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Bikdeli B, Krishnathasan D, Khairani CD, Bejjani A, Davies J, Porio N, Tristani A, Armero A, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Ortiz-Rios MD, Zuluaga-Sánchez V, Achanta A, Jesudasen SJ, Tiu B, Merli GJ, Leiva O, Fanikos J, Grandone E, Sharma A, Rizzo S, Pfeferman MB, Morrison RB, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll B, Goldhaber SZ, Lan Z, Piazza G. Low absolute risk of thrombotic and cardiovascular events in outpatient pregnant women with COVID-19. Thromb Res 2024; 237:209-215. [PMID: 38677791 DOI: 10.1016/j.thromres.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pregnancy may contribute to an excess risk of thrombotic or cardiovascular events. COVID-19 increases the risk of these events, although the risk is relatively limited among outpatients. We sought to determine whether outpatient pregnant women with COVID-19 are at a high risk for cardiovascular or thrombotic events. MATERIALS & METHODS We analyzed pregnant outpatients with COVID-19 from the multicenter CORONA-VTE-Network registry. The main study outcomes were a composite of adjudicated venous or arterial thrombotic events, and a composite of adjudicated cardiovascular events. Events were assessed 90 days after the COVID-19 diagnosis and reported for non-pregnant women ≤45 years, and for men ≤45 years, as points of reference. RESULTS Among 6585 outpatients, 169 were pregnant at diagnosis. By 90-day follow-up, two pregnant women during the third trimester had lower extremity venous thrombosis, one deep and one superficial vein thrombosis. The cumulative incidence of thrombotic events was 1.20 % (95 % confidence interval [CI]: 0.0 to 2.84 %). Respective rates were 0.47 % (95 % CI: 0.14 % to 0.79 %) among non-pregnant women, and 0.49 % (95 % CI: 0.06 % to 0.91 %) among men ≤45 years. No non-thrombotic cardiovascular events occurred in pregnant women. The rates of cardiovascular events were 0.53 % (95 % CI: 0.18 to 0.87) among non-pregnant women, and 0.68 % (95 % CI: 0.18 to 1.18) in men aged ≤45 years. CONCLUSIONS Thrombotic and cardiovascular events are rare among outpatients with COVID-19. Although a higher event rate among outpatient pregnant women cannot be excluded, the absolute event rates are low and do not warrant population-wide cardiovascular interventions to optimize outcomes.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ali A Assi
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Marcos D Ortiz-Rios
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy; Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Samantha Rizzo
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Mariana B Pfeferman
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ruth B Morrison
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett Carroll
- Smith Center for Cardiovascular Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA.
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Najarro M, Rodríguez C, Morillo R, Jara-Palomares L, Vinson DR, Muriel A, Álvarez-Mon M, Yusen RD, Bikdeli B, Jimenez D. C-reactive Protein and Risk of Right Ventricular Dysfunction and Mortality in Patients With Acute Symptomatic Pulmonary Embolism. Arch Bronconeumol 2024:S0300-2896(24)00084-X. [PMID: 38644151 DOI: 10.1016/j.arbres.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Right ventricle (RV) dysfunction increases the risk of death from pulmonary embolism (PE). C-reactive protein (CRP) might identify RV inflammation and dysfunction in patients with PE. METHODS This cohort study enrolled consecutive stable patients with acute PE between 2017 and 2023. We stratified patients by quartiles of CRP. We evaluated the association between CRP quartiles and the presence of RV dysfunction, and used multivariable models to assess for an association between CRP and the outcomes of all-cause and PE-specific mortality during the 30 days of follow-up after PE diagnosis. RESULTS The study included 633 stable patients with PE. Patients without RV dysfunction had significantly lower median (IQR) CRP levels compared with patients with RV dysfunction (n=509, 31.7 [10.0-76.4]mg/L vs n=124, 45.4 [16.0-111.4]mg/L; P=0.018). CRP showed a statistically significant positive association with the presence of RV dysfunction (P<0.01). On multivariable analysis, CRP level was not significantly associated with 30-day all-cause mortality (adjusted odds ratio [OR] per mg/L increment, 1.00; 95% CI, 1.00-1.01; P=0.095), but higher CRP was associated with significantly higher PE-related mortality (adjusted OR, 1.01; 95% CI, 1.00-1.01; P=0.026). Compared with patients in CRP quartile 1, patients in quartiles 2, 3, and 4 had a stepwise increase in the adjusted odds of 30-day all-cause death of 2.41 (P=0.148), 3.04 (P=0.062), and 3.15 (P=0.052), respectively. CONCLUSIONS As an indicator of RV dysfunction, CRP may improve risk stratification algorithms for hemodynamically stable patients with acute symptomatic PE.
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Affiliation(s)
- Marta Najarro
- Emergency Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital Virgen del Rocío, Sevilla, Spain
| | - David R Vinson
- The Permanente Medical Group and Kaiser Permanente Northern California Division of Research, Oakland, CA, USA; Emergency Department, Kaiser Permanente Roseville Medical Center, Roseville, CA, USA
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal, and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain.
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3
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Siniscalchi C, Bikdeli B, Jiménez D, Suriñach JM, Demelo-Rodríguez P, Moustafa F, Gil-Díaz A, García-Ortega A, Bui HM, Monreal M. Statin use and mortality in patients with deep vein thrombosis. Data from the RIETE Registry. Thromb Res 2024; 236:88-96. [PMID: 38417300 DOI: 10.1016/j.thromres.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/06/2024] [Accepted: 02/22/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The association between statin use and mortality in patients with deep vein thrombosis (DVT) has not been rigorously evaluated. METHODS We used the data in the RIETE registry to examine the association between statin use and mortality at 3 months. We used mixed effects survival models accounting for clinical covariates and clustering of patients in enrolling centers. RESULTS From January 2009 through April 2022, there were 46,440 patients with isolated DVT in RIETE (in the lower-limbs 42,291, in the upper limbs 4149). Of these, 21 % and 18 %, respectively, were using statins. Statin users were older than non-users (72 ± 12 vs. 62 ± 18 years), and more likely had diabetes, hypertension, prior myocardial infarction or ischemic stroke, or were receiving antiplatelets. The 3-month mortality rates were: 6.0 % vs. 5.8 %, respectively. On multilevel multivariable analysis, the adjusted hazard ratio (aHR) for all-cause death in statin users vs. non-users was 0.77 (95%CI: 0.69-0.86). The 3-month risk of death in statin users was significantly lower than in non-users in patients with upper-limb DVT (aHR: 0.81; 95%CI: 0.72-0.91), distal lower-limb DVT (aHR: 0.48; 95%CI: 0.32-0.72), or proximal lower-limb DVT (aHR: 0.69; 95%CI: 0.50-0.95), and in those receiving simvastatin (aHR: 0.73; 95%CI: 0.60-0.90), atorvastatin (aHR: 0.70; 95%CI: 0.59-0.85), or rosuvastatin (aHR: 0.47; 95%CI: 0.27-0.80). Major bleeding, used as a falsification endpoint, did not show an association with use of statins at 3-month follow-up. CONCLUSIONS Statin users with isolated DVT were at significantly lower risk for death at 3 months than non-users.
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Affiliation(s)
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - José María Suriñach
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Pablo Demelo-Rodríguez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Farès Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain; Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | - Hanh My Bui
- Department of Scientific research management, Hanoi Medical University Hospital, Hanoi, Viet Nam
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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4
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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5
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Briceño W, Díaz G, Castillo A, Jara I, Yong E, Lago L, Dam Lyhne M, Monreal M, Bikdeli B, Jimenez D. Time to Resolution of Right Ventricle Dysfunction in Patients With Acute Pulmonary Embolism. Arch Bronconeumol 2024:S0300-2896(24)00059-0. [PMID: 38514348 DOI: 10.1016/j.arbres.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/25/2024] [Accepted: 03/02/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Gema Díaz
- Respiratory Department, Hospital Puerta de Hierro, Madrid, Spain
| | - Ana Castillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Ignacio Jara
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Edwin Yong
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Laura Lago
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Mads Dam Lyhne
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark; Department of Clinical Medicine, Aarhus University, Denmark
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA; Cardiovascular Research Foundation, New York, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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6
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Rashedi S, Greason CM, Sadeghipour P, Talasaz AH, O'Donoghue ML, Jimenez D, Monreal M, Anderson CD, Elkind MSV, Kreuziger LMB, Lang IM, Goldhaber SZ, Konstantinides SV, Piazza G, Krumholz HM, Braunwald E, Bikdeli B. Fibrinolytic Agents in Thromboembolic Diseases: Historical Perspectives and Approved Indications. Semin Thromb Hemost 2024. [PMID: 38428841 DOI: 10.1055/s-0044-1781451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients with pulmonary embolism with hemodynamic compromise, ST-segment elevation myocardial infarction (STEMI), acute ischemic stroke, and central venous access device occlusion. Reteplase and tenecteplase have also received FDA approval for treating patients with STEMI. This review provides an overview of the historical background related to fibrinolytic agents and briefly summarizes their approved indications across various thromboembolic diseases.
