1
|
Verma M, Horrow J, Carmody S, Navarro V. Unmet Needs and Burden of Caregivers of Patients Being Evaluated for a Liver Transplant Are Similar to Those of Cancer Caregivers. Am J Hosp Palliat Care 2024; 41:391-397. [PMID: 37172071 DOI: 10.1177/10499091231176297] [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] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND The caregivers (CG) of patients with serious illnesses often experience stress and psycho-social issues. High burden is expected for CG of patients for whom liver transplant (LT) is the only curative option. This study aims to measure the burden, unmet needs, and quality of life (QoL) of CG of patients being evaluated for LT. METHODS This cross-sectional study enrolled CG of patients being evaluated for LT. CaTCoN (Caregiving Tasks, Consequences and Needs Questionnaire) was used to assess caregiving consequences and needs related to interactions with healthcare professionals (HCPs). ZBI-12 (Zarit Burden Interview) was used to assess CG burden, and PROMIS-29 (Patient Reported Outcomes Measurement Information System) to assess QoL. Caregivers completed the study instruments in person, while they were in the clinic. CaTCoN scores from our study were compared with cancer caregivers' historical data. RESULTS 18 CG were enrolled, mean age 54 [14] years; 72% were white and 77% were women. 61% worked full time; 45% provided >20 hours of care per week. Two-thirds cared for patients with alcoholic liver disease. All CaTCoN scores were no different from CGs of cancer patients (all P > .05). The total ZBI score (mean SD 12.4 [8.3]) did not differ from published scores for CG of cancer patients (12.0 [8.5]). 44% had high (≥12) ZBI scores reflecting "high burden." Their PROMIS-29 T scores, compared to those with low burden, showed more anxiety (P = .01), depression (P = .04), fatigue (P = .02) and deteriorated social function (P = .009). Physical function and social function were diminished among these CGs compared to the general population (P < .0001). CONCLUSION CGs of patients being evaluated for LT suffer from high burden similar to cancer CGs and have reduced physical and social function. Despite the small sample size, the data completion rate was almost 100%.
Collapse
Affiliation(s)
- Manisha Verma
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jay Horrow
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stacey Carmody
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, PA, USA
| |
Collapse
|
2
|
Liu X, Jiang J, Li D, Horrow J, Tamada H, Kahl A, Hariharan V, Avinav A, Li X. Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom. Cardiol Ther 2023; 12:675-687. [PMID: 37789237 DOI: 10.1007/s40119-023-00332-7] [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: 06/20/2023] [Accepted: 09/08/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA. METHODS This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported. RESULTS Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90 days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively. CONCLUSIONS In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.
Collapse
Affiliation(s)
- Xuejun Liu
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jenny Jiang
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Danshi Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jay Horrow
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Hiroshi Tamada
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Anja Kahl
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | | | | | - Xiaoyan Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA.
| |
Collapse
|
3
|
Verma M, Kalman R, Horrow J, Gallagher M, Woodrell C, Navarro V. Feasibility of a Palliative Care Intervention within Routine Care of Hepatocellular Carcinoma: A Pilot Randomized Controlled Trial. J Palliat Med 2023; 26:334-341. [PMID: 36149682 DOI: 10.1089/jpm.2022.0338] [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] [Indexed: 12/24/2022] Open
Abstract
Background: Patients with hepatocellular cancer (HCC) are at risk for poor quality of life (QoL) and high symptom burden, coupled with limited treatment options. Palliative care (PC) can play an important role in reducing the suffering of this population, but remains underutilized. Aim: To demonstrate feasibility of an outpatient PC intervention within HCC care. Methods: This is a pilot randomized controlled trial conducted at an academic center. All stages of HCC patients (except Barcelona Clinic Liver Cancer stage D) with a scheduled hepatology appointment were eligible. Patients were randomized to receive PC intervention or usual care (control arm). In the PC arm, patients received PC from a PC provider at enrollment and at three months from the baseline visit, in addition to continued standard of care. Control arm received only standard care. All patients completed FACT-Hep (Functional Assessment of Cancer Therapy-Hepatobiliary Cancer) and modified Edmonton Symptom Assessment Scale at baseline and at three-month visit. Descriptive statistics were utilized to summarize questionnaires, and change in QoL and symptoms from baseline to three months were compared between the two study groups. Results: Of the 109 approached, 57 patients (52.3%) consented to enroll, and 52 (91%) completed the study. QoL and symptom burden assessments demonstrated impaired QoL and high symptom burden in both arms of the study. At least 50% of enrolled patients in each arm had some degree of fatigue, pain, sleep disturbance, and appetite loss, at baseline. Post-intervention, symptom burden and QoL improved in the intervention arm and remained same or worsened in the control group. All FACT-Hep scores decreased numerically among controls and increased numerically among patients in the PC intervention group. Conclusion: Outpatient PC intervention within routine HCC care is feasible, and can potentially improve QoL and symptoms.
Collapse
Affiliation(s)
- Manisha Verma
- Division of Hepatology, Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Richard Kalman
- Division of Hepatology, Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Jay Horrow
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark Gallagher
- Division of Hepatology, Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| | - Christopher Woodrell
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Victor Navarro
- Division of Hepatology, Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
| |
Collapse
|
4
|
Zhong W, Liu X, Bash LD, Bortnichak E, Horrow J, Koro C. Neuromuscular Blocking Agents and Reversal Agents Among Hospitalized Children: A Cerner Database Study. Hosp Pharm 2021; 56:424-429. [PMID: 34720141 DOI: 10.1177/0018578720918332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Sugammadex (Bridion) was approved by the US Food and Drug Administration (FDA) in December 2015 for the reversal of neuromuscular block (NMB) induced by rocuronium and vecuronium bromide in adults undergoing surgery and approved for use in both adults and children in the European Union in 2008. Sugammadex use in children has been reported in the United States, but to what extent is not clear. Aims: The aim was to describe the utilization pattern of NMB agents and factors associated with the use of reversal agents (neostigmine and sugammadex) in US children. Methods: Cross-sectional study of children with exposure to NMB agents between 2015 and 2017 in the Cerner Health Facts® database, which is an electronic health record (EHR) database across 600 facilities in the United States. Logistic regression estimated factors associated with the use of sugammadex vs neostigmine. Results: A total of 27 094 pediatric clinical encounters were exposed to neuromuscular blocking agents (NMBAs), in which 21 845 were exposed to rocuronium (76%), vecuronium (18%), or both (6%). Among children with exposure to rocuronium and vecuronium, the use of sugammadex was 1.7% in 2016 and 7.6% in 2017. The multivariable logistic model suggested that children who were older (age 12-17 years vs 0-1 year; odds ratio [OR] 1.96; 95% confidence interval [CI], 1.36-2.83), Hispanic or Latino ethnicity and other ethnicities (vs non-Hispanic or Latino; OR 2.03 and 1.56; 95% CI, 1.55-2.67 and 1.15-2.13, respectively), in teaching facilities (OR 1.26; 95% CI, 1.00-1.59), or admitted through emergency departments (OR 1.65; 95% CI, 1.06-2.58) were independently more likely to receive sugammadex than neostigmine after controlling for other covariates. Conclusions: In Cerner Health Facts database 2015 to 2017, among children, rocuronium was more commonly used than vecuronium, and sugammadex use was observed since 2016. Sugammadex and neostigmine users varied by demographic, clinical, and site-level characteristics.
