network meta-analysis confirms that extending DAPT beyond 12 months confers a trade-off between reduced ischaemic events and increased bleeding. However, the network meta-analysis finds no credible increase in all-cause mortality if DAPT is lengthened from three to six months to 12 months (posterior median odds ratio [OR] 0.98; 95% Bayesian credible interval [BCI]: 0.73-1.43), from 12 months to 18-48 months (OR 0.87; 95% BCI: 0.64-1.17), or from three to six months to 18-48 months (OR 0.86; 95% BCI: 0.63-1.21). Future investigation should focus on identifying scoring systems that have excellent discrimination and calibration. Although predictive models should be incorporated into systems of care, most decisions about DAPT duration will be based on clinical judgement and patient preference.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
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16
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Nakamura M, Iijima R, Ako J, Shinke T, Okada H, Ito Y, Ando K, Anzai H, Tanaka H, Ueda Y, Takiuchi S, Nishida Y, Ohira H, Kawaguchi K, Kadotani M, Niinuma H, Omiya K, Morita T, Zen K, Yasaka Y, Inoue K, Ishiwata S, Ochiai M, Hamasaki T, Yokoi H. Dual Antiplatelet Therapy for 6 Versus 18 Months After Biodegradable Polymer Drug-Eluting Stent Implantation. JACC Cardiovasc Interv 2018. [PMID: 28641838 DOI: 10.1016/j.jcin.2017.04.019] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES The NIPPON (Nobori Dual Antiplatelet Therapy as Appropriate Duration) study was a multicenter randomized investigation of the noninferiority of short-term versus long-term dual antiplatelet therapy (DAPT) in patients with implantation of the Nobori drug-eluting stent (DES) (Terumo, Tokyo, Japan), which has a biodegradable abluminal coating. BACKGROUND The optimum duration of DAPT for patients with a biodegradable polymer-coated DES is unclear. METHODS The subjects were 3,773 patients with stable or acute coronary syndromes undergoing Nobori stent implantation. They were randomized 1:1 to receive DAPT for 6 or 18 months. The primary endpoint was net adverse clinical and cerebrovascular events (NACCE) (all-cause mortality, myocardial infarction, stroke, and major bleeding) from 6 to 18 months after stenting. Intention-to-treat analysis was performed in 3,307 patients who were followed for at least 6 months. RESULTS NACCE occurred in 34 patients (2.1%) receiving short-term DAPT and 24 patients (1.5%) receiving long-term DAPT (difference 0.6%, 95% confidence interval [CI]: 1.5 to 0.3). Because the lower limit of the 95% CI was inside the specified margin of -2%, noninferiority of short-term DAPT was confirmed. Mortality was 1.0% with short-term DAPT versus 0.4% with long-term DAPT, whereas myocardial infarction was 0.2% versus 0.1%, and major bleeding was 0.7% versus 0.7%, respectively. The estimated probability of NACCE was lower in the long-term DAPT group (hazard ratio: 1.44, 95% CI: 0.86 to 2.43). CONCLUSIONS Six months of DAPT was not inferior to 18 months of DAPT following implantation of a DES with a biodegradable abluminal coating. However, this result needs to be interpreted with caution given the open-label design and wide noninferiority margin of the present study. (Nobori Dual Antiplatelet Therapy as Appropriate Duration [NIPPON]; NCT01514227).
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
| | - Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Hospital, Sagamihara, Japan
| | - Toshiro Shinke
- Division of Cardiovascular Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hisayuki Okada
- Department of Cardiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
| | - Yoshiaki Ito
- Division of Cardiology, Saiseikai Yokohama-City Eastern Hospital, Yokohama, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Hitoshi Anzai
- Cardiology Department, Ota Memorial Hospital, Ota, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Shin Takiuchi
- Department of Cardiology, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Yasunori Nishida
- Department of Cardiovascular Medicine, Takai Hospital, Nara, Japan
| | - Hiroshi Ohira
- Department of Cardiology, Edogawa Hospital, Tokyo, Japan
| | | | - Makoto Kadotani
- Department of Cardiology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Hiroyuki Niinuma
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuto Omiya
- Division of Cardiology, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Takashi Morita
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Omihachiman Community Medical Center, Omihachiman, Japan
| | - Yoshinori Yasaka
- Department of Cardiology, Hyogo Brain and Heart Center, Himeji, Japan
| | - Kenji Inoue
- Department of Cardiology, Juntendo University Nerima Hospital, Tokyo, Japan
| | | | - Masahiko Ochiai
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroyoshi Yokoi
- Department of Cardiovascular Medicine Center, Fukuoka Sanno Hospital, Fukuoka, Japan
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Krackhardt F, Waliszewski M, Rischner J, Piot C, Pansieri M, Ruiz-Poveda FL, Boxberger M, Noutsias M, Ríos XF, Kherad B. Nine-month clinical outcomes in patients with diabetes treated with polymer-free sirolimus-eluting stents and 6‑month vs. 12‑month dual-antiplatelet therapy (DAPT). Herz 2018; 44:433-439. [PMID: 29356832 DOI: 10.1007/s00059-017-4675-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Diabetes mellitus is known to be associated with worse clinical outcomes in patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCI) with drug-eluting stents (DES). Defining the optimal duration of dual antiplatelet therapy (DAPT) after DES implantation is still under debate. The objective of this subgroup analysis of the all-comers ISAR 2000 registry was to assess the safety and efficacy of a short DAPT (<6 month) versus a longer DAPT (>6 month) in patients with diabetes electively treated with the polymer-free sirolimus-coated ultrathin strut drug-eluting stent (PF-SES). METHODS Patients who received the PF-SES were investigated in a multicenter all-comers observational study. The primary endpoint was the 9‑month target lesion revascularization (TLR) rate, whereas secondary endpoints included the 9‑month major adverse cardiac event (MACE) and procedural success rates. RESULTS In all, 167 patients were treated with DAPT for ≤6 months (S-DAPT group) and 350 patients underwent DAPT treatment for 12 months (L-DAPT group). There was no significant difference in the overall MACE rate (4.6% vs. 3.1%, p = 0.441), the 9‑month accumulated stent thrombosis rates (0.8% vs. 0.3%, p = 0.51), or the accumulated rate of bleeding complications (5.3% vs. 3.4%, p = 0.341). CONCLUSION PF-SES are safe and effective in daily clinical routine with low rates of TLR and MACE in patients with diabetes and stable disease. Our data suggest that extending the duration of DAPT beyond 6 months does not improve MACE or TLR at 9 months in patients with stable CAD (ClinicalTrials.gov Identifier NCT02629575).