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Affiliation(s)
- Sina Rashedi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Christie M Greason
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, Virginia
- Department of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York
- Department of Pharmacy, New York-Presbyterian Hospital Columbia University Medical Center, New York, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
- Universidad Catolica de Murcia, Murcia, Spain
| | - Christopher D Anderson
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, Massachusetts
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lisa M Baumann Kreuziger
- Medical College of Wisconsin, Milwaukee, Wisconsin
- Blood Research Institute, Versiti, Milwaukee, Wisconsin
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Eugene Braunwald
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
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7
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Barrios D, Durán D, Rodríguez C, Moisés J, Retegui A, Lobo JL, López R, Chasco L, Jara-Palomares L, Muriel A, Otero-Candelera R, Ruiz-Artacho P, Monreal M, Bikdeli B, Jiménez D. Oxygen Therapy in Patients With Intermediate-Risk Acute Pulmonary Embolism: A Randomized Trial. Chest 2024; 165:673-681. [PMID: 37717936 DOI: 10.1016/j.chest.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/23/2023] [Accepted: 09/06/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND The effect of supplemental oxygen therapy in patients with intermediate-risk pulmonary embolism (PE) who do not have hypoxemia at baseline is uncertain. RESEARCH QUESTION Does supplemental oxygen improve echocardiographic parameters in nonhypoxemic patients with intermediate-risk PE? STUDY DESIGN AND METHODS This pilot trial randomly assigned nonhypoxemic patients with stable PE and echocardiographic right ventricle (RV) enlargement to receive anticoagulation plus supplemental oxygen for the first 48 h vs anticoagulation alone. The primary outcome was normal echocardiographic RV size 48 h after randomization. Secondary efficacy outcomes were the numerical change in the RV to left ventricle (LV) diameter ratio measured 48 h and 7 days after randomization with respect to the baseline ratio measured at inclusion. RESULTS The study was stopped prematurely because of the COVID-19 pandemic after recruiting 70 patients (mean ± SD age, 67.3 ± 16.1 years; 36 female [51.4%]) with primary outcome data. Forty-eight h after randomization, normalization of the RV size occurred in 14 of the 33 patients (42.4%) assigned to oxygen and in eight of the 37 patients (21.6%) assigned to ambient air (P = .08). In the oxygen group, the mean RV to LV ratio was reduced from 1.28 ± 0.28 at baseline to 1.01 ± 0.16 at 48 h (P < .001); in the ambient air group, mean RV to LV ratios were 1.21 ± 0.18 at baseline and 1.08 ± 0.19 at 48 h (P < .01). At 90 days, one major bleeding event and one death (both in the ambient air group) had occurred. INTERPRETATION In analyses limited by a small number of enrollees, compared with ambient air, supplemental oxygen did not significantly increase the proportion of patients with nonhypoxemic intermediate-risk PE whose RV to LV ratio normalized after 48 h of treatment. This pilot trial showed improvement in some ancillary efficacy outcomes and provides support for a definitive clinical outcomes trial. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT04003116; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Jorge Moisés
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - José Luis Lobo
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital de Araba, Vitoria, Spain
| | - Raquel López
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Leyre Chasco
- Respiratory Department, Hospital Galdakao-Usansolo, Bilbao, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Remedios Otero-Candelera
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Pedro Ruiz-Artacho
- Department of Internal Medicine, Clínica Universidad de Navarra, Madrid; Interdisciplinar Teragnosis and Radiosomics Research Group, Universidad de Navarra, Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Director of the Chair for Thromboembolic Disorders, Universidad Católica de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
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8
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Galanaud JP, Trujillo-Santos J, Bikdeli B, Bertoletti L, Di Micco P, Poénou G, Falgá C, Zdraveska M, Lima J, Rivera-Civico F, Muixi JF, Monreal M. Clinical Presentation and Outcomes of Patients With Cancer-Associated Isolated Distal Deep Vein Thrombosis. J Clin Oncol 2024; 42:529-537. [PMID: 37471683 DOI: 10.1200/jco.23.00429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/26/2023] [Accepted: 05/23/2023] [Indexed: 07/22/2023] Open
Abstract
PURPOSE Patients with isolated distal deep vein thrombosis (DVT) have lower rates of adverse outcomes (death, venous thromboembolism [VTE] recurrence or major bleeding) than those with proximal DVT. It is uncertain if such findings are also observed in patients with cancer. METHODS Using data from the international Registro Informatizado de la Enfermedad TromboEmbolica venosa registry, we compared the risks of adverse outcomes at 90 days (adjusted odds ratio [aOR]; 95% CI) and 1 year (adjusted hazard ratio [aHR; 95% CI]) in 886 patients with cancer-associated distal DVT versus 5,196 patients with cancer-associated proximal DVT and 5,974 patients with non-cancer-associated distal DVT. RESULTS More than 90% of patients in each group were treated with anticoagulants for at least 90 days. At 90 days, the adjusted risks of death, VTE recurrence, or major bleeding were lower in patients with non-cancer-associated distal DVT than in patients with cancer-associated distal DVT (reference): aOR = 0.16 (0.11-0.22), aOR = 0.34 (0.22-0.54), and aOR = 0.47 (0.27-0.80), respectively. The results were similar at 1-year follow-up: aHR = 0.12 (0.09-0.15), aHR = 0.39 (0.28-0.55), and aHR = 0.51 (0.32-0.82), respectively. Risks of death, VTE recurrence, and major bleeding were not statistically different between patients with cancer-associated proximal versus distal DVT, both at 90 days: aOR = 1.11 (0.91-1.36), aOR = 1.10 (0.76-1.62), and aOR = 1.18 (0.76-1.83), respectively, and 1 year: aHR = 1.01 (0.89-1.15), aHR = 1.02 (0.76-1.35), and aHR = 1.10 (0.76-1.61), respectively. However, more patients with cancer-associated proximal DVT, compared with cancer-associated distal DVT, developed fatal pulmonary embolism (PE) during follow-up: The risk difference was 0.40% (95% CI, 0.23 to 0.58). CONCLUSION Cancer-associated distal DVT has serious and relatively comparable outcomes compared with cancer-associated proximal DVT. The lower risk of fatal PE from cancer-associated distal DVT needs further investigation.
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Affiliation(s)
- Jean-Philippe Galanaud
- Department of Medicine, Sunnybrook Heath Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT
- Cardiovascular Research Foundation (CRF), New York, NY
| | - Laurent Bertoletti
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Pierpaolo Di Micco
- Department of Internal Medicine and Emergency Room, Ospedale Buon Consiglio Fate bene fratelli, Naples, Italy
| | - Géraldine Poénou
- Department of Vascular Medicine and Therapeutics, Hôpital Nord-CHU St-Etienne, Saint-Etienne, France
| | - Conxita Falgá
- Department of Internal Medicine, Hospital de Mataró, Barcelona, Spain
| | - Marija Zdraveska
- University Clinic of Pneumology and Allergy Skopje, Skopje, Republic of Macedonia
| | - Jorge Lima
- Department of Pneumonology, Hospital Universitario Virgen de Valme, Sevilla, Spain
| | | | | | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
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9
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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10
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Bikdeli B, Sadeghipour P, Lou J, Bejjani A, Khairani CD, Rashedi S, Lookstein R, Lansky A, Vedantham S, Sobieszczyk P, Mena-Hurtado C, Aghayev A, Henke P, Mehdipoor G, Tufano A, Chatterjee S, Middeldorp S, Wasan S, Bashir R, Lang IM, Shishehbor MH, Gerhard-Herman M, Giri J, Menard MT, Parikh SA, Mazzolai L, Moores L, Monreal M, Jimenez D, Goldhaber SZ, Krumholz HM, Piazza G. Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review. Semin Thromb Hemost 2024. [PMID: 38176425 DOI: 10.1055/s-0043-1777991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Junyang Lou
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sina Rashedi
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robert Lookstein
- Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Piotr Sobieszczyk
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ayaz Aghayev
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Center for Evidence-based Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Zucker School of Medicine, New York, New York
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suman Wasan
- University of North Carolina, Chapel Hill, North Carolina
| | - Riyaz Bashir
- Departement of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Mehdi H Shishehbor
- University Hospitals Heath System, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Marie Gerhard-Herman
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahil A Parikh
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Lisa Moores
- Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | | | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Najarro M, Briceño W, Rodríguez C, Muriel A, González S, Castillo A, Jara I, Rali P, Toma C, Bikdeli B, Jiménez D. Shock score for prediction of clinical outcomes among stable patients with acute symptomatic pulmonary embolism. Thromb Res 2024; 233:18-24. [PMID: 37988846 DOI: 10.1016/j.thromres.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/13/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND The Composite Pulmonary Embolism Shock (CPES) score has been developed to identify normotensive patients with acute pulmonary embolism (PE) and a low cardiac index (referred to as normotensive shock). We aimed to externally assess the validity of this model for predicting a complicated course among hemodynamically stable patients with acute PE. METHODS Using prospectively collected data from the PROgnosTic valuE of Computed Tomography scan (PROTECT) study, we calculated the CPES score for each patient and the proportion of patients with a score > 3. We calculated the test performance characteristics to predict a complicated course (i.e., death from any cause, hemodynamic collapse, or recurrent PE) and the discriminatory power using the area under the receiver operating characteristic curve. RESULTS Sixty-three of the 848 (7.4 %) patients had a complicated course during the 30-day follow-up period. Of the 848 enrolled patients, the CPES score was positive (i.e., score > 3) in 78 (9.2 %). The specificity was 92.1 % (723/785), the positive predictive value was 20.5 % (16/78), and the positive likelihood ratio was 3.22 for a complicated course. The areas under the receiver operating characteristic curve for a complicated course were 0.71 (95 % confidence interval [CI], 0.65-0.78). With the higher score risk classification threshold (cutoff score > 4), the proportion of patients designated as positive was 2.1 %, and the specificity was 98.1 %. When echocardiographic right ventricle (RV) dysfunction was replaced by computed tomographic RV enlargement, the specificity was 85.4 %, the positive predictive value was 14.2 %, and the positive likelihood ratio was 2.06 for a complicated course. When analyses were restricted to the subgroup of patients with intermediate-risk PE, the specificity and the positive predictive value for a complicated course were identical to the overall cohort. CONCLUSIONS The CPES score has acceptable C-statistic, excellent specificity, and low positive predictive value for identification of hemodynamic deterioration in normotensive patients with PE. CLINICALTRIALS gov number: NCT02238639.
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Affiliation(s)
- Marta Najarro
- Emergency Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ana Castillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ignacio Jara
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Catalin Toma
- Division of Cardiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA.; Cardiovascular Research Foundation, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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Savani M, Bikdeli B, Kalra A, Aggarwal V, Mukherjee D, Chatterjee S. Association Between Blood Transfusion Treatment Strategy for Acute Coronary Syndromes and Clinical Outcomes: A Meta-analysis of Randomized Clinical Trials. Am J Ther 2024; 31:e84-e87. [PMID: 38231585 DOI: 10.1097/mjt.0000000000001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Maisha Savani
- Frank H Netter School of Medicine, Quinnipiac University, Hamden, CT
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Womens Hospital, Boston, MA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT; and Cardiovascular Research Foundation (CRF), New York, NY
| | - Ankur Kalra
- Division of Cardiovascular Medicine, Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, IN
| | - Vikas Aggarwal
- Division of Cardiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Texas Tech University Health Sciences Center, El Paso, TX
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Zucker School of Medicine, New York, NY
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Lyhne MD, Bikdeli B, Dudzinski DM, Muriel-García A, Kabrhel C, Sancho-Bueso T, Pérez-David E, Lobo JL, Alonso-Gómez Á, Jiménez D, Monreal M. Validation of Echocardiographic Measurements in Patients with Pulmonary Embolism in the RIETE Registry. TH Open 2024; 8:e1-e8. [PMID: 38197015 PMCID: PMC10774011 DOI: 10.1055/s-0043-1777765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 01/11/2024] Open
Abstract
Background In acute pulmonary embolism (PE), echocardiographic identification of right ventricular (RV) dysfunction will inform prognostication and clinical decision-making. Registro Informatizado Enfermedad TromboEmbolica (RIETE) is the world's largest registry of patients with objectively confirmed PE. The reliability of site-reported RV echocardiographic measurements is unknown. We aimed to validate site-reported key RV echocardiographic measurements in the RIETE registry. Methods Fifty-one randomly chosen patients in RIETE who had transthoracic echocardiogram (TTE) performed for acute PE were included. TTEs were de-identified and analyzed by a core laboratory of two independent observers blinded to site-reported data. To investigate reliability, intraclass correlation coefficients (ICCs) and Bland-Altman plots between the two observers, and between an average of the two observers and the RIETE site-reported data were obtained. Results Core laboratory interobserver variations were very limited with correlation coefficients >0.8 for all TTE parameters. Agreement was substantial between core laboratory observers and site-reported data for key parameters including tricuspid annular plane systolic excursion (ICC 0.728; 95% confidence interval [CI], 0.594-0.862) and pulmonary arterial systolic pressure (ICC 0.726; 95% CI, 0.601-0.852). Agreement on right-to-left ventricular diameter ratio (ICC 0.739; 95% CI, 0.443-1.000) was validated, although missing data limited the precision of the estimates. Bland-Altman plots showed differences close to zero. Conclusion We showed substantial reliability of key RV site-reported measurements in the RIETE registry. Ascertaining the validity of such data adds confidence and reliability for subsequent investigations.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Yale-New Haven Hospital (YNHH)/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, United States
| | - David M. Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Alfonso Muriel-García
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, Madrid and CIBERESP, Universidad de Alcalá, Madrid, Spain
| | - Christopher Kabrhel
- Department of Emergency Medicine, Centre of Vascular Emergencies, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Teresa Sancho-Bueso
- Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain
| | | | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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Shafi I, Zlotshewer B, Zhao M, Lakhter V, Bikdeli B, Comerota A, Zhao H, Bashir R. Association of vena cava filters and catheter-directed thrombolysis for deep vein thrombosis with hospital readmissions. J Vasc Surg Venous Lymphat Disord 2024; 12:101677. [PMID: 37696417 DOI: 10.1016/j.jvsv.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Acute deep vein thrombosis (DVT) affects >350,000 patients each year in the United States. Contemporary rehospitalization rates and predictors of acute DVT have not been well-characterized. We aimed to evaluate the all-cause 30-day readmission rate and its association with catheter-directed thrombolysis and vena cava filters in patients with proximal and caval DVT. METHODS Patients with an index hospitalization for acute proximal lower extremity DVT were evaluated for unplanned readmission rates at 30 days using the Nationwide Readmission Database from 2016 to 2017. We used Cox proportional hazard model to determine the predictors of 30-day readmissions and their association with inferior vena cava (IVC) filter and CDT use. RESULTS We identified 58,306 adult patients with an index hospitalization for acute proximal DVT. The unplanned 30-day rehospitalization rate was 14.7% (95% confidence interval [CI], 14.5-15.0%). There were 4995 patients (10.0%) who underwent CDT and 6085 (12.2%) who underwent IVC filter placement. In multivariable analysis, only CDT was associated with a lower hazard for rehospitalization (hazard ratio [HR], 0.77; 95% CI, 0.71-0.84; P < .001), whereas IVC filter placement (HR, 1.26; 95% CI, 1.19-1.34; P < .001), Charlson Comorbidity Index of >3 (HR, 1.47; 95% CI, 1.38-1.56; P < .001), malignancy (HR, 1.45; 95% CI, 1.34-1.57; P < .001), and length of stay >5 days (HR, 1.39; 95% CI, 1.33-1.46; P < .001), and acute kidney injury (HR, 1.18; 95% CI, 1.11-1.25; P < .001) were associated with higher readmission rates. CONCLUSIONS The 30-day unplanned rehospitalization rate continues to be high in patients with acute proximal DVT. CDT was associated with lower rehospitalization rates, whereas IVC filter placement was associated with increased rehospitalization rates.