Collapse
|
5
|
Raval AD, Deshpande S, Rabar S, Koufopoulou M, Neupane B, Iheanacho I, Bash LD, Horrow J, Fuchs-Buder T. Does deep neuromuscular blockade during laparoscopy procedures change patient, surgical, and healthcare resource outcomes? A systematic review and meta-analysis of randomized controlled trials. PLoS One 2020; 15:e0231452. [PMID: 32298304 PMCID: PMC7161978 DOI: 10.1371/journal.pone.0231452] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 03/24/2020] [Indexed: 01/02/2023] Open
Abstract
Background Deep neuromuscular blockade may facilitate the use of reduced insufflation pressure without compromising the surgical field of vision. The current evidence, which suggests improved surgical conditions compared with other levels of block during laparoscopic surgery, features significant heterogeneity. We examined surgical patient- and healthcare resource use-related outcomes of deep neuromuscular blockade compared with moderate neuromuscular blockade in adults undergoing laparoscopic surgery. Methods We conducted a systematic literature review according to the quality standards recommended by the Cochrane Handbook for Systematic Reviews. Randomized controlled trials comparing outcomes of deep neuromuscular blockade and moderate neuromuscular blockade among adults undergoing laparoscopic surgeries were included. A random-effects model was used to conduct pair-wise meta-analyses. Results The systematic literature review included 15 studies—only 13 were analyzable in the meta-analysis and none were judged to be at high risk of bias. Compared with moderate neuromuscular blockade, deep neuromuscular blockade was associated with improved surgical field of vision and higher vision quality scores. Also, deep neuromuscular blockade was associated with a reduction in the post-operative pain scores in the post-anesthesia care unit compared with moderate neuromuscular blockade, and there was no need for an increase in intra-abdominal pressure during the surgical procedures. There were minor savings on resource utilization, but no differences were seen in recovery in the post-anesthesia care unit or overall length of hospital stay with deep neuromuscular blockade. Conclusions Deep neuromuscular blockade may aid the patient and physician surgical experience by improving certain patient outcomes, such as post-operative pain and improved surgical ratings, compared with moderate neuromuscular blockade. Heterogeneity in the pooled estimates suggests the need for better designed randomized controlled trials.
Collapse
Affiliation(s)
- Amit D. Raval
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Sohan Deshpande
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Silvia Rabar
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Maria Koufopoulou
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Binod Neupane
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Ike Iheanacho
- Evidence, Modeling, and Synthesis, Evidera Inc., London, England, United Kingdom
| | - Lori D. Bash
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Jay Horrow
- Center for Observational and Real-world Evidence, Merck & Co., Inc., Kenilworth, NJ, United States of America
| | - Thomas Fuchs-Buder
- Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy, Vandoeuvre-les-Nancy, France
- * E-mail: ,
| |
Collapse
|
6
|
Raval AD, Deshpande S, Koufopoulou M, Rabar S, Neupane B, Iheanacho I, Bash LD, Horrow J, Fuchs-Buder T. The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials. Surg Endosc 2020; 34:2878-2890. [PMID: 32253560 PMCID: PMC7270984 DOI: 10.1007/s00464-020-07527-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 12/23/2019] [Accepted: 03/26/2020] [Indexed: 12/13/2022]
Abstract
Background Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. Methods An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials. Results The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]: − 0.70; 95% credible interval [CrI]: − 1.26, − 0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD: − 0.14 days; 95% CrI − 0.30, − 0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery. Conclusions Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients’ post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings. Electronic supplementary material The online version of this article (10.1007/s00464-020-07527-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Amit D Raval
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | - Sohan Deshpande
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Maria Koufopoulou
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Silvia Rabar
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Binod Neupane
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, Montreal, Canada
| | - Ike Iheanacho
- Evidence Synthesis, Modeling, and Communication, Evidera Inc, London, UK
| | - Lori D Bash
- Center for Observational and Real-World Evidence, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | - Thomas Fuchs-Buder
- Department of Anesthesiology & Critical Care, Brabois University Hospital, University de Lorraine, CHRU Nancy, 7 allée du Morvan, 54511, Vandoeuvre-les-Nancy, France.
| |
Collapse
|
7
|
Hoffman CR, Horrow J, Ranganna S, Green MS. Operating room first case start times: a metric to assess systems-based practice milestones? BMC Med Educ 2019; 19:446. [PMID: 31791314 PMCID: PMC6889181 DOI: 10.1186/s12909-019-1886-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 03/28/2019] [Accepted: 11/21/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Resident competence in peri-operative care is a reflection on education and cost-efficiency. Inspecting pre-existing operating room metrics for performance outliers may be a potential solution for assessing competence. Statistical correlation of problematic benchmarks may reveal future opportunities for educational intervention. METHODS Case-log database review yielded 3071 surgical cases involving residents over the course of 5 years. Surgery anticipated and actual start times were evaluated for delays and residents were assessed using the days of resident training performed at the time of each corresponding case. Other variables recorded included day of week, attending anesthesiologist name, attending surgeon name, patient age, sex, American Society of Anesthesiologists physical status classification (ASA PS), and in-patient versus day surgery status. Mixed-effect, multi-variable, linear regression determined independent determinants of delay time. RESULTS The analysis identified day of the week (F = 25.65, P < 0.0001), days of training (F = 8.39, P = 0.0038), attending surgeon (F = 2.67, P < 0.0001), and anesthesiology resident (F = 1.67, P = 0.0012) as independent predictors of delay time for first-start cases, with an overall regression model F = 3.09, r2 = 0.186, and P < 0.0001. CONCLUSIONS The day of the week and attending surgeon demonstrated significant impact of case delay compared to resident days trained. If a learning curve for first-case start punctuality exists for anesthesiology residents, it is subtle and irrelevant to operating room efficiency. The regression model accounted for only 19% of the variability in the outcome of delay time, indicating a multitude of additional unidentified factors contributing to operating room efficiency.
Collapse
Affiliation(s)
- Christopher Ryan Hoffman
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA, 19102, USA.
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, 111 S. 11th Street, Suite 8490G, Philadelphia, PA, USA.
| | - Jay Horrow
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA, 19102, USA
| | - Shreyas Ranganna
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA, 19102, USA
| | - Michael Stuart Green
- Department of Anesthesiology & Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital, 245 N. 15th Street, Suite 7502, MS 310, Philadelphia, PA, 19102, USA
- Department of Anesthesiology, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, 111 S. 11th Street, Suite 8490G, Philadelphia, PA, USA
| |
Collapse
|
8
|
Verma M, Horrow J, Navarro V. A Behavioral Health Program for Alcohol Use Disorder, Substance Abuse, and Depression in Chronic Liver Disease. Hepatol Commun 2019; 3:646-655. [PMID: 31061953 PMCID: PMC6492470 DOI: 10.1002/hep4.1328] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 12/16/2018] [Accepted: 01/22/2019] [Indexed: 01/19/2023] Open
Abstract
Alcohol use disorder, substance abuse, and depression are illnesses that deteriorate the quality of life (QOL) of patients with chronic liver disease (CLD). Screening and behavioral health programs integrated into routine practice can mitigate the deleterious effects of such illnesses but have not been adopted in hepatology practices. We implemented a behavioral health program based on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model and assessed its acceptability and effectiveness in improving QOL. This was a quality improvement study. Patients with CLD and a scheduled outpatient visit in the hepatology clinic were screened while waiting for their appointment. All patients who screened positive for any of the three illnesses were offered a brief intervention (BI) at the point of care and at 3 months by a trained social worker. The BI used the principles of motivational interviewing and cognitive behavioral therapy. Severity of illness was assessed at baseline, 3 months, and 6 months. Participants completed an acceptability survey at 6 months. We screened 303 patients; 61.7% were positive for any of the three illnesses assessed. Among the positive patients, depression was most common (48.4%), alcohol and substance abuse were each 26%. For the 95 patients who underwent BI, QOL improved from baseline to 3 and 6 months (P < 0.001) and patients with depression improved the most. Depression was the only independent predictor of change in QOL over time. Of the enrolled patients, 82% agreed BIs improved their overall care and 87% indicated a desire to continue with the behavioral program. Conclusion: An outpatient behavioral health program based on the SBIRT model is acceptable to patients with CLD and may help improve QOL over time.