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Affiliation(s)
- F Krackhardt
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353, Berlin, Germany
| | - M Waliszewski
- Medical Scientific Affairs, B. Braun Melsungen AG, Berlin, Germany
| | - J Rischner
- Hôpital Albert Schweitzer Colmar, Colmar, France
| | - C Piot
- Clinique du Millénaire Montpellier, Montpellier, France
| | - M Pansieri
- Centre Hospitalier d'Avigon, Avignon, France
| | - F L Ruiz-Poveda
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - M Boxberger
- Medical Scientific Affairs, B. Braun Melsungen AG, Berlin, Germany
| | - M Noutsias
- Midgerman Heart Center, Department of Internal Medicine III, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Halle, Germany
| | - X F Ríos
- Complexo Hospitalario Universitario de A Coruña, Coruña, Spain
| | - B Kherad
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353, Berlin, Germany.
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Ten Berg JM, Zwart B, van 't Hof AWJ, Liem A, Waltenberger J, de Winter RJ, Jukema JW. Optimal duration of dual antiplatelet therapy after percutaneous coronary intervention or after acute coronary syndrome : Practical lessons from a review. Neth Heart J 2017; 25:655-663. [PMID: 28762022 PMCID: PMC5691814 DOI: 10.1007/s12471-017-1023-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
To prevent recurrent ischaemic events, dual antiplatelet therapy (DAPT) is the standard of care after percutaneous coronary intervention and in the treatment of acute coronary syndrome. Recent evidence supports an adjusted DAPT duration in selected patients.The current paper aims to encourage cardiologists to actively search for patients benefiting from either shorter or prolonged duration DAPT and proposes an algorithm to identify patients who are likely to benefit from such an alternative strategy.Individualised DAPT duration should be considered in high-risk anatomic and/or clinical subgroups or in patients at increased haemorrhagic risk with low ischaemic risk. Both thrombotic and haemorrhagic risk should be assessed in all patients. In patients undergoing percutaneous coronary intervention, the interventional cardiologist could advise on the minimal duration of DAPT. However, in contrast to the minimum duration of DAPT for stent thrombosis prevention, longer duration DAPT is aimed at prevention of spontaneous myocardial infarction, and not at stent thrombosis, and thus the key to success is to treat the patient's overall thrombotic risk.The advice on the duration of DAPT must be documented in the patient's records and communicated with the treating physician and general practitioner. DAPT duration should be reassessed at least on a yearly basis.
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Affiliation(s)
- J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - B Zwart
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - A W J van 't Hof
- Department of Cardiology, Isala Klinieken Zwolle, Zwolle, The Netherlands
| | - A Liem
- Department of Cardiology, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - J Waltenberger
- Department of Cardiovascular Medicine, Universitätsklinikum Münster, Münster, Germany
| | - R J de Winter
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - J W Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Sharp MK, Haneef R, Ravaud P, Boutron I. Dissemination of 2014 dual antiplatelet therapy (DAPT) trial results: a systematic review of scholarly and media attention over 7 months. BMJ Open 2017; 7:e014503. [PMID: 29101129 PMCID: PMC5695450 DOI: 10.1136/bmjopen-2016-014503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To explore how the results from the 2014 dual antiplatelet therapy (DAPT) trial were disseminated to the scientific community and online media. DESIGN A a systematic review of scholarly and public attention surrounding the DAPT study. SETTINGS Data were collected from the ISI Web of Knowledge, Google Scholar, PubMed Commons, EurekAlert, the DAPT study website (www.daptstudy.org) and the New England Journal of Medicine website (for scholarly attention) and Altmetric Explorer, Snap Bird, YouTube (for public attention) citing DAPT study results appearing from 16 November 2014 to 10 June 2015. PARTICIPANTS No participants were involved in this study. MAIN OUTCOME MEASURE Proportion of contents highlighting the increased risk of mortality and critical to the author's interpretation of the results. RESULTS We identified 425 items reported by seven sources; 164 (39%) disseminated the authors' interpretation via an electronic link or a reference, with no additional text. Among 81 items (19 %), the message favoured prolonged treatment and consequently overstated the article conclusions. Among 119 items (28 %), the text was uncertain about the benefit of prolonged treatment but was reported with no or inappropriate mention of increased risk of mortality. Only 34 items (8 %) were uncertain about the benefit of prolonged treatment and mentioned increased risk of mortality. In all, 27 items (6 %) did not favour prolonged treatment, and only 12 of these (3 %) clearly raised some concerns about the reporting of increased risk of death. CONCLUSION Dissemination of the DAPT study results to the scientific community and on different media sources rarely criticised the interpretation of the study results.