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Affiliation(s)
- Irfan Shafi
- Division of Cardiovascular Medicine, Wayne State University/Detroit Medical Center, Detroit, MI
| | - Brooke Zlotshewer
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Matthew Zhao
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vladimir Lakhter
- Inova Alexandria Hospital, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Behnood Bikdeli
- Section of Vascular Medicine, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School Boston, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Cardiovascular Research Foundation (CRF), New York, NY
| | - Anthony Comerota
- Inova Alexandria Hospital, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
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15
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Bikdeli B, Muriel A, Rodríguez C, González S, Briceño W, Mehdipoor G, Piazza G, Ballaz A, Lippi G, Yusen RD, Otero R, Jiménez D. High-Sensitivity vs Conventional Troponin Cutoffs for Risk Stratification in Patients With Acute Pulmonary Embolism. JAMA Cardiol 2024; 9:64-70. [PMID: 37991780 PMCID: PMC10666041 DOI: 10.1001/jamacardio.2023.4356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/26/2023] [Indexed: 11/23/2023]
Abstract
Importance High-sensitivity troponin tests can detect even milder cardiac troponin elevations in plasma, beyond the threshold of conventional troponin tests. Whether detection of low-grade cardiac troponin elevation is associated with outcomes of patients with hemodynamically stable pulmonary embolism (PE) and helps with risk stratification is unknown. Objective To determine the association between high-sensitivity cardiac troponin I (hs-cTnI) compared with conventional cardiac troponin I (cTnI) and PE risk designations according to the European Society of Cardiology (ESC) 2019 classification scheme and clinical outcomes in patients with hemodynamically stable PE. Design, Setting, and Participants This is a post hoc analysis of data from the prospective Prognostic Value of Computed Tomography (PROTECT) multicenter cohort study enrolling patients from 12 hospital emergency departments in Spain. In this analysis, cTnI and hs-cTnI were compared with respect to ESC risk designation, and the association between troponin values and a complicated course after PE diagnosis was evaluated. Of 848 patients enrolled in PROTECT, 834 (98.3%) had hsTnI and cTnI values available and were included in the present analysis. Data were analyzed from May to December 2022. Exposures Troponin blood testing with cTnI (threshold of >0.05 ng/mL) vs hs-cTnI (threshold of >0.029 ng/mL) assays at the time of PE diagnosis. Main Outcomes Complicated course, defined as hemodynamic collapse, recurrent PE, or all-cause death, within 30 days after PE. Results Of 834 patients (mean [SEM] age, 67.5 [0.6] years; 424 [50.8%] female), 139 (16.7%) had elevated cTnI and 264 (31.7%) elevated hs-TnI, respectively. During follow-up, 62 patients (7.4%; 95% CI, 5.7-9.4) had a complicated course. Analyzing troponin elevation as a binary variable, elevated cTnI (odds ratio [OR], 2.84; 95% CI, 1.62-4.98) but not hs-cTnI (OR, 1.12; 95% CI, 0.65-1.93) was associated with increased odds of a complicated course. Of 125 patients who had elevated hs-cTnI but normal cTnI, none (0; 95% CI, 0.0-2.9) developed a complicated course. Using the 2019 ESC risk stratification scheme, hs-TnI classified fewer patients as low risk compared with cTnI. Among 78 patients designated as ESC low risk when using cTnI but not with hsTnI, none (0; 95% CI, 0.0-4.6) had a complicated course. Conclusions and Relevance In this study of patients with hemodynamically stable PE, hs-cTnI identified modest elevations in cardiac troponin levels. However, the results did not provide additive clinical value compared with cTnI. These findings suggest that use of hs-cTnI may result in overestimation of the risk in patients with stable PE.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Alfonso Muriel
- Clinical Biostatistics Unit, Hospital Ramón y Cajal and Universidad de Alcalá, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | | | - Sara González
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
| | | | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center and the Albert Einstein College of Medicine, The Bronx, New York
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aitor Ballaz
- Respiratory Department, Hospital Galdakao, Galdakao, Spain
| | - Giuseppe Lippi
- Section of Clinical Biochemistry and School of Medicine, University of Verona, Verona, Italy
| | - Roger D. Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Remedios Otero
- Respiratory Department, Hospital Virgen del Rocío, Sevilla, Spain
- Biomedical Research Networking Center Enfermedades Respiratorias, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
- Biomedical Research Networking Center Enfermedades Respiratorias, Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
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16
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Bertoletti L, Madridano O, Jiménez D, Muriel A, Bikdeli B, Ay C, Trujillo-Santos J, Bosevski M, Sigüenza P, Monreal M. Cancer-Associated Thrombosis: Trends in Clinical Features, Treatment, and Outcomes From 2001 to 2020. JACC CardioOncol 2023; 5:758-772. [PMID: 38205016 PMCID: PMC10774792 DOI: 10.1016/j.jaccao.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 01/12/2024] Open
Abstract
Background Despite advances in cancer and venous thromboembolism (VTE) management, the epidemiology of cancer-associated thrombosis management over time remains unclear. Objectives We analyzed data from the RIETE (Registro Informatizado de la Enfermedad Trombo Embólica) registry spanning 2001 to 2020 to investigate temporal trends in clinical characteristics and treatments for cancer-associated thrombosis. Methods Using multivariable survival regression, we examined temporal trends in risk-adjusted rates of symptomatic VTE recurrences, major bleeding, and death within 30 days after incident VTE. Results Among the 17,271 patients with cancer-associated thrombosis, there was a progressive increase in patients presenting with pulmonary embolism (from 44% in 2001-2005 to 55% in 2016-2020; P < 0.001 for trend), lung (from 12.7% to 18.1%; P < 0.001) or pancreatic cancer (from 3.8% to 5.6%; P = 0.003), and utilization of immunotherapy (from 0% to 7.4%; P < 0.001). Conversely, there was a decline in patients with prostate cancer (from 11.7% to 6.6%; P < 0.001) or carcinoma of unknown origin (from 3.5% to 0.7%; P < 0.001). At the 30-day follow-up, a reduction was observed in the proportion of patients experiencing symptomatic VTE recurrences (from 3.1% to 1.1%; P < 0.001), major bleeding (from 3.1% to 2.2%; P = 0.004), and death (from 11.9% to 8.4%; P < 0.001). Multivariable analyses revealed a decreased risk over time for VTE recurrence (adjusted subdistribution HR [asHR]: 0.94 per year; 95% CI: 0.92-0.98), major bleeding (asHR: 0.98; 95% CI: 0.96-0.99), and death (aHR: 0.97; 95% CI: 0.96-0.98). Conclusions In this multicenter study of cancer patients with VTE, there was a decline in thrombotic, hemorrhagic, and fatal events from 2001 to 2020. (Registro Informatizado de la Enfermedad Trombo Embólica [RIETE]; NCT02832245).
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Affiliation(s)
- Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
| | - Olga Madridano
- Department of Internal Medicine, Hospital Infanta Sofía, Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Unit, Ramón y Cajal Hospital IRYCIS, CIBERESP, Nursing and Physiotherapy Department, University of Alcala, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, Connecticut, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria
| | - Javier Trujillo-Santos
- Internal Medicine Department, Hospital Universitario Santa Lucía, Complejo Hospitalario Universitario de Cartagena, Murcia, Spain
- Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Marijan Bosevski
- University Cardiology Clinic Faculty of Medicine, Skopje, North Macedonia
| | - Patricia Sigüenza
- Department of Internal Medicine, Hospital Germans Trias I Pujol, Badalona, Barcelona, Spain
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
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Tritschler T, Sadeghipour P, Bikdeli B. Subgroup analysis in randomized controlled trials: Useful or misleading? Thromb Res 2023; 232:160-162. [PMID: 36357215 DOI: 10.1016/j.thromres.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland; Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA.
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Potpara T, Angiolillo DJ, Bikdeli B, Capodanno D, Cole O, Yataco AC, Dan GA, Harrison S, Iaccarino JM, Moores LK, Ntaios G, Lip GYH. Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. Chest 2023; 164:1531-1550. [PMID: 37392958 DOI: 10.1016/j.chest.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting. RESEARCH QUESTION What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19? STUDY DESIGN AND METHODS A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey. RESULTS The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19. INTERPRETATION The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.
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Affiliation(s)
- Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia; Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia.
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT; Cardiovascular Research Foundation, New York, NY
| | - Davide Capodanno
- Azienda Ospedalielo-Universitaria Policlinico "G- Rodolico-San Marco", University of Catania, Catania, Italy
| | - Oana Cole
- Liverpool Heart and Chest Hospital, Liverpool, England
| | - Angel Coz Yataco
- Departments of Critical Care and of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gheorghe-Andrei Dan
- "Carol Davila" University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England
| | - Jonathan M Iaccarino
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; American College of Chest Physicians, Glenview, IL
| | - Lisa K Moores
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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19
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Barco S, Klok FA, Bikdeli B. Optimizing and Extending the Risk-Adapted Management of Acute Pulmonary Embolism beyond the Acute Phase: Progress in Pulmonary Embolism Research. Semin Thromb Hemost 2023; 49:783-784. [PMID: 37832583 DOI: 10.1055/s-0043-1775978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Affiliation(s)
- Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut
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20
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Bikdeli B, Piazza G. The CORONA-VTE network registry: Revisiting the realities while encouraging enthusiasm. Thromb Res 2023; 231:7. [PMID: 37738773 DOI: 10.1016/j.thromres.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA.