Collapse
Affiliation(s)
- Manisha Verma
- Department of Digestive Diseases and Transplantation Einstein Medical Center Philadelphia PA
| | - Jay Horrow
- Department of Anesthesiology and Perioperative Medicine Drexel University Philadelphia PA
| | - Victor Navarro
- Department of Digestive Diseases and Transplantation Einstein Medical Center Philadelphia PA
| |
Collapse
|
9
|
Patel MR, Becker RC, Wojdyla DM, Emanuelsson H, Hiatt WR, Horrow J, Husted S, Mahaffey KW, Steg PG, Storey RF, Wallentin L, James SK. Cardiovascular events in acute coronary syndrome patients with peripheral arterial disease treated with ticagrelor compared with clopidogrel: Data from the PLATO Trial. Eur J Prev Cardiol 2014; 22:734-42. [PMID: 24830710 DOI: 10.1177/2047487314533215] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 04/05/2014] [Indexed: 12/22/2022]
Abstract
AIMS To determine the effect of ticagrelor compared to clopidogrel in patients with peripheral artery disease (PAD) and acute coronary syndromes (ACS). METHODS AND RESULTS PLATO (n = 18,624) was a multicentre, double-blind, randomized trial in ACS, that showed a 16% reduction in cardiovascular death (CV-death), myocardial infarction (MI) and stroke with ticagrelor compared with clopidogrel, without significant increase in overall major bleeding. We performed a post-hoc analysis of cardiovascular and bleeding outcomes in PLATO according to reported PAD status at baseline. At one year, CV death, MI or stroke occurred in 19.3% of patients with PAD (n = 1144) compared to 10.2% in patients without PAD (p < 0.001). The Kaplan-Meier one year event rate for the primary endpoint of CV death, MI or stroke in PAD patients treated with ticagrelor as compared with clopidogrel, was 18% vs 20.6% (HR: 0.85 95% CI 0.64-1.11; for PAD status by treatment interaction, p = 0.99) and for death from any cause 8.7% vs 11.9%, (HR: 0.74 95% CI 0.50-1.08; interaction p = 0.73). PLATO-defined major bleeding event rates at one year were 14.8% for ticagrelor compared to 17.9% for clopidogrel, (HR: 0.81 95% CI 0.59-1.10; interaction p = 0.09). CONCLUSION PAD patients have a high rate of ischaemic and bleeding events post ACS. The reduction of CV death, MI or stroke with ticagrelor compared with clopidogrel in PAD patients was consistent with the overall trial result although it did not reach statistical significance. Overall major bleeding was similar between the therapies.
Collapse
Affiliation(s)
| | - Richard C Becker
- Duke Clinical Research Institute, Durham, NC, USA Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, Academic Health Center, University of Cincinnati, Cincinnati, OH, USA
| | | | | | - William R Hiatt
- University of Colorado, School of Medicine Division of Cardiology and CPC Clinical Research, Aurora, CO, USA
| | - Jay Horrow
- AstraZeneca Research and Development, Wilmington, DE, USA
| | - Steen Husted
- Medical Department, Hospital Unit West, Herning, Denmark
| | - Kenneth W Mahaffey
- Department of Medicine, Division of Cardiology, Stanford University, CA, USA
| | - P Gabriel Steg
- INSERM-Unité 1148, Paris, France Assistance Publique-Hôpitaux de Paris; Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| |
Collapse
|
10
|
Husted S, James SK, Bach RG, Becker RC, Budaj A, Heras M, Himmelmann A, Horrow J, Katus HA, Lassila R, Morais J, Nicolau JC, Steg PG, Storey RF, Wojdyla D, Wallentin L. The efficacy of ticagrelor is maintained in women with acute coronary syndromes participating in the prospective, randomized, PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J 2014; 35:1541-50. [PMID: 24682844 PMCID: PMC4057642 DOI: 10.1093/eurheartj/ehu075] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Aims The aim of this study was to assess the relationship between sex and clinical outcomes and treatment-related complications in patients with ST-elevation or non-ST-elevation acute coronary syndromes (ACS) randomized to treatment with ticagrelor or clopidogrel in the PLATelet inhibition and patient Outcomes (PLATO) trial. Methods The associations between sex subgroup and the primary composite outcomes, secondary outcomes, and major bleeding endpoints as well as interaction of sex subgroup with treatment effects were analysed using Cox proportional-hazards models. Results Sex was not significantly associated with the probability of the primary composite endpoint [adjusted hazard ratio (HR): 1.02 (0.91−1.16)], or other adverse cardiovascular endpoints. Ticagrelor was similarly more effective than clopidogrel in reducing rates of the primary endpoint in women 11.2 vs. 13.2% [adjusted HR: 0.88 (0.74−1.06)] and men 9.4 vs. 11.1% [adjusted HR: 0.86 (0.76−0.97)] (interaction P-value 0.78), all-cause death in women 5.8 vs. 6.8% [adjusted HR: 0.90 (0.69−1.16)] and men 4.0 vs. 5.7% [adjusted HR: 0.80 (0.67−0.96)] (interaction P-value 0.49), and definite stent thrombosis in women 1.2 vs. 1.4% [adjusted HR: 0.71 (0.36−1.38)] and men 1.4 vs. 2.1% [adjusted HR: 0.63 (0.45−0.89)] (interaction P-value 0.78). The treatments did not differ for PLATO-defined overall major bleeding complications in women [adjusted HR: 1.01 (0.83−1.23)] or men [adjusted HR: 1.10 (0.98−1.24)]. Sex had no significant association with these outcomes (interactions P = 0.43−0.88). Conclusion Female sex is not an independent risk factor for adverse clinical outcomes in moderate-to-high risk ACS patients. Ticagrelor has a similar efficacy and safety profile in men and women.
Collapse
Affiliation(s)
- Steen Husted
- Medical Department, Hospital Unit West, GI, Landevej 61, Herning 7400, Denmark
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard G Bach
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO, USA
| | - Richard C Becker
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Magda Heras
- Cardiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | - Jay Horrow
- AstraZeneca Research and Development, Wilmington, DE, USA
| | - Hugo A Katus
- Medizinishe Klinik, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Riita Lassila
- Division of Hematology and Laboratory Services Coagulation Disorders, Helsinki University Central Hospital, Helsinki, Finland
| | | | - José C Nicolau
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
| | - Ph Gabriel Steg
- INSERM-Unité 698, Paris, France Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Lars Wallentin
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | |
Collapse
|
11
|
Åkerblom A, Wallentin L, Larsson A, Siegbahn A, Becker RC, Budaj A, Himmelmann A, Horrow J, Husted S, Storey RF, Åsenblad N, James SK. Cystatin C– and Creatinine-Based Estimates of Renal Function and Their Value for Risk Prediction in Patients with Acute Coronary Syndrome: Results from the PLATelet Inhibition and Patient Outcomes (PLATO) Study. Clin Chem 2013; 59:1369-75. [DOI: 10.1373/clinchem.2012.200709] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
The estimated glomerular filtration rate (eGFR) independently predicts cardiovascular death or myocardial infarction (MI) and can be estimated by creatinine and cystatin C concentrations. We evaluated 2 different cystatin C assays, alone or combined with creatinine, in patients with acute coronary syndrome.
METHODS
We analyzed plasma cystatin C, measured with assays from Gentian and Roche, and serum creatinine in 16 279 patients from the PLATelet Inhibition and Patient Outcomes (PLATO) trial. We evaluated Pearson correlation and agreement (Bland–Altman) between methods, as well as prognostic value in relation to cardiovascular death or MI during 1 year of follow up by multivariable logistic regression analysis including clinical variables, biomarkers, c-statistics, and relative integrated discrimination improvement (IDI).
RESULTS
Median cystatin C concentrations (interquartile intervals) were 0.83 (0.68–1.01) mg/L (Gentian) and 0.94 (0.80–1.14) mg/L (Roche). Overall correlation was 0.86 (95% CI 0.85–0.86). The level of agreement was within 0.39 mg/L (2 SD) (n = 16 279).
The areas under the curve (AUCs) in the multivariable risk prediction model with cystatin C (Gentian, Roche) or Chronic Kidney Disease Epidemiology Collaboration eGFR (CKD-EPI) added were 0.6914, 0.6913, and 0.6932. Corresponding relative IDI values were 2.96%, 3.86%, and 4.68% (n = 13 050). Addition of eGFR by the combined creatinine–cystatin C equation yielded AUCs of 0.6923 (Gentian) and 0.6924 (Roche) with relative IDI values of 3.54% and 3.24%.
CONCLUSIONS
Despite differences in cystatin C concentrations, overall correlation between the Gentian and Roche assays was good, while agreement was moderate. The combined creatinine–cystatin C equation did not outperform risk prediction by CKD-EPI.