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Affiliation(s)
- Melissa K Sharp
- Mailman School of Public Health, Columbia University, New York, USA
- METHODS Team, Center of Research in Epidemiology and Statistics Sorbonne Paris Cité INSERM UMR 1153, Paris, France
- University of Paris Descartes, Paris, France
| | - Romana Haneef
- METHODS Team, Center of Research in Epidemiology and Statistics Sorbonne Paris Cité INSERM UMR 1153, Paris, France
- University of Paris Descartes, Paris, France
- Centre d'épidémiologie clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Philippe Ravaud
- Mailman School of Public Health, Columbia University, New York, USA
- METHODS Team, Center of Research in Epidemiology and Statistics Sorbonne Paris Cité INSERM UMR 1153, Paris, France
- University of Paris Descartes, Paris, France
- Centre d'épidémiologie clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
- Cochrane France, Paris, France
| | - Isabelle Boutron
- METHODS Team, Center of Research in Epidemiology and Statistics Sorbonne Paris Cité INSERM UMR 1153, Paris, France
- University of Paris Descartes, Paris, France
- Centre d'épidémiologie clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
- Cochrane France, Paris, France
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Russo JJ, Goodman SG, Bagai A, Déry JP, Tan MK, Fisher HN, Zhang X, Zhu YE, Welsh RC, Siega AD, Kokis A, Wong BYL, Henderson M, Lutchmedial S, Lavi S, Mehta SR, Yan AT. Duration of dual antiplatelet therapy and associated outcomes following percutaneous coronary intervention for acute myocardial infarction: contemporary practice insights from the Canadian Observational Antiplatelet Study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2017; 3:303-311. [PMID: 29044393 DOI: 10.1093/ehjqcco/qcw051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Indexed: 12/22/2022]
Abstract
Aims There is a paucity of real-world, contemporary data of practice patterns and clinical outcomes following dual-antiplatelet therapy (DAPT) in acute myocardial infarction (AMI) patients treated with percutaneous coronary intervention (PCI). Methods and results The Canadian Observational Antiplatelet Study was a prospective, multicentre, cohort study examining adenosine diphosphate receptor antagonist use following PCI for AMI. We compared practice patterns, patient characteristics, and clinical outcomes in relation to DAPT duration (<6 weeks, 6 weeks to <6 months, 6 to <12, and ≥12 months). The primary outcome was the composite of non-fatal AMI, unplanned coronary revascularization, stent thrombosis, new or worsening heart failure, cardiogenic shock, or stroke. We identified 2034 patients with AMI treated with PCI. DAPT duration was <6 weeks in 5.2% of patients; 6 weeks to <6 months in 7.0%; 6 to <12 months in 12.6%; and ≥12 months in 75.3%. Patients who discontinued DAPT early had higher GRACE risk scores. Overall, mortality rate at 15 months was 2.5%. Compared with a duration of DAPT of ≥12 months, discontinuation of DAPT <6 weeks (P < 0.0001) and 6 weeks to <6 months (P = 0.02), but not 6 months to <12 months (P = 0.06), were independently associated with a higher incidence of the primary outcome among survivors. Conclusion One-in-four patients with AMI treated with PCI discontinued DAPT prior to the guideline-recommended 12-month duration. Patients in whom DAPT was discontinued early were at higher baseline risk and had higher rates of non-fatal ischaemic events during follow up.
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Affiliation(s)
- Juan J Russo
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond Street, Donnelly 6-030, Toronto, ON M5B 1W8, Canada
- University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun G Goodman
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond Street, Donnelly 6-030, Toronto, ON M5B 1W8, Canada
- Canadian Heart Research Centre, Toronto, ON, Canada
| | - Akshay Bagai
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond Street, Donnelly 6-030, Toronto, ON M5B 1W8, Canada
| | - Jean-Pierre Déry
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, QC, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, ON, Canada
| | | | | | | | - Robert C Welsh
- The Mazankowski Alberta Heart Institute, University of Alberta, VIGOUR Centre, Edmonton, AB, Canada
| | | | - Andre Kokis
- Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | | | - Mark Henderson
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Sohrab Lutchmedial
- New Brunswick Heart Centre, CardioVascular Research New Brunswick, Saint John, NB, Canada
| | - Shahar Lavi
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Population Health Research Institute, Hamilton, ON, Canada
| | - Andrew T Yan
- Division of Cardiology, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond Street, Donnelly 6-030, Toronto, ON M5B 1W8, Canada
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Short versus prolonged dual antiplatelet therapy (DAPT) duration after coronary stent implantation: A comparison between the DAPT study and 9 other trials evaluating DAPT duration. PLoS One 2017; 12:e0174502. [PMID: 28931015 PMCID: PMC5607128 DOI: 10.1371/journal.pone.0174502] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 09/29/2016] [Indexed: 11/24/2022] Open
Abstract
Aims The Dual Antiplatelet Therapy (DAPT) study demonstrated that DAPT beyond 1-year after drug-eluting stent (DES) implantation, as compared with aspirin therapy alone, significantly reduced the risk of major cardiovascular and cerebrovascular events, which was mainly driven by the large risk reduction for myocardial infarction (MI). We sought to compare the largest DAPT study with other trials evaluating DAPT durations after DES implantation. Methods and results By a systematic literature search, we identified 9 trials comparing prolonged- versus short-DAPT in addition to the DAPT study. The result from the DAPT study (N = 9961) with public–private collaboration was different from the pooled result of the 9 other investigator-driven trials (N = 22174) in terms of the effect of prolonged-DAPT on MI (odds ratio [OR] 0.48 [95%CI 0.38–0.62] versus pooled OR 0.88 [95%CI 0.67–1.15]: P = 0.001 for difference), while the trends for excess risk of prolonged-DAPT relative to short-DAPT for all-cause death (OR 1.31 [95%CI 0.97–1.78] versus pooled OR 1.16 [95%CI 0.92–1.45]: P = 0.53 for difference), and bleeding (OR 1.62 [95%CI 1.21–2.17] versus pooled OR 2.08 [95%CI 1.51–2.84]: P = 0.25 for difference) were consistently seen in both the DAPT and other trials. The annual rate of MI during aspirin mono-therapy in the DAPT study was much higher than that those in the other trials (2.7% versus 0.6–1.6%). Conclusions Given the difference between the DAPT study and other trials, future studies should focus on certain subgroups of patients that are more or less likely to benefit from longer duration DAPT.