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
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21
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Ortega-Paz L, Talasaz AH, Sadeghipour P, Potpara TS, Aronow HD, Jara-Palomares L, Sholzberg M, Angiolillo DJ, Lip GYH, Bikdeli B. COVID-19-Associated Pulmonary Embolism: Review of the Pathophysiology, Epidemiology, Prevention, Diagnosis, and Treatment. Semin Thromb Hemost 2023; 49:816-832. [PMID: 36223804 DOI: 10.1055/s-0042-1757634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
COVID-19 is associated with endothelial activation in the setting of a potent inflammatory reaction and a hypercoagulable state. The end result of this thromboinflammatory state is an excess in thrombotic events, in particular venous thromboembolism. Pulmonary embolism (PE) has been of special interest in patients with COVID-19 given its association with respiratory deterioration, increased risk of intensive care unit admission, and prolonged hospital stay. The pathophysiology and clinical characteristics of COVID-19-associated PE may differ from the conventional non-COVID-19-associated PE. In addition to embolic events from deep vein thrombi, in situ pulmonary thrombosis, particularly in smaller vascular beds, may be relevant in patients with COVID-19. Appropriate prevention of thrombotic events in COVID-19 has therefore become of critical interest. Several changes in viral biology, vaccination, and treatment management during the pandemic may have resulted in changes in incidence trends. This review provides an overview of the pathophysiology, epidemiology, clinical characteristics, and risk factors of COVID-19-associated PE. Furthermore, we briefly summarize the results from randomized controlled trials of preventive antithrombotic therapies in COVID-19, focusing on their findings related to PE. We discuss the acute treatment of COVID-19-associated PE, which is substantially similar to the management of conventional non-COVID-19 PE. Ultimately, we comment on the current knowledge gaps in the evidence and the future directions in the treatment and follow-up of COVID-19-associated PE, including long-term management, and its possible association with long-COVID.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tatjana S Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Intensive Arrhythmia Care, Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| | - Herbert D Aronow
- Department of Cardiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Luis Jara-Palomares
- Respiratory Unit, Hospital Universitario Virgen del Rocio, Sevilla, Spain
- Centro de Investigacion Biomedica en Red de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Michelle Sholzberg
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
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22
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Zuin M, Piazza G, Barco S, Bikdeli B, Hobohm L, Giannakoulas G, Konstantinides S. Time-based reperfusion in haemodynamically unstable pulmonary embolism patients: does early reperfusion therapy improve survival? Eur Heart J Acute Cardiovasc Care 2023; 12:714-720. [PMID: 37421358 DOI: 10.1093/ehjacc/zuad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/07/2023] [Indexed: 07/10/2023]
Abstract
High-risk pulmonary embolism (PE) is associated with significant morbidity and mortality. Systemic thrombolysis remains the most evidenced-based treatment for haemodynamically unstable PE, but in daily clinical practice, it remains largely underused. In addition, unlike acute myocardial infarction or stroke, a clear time window for reperfusion therapy, including fibrinolysis, for high-risk PE has not been defined either for fibrinolysis or for the more recently incorporated options of catheter-based thrombolysis or thrombectomy. The aim of the present article is to review the current evidence supporting the potential benefit of earlier administration of reperfusion in haemodynamically unstable PE patients and suggest some potential strategies to further explore this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8, Ferrara, 44100, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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23
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Bikdeli B, Erlinge D, Valgimigli M, Kastrati A, Han Y, Steg PG, Stables RH, Mehran R, James SK, Frigoli E, Goldstein P, Li Y, Shahzad A, Schüpke S, Mehdipoor G, Chen S, Redfors B, Crowley A, Zhou Z, Stone GW. Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials. Circulation 2023; 148:1207-1219. [PMID: 37746717 DOI: 10.1161/circulationaha.123.063946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI. METHODS We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding. RESULTS A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up. CONCLUSIONS In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT (B.B.)
| | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, French Alliance for Cardiovascular Trials, L'Institut national de la santé et de la recherche médicale U-1148, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.)
- Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Rod H Stables
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | | | - Enrico Frigoli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | | | - Yi Li
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY (G.M.)
| | - Shmuel Chen
- Weill-Cornell Cornell Medical Center/ New York-Presbyterian Hospital, New York, NY (S.C.)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | | | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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24
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Rodríguez C, Muriel A, Carrasco L, González S, Briceño W, Durán D, Retegui A, Yusen RD, Bikdeli B, Jiménez D. National Early Warning Score-2 for Identification of Patients with Intermediate-High-Risk Pulmonary Embolism. Semin Thromb Hemost 2023; 49:716-724. [PMID: 37327883 DOI: 10.1055/s-0043-1769938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Consensus statements have proposed the use of the National Early Warning Score 2 (NEWS2) to identify stable patients with acute pulmonary embolism (PE) and an intermediate-high risk of adverse outcomes. We aimed to externally validate NEWS2 and compare it to another predictive score (Bova). Using NEWS2 (cutoff ≥5 and ≥7) and the Bova score (cutoff >4), we classified patients as intermediate-high risk (vs. non-intermediate-high risk), and we compared the test characteristics of these risk classification tools for a complicated course within 30 days after PE diagnosis. We also assessed the validity of NEWS2 for predicting a complicated course by adding the results of echocardiography and troponin testing to the model. Of the 848 enrolled patients, the NEWS2 score ≥5 classified 471 (55.5%) and the Bova score classified 37 (4.4%) as intermediate-high risk. NEWS2 had a significantly lower specificity for a 30-day complicated course than Bova (45.4 vs. 96.3%, respectively; p < 0.001). Using the higher score threshold (≥7), the NEWS2 classified 99 (11.7%) as intermediate-high risk, and the specificity was 88.9% (difference with Bova, 7.4%; p < 0.001). The proportion of patients with intermediate-high risk PE was 2.4% for the combination of a positive troponin testing and echocardiographic right ventricle dysfunction and a positive NEWS2 (score ≥7), while the specificity was 97.8% (difference with Bova, 1.5%; p = 0.07). Bova outperforms NEWS2 for predicting a complicated course among stable patients with PE. Addition of troponin testing and echocardiography improved the specificity of NEWS2, although it was not superior to Bova. CLINICALTRIALS.GOV NUMBER: : NCT02238639.
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Affiliation(s)
- Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Alfonso Muriel
- Department of Biostatistics, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Luis Carrasco
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Roger D Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Department of Medicine, Universidad de Alcalá, Madrid, Spain
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25
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Bikdeli B, Muriel A, Wang Y, Piazza G, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Madridano O, Lopez-Saez JB, Mellado M, Brasero AMD, Grandone E, Spagnolo PA, Lu Y, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Gerhard-Herman M, Goldhaber SZ, Bates SM, Jimenez D, Krumholz HM, Monreal M. Sex-Related Differences in Patient Characteristics, Risk Factors, and Symptomatology in Older Adults with Pulmonary Embolism: Findings from the SERIOUS-PE Study. Semin Thromb Hemost 2023; 49:725-735. [PMID: 36868268 DOI: 10.1055/s-0043-1764231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Sex-specific factors are implicated in pulmonary embolism (PE) presentation in young patients, as indicated by increased risk in pregnancy. Whether sex differences exist in PE presentation, comorbidities, and symptomatology in older adults, the age group in which most PEs occur, remains unknown. We identified older adults (aged ≥65 years) with PE in a large international PE registry replete with information about relevant clinical characteristics (RIETE registry, 2001-2021). To provide national data from the United States, we assessed sex differences in clinical characteristics and risk factors of Medicare beneficiaries with PE (2001-2019). The majority of older adults with PE in RIETE (19,294/33,462, 57.7%) and in the Medicare database (551,492/948,823, 58.7%) were women. Compared with men, women with PE less frequently had atherosclerotic diseases, lung disease, cancer, or unprovoked PE, but more frequently had varicose veins, depression, prolonged immobility, or history of hormonal therapy (p < 0.001 for all). Women less often presented with chest pain (37.3 vs. 40.6%) or hemoptysis (2.4 vs. 5.6%) but more often with dyspnea (84.6 vs. 80.9%) (p < 0.001 for all). Measures of clot burden, PE risk stratification, and use of imaging modalities were comparable between women and men. PE is more common in elderly women than in men. Cancer and cardiovascular disease are more common in men, whereas transient provoking factors including trauma, immobility, or hormone therapy are more common in elderly women with PE. Whether such differences correlate with disparities in treatment or differences in short- or long-term clinical outcomes warrants further investigation.
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Affiliation(s)
- Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Alfonso Muriel
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP: Universidad de Alcalá, Madrid, Spain
| | - Yun Wang
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts
| | - Olga Madridano
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Juan Bosco Lopez-Saez
- Department of Internal Medicine, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - Meritxell Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Ana Maria Diaz Brasero
- Department of Internal Medicine, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza," Foggia, S. Giovanni Rotondo, Italy
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
- Department of Obstetrics Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Primavera A Spagnolo
- Mary Horrigan Connors Center for Women's Health & Gender Biology, Harvard Medical School, Boston, Massachusetts
| | - Yuan Lu
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
| | - Laurent Bertoletti
- Department of Psychiatry, Brigham and Women Hospital, Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Manuel Jesús Núñez
- Department of Internal Medicine, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
| | | | - Marie Gerhard-Herman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Jimenez
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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26
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Zuin M, Bikdeli B, Armero A, Porio N, Rigatelli G, Bilato C, Piazza G. Trends in Pulmonary Embolism Deaths Among Young Adults Aged 25 to 44 Years in the United States, 1999 to 2019. Am J Cardiol 2023; 202:169-175. [PMID: 37441831 DOI: 10.1016/j.amjcard.2023.06.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/06/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023]
Abstract
A concerning increase in mortality from acute pulmonary embolism (PE) in young adults in the United States has been reported. We extracted PE-related mortality rates (number of deaths per US population) from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database from 1999 to 2019, focusing on subjects aged 25 to 44 years. Age-adjusted mortality rates (AAMRs) were assessed using the Joinpoint regression modeling and expressed as the estimated average annual percentage change (AAPC) with relative 95% confidence intervals (95% CIs) and stratified by urbanization, gender, age, and race. Between 1999 and 2019, the AAMR from acute PE in US adults aged 25 to 44 years linearly increased without any difference between genders (AAPC +1.5%, 95% CI 1.2 to 1.8, p <0.001). AAMR increase was more pronounced in American-Indians/Alaska Natives and in Asian/Pacific Islanders (AAPC +2.5%, 95% CI 1.6 to 3.4, p <0.001), Whites (AAPC +1.7%, 95% CI 1.4 to 2.0, p <0.001), Latinx/Hispanic patients (AAPC +1.7%, 95% CI 0.6 to 3.0, p = 0.003), and residents of rural areas (AAPC +2.4%, 95% CI 1.9 to 2.8, p <0.001). A higher AAMR (4.02 per 100,000 residents, 95% CI 3.90 to 4.15) and absolute number of PE-related deaths were observed in the South. PE-related mortality in adults aged 25 to 44 years has increased over the last 2 decades in the United States. Stratification by race, ethnicity, urbanization, and census region showed ethnoracial and regional disparities that will require further evaluation and remedy.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Andre Armero
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole Porio
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Jiménez D, Tapson V, Yusen RD, Becattini C, Moores L, Barnes GD, Monreal M, Konstantinides S, Bikdeli B. Revised Paradigm for Acute Pulmonary Embolism Prognostication and Treatment. Am J Respir Crit Care Med 2023; 208:524-527. [PMID: 37450886 PMCID: PMC10492237 DOI: 10.1164/rccm.202212-2234vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 07/14/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- David Jiménez
- Servicio de Neumología, Hospital Ramón y Cajal e Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- Departamento de Medicina, Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Victor Tapson
- Cedars-Sinai Medical Center, Los Angeles, California
| | - Roger D. Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine–Stroke Unit, University of Perugia, Perugia, Italy
| | - Lisa Moores
- F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Geoffrey D. Barnes
- Frankel Cardiovascular Center and Institute for Healthcare Policy and Innovation, University of Michigan Medical School, Ann Arbor, Michigan
| | - Manuel Monreal
- Centro de Investigación en Red de Enfermedades Respiratorias, Madrid, Spain
- Facultad de Ciencias de la Salud, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut; and
- Cardiovascular Research Foundation, New York, New York
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Jiménez D, Bikdeli B, Rodríguez C, Muriel A, Ballaz A, Soler S, Schellong S, Gil-Díaz A, Skride A, Riera-Mestre A, Monreal M. Identification of Low-risk Patients With Acute Symptomatic Pulmonary Embolism. Arch Bronconeumol 2023; 59:575-580. [PMID: 37455150 DOI: 10.1016/j.arbres.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/03/2023] [Accepted: 06/20/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Identification of patients with acute symptomatic pulmonary embolism (PE) who are at low-risk for short-term complications to warrant outpatient care lacks clarity. METHOD In order to identify patients at low-risk for 30-day all-cause and PE-related mortality, we used a cohort of haemodynamically stable patients from the RIETE registry to compare the false-negative rate of four strategies: the simplified Pulmonary Embolism Severity Index (sPESI); a modified (i.e., heart rate cutoff of 100beats/min) sPESI; and a combination of the original and the modified sPESI with computed tomography (CT)-assessed right ventricle (RV)/left ventricle (LV) ratio. RESULTS Overall, 137 of 3117 patients with acute PE (4.4%) died during the first month. Of these, 41 (1.3%) died from PE, and 96 (3.1%) died from other causes. The proportion of patients categorized as having low-risk was highest with the sPESI and lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio (32.5% versus 16.5%; P<0.001). However, among patients identified as low-risk, the 30-day mortality rate was lowest with the combination of a modified sPESI and CT-assessed RV/LV ratio and highest with the sPESI (0.4% versus 1.0%; P=0.03). The 30-day PE-related mortality rates for patients designated as low-risk by the sPESI, the modified sPESI, and the combination of the original and modified sPESI with CT-assessed RV/LV ratio were 0.7%, 0.4%, 0.7%, and 0.2%, respectively. CONCLUSIONS The combination of a negative modified sPESI with CT-assessed RV/LV ratio ≤1 identifies patients with acute PE who are at very low-risk for short-term mortality.