Collapse
Affiliation(s)
- Axel Åkerblom
- Department of Medical Sciences, Cardiology
- Uppsala Clinical Research Center
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology
- Uppsala Clinical Research Center
| | | | - Agneta Siegbahn
- Department of Medical Sciences, Center of Excellence–Inflammation, Uppsala University, Uppsala Sweden
| | | | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | | | - Jay Horrow
- AstraZeneca Research and Development, Wilmington, DE
| | - Steen Husted
- Department of Cardiology, Århus University Hospital, Århus, Denmark
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | | | - Stefan K James
- Department of Medical Sciences, Cardiology
- Uppsala Clinical Research Center
| |
Collapse
|
12
|
Kohli P, Wallentin L, Reyes E, Horrow J, Husted S, Angiolillo DJ, Ardissino D, Maurer G, Morais J, Nicolau JC, Oto A, Storey RF, James SK, Cannon CP. Reduction in first and recurrent cardiovascular events with ticagrelor compared with clopidogrel in the PLATO Study. Circulation 2012; 127:673-80. [PMID: 23277305 DOI: 10.1161/circulationaha.112.124248] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [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: 11/16/2022]
Abstract
BACKGROUND We sought to evaluate the effect of potent platelet inhibition after acute coronary syndrome on total (ie, first and recurrent) occurrences of any of the primary outcome events (e.g., cardiovascular death, myocardial infarction, and stroke) as well as on other ischemic events, such as urgent revascularization, (severe) recurrent ischemia, transient ischemic attacks, and arterial thrombotic events. METHODS AND RESULTS In the PLATelet inhibition and patient Outcomes (PLATO) study, 18 624 patients presenting with acute coronary syndromes randomly received ticagrelor (n=9333) or clopidogrel (n=9291). Cox proportional hazard models were used to calculate time to first event and hazard ratios. Total events were compared using a Poisson regression model, and time to second event or death was calculated with the Wei Lin Weissfeld method. Patients randomized to ticagrelor had 1057 total primary end point events versus 1225 for patients on clopidogrel (rate ratio, 0.86; 95% confidence interval, 0.79-0.93; P=0.003). The number of additional events was numerically lower for ticagrelor (189 versus 205; P=0.40), resulting in a hazard for time to second event/death of 0.80 (95% confidence interval, 0.70-0.90; P<0.001) and a number needed to treat of 54. For cardiovascular death/myocardial infarction/stroke/(severe) recurrent ischemia/transient ischemic attack/arterial thrombotic events, total events were fewer with ticagrelor (2030 versus 2290; rate ratio, 0.88; 95% confidence interval, 0.82-0.95; P<0.001), with fewer recurrent events with ticagrelor (740 versus 834; P=0.01) and a highly significant concurrent reduction in hazard for time to second event or death of 0.83 (95% confidence interval, 0.75-0.91; P<0.001). Recurrent PLATO major or Thrombolysis in Myocardial Infarction (TIMI) major non-coronary artery bypass graft bleeding events were infrequent and not different between the two therapies (P=0.96 and 0.38, respectively). CONCLUSIONS In PLATO, treatment with ticagrelor compared with clopidogrel resulted in a reduction in total events, including first and subsequent recurrent cardiovascular events, when compared with clopidogrel. These types of analyses demonstrate an even greater absolute benefit of ticagrelor over clopidogrel than previously reported. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov/. Unique identifier: NCT00391872.
Collapse
Affiliation(s)
- Payal Kohli
- TIMI Study Group/Cardiovascular Division, Brigham and Women's Hospital, 350 Longwood Avenue, 1 floor office, Boston, MA 02115, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Akerblom A, Wallentin L, Siegbahn A, Becker RC, Budaj A, Horrow J, Husted S, Katus H, Claeys MJ, Storey RF, Asenblad N, James SK. Outcome and causes of renal deterioration evaluated by serial cystatin C measurements in acute coronary syndrome patients -- results from the PLATelet inhibition and patient Outcomes (PLATO) study. Am Heart J 2012; 164:728-34. [PMID: 23137503 DOI: 10.1016/j.ahj.2012.08.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [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: 06/21/2012] [Accepted: 08/22/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND To investigate if ticagrelor treatment and other clinical characteristics were associated with increased cystatin C concentrations and if a deterioration in estimated renal function was associated with worse outcome in patients with acute coronary syndromes (ACS). METHODS Plasma cystatin C concentrations were determined within 24 hours of admission (baseline), at discharge, 1 month, and 6 months in the PLATO trial. The changes over time in relation to randomized treatment were analyzed by analysis of covariance. C-statistics and the relative Integrated Discrimination Improvement of the cystatin C concentrations regarding the primary outcome (cardiovascular death or myocardial infarction) was evaluated by multivariable analysis including background characteristics and biomarkers: N-terminal-pro-B-type natriuretic peptide and Troponin I. RESULTS Mean cystatin C concentrations in 2133 ticagrelor- and 2162 clopidogrel-treated patients were at baseline (0.86 mg/L and 0.86 mg/L), discharge (1.01 mg/L and 0.98 mg/L) (P < .0005), 1 month (1.00 mg/L and 0.98 mg/L) (P = .12), and 6 months (1.00 mg/L and 0.99 mg/L) (P = .17), respectively. Age, heart failure, and type of ACS were major determinants of the cystatin C concentration. c Statistics and the relative Integrated Discrimination Improvement of the primary outcome for the baseline cystatin C concentration were 0.687 and 5.2%, compared to 0.684 and 4.5% at discharge (n = 4034) and 0.693 and 5.1% at one month (n = 3096), respectively. CONCLUSIONS Mean cystatin C concentrations increased in ACS patients, most importantly determined by age. The initial greater increase in ticagrelor-treated patients was not sustained over time. Risk prediction did not improve with serial measurements of renal markers.
Collapse
Affiliation(s)
- Axel Akerblom
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Varenhorst C, Alström U, Scirica BM, Hogue CW, Åsenblad N, Storey RF, Steg PG, Horrow J, Mahaffey KW, Becker RC, James S, Cannon CP, Brandrup-Wognsen G, Wallentin L, Held C. Factors Contributing to the Lower Mortality With Ticagrelor Compared With Clopidogrel in Patients Undergoing Coronary Artery Bypass Surgery. J Am Coll Cardiol 2012; 60:1623-30. [DOI: 10.1016/j.jacc.2012.07.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 07/02/2012] [Accepted: 07/02/2012] [Indexed: 01/12/2023]
|
15
|
Wallentin L, James S, Storey R, Barratt B, Horrow J, Husted S, Katus H, Steg P, Becker R. GREATER EFFICACY OF TICAGRELOR COMPARED TO CLOPIDOGREL IN ACUTE CORONARY SYNDROME IS NOT DRIVEN BY OUTCOMES IN POOR METABOLIZERS OF CLOPIDOGREL. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60501-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Husted S, James S, Becker R, Horrow J, Katus H, Storey R, Cannon C, Heras M, Lopes R, Morais J, Mahaffey K, Bach R, Wojdyla D, Wallentin L. TICAGRELOR VERSUS CLOPIDOGREL IN WOMEN WITH ACUTE CORONARY SYNDROMES – A SUBSTUDY FROM THE PROSPECTIVE RANDOMIZED PLATELET INHIBITION AND PATIENT OUTCOMES (PLATO) TRIAL. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60508-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
17
|
Cornel JH, Becker R, Goodman S, Husted S, Katus H, Santoso A, Steg P, Storey R, Vintila M, sun J, Horrow J, Wallentin L, Harrington R, James S. PRIOR SMOKING STATUS, CLINICAL OUTCOMES, AND THE COMPARISON OF TICAGRELOR WITH CLOPIDOGREL IN ACUTE CORONARY SYNDROMES – INSIGHTS FROM THE PLATELET INHIBITION AND PATIENT OUTCOMES (PLATO) TRIAL. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60496-3] [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: 11/29/2022]
|
18
|
Kohli P, Wallentin L, Reyes E, Horrow J, Husted S, Storey R, James S, Cannon C. REDUCTION IN FIRST AND RECURRENT CARDIOVASCULAR AND ISCHEMIC EVENTS WITH TICAGRELOR COMPARED WITH CLOPIDOGREL IN THE PLATO STUDY. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60505-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
19
|
Bui AH, Cannon C, Steg P, Storey R, Husted S, Ren F, James S, Michelson E, Horrow J, Wallentin L, Scirica B. RELATIONSHIP BETWEEN NONSUSTAINED VENTRICULAR TACHYCARDIA AND VASCULAR DEATH IN PATIENTS WITH ACUTE CORONARY SYNDROME IN THE PLATO (PLATELET INHIBITION AND PATIENT OUTCOMES) TRIAL. J Am Coll Cardiol 2012. [DOI: 10.1016/s0735-1097(12)60630-5] [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: 10/28/2022]
|
20
|
Armstrong PW, Siha H, Fu Y, Westerhout CM, Steg PG, James SK, Storey RF, Horrow J, Katus H, Clemmensen P, Harrington RA, Wallentin L. ST-Elevation Acute Coronary Syndromes in the Platelet Inhibition and Patient Outcomes (PLATO) Trial. Circulation 2012; 125:514-21. [DOI: 10.1161/circulationaha.111.047530] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [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: 11/16/2022]
Abstract
Background—
Ticagrelor, when compared with clopidogrel, reduced the 12-month risk of vascular death/myocardial infarction and stroke in patients with ST-elevation acute coronary syndromes intended to undergo primary percutaneous coronary intervention in the PLATelet inhibition and patient Outcomes (PLATO) trial. This prespecified ECG substudy explored whether ticagrelor's association with vascular death and myocardial infarction within 1 year would be amplified by (1) the extent of baseline ST shift and (2) subsequently associated with fewer residual ST changes at hospital discharge.