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GRADE guidelines 17: assessing the risk of bias associated with missing participant outcome data in a body of evidence. J Clin Epidemiol 2017; 87:14-22. [PMID: 28529188 DOI: 10.1016/j.jclinepi.2017.05.005] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 04/17/2017] [Accepted: 05/02/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To provide GRADE guidance for assessing risk of bias across an entire body of evidence consequent on missing data for systematic reviews of both binary and continuous outcomes. STUDY DESIGN AND SETTING Systematic survey of published methodological research, iterative discussions, testing in systematic reviews, and feedback from the GRADE Working Group. RESULTS Approaches begin with a primary meta-analysis using a complete case analysis followed by sensitivity meta-analyses imputing, in each study, data for those with missing data, and then pooling across studies. For binary outcomes, we suggest use of "plausible worst case" in which review authors assume that those with missing data in treatment arms have proportionally higher event rates than those followed successfully. For continuous outcomes, imputed mean values come from other studies within the systematic review and the standard deviation (SD) from the median SDs of the control arms of all studies. CONCLUSIONS If the results of the primary meta-analysis are robust to the most extreme assumptions viewed as plausible, one does not rate down certainty in the evidence for risk of bias due to missing participant outcome data. If the results prove not robust to plausible assumptions, one would rate down certainty in the evidence for risk of bias.
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The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol 2017; 87:4-13. [PMID: 28529184 DOI: 10.1016/j.jclinepi.2017.05.006] [Citation(s) in RCA: 456] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 04/11/2017] [Accepted: 05/02/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To clarify the grading of recommendations assessment, development and evaluation (GRADE) definition of certainty of evidence and suggest possible approaches to rating certainty of the evidence for systematic reviews, health technology assessments, and guidelines. STUDY DESIGN AND SETTING This work was carried out by a project group within the GRADE Working Group, through brainstorming and iterative refinement of ideas, using input from workshops, presentations, and discussions at GRADE Working Group meetings to produce this document, which constitutes official GRADE guidance. RESULTS Certainty of evidence is best considered as the certainty that a true effect lies on one side of a specified threshold or within a chosen range. We define possible approaches for choosing threshold or range. For guidelines, what we call a fully contextualized approach requires simultaneously considering all critical outcomes and their relative value. Less-contextualized approaches, more appropriate for systematic reviews and health technology assessments, include using specified ranges of magnitude of effect, for example, ranges of what we might consider no effect, trivial, small, moderate, or large effects. CONCLUSION It is desirable for systematic review authors, guideline panelists, and health technology assessors to specify the threshold or ranges they are using when rating the certainty in evidence.
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Basaraba JE, Barry AR. What is the optimal duration of dual antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent implantation? Am J Health Syst Pharm 2017; 73:e229-37. [PMID: 27099329 DOI: 10.2146/ajhp150655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Published evidence on varying durations of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with implantation of a drug-eluting stent (DES) is reviewed. SUMMARY A systematic literature search identified 13 randomized controlled trials and eight meta-analyses evaluating patient outcomes of standard (12-month) versus shorter or longer courses of DAPT (aspirin and a P2Y12 inhibitor, usually clopidogrel) after PCI with DES implantation. Evaluated outcomes included cardiovascular (CV) events, stent thrombosis, bleeding events, and mortality. Overall, the available evidence indicates that DAPT for periods of 3-6 months was as effective as DAPT courses of 12 months or more in reducing rates of CV events and stent thrombosis and was associated with similar or lower rates of bleeding; however, the quality of that evidence was limited by methodological shortcomings, including open-label study designs and low overall event rates. Relative to 12-month DAPT, DAPT for longer periods (up to four years) was associated with decreased rates of CV events and stent thrombosis (the reduction in thrombosis risk was greatest in patients who received a first-generation DES) but also increased bleeding events; all-cause mortality appears to be similar or potentially higher with extended-duration DAPT. CONCLUSION DAPT for a period of 12 months should continue to be the standard recommendation after PCI with DES implantation. Routine use of shorter- or longer-duration DAPT should be discouraged; if such therapy is considered, prescribing decisions should be based on individual patient risk factors.
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Affiliation(s)
- Jade E Basaraba
- Mazankowski Alberta Heart Institute, Alberta Health Services, Edmonton, Canada, and Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Arden R Barry
- Lower Mainland Pharmacy Services, Chilliwack, Canada, and Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada.