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Affiliation(s)
- David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | - Aitor Ballaz
- Department of Pneumonology, Hospital de Galdakao, Vizcaya, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - Sebastian Schellong
- Department of Medical Clinic, Municipal Hospital of Dresden Friedrichstadt, Dresden, Germany
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Murcia, Spain
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Fanikos J, Tawfik Y, Almheiri D, Sylvester K, Buckley LF, Dew C, Dell'Orfano H, Armero A, Bejjani A, Bikdeli B, Campia U, Davies J, Fiumara K, Hogan H, Khairani CD, Krishnathasan D, Lou J, Makawi A, Morrison RH, Porio N, Tristani A, Connors JM, Goldhaber SZ, Piazza G. Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods. Am J Med 2023; 136:927-936.e3. [PMID: 37247752 DOI: 10.1016/j.amjmed.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/05/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009). METHODS We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event. RESULTS Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods. CONCLUSIONS We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.
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Affiliation(s)
- John Fanikos
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Yahya Tawfik
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Danya Almheiri
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Katelyn Sylvester
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Leo F Buckley
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Chris Dew
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Dell'Orfano
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andre Armero
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Umberto Campia
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Julia Davies
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Karen Fiumara
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Hogan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Candrika Dini Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Darsiya Krishnathasan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Junyang Lou
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alaa Makawi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ruth H Morrison
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Nicole Porio
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anthony Tristani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Jean M Connors
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Zuin M, Bikdeli B, Davies J, Krishnathasan D, Rigatelli G, Roncon L, Bilato C, Piazza G. Contemporary trends in mortality related to high-risk pulmonary embolism in US from 1999 to 2019. Thromb Res 2023; 228:72-80. [PMID: 37295022 DOI: 10.1016/j.thromres.2023.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 06/11/2023]
Abstract
BACKGROUND Population-based data on high-risk pulmonary embolism (PE) mortality trends in the United States (US) are scant. OBJECTIVES To assess current trends in US mortality related to high-risk PE over the past 21 years and determine differences by sex, race, ethnicity, age and census region. METHODS Data were extracted from the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER) to determine trends in age-adjusted mortality rates (AAMR) per 100,000 people, due to high-risk PE. To calculate nationwide annual trends, we assessed the average (AAPC) and annual percent change (APC) with relative 95 % confidence intervals (CIs) using Joinpoint regression. RESULTS Between 1999 and 2019, high-risk PE was listed as the underlying cause of death in 209,642 patients, corresponding to an AAMR of 3.01 per 100,000 people (95 % CI: 2.99 to 3.02). AAMR from high-risk PE remained stable from 1999 to 2007 [APC: -0.2 %, (95 % CI: -2.0 to 0.5, p = 0.22)] and then significantly increased [APC: 3.1 % (95 % CI: 2.6 to 3.6), p < 0.0001], especially in males [AAPC: 1.9 % (95 % CI: 1.4 to 2.4), p < 0.001 vs AAPC: 1.5 % (95 % CI: 1.1 to 2.2), p < 0.001]. AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. CONCLUSIONS In an US population analysis, high-risk PE mortality rate increased, with racial, sex-based, and regional variations. Further studies are needed to understand root causes for these trends and to implement appropriate corrective strategies.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy.
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, CT, United States
| | - Julia Davies
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Loris Roncon
- Department of Cardiology, Santa Maria della Misericordia Hospital, Rovigo, Italy
| | - Claudio Bilato
- Department of Cardiology, West Vicenza Hospital, Arzignano, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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31
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Bikdeli B, Eikelboom JW. P-Selectin de-ACTIVation in COVID-19: What Have We Learned? Circulation 2023; 148:391-393. [PMID: 37523764 DOI: 10.1161/circulationaha.123.065619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Behnood Bikdeli
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, CT (B.B.)
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Canada (J.W.E.)
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Bikdeli B, Khairani CD, Krishnathasan D, Bejjani A, Armero A, Tristani A, Davies J, Porio N, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Achanta A, Jesudasen SJ, Tiu BC, Merli GJ, Leiva O, Fanikos J, Sharma A, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll BJ, Lan Z, Goldhaber SZ, Piazza G. Major cardiovascular events after COVID-19, event rates post-vaccination, antiviral or anti-inflammatory therapy, and temporal trends: Rationale and methodology of the CORONA-VTE-Network study. Thromb Res 2023; 228:94-104. [PMID: 37302267 PMCID: PMC10226776 DOI: 10.1016/j.thromres.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular and thrombotic events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to more recent event rates, temporal trends, association between vaccination status and outcomes, and findings within vulnerable subgroups such as older adults (aged 65 years or older), or those undergoing hemodialysis. Sex-informed findings, including results among pregnant and breastfeeding women, as well as adjusted comparisons between male and female adults are similarly understudied. METHODS Adult patients, aged ≥18 years, with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at the participating centers of the registry are eligible for inclusion. A total of 10,000 patients have been included in this multicenter study, with Brigham and Women's Hospital (Boston, MA) serving as the coordinating center. Other sites include Beth Israel Deaconess Medical Center, Anne Arundel Medical Center, University of Virginia Medical Center, University of Colorado Health System, and Thomas Jefferson University Health System. Data elements will be ascertained manually for accuracy. The two main outcomes are 1) a composite of venous or arterial thrombotic events, and 2) a composite of major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Clinical outcomes are adjudicated by independent physicians. Vaccination status and time of inclusion in the study will be ascertained for subgroup-specific analyses. Outcomes are pre-specified to be reported separately for hospitalized patients versus those who were initially receiving outpatient care. Outcomes will be reported at 30-day and 90-day follow-up. Data cleaning at the sites and the data coordinating center and outcomes adjudication process are in-progress. CONCLUSIONS The CORONA-VTE-Network study will share contemporary information related to rates of cardiovascular and thrombotic events in patients with COVID-19 overall, as well as within key subgroups, including by time of inclusion, vaccination status, patients undergoing hemodialysis, the elderly, and sex-informed analyses such as comparison of women and men, or among pregnant and breastfeeding women.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali A Assi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce C Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett J Carroll
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Piazza G, Hurwitz S, Campia U, Bikdeli B, Lou J, Khairani CD, Bejjani A, Snyder JE, Pfeferman M, Barns B, Rizzo S, Glezer A, Goldhaber SZ. Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2). Thromb Res 2023; 227:1-7. [PMID: 37182298 DOI: 10.1016/j.thromres.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier- NCT02958943.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale New Haven Hospital (YNHH), Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Junyang Lou
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briana Barns
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alexandra Glezer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Vaduganathan M, Bikdeli B. Closer to FREEDOM From Uncertainty. J Am Coll Cardiol 2023; 81:1763-1765. [PMID: 37137585 PMCID: PMC10150780 DOI: 10.1016/j.jacc.2023.03.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/22/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale New Haven Hospital, Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
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Mehdizadeh K, Mohseni Salehi M, Moosavi J, Mohebbi B, Klok F, Bikdeli B, Shafe O, Pouraliakbar H, Alizadehasl A, Farrashi M, Kaviani R, Mehrvarz F, Rashidi F, Talakoob H, Bakhshandeh H, Sadeghipour P. Cross-cultural Validity of the PEmb-QoL in Quality of Life survey after Pulmonary Embolism: a Persian-speaking cohort. Res Pract Thromb Haemost 2023; 7:100145. [PMID: 37159746 PMCID: PMC10163673 DOI: 10.1016/j.rpth.2023.100145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/21/2023] [Accepted: 03/24/2023] [Indexed: 04/03/2023] Open
Abstract
Background The Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire is the first disease-specific scale for assessing the quality of life in patients with a history of pulmonary embolism (PE). Objectives To assess the cross-cultural validity and reliability of the disease-specific PEmb-QoL questionnaire. Methods The Persian version was prepared through the forward and backward translation of the English questionnaire. Six months after the diagnosis of acute PE, consecutive Persian-speaking patients were asked to complete the PEmb-QoL, the generic 36-item Short Form (SF-36) questionnaires and undertake a 6-minute walk test (6MWT). Acceptability was assessed via item missing rate, reproducibility by the test-retest method, and internal consistency reliability by Cronbach's α and McDonald's ω coefficients. Convergence validity was assessed using the Spearman rank correlation between scores of PEmb-QoL, SF-36, and 6MWT. The questionnaire structure was evaluated through exploratory factor analysis. Results Ninety-six patients with a confirmed diagnosis of PE completed the questionnaires. The Persian version of PEmb-QoL had good internal consistency (α = 0.95, 3-factor ω = 0.96), inter-item correlation (0.3-0.62), item-total correlation (0.38-0.71), reproducibility (test-retest ICC with 25 participants = 0.92-0.99), and good discriminant validity. Convergence validity was confirmed by the moderate-to-high correlations between PEmb-QoL and SF-36 scores, and a good correlation between the "limitation in daily activities" dimension of the PEmb-QoL questionnaire and 6MWT results. Exploratory factor analysis suggested a 3-component structure with functional (items 1h, 4b-5d, 6, 8, 9i, and 9j), symptoms (1b-h, 7, and 8), and emotional (5a, 6, and 9a-h) components. Conclusion The Persian version of the PEmb-QoL questionnaire is valid and reliable for measuring the disease-specific quality of life in patients with PE.
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Mora D, Mateo J, Nieto JA, Bikdeli B, Yamashita Y, Barco S, Jimenez D, Demelo-Rodriguez P, Rosa V, Yoo HHB, Sadeghipour P, Monreal M. Machine learning to predict major bleeding during anticoagulation for venous thromboembolism: possibilities and limitations. Br J Haematol 2023; 201:971-981. [PMID: 36942630 DOI: 10.1111/bjh.18737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/20/2023] [Accepted: 02/24/2023] [Indexed: 03/23/2023]
Abstract
Predictive tools for major bleeding (MB) using machine learning (ML) might be advantageous over traditional methods. We used data from the Registro Informatizado de Enfermedad TromboEmbólica (RIETE) to develop ML algorithms to identify patients with venous thromboembolism (VTE) at increased risk of MB during the first 3 months of anticoagulation. A total of 55 baseline variables were used as predictors. New data prospectively collected from the RIETE were used for further validation. The RIETE and VTE-BLEED scores were used for comparisons. External validation was performed with the COMMAND-VTE database. Learning was carried out with data from 49 587 patients, of whom 873 (1.8%) had MB. The best performing ML method was XGBoost. In the prospective validation cohort the sensitivity, specificity, positive predictive value and F1 score were: 33.2%, 93%, 10%, and 15.4% respectively. F1 value for the RIETE and VTE-BLEED scores were 8.6% and 6.4% respectively. In the external validation cohort the metrics were 10.3%, 87.6%, 3.5% and 5.2% respectively. In that cohort, the F1 value for the RIETE score was 17.3% and for the VTE-BLEED score 9.75%. The performance of the XGBoost algorithm was better than that from the RIETE and VTE-BLEED scores only in the prospective validation cohort, but not in the external validation cohort.