Methods and Results—
ECGs were evaluated centrally in a core laboratory in 3122 ticagrelor- and 3084 clopidogrel-assigned patients having at least 1 mm ST-elevation in 2 contiguous leads as identified by site investigators on the qualifying ECG. Patients with greater ST-segment shift at baseline had higher rates of vascular death/myocardial infarction within 1 year. Among those who also had an ECG at hospital discharge (n=4798), patients with ≥50% ΣST-deviation (ΣST-dev) resolution had higher event-free survival than those with incomplete resolution (6.4% versus 8.8%, adjusted hazard ratio 0.69 (0.54–0.88),
P
=0.003). The extent of ΣST-dev resolution was similar irrespective of treatment assignment. The benefit of ticagrelor versus clopidogrel on clinical events was consistent irrespective of the extent of baseline ΣST-dev (
P
(interaction)=0.728). When stratified according to conventional times from symptom onset, ie, ≤3 hours, 3 to 6 hours, >6 hours, the extent of baseline ΣST-dev declined progressively over time. As time from symptom onset increased beyond 3 hours, the benefit of ticagrelor appeared to be more pronounced; however, the interaction between time and treatment was not significant (
P
=0.175).
Conclusions—
Ticagrelor did not modify ΣST-dev resolution at discharge nor was its benefit affected by the extent of baseline ΣST-dev. These hypothesis-generating observations suggest that the main effects of ticagrelor may not relate to the rapidity or the completeness of acute reperfusion, but rather the prevention of recurrent vascular events by more powerful platelet inhibition or other mechanisms.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00391872.
Collapse
Affiliation(s)
- Paul W. Armstrong
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Hany Siha
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Yuling Fu
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Cynthia M. Westerhout
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Ph. Gabriel Steg
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Stefan K. James
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Robert F. Storey
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Jay Horrow
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Hugo Katus
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Peter Clemmensen
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Robert A. Harrington
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| | - Lars Wallentin
- From the University of Alberta, Edmonton, Canada (P.W.A., H.S., Y.F., C.M.W.); INSERM U-698, Assistance Publique-Hôpitaux de Paris, and Universite Paris-Diderot, Paris, France (G.S.); Uppsala University Hospital, Uppsala, Sweden (S.K.H.); University of Sheffield, Sheffield, United Kingdom (R.F.S.); AstraZeneca, Wilmington, MA (J.H.); University of Heidelberg, Heidelberg, Germany (H.K.); Copenhagen University Hospital, Copenhagen, Denmark (P.C.); Duke Clinical Research Institute, Durham, NC (R.A.H.)
| |
Collapse
|
21
|
Akerblom Å, Wallentin L, Siegbahn A, Becker RC, Budaj A, Buck K, Giannitsis E, Horrow J, Husted S, Katus HA, Steg PG, Storey RF, Åsenblad N, James SK. Cystatin C and estimated glomerular filtration rate as predictors for adverse outcome in patients with ST-elevation and non-ST-elevation acute coronary syndromes: results from the Platelet Inhibition and Patient Outcomes study. Clin Chem 2011; 58:190-9. [PMID: 22126936 DOI: 10.1373/clinchem.2011.171520] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND We evaluated the predictive ability of cystatin C and creatinine-based estimations of glomerular filtration rate (eGFR), including the Chronic Kidney Disease-Epidemiology (CKD-EPI) equation, in acute coronary syndrome (ACS) patients with (STE-ACS) or without (NSTE-ACS) ST elevation in a large contemporary ACS population. METHODS Concentrations of cystatin C and creatinine, as well as eGFR at randomization, were measured in 16 401 patients in the Platelet Inhibition and Patient Outcomes (PLATO) study and evaluated as predictors of the composite end point of cardiovascular death or myocardial infarction within 1 year. Two Cox proportional hazards models were used, the first adjusting for clinical characteristics and the second for clinical characteristics plus the biomarkers N-terminal pro-B-type natriuretic peptide, troponin I, and C-reactive protein. RESULTS The median cystatin C value was 0.83 mg/L. Increasing quartiles of cystatin C were strongly associated with poor outcome (6.9%, 7.1%, 9.5%, and 16.2%). The fully adjusted hazard ratios per SD of cystatin C in the NSTE-ACS and STE-ACS populations were 1.12 (95% CI 1.04-1.20) (n=8053) and 1.06 (95% CI 0.97-1.17) (n=5278), respectively. There was no significant relationship of cystatin C with type of ACS (STE or NSTE). c Statistics ranged from 0.6923 (cystatin C) to 0.6941 (CKD-EPI). CONCLUSIONS Cystatin C concentration contributes independently in predicting the risk of cardiovascular death or myocardial infarction in NSTE-ACS, with no interaction by type of ACS. CKD-EPI exhibited the largest predictive value of all renal markers. Nevertheless, the additive predictive value of cystatin C or creatinine-based eGFR measures in the unselected ACS patient is small.
Collapse
Affiliation(s)
- Åxel Akerblom
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Becker RC, Bassand JP, Budaj A, Wojdyla DM, James SK, Cornel JH, French J, Held C, Horrow J, Husted S, Lopez-Sendon J, Lassila R, Mahaffey KW, Storey RF, Harrington RA, Wallentin L. Bleeding complications with the P2Y12 receptor antagonists clopidogrel and ticagrelor in the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J 2011; 32:2933-44. [PMID: 22090660 DOI: 10.1093/eurheartj/ehr422] [Citation(s) in RCA: 275] [Impact Index Per Article: 21.2] [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: 01/03/2023] Open
Abstract
AIMS More intense platelet-directed therapy for acute coronary syndrome (ACS) may increase bleeding risk. The aim of the current analysis was to determine the rate, clinical impact, and predictors of major and fatal bleeding complications in the PLATO study. METHODS AND RESULTS PLATO was a randomized, double-blind, active control international, phase 3 clinical trial in patients with acute ST elevation and non-ST-segment elevation ACS. A total of 18 624 patients were randomized to either ticagrelor, a non-thienopyridine, reversibly binding platelet P2Y(12) receptor antagonist, or clopidogrel in addition to aspirin. Patients randomized to ticagrelor and clopidogrel had similar rates of PLATO major bleeding (11.6 vs. 11.2%; P = 0.43), TIMI major bleeding (7.9 vs. 7.7%, P = 0.56) and GUSTO severe bleeding (2.9 vs. 3.1%, P = 0.22). Procedure-related bleeding rates were also similar. Non-CABG major bleeding (4.5 vs. 3.8%, P = 0.02) and non-procedure-related major bleeding (3.1 vs. 2.3%, P = 0.05) were more common in ticagrelor-treated patients, primarily after 30 days on treatment. Fatal bleeding and transfusion rates did not differ between groups. There were no significant interactions for major bleeding or combined minor plus major bleeding between treatment groups and age ≥75 years, weight <60 kg, region, chronic kidney disease, creatinine clearance <60 mL/min, aspirin dose >325 mg on the day of randomization, pre-randomization clopidogrel administration, or clopidogrel loading dose. CONCLUSION Ticagrelor compared with clopidogrel was associated with similar total major bleeding but increased non-CABG and non-procedure-related major bleeding, primarily after 30 days on study drug treatment. Fatal bleeding was low and did not differ between groups.