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Qintar M, Chhatriwalla AK, Arnold SV, Tang F, Buchanan DM, Shafiq A, Pokharel Y, deBronkart D, Ashraf JM, Spertus JA. Beyond restenosis: Patients' preference for drug eluting or bare metal stents. Catheter Cardiovasc Interv 2017; 90:357-363. [PMID: 28168845 DOI: 10.1002/ccd.26946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 12/22/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To assess patients' perspective about factors associated with stent choice. BACKGROUND Drug eluting stents (DES) markedly reduce the risk of repeat percutaneous coronary intervention (PCI), but necessitate a longer duration of dual anti-platelet therapy (DAPT) as compared with bare metal stents (BMS). Thus, understanding patients' perspective about factors associated with stent choice is paramount. METHODS Patients undergoing angiography rated, on a 10-point scale, the importance (1 = not important, 10 = most important) of avoiding repeat revascularization and avoiding the following potential DAPT drawbacks: bleeding/bruising, more pills/day, medication costs and delaying elective surgery. The factor, or group of factors, that was rated highest by each patient was identified. RESULTS Among 311 patients, repeat revascularization was the single most important consideration to 14.4% of patients, while 20.6% considered avoiding one of the DAPT drawbacks as most important. Most patients (65%) considered avoiding at least one DAPT drawback as important as avoiding repeat revascularization. In no subgroup of patients did more than a quarter of patients prefer avoiding repeat revascularization above all other concerns. Among patients undergoing PCI, more than three quarters received a DES, regardless of their stated preferences (DES use among those most valuing DES benefits, avoiding DAPT drawbacks, or both equally were 78.7%, 86.2%, and 85.6%, respectively, P = 0.56). CONCLUSION Most patients reported that avoiding DAPT drawbacks was as important as avoiding repeat revascularization. Eliciting patient preferences regarding stent type can enhance shared decision-making and allow physicians to better tailor stent choice to patients' goals and values. TRIAL REGISTRATION Developing and Testing a Personalized Evidence-based Shared Decision-making Tool for Stent Selection (DECIDE-PCI). ClinicalTrials.gov Identifier: NCT02046902. URL: https://clinicaltrials.gov/ct2/show/NCT02046902 © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Mohammed Qintar
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Adnan K Chhatriwalla
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO
| | - Donna M Buchanan
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Ali Shafiq
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Yashashwi Pokharel
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - Dave deBronkart
- e-Patient Dave LLC and Society for Participatory Medicine, Newburyport, MA
| | - Javed M Ashraf
- Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Division of Cardiology, Kansas City, MO.,Division of Medicine, University of Missouri at Kansas City, Kansas City, Missouri
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Dalal A. Organ transplantation and drug eluting stents: Perioperative challenges. World J Transplant 2016; 6:620-631. [PMID: 28058211 PMCID: PMC5175219 DOI: 10.5500/wjt.v6.i4.620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/18/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Patients listed for organ transplant frequently have severe coronary artery disease (CAD), which may be treated with drug eluting stents (DES). Everolimus and zotarolimus eluting stents are commonly used. Newer generation biolimus and novolimus eluting biodegradable stents are becoming increasingly popular. Patients undergoing transplant surgery soon after the placement of DES are at increased risk of stent thrombosis (ST) in the perioperative period. Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel and ticagrelor is instated post stenting to decrease the incident of ST. Cangrelor has recently been approved by Food and Drug Administration and can be used as a bridging antiplatelet drug. The risk of ischemia vs bleeding must be considered when discontinuing or continuing DAPT for surgery. Though living donor transplant surgery is an elective procedure and can be optimally timed, cadaveric organ availability is unpredictable, therefore, discontinuation of antiplatelet medication cannot be optimally timed. The type of stent and timing of transplant surgery can be of utmost importance. Many platelet function point of care tests such as Light Transmittance Aggregrometry, Thromboelastography Platelet Mapping, VerifyNow, Multiple Electrode Aggregrometry are used to assess bleeding risk and guide perioperative platelet transfusion. Response to allogenic platelet transfusion to control severe intraoperative bleeding may differ with the antiplatelet drug. In stent thrombosis is an emergency where management with either a drug eluting balloon or a DES has shown superior outcomes. Post-transplant complications often involved stenosis of an important vessel that may need revascularization. DES are now used for endovascular interventions for transplant orthotropic heart CAD, hepatic artery stenosis post liver transplantation, transplant renal artery stenosis following kidney transplantation, etc. Several antiproliferative drugs used in the DES are inhibitors of mammalian target of rapamycin. Thus they are used for post-transplant immunosuppression to prevent acute rejection in recipients with heart, liver, lung and kidney transplantation. This article describes in detail the various perioperative challenges encountered in organ transplantation surgery and patients with drug eluting stents.
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Villablanca PA, Massera D, Mathew V, Bangalore S, Christia P, Perez I, Wan N, Schulz-Schüpke S, Briceno DF, Bortnick AE, Garcia MJ, Lucariello R, Menegus M, Pyo R, Wiley J, Ramakrishna H. Outcomes of ≤6-month versus 12-month dual antiplatelet therapy after drug-eluting stent implantation: A meta-analysis and meta-regression. Medicine (Baltimore) 2016; 95:e5819. [PMID: 28033306 PMCID: PMC5207602 DOI: 10.1097/md.0000000000005819] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The benefit of ≤6-month compared with 12-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) placement remains controversial. We performed a meta-analysis and meta-regression of ≤6-month versus 12-month DAPT in patients undergoing PCI with DES placement. METHODS We conducted electronic database searches of randomized controlled trials (RCTs) comparing DAPT durations after DES placement. For studies with longer follow-up, outcomes at 12 months were identified. Odds ratios and 95% confidence intervals were computed with the Mantel-Haenszel method. Fixed-effect models were used; if heterogeneity (I) > 40 was identified, effects were obtained with random models. RESULTS Nine RCTs were included with total n = 19,224 patients. No significant differences were observed between ≤6-month compared with 12-month DAPT in all-cause mortality (OR 0.87; 95% confidence interval (CI): 0.69-1.11), cardiovascular (CV) mortality (OR 0.89; 95% CI: 0.66-1.21), non-CV mortality (OR 0.85; 95% 0.58-1.24), myocardial infarction (OR 1.10; 95% CI: 0.89-1.37), stroke (OR 0.97; 95% CI: 0.67-1.42), stent thrombosis (ST) (OR 1.37; 95% CI: 0.89-2.10), and target vessel revascularization (OR 0.95; 95% CI: 0.77-1.18). No significant difference in major bleeding (OR 0.72; 95% CI: 0.49-1.05) was observed, though the all-bleeding event rate was significantly lower in the ≤6-month DAPT group (OR 0.76; 95% CI: 0.59-0.96). In the meta-regression analysis, a significant association between bleeding events and non-CV mortality with 12-month DAPT was found, as well as between ST and mortality in addition to MI with ≤6-month DAPT. CONCLUSION DAPT for ≤6 months is associated with similar mortality and ischemic outcomes but less bleeding events compared with 12-month DAPT after PCI with DES.