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Affiliation(s)
- Damián Mora
- Department of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - Jorge Mateo
- Institute of Technology, Universidad de Castilla-La Mancha, Cuenca, Spain
| | - José A Nieto
- Department of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, USA
- Cardiovascular Research Foundation (CRF), New York, New York, USA
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, University Hospital Mainz, Mainz, Germany
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Pablo Demelo-Rodriguez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Vladimir Rosa
- Department of Internal Medicine, Hospital Universitario Virgen de Arrixaca, Murcia, Spain
| | - Hugo Hyung Bok Yoo
- Department of Internal Medicine - Pulmonary Division, Botucatu Medical School - São Paulo State University (UNESP), São Paulo, Brazil
| | - Parham Sadeghipour
- Department of Peripheral Vascular Diseases, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Manuel Monreal
- Chair of Thromboembolic Diseases, Universidad Católica San Antonio de Murcia, Murcia, Spain
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Talasaz AH, Sadeghipour P, Bakhshandeh H, Sharif-Kashani B, Rashidi F, Beigmohammadi MT, Gohari Moghadam K, Rezaian S, Dabbagh A, Sezavar SH, Farrokhpour M, Abedini A, Aliannejad R, Riahi T, Yadollahzadeh M, Lookzadeh S, Rezaeifar P, Matin S, Tahamtan O, Mohammadi K, Zoghi E, Rahmani H, Hosseini SH, Mousavian SM, Abri H, Sadeghipour P, Baghizadeh E, Rafiee F, Jamalkhani S, Amin A, Mohebbi B, Parhizgar SE, Soleimanzadeh M, Aghakouchakzadeh M, Eslami V, Payandemehr P, Khalili H, Talakoob H, Tojari T, Shafaghi S, Tabrizi S, Kakavand H, Kashefizadeh A, Najafi A, Jiménez D, Gupta A, Madhavan MV, Sethi S, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Ansarin K, Maleki M, Sadeghian S, Barco S, Siegerink B, Spatz E, Piazza G, Kirtane AJ, Van Tassell BW, Lip GY, Klok E, Goldhaber SZ, Stone G, Krumholz H, Bikdeli B. Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial. Thromb Haemost 2023. [PMID: 36944357 DOI: 10.1055/a-2059-4844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUNDS In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a non-significant 16% reduction in 30-day composite of venous/arterial thrombosis or death in ICU patients with COVID-19. Thrombo-inflammatory response in COVID-19 may last beyond the first 30 days. METHODS This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this pre-specified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with Post-COVID-19 Functional Scale (PCFS). RESULTS In the primary analysis, 587 patients were included (age: 57 (Q1, Q3: 45, 68) years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio, HR: 0.80, 95% confidence interval, CI: 0.60-1.05, P=0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, Pinteraction=0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (ORordinal, 0.64, 95% CI: 0.41 to 1.01, P=0.05). CONCLUSIONS Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset. (NCT04486508).
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Affiliation(s)
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Babak Sharif-Kashani
- Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | | | - Mohammad Taghi Beigmohammadi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Keivan Gohari Moghadam
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Somayeh Rezaian
- Alborz University of Medicine Science, Karaj, Iran., Tehran, Iran (the Islamic Republic of)
| | - Ali Dabbagh
- Cardiac Anesthesiology, Anesthesiology Research Center, Tehran, Iran (the Islamic Republic of)
| | - Seyed Hashem Sezavar
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Mohsen Farrokhpour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Atefeh Abedini
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Rasoul Aliannejad
- Department of Pulmonary and Critical Care, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Taghi Riahi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Mahdi Yadollahzadeh
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Somayeh Lookzadeh
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Parisa Rezaeifar
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Samira Matin
- Tuberclosis and Lung Diseases Research Center, Tabriz, Iran (the Islamic Republic of)
| | - Ooria Tahamtan
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Keyhan Mohammadi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Elnaz Zoghi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hamid Rahmani
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed Hossein Hosseini
- School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed Masoud Mousavian
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Homa Abri
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Pardis Sadeghipour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Elahe Baghizadeh
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Farnaz Rafiee
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Sepehr Jamalkhani
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Seyed Ehsan Parhizgar
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Mahshid Soleimanzadeh
- Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | | | - Vahid Eslami
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Pooya Payandemehr
- Sina hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hamed Talakoob
- Cardiovascular Research Center, Alborz University of Medical Sciences, Karaj, Iran, Tehran, Iran (the Islamic Republic of)
| | - Taranom Tojari
- Department of Biotechnology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran., Tehran, Iran (the Islamic Republic of)
| | - Shadi Shafaghi
- Lung Transplantion Research Center, Department of Cardiology, National Research Institute of Tuberculosls and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Sanaz Tabrizi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hessam Kakavand
- School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Alireza Kashefizadeh
- Shahid Dr. Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran., Tehran, Iran (the Islamic Republic of)
| | - Atabak Najafi
- Sina Hospital, Tehran, Iran (the Islamic Republic of)
| | - David Jiménez
- Respiratory Division, Medicine Department, Ramón y Cajal Hospital, IRYCIS and Alcalá de Henares University, Madrid, Spain
| | - Aakriti Gupta
- Cardiovascular Research Foundation, New York, United States
| | | | - Sanjum Sethi
- Columbia University Irving Medical Center, New York, United States
| | - Sahil A Parikh
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, United States
| | - Manuel Monreal
- Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | | | - Khalil Ansarin
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | | | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Bob Siegerink
- Leiden University Medical Center Department of Clinical Epidemiology, Leiden, Netherlands
| | - Erica Spatz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | - Ajay J Kirtane
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, United States
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, United States
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool Institute of Ageing and Chronic Disease, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Erik Klok
- Dept. of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Gregg Stone
- Cardiovascular Research Foundation, New York, United States
| | - Harlan Krumholz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Behnood Bikdeli
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
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Durán D, Barrios D, Moisés J, Retegui A, Rodríguez C, Lobo JL, López-Reyes R, Chasco L, Jara-Palomares L, Monreal M, Bikdeli B, Jiménez D. The rationale, design, and methods of a trial to evaluate the efficacy and safety of oxygen therapy in patients with intermediate-risk acute pulmonary embolism. Am Heart J 2023; 257:62-68. [PMID: 36436613 DOI: 10.1016/j.ahj.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/15/2022] [Accepted: 11/19/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND In patients with intermediate-risk pulmonary embolism (PE), reversal of hypoxic vasoconstriction could constitute a target for treatment that protects the right ventricular (RV) function until endogenous fibrinolysis occurs. The Air vs oxygen for Intermediate-Risk pulmonary embolism (AIR) trial aims to assess the effect of oxygen therapy in patients with intermediate-risk acute PE who do not have hypoxemia at baseline. METHODS AND ANALYSES AIR is a prospective, multicenter, randomized, open-label, parallel-group, proof-of-concept trial. A total of 90 patients hospitalized with intermediate-risk PE and an oxygen saturation of 90% or higher at baseline will be randomized in a 1:1 fashion to receive supplemental oxygen or ambient air. The primary outcome is a RV/LV diameter ratio equal or less than 1.0 on echocardiography measured 48 hours after the start of treatment. Secondary efficacy outcomes are the numerical change in the ratio of the RV to the LV diameter measured 48 hours and 7 days after the start of treatment, with respect to the baseline ratio measured at randomization. Clinical adverse events will be also collected. RESULTS Enrollment started in July 2019 and is expected to proceed until 2022. Median age of the first 50 patients was 74 years (interquartile range, 61-81), and 50% were female. CONCLUSIONS This multicenter trial will provide information about the value of supplemental oxygen in patients with intermediate-risk acute PE who do not have hypoxemia at baseline. The results will contribute to research that may assist patients with intermediate-risk PE in the future.
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Affiliation(s)
- Diego Durán
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Deisy Barrios
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Jorge Moisés
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
| | - José L Lobo
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital de Araba, Vitoria, Spain
| | - Raquel López-Reyes
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Hospital La Fe, Valencia, Spain
| | - Leyre Chasco
- Respiratory Department, Hospital Galdakao-Usansolo, Bilbao, Spain
| | - Luis Jara-Palomares
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla
| | - Manuel Monreal
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain; Universidad Católica de Murcia, Murcia, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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Mirambeaux R, Rodríguez C, Muriel A, González S, Briceño W, Durán D, Retegui A, Otero R, Bikdeli B, Jiménez D. Comparison of various prognostic scores for identification of patients with intermediate-high risk pulmonary embolism. Thromb Res 2023; 223:61-68. [PMID: 36708691 DOI: 10.1016/j.thromres.2023.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/11/2022] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND Various risk assessment tools have been proposed to identify stable patients with acute pulmonary embolism (PE) who are at high risk of early adverse outcome (i.e., intermediate-high risk). METHODS We evaluated the ability of the 2019 ESC, Bova, modified FAST and PEITHO-3 models for predicting a 30-day complicated course (death, haemodynamic collapse, and/or recurrent PE) in a cohort of 848 stable patients with acute PE. We also tested whether replacement of echocardiographic right ventricle (RV) dysfunction by computed tomographic (CT) RV enlargement provides comparable prognostic information for identifying these patients. RESULTS A complicated course occurred in 63 (7.4 %) of the 848 patients with PE during the first month of follow-up. The proportion of patients designated as having intermediate-high risk PE was 6.7 % with the ESC model, 4.4 % with the Bova score, 15.7 % with the FAST score, and 5.2 % with the PEITHO-3 model. However, among patients identified as intermediate-high risk, the 30-day complicated course rate was higher with the Bova score (21.6 %) than with the ESC model (17.5 %), the PEITHO-3 model (15.9 %), or the modified FAST score (14.3 %). When echocardiographic RV dysfunction was replaced by CT RV enlargement in the models, the proportion of patients classified as having intermediate-high risk PE and the rate of an adverse outcome among them slightly increased. CONCLUSIONS The Bova score might identify patients with intermediate-high risk PE slightly better than the ESC, PEITHO-3, and modified FAST score. When echocardiography is not readily available, CT-assessed RV enlargement might be used for identifying intermediate-high risk PE. CLINICALTRIALS gov number: NCT02238639.
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Affiliation(s)
- Rosa Mirambeaux
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Carmen Rodríguez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Sara González
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Ana Retegui
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Remedios Otero
- Respiratory Department, Virgen del Rocío Hospital and Instituto de Biomedicina, Sevilla, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA; Cardiovascular Research Foundation, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain.
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40
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Bikdeli B, Lo YC, Khairani C, Bejjani A, Jiménez D, Barco S, Mahajan S, Caraballo C, Secemsky E, Klok E, Hunsaker A, Aghayev A, Muriel A, Wang Y, Hussain M, Appah-Sampong A, Lu Y, Lin Z, Aneja S, Khera R, Goldhaber SZ, Zhou L, Monreal M, Krumholz H, Piazza G. Developing Validated Tools to Identify Pulmonary Embolism in Electronic Databases: Rationale and Design of the PE-EHR+ Study. Thromb Haemost 2023; 123:649-662. [PMID: 36809777 DOI: 10.1055/a-2039-3222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Contemporary pulmonary embolism (PE) research relies on data from electronic health records (EHRs) and administrative databases that use International Classification of Diseases (ICD) codes. Natural language processing (NLP) tools can be used for automated chart review and patient identification. However, there remains uncertainty with the validity of ICD-10 codes or NLP algorithms for patient identification. METHODS The PE-EHR+ study has been designed to validate ICD-10 codes as Principal Discharge Diagnosis, or Secondary Discharge Diagnoses, as well as NLP tools set out in prior studies to identify patients with PE within EHRs. Manual chart review by two independent abstractors by predefined criteria will be the reference standard. Sensitivity, specificity, and positive and negative predictive values will be determined. We will assess the discriminatory function of code subgroups for intermediate- and high-risk PE. In addition, accuracy of NLP algorithms to identify PE from radiology reports will be assessed. RESULTS A total of 1,734 patients from the Mass General Brigham health system have been identified. These include 578 with ICD-10 Principal Discharge Diagnosis codes for PE, 578 with codes in the secondary position, and 578 without PE codes during the index hospitalization. A smaller subset of patients will also be identified from the Yale-New Haven Health System. Data validation and analyses will be forthcoming. CONCLUSIONS The PE-EHR+ study will help validate efficient tools for identification of patients with PE in EHRs, improving the reliability of efficient observational studies or randomized trials of patients with PE using electronic databases.