Collapse
Affiliation(s)
- Richard C Becker
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC 27715, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Mahaffey KW, Wojdyla DM, Carroll K, Becker RC, Storey RF, Angiolillo DJ, Held C, Cannon CP, James S, Pieper KS, Horrow J, Harrington RA, Wallentin L. Ticagrelor Compared With Clopidogrel by Geographic Region in the Platelet Inhibition and Patient Outcomes (PLATO) Trial. Circulation 2011; 124:544-54. [DOI: 10.1161/circulationaha.111.047498] [Citation(s) in RCA: 341] [Impact Index Per Article: 26.2] [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: 11/16/2022]
Abstract
Background—
In the Platelet Inhibition and Patient Outcomes (PLATO) trial, a prespecified subgroup analysis showed a significant interaction between treatment and region (
P
=0.045), with less effect of ticagrelor in North America than in the rest of the world.
Methods and Results—
Reasons for the interaction were explored independently by 2 statistical groups. Systematic errors in trial conduct were investigated. Statistical approaches evaluated the likelihood of play of chance. Cox regression analyses were performed to quantify how much of the regional interaction could be explained by patient characteristics and concomitant treatments, including aspirin maintenance therapy. Landmark Cox regressions at 8 time points evaluated the association of selected factors, including aspirin dose, with outcomes by treatment. Systematic errors in trial conduct were ruled out. Given the large number of subgroup analyses performed and that a result numerically favoring clopidogrel in at least 1 of the 4 prespecified regions could occur with 32% probability, chance alone cannot be ruled out. More patients in the United States (53.6%) than in the rest of the world (1.7%) took a median aspirin dose ≥300 mg/d. Of 37 baseline and postrandomization factors explored, only aspirin dose explained a substantial fraction of the regional interaction. In adjusted analyses, both Cox regression with median maintenance dose and landmark techniques showed that, in patients taking low-dose maintenance aspirin, ticagrelor was associated with better outcomes compared with clopidogrel, with statistical superiority in the rest of the world and similar outcomes in the US cohort.
Conclusions—
The regional interaction could arise from chance alone. Results of 2 independently performed analyses identified an underlying statistical interaction with aspirin maintenance dose as a possible explanation for the regional difference. The lowest risk of cardiovascular death, myocardial infarction, or stroke with ticagrelor compared with clopidogrel is associated with a low maintenance dose of concomitant aspirin.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00391872.
Collapse
Affiliation(s)
- Kenneth W. Mahaffey
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Daniel M. Wojdyla
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Kevin Carroll
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Richard C. Becker
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Robert F. Storey
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Dominick J. Angiolillo
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Claes Held
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Christopher P. Cannon
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Stefan James
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Karen S. Pieper
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Jay Horrow
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Robert A. Harrington
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| | - Lars Wallentin
- From the Duke Clinical Research Institute, Durham, NC (K.W.M., D.M.W., R.C.B., K.S.P., R.A.H.); AstraZeneca Research and Development, Wilmington, DE (K.C., J.H.); University of Sheffield, Sheffield, UK (R.F.S.); University of Florida College of Medicine–Jacksonville (D.J.A.); Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden (C.H., S.J., L.W.); and TIMI Study Group, Brigham and Women's Hospital, Boston, MA (C.P.C.)
| |
Collapse
|
24
|
James SK, Roe MT, Cannon CP, Cornel JH, Horrow J, Husted S, Katus H, Morais J, Steg PG, Storey RF, Stevens S, Wallentin L, Harrington RA. Ticagrelor versus clopidogrel in patients with acute coronary syndromes intended for non-invasive management: substudy from prospective randomised PLATelet inhibition and patient Outcomes (PLATO) trial. BMJ 2011; 342:d3527. [PMID: 21685437 PMCID: PMC3117310 DOI: 10.1136/bmj.d3527] [Citation(s) in RCA: 188] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate efficacy and safety outcomes in patients in the PLATelet inhibition and patient Outcomes (PLATO) trial who at randomisation were planned for a non-invasive treatment strategy. DESIGN Pre-specified analysis of pre-randomisation defined subgroup of prospective randomised clinical trial. SETTING 862 centres in 43 countries. PARTICIPANTS 5216 (28%) of 18,624 patients admitted to hospital for acute coronary syndrome who were specified as planned for non-invasive management. INTERVENTIONS Randomised treatment with ticagrelor (n=2601) versus clopidogrel (2615). MAIN OUTCOME MEASUREMENTS Primary composite end point of cardiovascular death, myocardial infarction, and stroke; their individual components; and PLATO defined major bleeding during one year. RESULTS 2183 (41.9%) patients had coronary angiography during their initial hospital admission, 1065 (20.4%) had percutaneous coronary intervention, and 208 (4.0%) had coronary artery bypass surgery. Cumulatively, 3143 (60.3%) patients had been managed non-invasively by the end of follow-up. The incidence of the primary end point was lower with ticagrelor than with clopidogrel (12.0% (n=295) v 14.3% (346); hazard ratio 0.85, 95% confidence interval 0.73 to 1.00; P=0.04). Overall mortality was also lower (6.1% (147) v 8.2% (195); 0.75, 0.61 to 0.93; P=0.01). The incidence of total major bleeding (11.9% (272) v 10.3% (238); 1.17, 0.98 to 1.39; P=0.08) and non-coronary artery bypass grafting related major bleeding (4.0% (90) v 3.1% (71); 1.30, 0.95 to 1.77; P=0.10) was numerically higher with ticagrelor than with clopidogrel. CONCLUSIONS In patients with acute coronary syndrome initially intended for non-invasive management, the benefits of ticagrelor over clopidogrel were consistent with those from the overall PLATO results, indicating the broad benefits of P2Y12 inhibition with ticagrelor regardless of intended management strategy. TRIAL REGISTRATION Clinical trials NCT00391872.
Collapse
Affiliation(s)
- Stefan K James
- Uppsala Clinical Research Center, Uppsala University, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Åkerblom A, Wallentin L, Siegbahn A, Becker RC, Budaj A, Buck K, Horrow J, Husted S, Katus H, Steg PG, Storey RF, Åsenblad N, James SK. CYSTATIN C IS AN INDEPENDENT RISK PREDICTOR FOR DEATH OR MYOCARDIAL INFARCTION IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) AS WELL AS IN NON-ST-ELEVATION ACUTE CORONARY SYNDROME (NSTE-ACS). J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60999-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
26
|
Held C, Åsenblad N, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW, Nicolau JC, Scirica BM, Storey RF, Vintila M, Ycas J, Wallentin L. Ticagrelor Versus Clopidogrel in Patients With Acute Coronary Syndromes Undergoing Coronary Artery Bypass Surgery. J Am Coll Cardiol 2011; 57:672-84. [DOI: 10.1016/j.jacc.2010.10.029] [Citation(s) in RCA: 380] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 10/11/2010] [Accepted: 10/12/2010] [Indexed: 12/31/2022]
|
27
|
Wallentin L, James S, Storey RF, Armstrong M, Barratt BJ, Horrow J, Husted S, Katus H, Steg PG, Shah SH, Becker RC. Effect of CYP2C19 and ABCB1 single nucleotide polymorphisms on outcomes of treatment with ticagrelor versus clopidogrel for acute coronary syndromes: a genetic substudy of the PLATO trial. Lancet 2010; 376:1320-8. [PMID: 20801498 DOI: 10.1016/s0140-6736(10)61274-3] [Citation(s) in RCA: 563] [Impact Index Per Article: 40.2] [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] [Indexed: 12/23/2022]
Abstract
BACKGROUND In the PLATO trial of ticagrelor versus clopidogrel for treatment of acute coronary syndromes, ticagrelor reduced the composite outcome of cardiovascular death, myocardial infarction, and stroke, but increased events of major bleeding related to non-coronary artery bypass graft (CABG). CYP2C19 and ABCB1 genotypes are known to influence the effects of clopidogrel. In this substudy, we investigated the effects of these genotypes on outcomes between and within treatment groups. METHODS DNA samples obtained from patients in the PLATO trial were genotyped for CYP2C19 loss-of-function alleles (*2, *3, *4, *5, *6, *7, and *8), the CYP2C19 gain-of-function allele *17, and the ABCB1 single nucleotide polymorphism 3435C→T. For the CYP2C19 genotype, patients were stratified by the presence or absence of any loss-of-function allele, and for the ABCB1 genotype, patients were stratified by predicted gene expression (high, intermediate, or low). The primary efficacy endpoint was the composite of cardiovascular death, myocardial infarction, or stroke after up to 12 months' treatment with ticagrelor or clopidogrel. FINDINGS 10 285 patients provided samples for genetic analysis. The primary outcome occurred less often with ticagrelor versus clopidogrel, irrespective of CYP2C19 genotype: 8·6% versus 11·2% (hazard ratio 0·77, 95% CI 0·60-0·99, p=0·0380) in patients with any loss-of-function allele; and 8·8% versus 10·0% (0·86, 0·74-1·01, p=0·0608) in those without any loss-of-function allele (interaction p=0·46). For the ABCB1 genotype, event rates for the primary outcome were also consistently lower in the ticagrelor than in the clopidogrel group for all genotype groups (interaction p=0·39; 8·8%vs 11·9%; 0·71, 0·55-0·92 for the high-expression genotype). In the clopidogrel group, the event rate at 30 days was higher in patients with than in those without any loss-of-function CYP2C19 alleles (5·7%vs 3·8%, p=0·028), leading to earlier separation of event rates between treatment groups in patients with loss-of-function alleles. Patients on clopidogrel who had any gain-of-function CYP2C19 allele had a higher frequency of major bleeding (11·9%) than did those without any gain-of-function or loss-of-function alleles (9·5%; p=0·022), but interaction between treatment and genotype groups was not significant for any type of major bleeding. INTERPRETATION Ticagrelor is a more efficacious treatment for acute coronary syndromes than is clopidogrel, irrespective of CYP2C19 and ABCB1 polymorphisms. Use of ticagrelor instead of clopidogrel eliminates the need for presently recommended genetic testing before dual antiplatelet treatment. FUNDING AstraZeneca.