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Affiliation(s)
- Pedro A. Villablanca
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Daniele Massera
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Verghese Mathew
- Division of Cardiology, Loyola University Stritch School of Medicine, Maywood, IL
| | | | - Panagiota Christia
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Irving Perez
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Ningxin Wan
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Stefanie Schulz-Schüpke
- Deutsches Herzzentrum München, Technische Universität, Klinik für Herz- und Kreislauferkrankungen, Munich, Germany
| | - David F. Briceno
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Anna E. Bortnick
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Mario J. Garcia
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Richard Lucariello
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Mark Menegus
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Robert Pyo
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Jose Wiley
- Division of Cardiovascular Diseases, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic College of Medicine, Scottsdale, AZ
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Ho HH, Mok KH. Successful drug-coated balloon angioplasty and single anti-platelet therapy to treat an ischaemic stroke patient with haemorrhage and acute coronary syndrome. ACTA ACUST UNITED AC 2016; 18:28-30. [PMID: 27869561 DOI: 10.1080/17482941.2016.1234054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A 55-year-old male presented with two challenging problems, i.e. acute coronary syndrome (ACS) and a major bleeding episode. He first presented with ischaemic stroke and was treated with thrombolysis. However this was complicated by haemorrhagic transformation. He subsequently developed ACS with urgent coronary angiography demonstrating a critical stenosis in the proximal left anterior descending artery. Percutaneous coronary intervention (PCI) was deemed necessary but we were mindful of causing bleeding complications from the use of anti-thrombotic therapy. Despite the complexities, we used a novel approach in terms of PCI strategy and anti-platelet regimen (drug-coated balloon angioplasty and a single anti-platelet therapy) and achieved a successful outcome.
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Affiliation(s)
- Hee Hwa Ho
- a Department of Cardiology , Tan Tock Seng Hospital , Singapore
| | - Kwang How Mok
- a Department of Cardiology , Tan Tock Seng Hospital , Singapore
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Cho MH, Shin DW, Yun JM, Shin JH, Lee SP, Lee H, Lim YK, Kim EH, Kim HK. Prevalence and Predictors of Early Discontinuation of Dual-Antiplatelet Therapy After Drug-Eluting Stent Implantation in Korean Population. Am J Cardiol 2016; 118:1448-1454. [PMID: 27645764 DOI: 10.1016/j.amjcard.2016.07.073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 11/15/2022]
Abstract
The administration of antiplatelet drugs for months after a drug-eluting stent implantation is critical in decreasing the risk of complications, and premature discontinuation of antiplatelet therapy before the recommended period is the most important predictor for late complications. Therefore, we investigated the prevalence and associated factors of premature discontinuation of antiplatelet therapy in patients in Korea. This retrospective cohort study was conducted using the Korean National Health Insurance Service-National Sample Cohort data. Patients who were treated with dual-antiplatelet therapy (DAPT) were identified with medication prescription data. The Kaplan-Meier failure time plot was used to illustrate the cumulative probability of treatment discontinuation. Cox regression analysis was conducted to compare predictors of early discontinuation of DAPT. The characteristics of the early discontinuation group were not significantly different from the guideline concordance group, except for a higher prevalence of disability and a lower rate of chronic kidney disease. In a Cox regression model, the presence of hypertension was identified as a negative predictor of early discontinuation, and disability was not a statistically significant predictor. The prevalence of early discontinuation was 31.0% and seems to be significantly higher than those reported from prospective studies, which may more accurately reflect the real-world situation. In conclusion, physicians should make more effort to educate patients on the risk associated with premature discontinuation of antiplatelet therapy after percutaneous coronary intervention with drug-eluting stent, and further studies investigating the reasons for nonadherence of DAPT are needed to improve DAPT compliance.
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Affiliation(s)
- Mi Hee Cho
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Wook Shin
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Jae Moon Yun
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Joong Hyun Shin
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seung Pyo Lee
- Department of Cardiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyejin Lee
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Yoo Kyoung Lim
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Ha Kim
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun Kyoung Kim
- Department of Family Medicine and Health Promotion Center, Seoul National University Hospital, Seoul, Republic of Korea
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How long should dual antiplatelet therapy be used in diabetic patients after implantation of drug-eluting stents? Curr Opin Cardiol 2016; 31:677-682. [DOI: 10.1097/hco.0000000000000333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis JS, Joglar JA, Pressler SJ, Wijeysundera DN. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease. J Thorac Cardiovasc Surg 2016; 152:1243-1275. [DOI: 10.1016/j.jtcvs.2016.07.044] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Six Versus Twelve Months Clopidogrel Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndrome: An ISAR-SAFE Study Subgroup Analysis. Sci Rep 2016; 6:33054. [PMID: 27624287 PMCID: PMC5021963 DOI: 10.1038/srep33054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/05/2016] [Indexed: 02/02/2023] Open
Abstract
In patients presenting with acute coronary syndrome (ACS) the optimal duration of dual-antiplatelet therapy after drug-eluting stent (DES) implantation remains unclear. At 6 months after intervention, patients receiving clopidogrel were randomly assigned to either a further 6-month period of placebo or clopidogrel. The primary composite endpoint was death, myocardial infarction, stent thrombosis, stroke, or major bleeding 9 months after randomization. The ISAR-SAFE trial was terminated early due to low event rates and slow recruitment. 1601/4000 (40.0%) patients presented with ACS and were randomized to 6 (n = 794) or 12 months (n = 807) clopidogrel. The primary endpoint occurred in 14 patients (1.8%) receiving 6 months of clopidogrel and 17 patients (2.2%) receiving 12 months; hazard ratio (HR) 0.83, 95% confidence interval (CI) 0.41-1.68, P = 0.60. There were 2 (0.3%) cases of stent thrombosis in each group; HR 1.00, 95% CI 0.14-7.09, P = >0.99. Major bleeding occurred in 3 patients (0.4%) receiving 6 months clopidogrel and 5 (0.6%) receiving 12 months; HR 0.60, 95% CI 0.15-2.49, P = 0.49. There was no significant difference in net clinical outcomes after DES implantation in ACS patients treated with 6 versus 12 months clopidogrel. Ischaemic and bleeding events were low beyond 6-months.