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Affiliation(s)
- Behnood Bikdeli
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Ying-Chih Lo
- Brigham and Women's Hospital, Boston, United States
| | | | | | - David Jiménez
- Respiratory Division, Medicine Department, Ramón y Cajal Hospital, IRYCIS and Alcalá de Henares University, Madrid, Spain
| | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Cesar Caraballo
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, United States
| | - Erik Klok
- Dept. of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.,Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Ayaz Aghayev
- Brigham and Women's Hospital, Boston, United States
| | | | - Yun Wang
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | | | - Yuan Lu
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Zhenqui Lin
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Sanjay Aneja
- Yale School of Medicine, New Haven, United States
| | - Rohan Khera
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | - Li Zhou
- Brigham and Women's Hospital, Boston, United States
| | - Manuel Monreal
- Universidad Catolica San Antonio de Murcia Facultad de Ciencias de la Salud, Barcelona, Spain
| | - Harlan Krumholz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
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Rashedi S, Bejjani A, Khairani CD, Lou J, Chatterjee S, Jiménez D, Gerhard-Herman M, Mena-Hurtado C, Goldhaber SZ, Piazza G, Krumholz HM, Sadeghipour P, Bikdeli B. CRT-300.15 Safety and Efficacy of Inferior Vena Cava Filters in Patients at Risk of Pulmonary Embolism: A Systematic Review and Meta-Analysis. JACC Cardiovasc Interv 2023. [DOI: 10.1016/j.jcin.2023.01.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
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Buso G, Mazzolai L, Rueda-Camino JA, Fernández-Capitán C, Jiménez D, Bikdeli B, Lobo JL, Fernández-Reyes JL, Ciammaichella M, Monreal M. Pulmonary Embolism in Patients with COVID-19: Comparison between Different Care Settings. Semin Thromb Hemost 2023; 49:34-46. [PMID: 34902865 DOI: 10.1055/s-0041-1740152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The clinical characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) who develop pulmonary embolism (PE) in the full spectrum of patient care settings need to be elucidated. The aim of this study was to compare the clinical characteristics, treatment, and 90-day outcomes in patients diagnosed with PE while recovering from COVID-19 in the outpatient setting versus those who were diagnosed with PE while being hospitalized with COVID-19. Data from the international Registro Informatizado de Enfermedad TromboEmbólica (RIETE) registry were used. The major study outcomes were all-cause death, major bleeding, and venous thromboembolism (VTE) recurrences during the first 90 days after PE. From March 2020 to March 2021, 737 patients with COVID-19 experienced acute PE. Of these, 340 (46%) were recovering from COVID-19 as outpatients (267 patients who had been treated at home for COVID-19 and 73 discharged after being hospitalized with COVID-19). Compared with inpatients with COVID-19, those recovering in the outpatient setting upon PE were less likely to be men (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.40-0.72) and less likely to have hypertension (OR: 0.55; 95% CI: 0.41-0.74) or diabetes (OR: 0.51; 95% CI: 0.33-0.76). At 90-day follow-up, eight patients (none recovering from COVID-19 as outpatient vs. 2.4% of inpatients with COVID-19) developed recurrent VTE, 34 (1.9 vs. 7.9%) had major bleeding, and 128 (10 vs. 24%) died. On multivariable analysis, inpatients with COVID-19 were at a higher risk of major bleeding (adjusted hazard ratio [HR]: 6.80; 95% CI: 1.52-30.4) or death (adjusted HR: 2.24; 95% CI: 1.40-3.58). In conclusion, using a large multinational registry of patients with COVID-19 who experienced PE, thromboembolic episodes occurring in those recovering from COVID-19 as outpatients were associated with less ominous outcomes than inpatients with COVID-19.
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Affiliation(s)
- Giacomo Buso
- Angiology Division, Heart and Vessels Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Lucia Mazzolai
- Angiology Division, Heart and Vessels Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | | | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain.,Medicine Department, Universidad de Alcala, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Yale/YNHH Center for Outcomes Research & Evaluation (CORE), New Haven, Connecticut.,Cardiovascular Research Foundation (CRF), New York, New York
| | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | | | | | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol. Badalona, Barcelona, Spain.,Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Spain
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Khairani CD, Bejjani A, Piazza G, Jimenez D, Monreal M, Chatterjee S, Pengo V, Woller SC, Cortes-Hernandez J, Connors JM, Kanthi Y, Krumholz HM, Middeldorp S, Falanga A, Cushman M, Goldhaber SZ, Garcia DA, Bikdeli B. Direct Oral Anticoagulants vs Vitamin K Antagonists in Patients With Antiphospholipid Syndromes: Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2023; 81:16-30. [PMID: 36328154 PMCID: PMC9812926 DOI: 10.1016/j.jacc.2022.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) for patients with thrombotic antiphospholipid syndrome remain controversial. OBJECTIVES The authors performed a systematic review and meta-analysis of randomized controlled trials that compared DOACs with vitamin K antagonists (VKAs). METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through April 9, 2022. The 2 main efficacy outcomes were a composite of arterial thrombotic events and venous thromboembolic events (VTEs). The main safety outcome was major bleeding. Random effects models with inverse variance were used. RESULTS Our search retrieved 253 studies. Four open-label randomized controlled trials involving 472 patients were included (mean control-arm time-in-therapeutic-range 60%). All had proper random sequence generation and adequate allocation concealment. Overall, the use of DOACs compared with VKAs was associated with increased odds of subsequent arterial thrombotic events (OR: 5.43; 95% CI: 1.87-15.75; P < 0.001, I2 = 0%), especially stroke, and the composite of arterial thrombotic events or VTE (OR: 4.46; 95% CI: 1.12-17.84; P = 0.03, I2 = 0%). The odds of subsequent VTE (OR: 1.20; 95% CI: 0.31-4.55; P = 0.79, I2 = 0%), or major bleeding (OR: 1.02; 95% CI: 0.42-2.47; P = 0.97; I2 = 0%) were not significantly different between the 2 groups. Most findings were consistent within subgroups. CONCLUSIONS Patients with thrombotic antiphospholipid syndrome randomized to DOACs compared with VKAs appear to have increased risk for arterial thrombosis. No significant differences were observed between patients randomized to DOACs vs VKAs in the risk of subsequent VTE or major bleeding.
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Affiliation(s)
- Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Saurav Chatterjee
- Division of Cardiology, St Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York, New York, USA
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, Utah, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna Falanga
- University of Milan Bicocca, School of Medicine, Milan, Italy; Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Cardiovascular Research Foundation, New York, New York, USA.
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Talasaz AH, Sadeghipour P, Mehdizadeh K, Khoshnam Rad N, Bikdeli B, Lip GYH, Harenberg J. Knowledge Gaps for Prophylactic Use of Antithrombotic Agents in Patients with COVID-19: Insights into New SARS-CoV-2 Variants, Vaccination Status, and Emerging Oral Antivirals. Thromb Haemost 2022; 123:186-191. [PMID: 36206775 PMCID: PMC9904967 DOI: 10.1055/a-1956-9641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Data suggest that coronavirus disease 2019 (COVID-19) results in a prothrombotic state leading to arterial and venous thromboses. Vaccination, novel antiviral drugs, and emerging variants have changed the course of the disease in many ways; however, their effects on the incidence of thrombotic events and the efficacy of preventative antithrombotic agents have not been yet evaluated. A systematic search was conducted to identify studies reported on the incidence of thrombotic events based on vaccination status, use of novel antiviral drugs, and emerging viral variants. Similarly, we screened the ongoing/published randomized trials of preventative antithrombotic therapy in any COVID-19 population to assess whether subgroup-specific results were reported based on any of these variants. Upon searching a total of 3,451 records, only one entry fulfilled the inclusion criteria of our systematic review, which was a self-controlled case series on 29,121,633 vaccinated individuals, the incidence rate ratio of thrombotic complication after breakthrough infection was 13.86 (95% confidence interval [CI]: 12.76-15.05) compared with 1.10 (95% CI: 1.02-1.18) during the 28-day postvaccination. In conclusion, although the mortality benefit of mass vaccination and the early promising results of the new antiviral therapies are well known, we were unable to find clinical evidence on whether vaccination, the use of novel antiviral agents, and emerging viral variants have affected the incidence rate of thrombotic events or impacted the efficacy of prophylactic antithrombotic therapy in patients with COVID-19. Analyses from existing trials and large-scale registries can provide interim knowledge and any findings of relevance should be incorporated in the design of future trials.
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Affiliation(s)
- Azita H. Talasaz
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran,Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, Virginia, United States,Address for correspondence Azita H. Talasaz, PharmD, BCPS, BCCP Department of Clinical Pharmacy, Tehran University of Medical Sciences16 Azar St., TehranIran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran,Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kasra Mehdizadeh
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Niloofar Khoshnam Rad
- Department of Clinical Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States,Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States,Yale/YNHH Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut, United States,Cardiovascular Research Foundation (CRF), New York, New York, United States
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Job Harenberg
- Ruprecht Karls University, Heidelberg, Germany,Ruperto Carola University of Heidelberg, Heidelberg, Germany,Job Harenberg, MD Department of MedicineDOASENSE GmbH, Waldhofer Strasse 102, 69123 HeidelbergGermany
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45
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Ortega-Paz L, Arévalos V, Fernández-Rodríguez D, Jiménez-Díaz V, Bañeras J, Campo G, Rodríguez-Santamarta M, Díaz JF, Scardino C, Gómez-Álvarez Z, Pernigotti A, Alfonso F, Amat-Santos IJ, Silvestro A, Rampa L, de la Torre Hernández JM, Bastidas G, Gómez-Lara J, Bikdeli B, García-García HM, Angiolillo DJ, Rodés-Cabau J, Sabaté M, Brugaletta S. One-year cardiovascular outcomes after coronavirus disease 2019: The cardiovascular COVID-19 registry. PLoS One 2022; 17:e0279333. [PMID: 36583998 PMCID: PMC9803130 DOI: 10.1371/journal.pone.0279333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The long-term cardiovascular (CV) outcomes of COVID-19 have not been fully explored. METHODS This was an international, multicenter, retrospective cohort study conducted between February and December 2020. Consecutive patients ≥18 years who underwent a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV2 were included. Patients were classified into two cohorts depending on the nasopharyngeal swab result and clinical status: confirmed COVID-19 (positive RT-PCR) and control (without suggestive symptoms and negative RT-PCR). Data were obtained from electronic records, and clinical follow-up was performed at 1-year. The primary outcome was CV death at 1-year. Secondary outcomes included arterial thrombotic events (ATE), venous thromboembolism (VTE), and serious cardiac arrhythmias. An independent clinical event committee adjudicated events. A Cox proportional hazards model adjusted for all baseline characteristics was used for comparing outcomes between groups. A prespecified landmark analysis was performed to assess events during the post-acute phase (31-365 days). RESULTS A total of 4,427 patients were included: 3,578 (80.8%) in the COVID-19 and 849 (19.2%) control cohorts. At one year, there were no significant differences in the primary endpoint of CV death between the COVID-19 and control cohorts (1.4% vs. 0.8%; HRadj 1.28 [0.56-2.91]; p = 0.555), but there was a higher risk of all-cause death (17.8% vs. 4.0%; HRadj 2.82 [1.99-4.0]; p = 0.001). COVID-19 cohort had higher rates of ATE (2.5% vs. 0.8%, HRadj 2.26 [1.02-4.99]; p = 0.044), VTE (3.7% vs. 0.4%, HRadj 9.33 [2.93-29.70]; p = 0.001), and serious cardiac arrhythmias (2.5% vs. 0.6%, HRadj 3.37 [1.35-8.46]; p = 0.010). During the post-acute phase, there were no significant differences in CV death (0.6% vs. 0.7%; HRadj 0.67 [0.25-1.80]; p = 0.425), but there was a higher risk of deep vein thrombosis (0.6% vs. 0.0%; p = 0.028). Re-hospitalization rate was lower in the COVID-19 cohort compared to the control cohort (13.9% vs. 20.6%; p = 0.001). CONCLUSIONS At 1-year, patients with COVID-19 experienced an increased risk of all-cause death and adverse CV events, including ATE, VTE, and serious cardiac arrhythmias, but not CV death. STUDY REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT04359927.