Collapse
Affiliation(s)
- Lars Wallentin
- Uppsala Clinical Research Centre, Uppsala University, Uppsala, Sweden.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
James S, Budaj A, Aylward P, Buck KK, Cannon CP, Cornel JH, Harrington RA, Horrow J, Katus H, Keltai M, Lewis BS, Parikh K, Storey RF, Szummer K, Wojdyla D, Wallentin L. Ticagrelor versus clopidogrel in acute coronary syndromes in relation to renal function: results from the Platelet Inhibition and Patient Outcomes (PLATO) trial. Circulation 2010; 122:1056-67. [PMID: 20805430 DOI: 10.1161/circulationaha.109.933796] [Citation(s) in RCA: 276] [Impact Index Per Article: 19.7] [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: 01/26/2023]
Abstract
BACKGROUND Reduced renal function is associated with a poorer prognosis and increased bleeding risk in patients with acute coronary syndromes and may therefore alter the risk-benefit ratio with antiplatelet therapies. In the Platelet Inhibition and Patient Outcomes (PLATO) trial, ticagrelor compared with clopidogrel reduced the primary composite end point of cardiovascular death, myocardial infarction, and stroke at 12 months but with similar major bleeding rates. METHODS AND RESULTS Central laboratory serum creatinine levels were available in 15 202 (81.9%) acute coronary syndrome patients at baseline, and creatinine clearance, estimated by the Cockcroft Gault equation, was calculated. In patients with chronic kidney disease (creatinine clearance <60 mL/min; n=3237), ticagrelor versus clopidogrel significantly reduced the primary end point to 17.3% from 22.0% (hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.65 to 0.90) with an absolute risk reduction greater than that of patients with normal renal function (n=11 965): 7.9% versus 8.9% (HR, 0.90; 95% CI, 0.79 to 1.02). In patients with chronic kidney disease, ticagrelor reduced total mortality (10.0% versus 14.0%; HR, 0.72; 95% CI, 0.58 to 0.89). Major bleeding rates, fatal bleedings, and non-coronary bypass-related major bleedings were not significantly different between the 2 randomized groups (15.1% versus 14.3%; HR, 1.07; 95% CI, 0.88 to 1.30; 0.34% versus 0.77%; HR, 0.48; 95% CI, 0.15 to 1.54; and 8.5% versus 7.3%; HR, 1.28; 95% CI, 0.97 to 1.68). The interactions between creatinine clearance and randomized treatment on any of the outcome variables were nonsignificant. CONCLUSIONS In acute coronary syndrome patients with chronic kidney disease, ticagrelor compared with clopidogrel significantly reduces ischemic end points and mortality without a significant increase in major bleeding but with numerically more non-procedure-related bleeding. CLINICAL TRIAL REGISTRATION URL:http://www.clinicatrials.gov. Unique identifier: NCT00391872.
Collapse
Affiliation(s)
- Stefan James
- Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Parva M, Chamchad D, Keegan J, Gerson A, Horrow J. Placenta percreta with invasion of the bladder wall: management with a multi-disciplinary approach. J Clin Anesth 2010; 22:209-12. [DOI: 10.1016/j.jclinane.2009.03.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2008] [Revised: 03/06/2009] [Accepted: 03/18/2009] [Indexed: 10/19/2022]
|
30
|
Held C, Bassand JP, Becker RC, Cannon CP, Claeys MJ, Harrington RA, Horrow J, Husted S, James SK, Mahaffey KW. TICAGRELOR VERSUS CLOPIDOGREL IN PATIENTS WITH ACUTE CORONARY SYNDROMES UNDERGOING CORONARY ARTERY BY-PASS SURGERY: RESULTS FROM THE PLATO TRIAL. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61164-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
31
|
Phon H, Jaffe J, Horrow J. Perioperative management of acute ischemic stroke: a case report. J Clin Anesth 2010; 21:602-5. [PMID: 20122594 DOI: 10.1016/j.jclinane.2009.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 01/03/2009] [Accepted: 01/05/2009] [Indexed: 11/18/2022]
Abstract
Interrupting anticoagulation in patients at high risk for thromboembolism, even for critically important surgery, may lead to devastating outcomes. The patient described developed "Locked-in Syndrome" from basilar arterial thrombosis within 24 hours of withholding anticoagulation for urgent airway surgery. Emergency thrombolysis partially restored arterial flow, with recovery of some function. The dangers of hemorrhage during surgery must be balanced against the potentially devastating consequences of withholding anticoagulation in patients at high risk for thrombosis.
Collapse
Affiliation(s)
- Hla Phon
- Department of Anesthesiology, Drexel University College of Medicine, Philadelphia, PA 19102-1192, USA
| | | | | |
Collapse
|
32
|
Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361:1045-57. [PMID: 19717846 DOI: 10.1056/nejmoa0904327] [Citation(s) in RCA: 4901] [Impact Index Per Article: 326.7] [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] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ticagrelor is an oral, reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12 that has a more rapid onset and more pronounced platelet inhibition than clopidogrel. METHODS In this multicenter, double-blind, randomized trial, we compared ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) and clopidogrel (300-to-600-mg loading dose, 75 mg daily thereafter) for the prevention of cardiovascular events in 18,624 patients admitted to the hospital with an acute coronary syndrome, with or without ST-segment elevation. RESULTS At 12 months, the primary end point--a composite of death from vascular causes, myocardial infarction, or stroke--had occurred in 9.8% of patients receiving ticagrelor as compared with 11.7% of those receiving clopidogrel (hazard ratio, 0.84; 95% confidence interval [CI], 0.77 to 0.92; P<0.001). Predefined hierarchical testing of secondary end points showed significant differences in the rates of other composite end points, as well as myocardial infarction alone (5.8% in the ticagrelor group vs. 6.9% in the clopidogrel group, P=0.005) and death from vascular causes (4.0% vs. 5.1%, P=0.001) but not stroke alone (1.5% vs. 1.3%, P=0.22). The rate of death from any cause was also reduced with ticagrelor (4.5%, vs. 5.9% with clopidogrel; P<0.001). No significant difference in the rates of major bleeding was found between the ticagrelor and clopidogrel groups (11.6% and 11.2%, respectively; P=0.43), but ticagrelor was associated with a higher rate of major bleeding not related to coronary-artery bypass grafting (4.5% vs. 3.8%, P=0.03), including more instances of fatal intracranial bleeding and fewer of fatal bleeding of other types. CONCLUSIONS In patients who have an acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rate of overall major bleeding but with an increase in the rate of non-procedure-related bleeding. (ClinicalTrials.gov number, NCT00391872.)