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O’Gara PT, Sabatine MS, Smith PK, Smith SC. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 2016; 134:e123-55. [PMID: 27026020 DOI: 10.1161/cir.0000000000000404] [Citation(s) in RCA: 955] [Impact Index Per Article: 119.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Glenn N. Levine
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Eric R. Bates
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - John A. Bittl
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Ralph G. Brindis
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Stephan D. Fihn
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Lee A. Fleisher
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Christopher B. Granger
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Richard A. Lange
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Michael J. Mack
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Laura Mauri
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Roxana Mehran
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Debabrata Mukherjee
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - L. Kristin Newby
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Patrick T. O’Gara
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Marc S. Sabatine
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Peter K. Smith
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
| | - Sidney C. Smith
- Focused Update writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for detailed information. ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ACC/AHA Representative. Evidence Review Committee Chair. American Society of Anesthesiologists/Society of Cardiovascular Anesthesiologists Representative. American Association for Thoracic Surgery/Society of Thoracic Surgeons Representative
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Szostek JH, Wieland ML, Post JA, Sundsted KK, Mauck KF. Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2015. Am J Med 2016; 129:879.e13-8. [PMID: 27046243 DOI: 10.1016/j.amjmed.2016.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 03/14/2016] [Accepted: 03/14/2016] [Indexed: 12/01/2022]
Abstract
Identifying new practice-changing articles is challenging. To determine the 2015 practice-changing articles most relevant to outpatient general internal medicine, 3 internists independently reviewed the titles and abstracts of original articles, synopses of single studies and syntheses, and databases of syntheses. For original articles, internal medicine journals with the 7 highest impact factors were reviewed: New England Journal of Medicine, Lancet, Journal of the American Medical Association (JAMA), British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine. For synopses of single studies and syntheses, collections in American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine were reviewed. For databases of synthesis, Evidence Updates and the Cochrane Library were reviewed. More than 100 articles were identified. Criteria for inclusion were as follows: clinical relevance, potential for practice change, and strength of evidence. Clusters of important articles around one topic were considered as a single-candidate series. The 5 authors used a modified Delphi method to reach consensus on inclusion of 7 topics for in-depth appraisal.
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Affiliation(s)
- Jason H Szostek
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn.
| | - Mark L Wieland
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Jason A Post
- Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Karna K Sundsted
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, Minn
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Levine GN, Bates ER, Bittl JA, Brindis RG, Fihn SD, Fleisher LA, Granger CB, Lange RA, Mack MJ, Mauri L, Mehran R, Mukherjee D, Newby LK, O'Gara PT, Sabatine MS, Smith PK, Smith SC. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1082-115. [PMID: 27036918 DOI: 10.1016/j.jacc.2016.03.513] [Citation(s) in RCA: 1027] [Impact Index Per Article: 128.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of Dual Antiplatelet Therapy: A Systematic Review for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2016; 68:1116-39. [PMID: 27036919 DOI: 10.1016/j.jacc.2016.03.512] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The optimal duration of dual antiplatelet therapy (DAPT) after implantation of newer-generation drug-eluting stents (DES) remains uncertain. Similarly, questions remain about the role of DAPT in long-term therapy of stable post-myocardial infarction (MI) patients. AIM Our objective was to compare the incidence of death, major hemorrhage, MI, stent thrombosis, and major adverse cardiac events in patients randomized to prolonged or short-course DAPT after implantation of newer-generation DES and in secondary prevention after MI. METHODS We used traditional frequentist statistical and Bayesian approaches to address the following questions: Q1) What is the minimum duration of DAPT required after DES implantation? Q2) What is the clinical benefit of prolonging DAPT up to 18 to 48 months? Q3) What is the clinical effect of DAPT in stable patients who are >1 year past an MI? RESULTS We reviewed evidence from 11 randomized controlled trials (RCTs) that enrolled 33 051 patients who received predominantly newer-generation DES to answer: A1) Use of DAPT for 12 months, as compared with use for 3 to 6 months, resulted in no significant differences in incidence of death (odds ratio [OR]: 1.17; 95% confidence interval [CI]: 0.85 to 1.63), major hemorrhage (OR: 1.65; 95% CI: 0.97 to 2.82), MI (OR: 0.87; 95% CI: 0.65 to 1.18), or stent thrombosis (OR: 0.87; 95% CI: 0.49 to 1.55). Bayesian models confirmed the primary analysis. A2) Use of DAPT for 18 to 48 months, compared with use for 6 to 12 months, was associated with no difference in incidence of all-cause death (OR: 1.14; 95% CI: 0.92 to 1.42) but was associated with increased major hemorrhage (OR: 1.58; 95% CI: 1.20 to 2.09), decreased MI (OR: 0.67; 95% CI: 0.47 to 0.95), and decreased stent thrombosis (OR: 0.45; 95% CI: 0.24 to 0.74). A risk-benefit analysis found 3 fewer stent thromboses (95% CI: 2 to 5) and 6 fewer MIs (95% CI: 2 to 11) but 5 more major bleeds (95% CI: 3 to 9) per 1000 patients treated with prolonged DAPT per year. Post hoc analyses provided weak evidence of increased mortality with prolonged DAPT. We reviewed evidence from 1 RCT of 21 162 patients and a post hoc analysis of 1 RCT of 15 603 patients to answer: A3): Use of DAPT >1 year after MI reduced the composite risk of cardiovascular death, MI, or stroke (hazard ratio: 0.84; 95% CI: 0.74 to 0.95) but increased major bleeding (hazard ratio: 2.32; 95% CI: 1.68 to 3.21). A meta-analysis and a post hoc analysis of an RCT in patients with stable cardiovascular disease produced similar findings. CONCLUSIONS The primary analysis provides moderately strong evidence that prolonged DAPT after implantation of newer-generation DES entails a tradeoff between reductions in stent thrombosis and MI and increases in major hemorrhage. Secondary analyses provide weak evidence of increased mortality with prolonged DAPT after DES implantation. In patients whose coronary thrombotic risk was defined by a prior MI rather than by DES implantation, the primary analysis provides moderately strong evidence of reduced cardiovascular events at the expense of increased bleeding.