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Affiliation(s)
- Luis Ortega-Paz
- Department of Cardiology, Clinic Cardiovascular Institute, Hospital Universitari Clinic, Barcelona, Spain
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States of America
| | - Victor Arévalos
- Department of Cardiology, Clinic Cardiovascular Institute, Hospital Universitari Clinic, Barcelona, Spain
| | | | | | - Jordi Bañeras
- Department of Cardiology, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Gianluca Campo
- Department of Cardiology, Azienda Ospedaliero-Universitaria di Ferrara, Ferrara, Italy
| | | | | | - Claudia Scardino
- Department of Cardiology, Hospital Universitario Joan XXIII, Tarragona, Spain
| | | | - Alberto Pernigotti
- Department of Cardiology, Hospital de Tortosa Verge de la Cinta, Tarragona, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario La Princesa, Madrid, Spain
| | - Ignacio J. Amat-Santos
- Department of Cardiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Antonio Silvestro
- Department of Cardiology, Azienda Ospedaliera Bolognini Seriate, Bérgamo, Italy
| | - Lorenzo Rampa
- Department of Cardiology, Clinical Institute Saint Ambrogio, Milano, Italy
| | | | - Gabriela Bastidas
- Department of Cardiology, Hospital Universitario Sagrat Cor, Barcelona, Spain
| | - Josep Gómez-Lara
- Department of Cardiology, Hospital de Bellvitge, Barcelona, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, United States of America
- Cardiovascular Research Foundation (CRF), New York, New York, United States of America
| | - Hector M. García-García
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States of America
| | - Josep Rodés-Cabau
- Department of Cardiology, Clinic Cardiovascular Institute, Hospital Universitari Clinic, Barcelona, Spain
| | - Manel Sabaté
- Department of Cardiology, Clinic Cardiovascular Institute, Hospital Universitari Clinic, Barcelona, Spain
| | - Salvatore Brugaletta
- Department of Cardiology, Clinic Cardiovascular Institute, Hospital Universitari Clinic, Barcelona, Spain
- * E-mail:
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46
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Jara-Palomares L, Bikdeli B, Jiménez D, Muriel A, Martin Del Pozo M, Demelo-Rodríguez P, Monreal M. Rate of Recurrence After Discontinuing Anticoagulation Therapy in Patients With COVID-19-Associated Venous Thromboembolism. JAMA Intern Med 2022; 182:1326-1328. [PMID: 36342711 PMCID: PMC9641587 DOI: 10.1001/jamainternmed.2022.4954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This cohort study assesses the rate of recurrence of venous thromboembolism (VTE) in patients with COVID-19–associated VTE who discontinued anticoagulation therapy.
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Affiliation(s)
- Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Virgen del Rocio Hospital and Instituto de Biomedicina, Seville, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Yale New Haven Hospital, Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut.,Cardiovascular Research Foundation, New York, New York
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal, Instituto Ramón y Cajal de Investigacion Sanitaria (IRYCIS), Madrid, Spain.,Medicine Department, Universidad de Alcalá, Madrid, Spain.,CIBERES, Madrid, Spain
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital, IRYCIS, CIBERES, Madrid, Spain.,University of Alcala, Madrid, Spain
| | - Mar Martin Del Pozo
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Pablo Demelo-Rodríguez
- Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
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Sadeghipour P, Jenab Y, Moosavi J, Hosseini K, Mohebbi B, Hosseinsabet A, Chatterjee S, Pouraliakbar H, Shirani S, Shishehbor MH, Alizadehasl A, Farrashi M, Rezvani MA, Rafiee F, Jalali A, Rashedi S, Shafe O, Giri J, Monreal M, Jimenez D, Lang I, Maleki M, Goldhaber SZ, Krumholz HM, Piazza G, Bikdeli B. Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial. JAMA Cardiol 2022; 7:1189-1197. [PMID: 36260302 PMCID: PMC9582964 DOI: 10.1001/jamacardio.2022.3591] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2023]
Abstract
Importance The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration ClinicalTrials.gov Identifier: NCT05172115.
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Affiliation(s)
- Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yaser Jenab
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinsabet
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Northshore-LIJ Hospitals of Northwell Health, New York, New York
- Zucker School of Medicine, New York, New York
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi H. Shishehbor
- University Hospitals, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Azin Alizadehasl
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Melody Farrashi
- Echocardiography Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Rezvani
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnaz Rafiee
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Rashedi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Shafe
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Irene Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Majid Maleki
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Samuel Z. Goldhaber
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
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Farmakis I, Valerio L, Mavromanoli AC, Bikdeli B, Connors JM, Giannakoulas G, Goldhaber SZ, Hobohm L, Hunt BJ, Keller K, Klok FA, Spyropoulos AC, Kucher N, Konstantinides S, Barco S. Mortality related to pulmonary embolism in the United States before and during the COVID-19 pandemic: an analysis of the CDC Multiple Cause of Death database. Eur Heart J 2022. [PMCID: PMC9619500 DOI: 10.1093/eurheartj/ehac544.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The COVID-19 pandemic caused a large number of excess deaths. COVID-19 emerged as a prothrombotic disease often complicated by pulmonary embolism (PE). In light of this, we hypothesized that PE-related mortality rates (stable before the pandemic) would be characterized by an increasing trend following the COVID-19 outbreak. Purpose To investigate the mortality rates associated with PE among deaths with or without COVID-19 during the 2020 pandemic in the United States (US). Methods For this retrospective epidemiological study, we analyzed public medically certified vital registration data (death certificates encompassing underlying and multiple causes of death) from the Mortality Multiple Cause-of-Death database provided by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2018–20). We investigated the time trends in monthly PE-related crude mortality rates for 2018–2019 and for 2020 (the latter associated vs. not associated with COVID-19), utilizing annual national population totals from the US Census Bureau. Second, we calculated the PE-related proportionate mortality among COVID-19 deaths (overall and limited to autopsy-based diagnosis). We performed subgroup analyses based on age groups, sex and race. Results During 2020, 49,423 deaths in association with PE were reported, vs. 39,450 in 2019 and 38,215 in 2018. The crude PE-related mortality rate without COVID-19 was 13.3 per 100,000 population in 2020 compared to 11.7 in 2018 and 12.0 in 2019 (Figure 1A). The PE-related mortality rate with COVID-19 was 1.6 per 100,000 population in 2020. Among non-COVID-19-related deaths, the crude PE-related mortality rate was higher in women; among COVID-19-related deaths, it was higher in men. PE-related mortality rates were approximately two-fold higher among black (vs. white) general population irrespective of COVID-19 status (Figures 1B and 1C). Among COVID-19 deaths, PE-related deaths corresponded to 1.4% of total; the value rose to 6.0% when an autopsy was performed. This figure was higher in men and its time evolution is depicted in Figure 2A. The proportionate mortality of PE in COVID-19 deaths was higher for younger age groups (15–44 years) compared to non-COVID-19-related deaths (Figure 2B). Conclusion In 2020, an overall 20%-increase in PE-related mortality was reported, not being limited to patients with COVID-19. Our findings could be interpreted in the context of undiagnosed COVID-19 cases, uncounted late sequelae, and possibly sedentary lifestyle and avoidance of healthcare facilities during the pandemic that may have prevented timely diagnosis and treatment of other diseases. Whether vaccination programs had an impact on PE-associated mortality in the year 2021, remains to be determined. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- I Farmakis
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - L Valerio
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | | | - B Bikdeli
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - J M Connors
- Brigham and Women's Hospital, Hematology Division , Boston , United States of America
| | - G Giannakoulas
- AHEPA University General Hospital, Department of Cardiology , Thessaloniki , Greece
| | - S Z Goldhaber
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - L Hobohm
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - B J Hunt
- Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group , London , United Kingdom
| | - K Keller
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - F A Klok
- Leiden University Medical Center, Department of Medicine - Thrombosis and Hemostasis , Leiden , The Netherlands
| | - A C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead , United States of America
| | - N Kucher
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
| | | | - S Barco
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
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49
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Farmakis IT, Valerio L, Bikdeli B, Connors JM, Giannakoulas G, Goldhaber SZ, Hobohm L, Hunt BJ, Keller K, Spyropoulos AC, Barco S. Annual mortality related to pulmonary embolism in the US before and during the COVID-19 pandemic. J Am Coll Cardiol 2022; 80:1579-1581. [PMID: 36038034 PMCID: PMC9412135 DOI: 10.1016/j.jacc.2022.08.721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/27/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Jean M Connors
- Brigham and Women's Hospital, Hematology Division, Harvard Medical School, Boston, United States
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Beverley J Hunt
- St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, University Medical Center Mainz, Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Alex C Spyropoulos
- Department of Medicine, Lenox Hill Hospital at Northwell Health and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
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50
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Siniscalchi C, Muriel A, Suriñach Caralt JM, Bikdeli B, Jiménez D, Lobo JL, Amado C, Gil-Díaz A, Imbalzano E, Monreal M. Statin use and 30-day mortality in patients with acute symptomatic pulmonary embolism. J Thromb Haemost 2022; 20:1839-1851. [PMID: 35510755 DOI: 10.1111/jth.15753] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/30/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Statins possess antithrombotic and profibrinolytic properties. The association between statin use and short-term outcomes in patients with acute pulmonary embolism (PE) remains unknown. METHODS We used the data from the Registro Informatizado de Pacientes con Enfermedad TromboEmbólica registry to compare the 30-day all-cause mortality in patients with acute PE according to the use of statins. Secondary outcome was fatal PE. We used cancer-related mortality as a falsification endpoint. RESULTS From January 2009 to April 2021, 31 169 patients with PE were recruited. Of these, 5520 (18%) were using statins at baseline: low intensity: 829, moderate: 3636, high intensity: 1055. Statin users were older and had a higher frequency of diabetes, hypertension, or atherosclerotic disease than non-users (P <0.001 for all comparisons). During the first 30 days, 1475 patients died (fatal PE, 255). On multivariable analysis, statin users had a lower risk of all-cause death (odds ratio [OR]: 0.65; 95% confidence interval [CI]: 0.56-0.76) and fatal PE (OR: 0.42; 95% CI: 0.28-0.62) than non-users. The risk for death was lower in patients using either low- (OR: 0.51; 95% CI: 0.34-0.77), moderate- (OR: 0.68; 95% CI: 0.57-0.81), or high-intensity statins (OR: 0.68; 95% CI: 0.51-0.92). Results did not change in mixed effects logistic regression models with hospitals as a random effect. Statins were not associated with a significant chance in cancer mortality (falsification endpoint). CONCLUSIONS PE patients using statins at baseline had a significantly lower risk of dying within the first 30 days than non-users. Randomized trials are needed to confirm these data.
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Affiliation(s)
| | - Alfonso Muriel
- Biostatistics Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, CIBERESP, Madrid, Spain
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - José Luis Lobo
- Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | - Cristina Amado
- Department of Internal Medicine, Hospital Sierrallana, Santander, Spain
| | - Aída Gil-Díaz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, A.O.U Policlinico "G. Martino,", Messina, Italy
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM-Universidad Católica San Antonio de Murcia, Universidad Autónoma de Barcelona, Barcelona, Spain
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