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Fitchett DH, Goodman SG, Leiter LA, Lin P, Welsh R, Stone J, Grégoire J, Mcfarlane P, Langer A. Secondary Prevention Beyond Hospital Discharge for Acute Coronary Syndrome: Evidence-Based Recommendations. Can J Cardiol 2016; 32:S15-34. [PMID: 27342696 DOI: 10.1016/j.cjca.2016.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/20/2016] [Accepted: 03/01/2016] [Indexed: 12/21/2022] Open
Abstract
In the past 3 decades, a better understanding of the pathophysiology of cardiovascular disease has resulted in innovations in the treatment and prevention of its clinical manifestations such as death, myocardial infarction, or stroke. After an acute coronary syndrome there are short- and long-term risks of subsequent cardiovascular events. This leads to opportunities to initiate strategies to reduce complications resulting from myocardial injury (cardiac protection) and to prevent recurrent acute coronary events (vascular protection). The results from clinical trials inform best practice and guidelines for patient management. Despite clear and consistent guidelines, an important number of patients are not receiving these treatments. Moreover, many others do not receive treatment that follows the strategy proven in the clinical trial and this is associated with a significant loss of opportunities to improve outcomes. The Canadian Heart Research Centre has therefore assembled a panel of experts to provide a review of available data and distill it to specific evidence-based recommendations that can be used by specialists and primary care physicians as a platform for secondary prevention. The therapeutic recommendations are conveniently divided into vascular protection (dual antiplatelet therapy, lipid-lowering, and renin angiotensin system inhibition) which should be considered in all patients; cardiac protection (addition of β-blocker therapy) in patients with left ventricular dysfunction including consideration for management of heart failure; and continuing management of risk factors and comorbid conditions on the basis of the specific patient profile. These recommendations are intended as a decision support tool and a quick reference for Canadian physicians.
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Affiliation(s)
- David H Fitchett
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, University of Alberta, Edmonton, Alberta, Canada; Vigour Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Lawrence A Leiter
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter Lin
- Canadian Heart Research Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Welsh
- Vigour Centre, University of Alberta, Edmonton, Alberta, Canada
| | - James Stone
- University of Calgary, Calgary, Alberta, Canada
| | - Jean Grégoire
- Montreal Heart Centre, University of Montreal, Montreal, Quebec, Canada
| | - Philip Mcfarlane
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anatoly Langer
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian Heart Research Centre, University of Alberta, Edmonton, Alberta, Canada
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Optimal duration of dual antiplatelet therapy after drug-eluting stent implantation: conceptual evolution based on emerging evidence. Eur Heart J 2016; 37:353-64. [DOI: 10.1093/eurheartj/ehv712] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Keach JW, Yeh RW, Maddox TM. Dual Antiplatelet Therapy in Patients with Stable Ischemic Heart Disease. Curr Atheroscler Rep 2016; 18:5. [DOI: 10.1007/s11883-015-0553-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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The Tradeoff Between Shorter and Longer Courses of Dual Antiplatelet Therapy After Implantation of Newer Generation Drug-Eluting Stents. Curr Cardiol Rep 2016; 18:8. [PMID: 26732901 DOI: 10.1007/s11886-015-0683-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The benefit of prolonged dual antiplatelet therapy (DAPT) after implantation of drug-eluting stents (DESs) remains uncertain. In 10 randomized controlled trials (RCTs) of 31,666 predominantly low-risk patients undergoing DES implantation, shorter courses (3-12 months) of DAPT resulted in lower mortality (odds ratio [OR] 0.83, 95 % confidence interval [CI] 0.69-0.98) and major hemorrhage (OR 0.60, 95 % CI 0.48-0.75) but increased myocardial infarction (MI, OR 1.34, 95 % CI 1.04-1.73) and stent thrombosis (ST, OR 1.75, 95 % CI 1.08-2.82) than did longer courses (12-36 months) of DAPT. A risk-benefit analysis identified 3 fewer deaths and 5 fewer bleeds but 4 more MIs and 3 more STs annually for every 1000 patients treated with the shorter courses. In the predominantly low-risk population enrolled in RCTs, limiting DAPT to 3 to 12 months after DES implantation saved lives and prevented bleeding at the expense of increased ST and MI.
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Is Prolonged DAPT Apt or a Study in Zero-Sum Games? JACC Cardiovasc Interv 2016; 9:148-50. [DOI: 10.1016/j.jcin.2015.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/19/2015] [Indexed: 11/20/2022]
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Kline KP, Conti CR, Winchester DE. Historical perspective and contemporary management of acute coronary syndromes: from MONA to THROMBINS2. Postgrad Med 2015; 127:855-62. [DOI: 10.1080/00325481.2015.1092374] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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The saga of the duration of dual antiplatelet therapy after drug-eluting stent placement. Arch Cardiovasc Dis 2015; 108:469-71. [DOI: 10.1016/j.acvd.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/18/2022]
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