Collapse
|
33
|
Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009. [PMID: 19717846 DOI: 10.1161/circulationaha.113.004420] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [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: 01/17/2023]
Abstract
BACKGROUND Ticagrelor is an oral, reversible, direct-acting inhibitor of the adenosine diphosphate receptor P2Y12 that has a more rapid onset and more pronounced platelet inhibition than clopidogrel. METHODS In this multicenter, double-blind, randomized trial, we compared ticagrelor (180-mg loading dose, 90 mg twice daily thereafter) and clopidogrel (300-to-600-mg loading dose, 75 mg daily thereafter) for the prevention of cardiovascular events in 18,624 patients admitted to the hospital with an acute coronary syndrome, with or without ST-segment elevation. RESULTS At 12 months, the primary end point--a composite of death from vascular causes, myocardial infarction, or stroke--had occurred in 9.8% of patients receiving ticagrelor as compared with 11.7% of those receiving clopidogrel (hazard ratio, 0.84; 95% confidence interval [CI], 0.77 to 0.92; P<0.001). Predefined hierarchical testing of secondary end points showed significant differences in the rates of other composite end points, as well as myocardial infarction alone (5.8% in the ticagrelor group vs. 6.9% in the clopidogrel group, P=0.005) and death from vascular causes (4.0% vs. 5.1%, P=0.001) but not stroke alone (1.5% vs. 1.3%, P=0.22). The rate of death from any cause was also reduced with ticagrelor (4.5%, vs. 5.9% with clopidogrel; P<0.001). No significant difference in the rates of major bleeding was found between the ticagrelor and clopidogrel groups (11.6% and 11.2%, respectively; P=0.43), but ticagrelor was associated with a higher rate of major bleeding not related to coronary-artery bypass grafting (4.5% vs. 3.8%, P=0.03), including more instances of fatal intracranial bleeding and fewer of fatal bleeding of other types. CONCLUSIONS In patients who have an acute coronary syndrome with or without ST-segment elevation, treatment with ticagrelor as compared with clopidogrel significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke without an increase in the rate of overall major bleeding but with an increase in the rate of non-procedure-related bleeding. (ClinicalTrials.gov number, NCT00391872.)
Collapse
|
34
|
|
35
|
Baruch L, Gage B, Horrow J. Response to Letter by Taggar et al. Stroke 2008. [DOI: 10.1161/strokeaha.107.504191] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Lawrence Baruch
- Department of Medicine, Bronx Veterans Affairs Medical Center, Bronx, NY, Mount Sinai School of Medicine, New York, NY
| | - Brian Gage
- Department of Medicine, Washington University, St. Louis, Mo
| | - Jay Horrow
- Drexel University College of Medicine, Philadelphia, Pa
| |
Collapse
|
36
|
Baruch L, Gage BF, Horrow J, Juul-Möller S, Labovitz A, Persson M, Zabalgoitia M. Can Patients at Elevated Risk of Stroke Treated With Anticoagulants Be Further Risk Stratified? Stroke 2007; 38:2459-63. [PMID: 17673721 DOI: 10.1161/strokeaha.106.477133] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [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: 11/16/2022]
Abstract
Background and Purpose—
Patients with atrial fibrillation have a varied risk of stroke, depending on age and comorbid conditions. The objective of this study was to assess the predictive value of stroke risk classification schemes and to identify patients with atrial fibrillation who are at substantial risk of stroke despite optimal anticoagulant therapy.
Methods—
Seven recognized classification schemes—the American College of Chest Physicians 2001, American College of Chest Physicians 2004, Stroke Prevention in Atrial Fibrillation (SPAF), Atrial Fibrillation Investigators, Framingham, van Walraven, and CHADS
2
—were compared for their ability to predict ischemic stroke in patients receiving anticoagulant therapy. Data came from the Stroke Prevention using an ORal Thrombin Inhibitor in atrial Fibrillation III and V trials, which compared the efficacy of adjusted-dose warfarin and the direct thrombin inhibitor ximelagatran (36 mg twice daily) in preventing thromboembolic events in 7329 patients with chronic or paroxysmal nonvalvular atrial fibrillation who were at moderate or high risk of ischemic stroke. The main outcome measure was ischemic stroke, as determined by a central event adjudication committee.
Results—
During 11 245 patient-years of follow-up, 159 patients had an ischemic stroke (1.4%/year). As indicated by
c
statistics and hazard ratios, 3 of the classification schemes predicted stroke significantly better than chance: Framingham (
c
=0.64), CHADS
2
(
c
=0.65), and SPAF (
c
=0.61).
Conclusions—
In a large cohort of atrial fibrillation patients at moderate or high risk of ischemic stroke treated with warfarin or ximelagatran, the CHADS
2
, SPAF, and Framingham schemes had greater predictive accuracy than chance. This predictive ability may allow clinicians to target high-risk patients for more aggressive intervention.
Collapse
|
37
|
Flaker GC, Gruber M, Connolly SJ, Goldman S, Chaparro S, Vahanian A, Halinen MO, Horrow J, Halperin JL. Risks and benefits of combining aspirin with anticoagulant therapy in patients with atrial fibrillation: an exploratory analysis of stroke prevention using an oral thrombin inhibitor in atrial fibrillation (SPORTIF) trials. Am Heart J 2006; 152:967-73. [PMID: 17070169 DOI: 10.1016/j.ahj.2006.06.024] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [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: 04/14/2006] [Accepted: 06/16/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aspirin is used in combination with anticoagulant therapy in patients with atrial fibrillation (AF), but evidence of additional efficacy is not available. METHODS We compared ischemic events and bleeding in the SPORTIF III and IV randomized trials of anticoagulation with warfarin (international normalized ratio 2-3) or fixed-dose ximelagatran. Low-dose aspirin (<100 mg/d) was allowed based on prevailing guidelines. RESULTS The 14% of patients receiving aspirin more often had diabetes (27.5% vs 23%, P < .01), coronary artery disease (69% vs 41%, P < .01), previous stroke or transient ischemic attack (26% vs 20%, P < .01), and left ventricular dysfunction (41% vs 36%, P < .01). Addition of aspirin to either warfarin or ximelagatran was associated with no reduction in stroke or systemic embolism. Major bleeding occurred significantly more often with aspirin plus warfarin (3.9% per year) than with warfarin alone (2.3% per year, P < .01), aspirin plus ximelagatran (2.0% per year), or ximelagatran alone (1.9% per year). The rate of myocardial infarction with aspirin and warfarin (0.6% per year) was not significantly different from that with ximelagatran alone (1.0% per year), warfarin alone (1.0% per year), or aspirin and ximelagatran (1.4% per year). CONCLUSIONS Aspirin combined with anticoagulant therapy was associated with no reduction in stroke, systemic embolism, or myocardial infarction in patients with AF. Aspirin combined with warfarin was associated with an incremental rate of major bleeding of 1.6% per year. No increased major bleeding occurred with aspirin and ximelagatran. These results suggest that the risks associated with addition of aspirin to anticoagulation in patients with AF outweigh the benefit.
Collapse
Affiliation(s)
- Greg C Flaker
- Department of Medicine, University of Missouri-Columbia, Columbia, MO, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Albers GW, Diener HC, Frison L, Grind M, Horrow J, Nevinson M, Olsson SB, Partridge S, Petersen P, Vahanian A, Halperin JL. Trials and Tribulations of Noninferiority: The Ximelagatran Experience. J Am Coll Cardiol 2006; 48:1058; author reply 1059. [PMID: 16949503 DOI: 10.1016/j.jacc.2006.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
39
|
Douketis JD, Arneklev K, Goldhaber SZ, Spandorfer J, Halperin F, Horrow J. Comparison of bleeding in patients with nonvalvular atrial fibrillation treated with ximelagatran or warfarin: assessment of incidence, case-fatality rate, time course and sites of bleeding, and risk factors for bleeding. Arch Intern Med 2006; 166:853-9. [PMID: 16636210 DOI: 10.1001/archinte.166.8.853] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
BACKGROUND Ximelagatran is a novel direct thrombin inhibitor that can be administered as a fixed oral dose, without the need for anticoagulant monitoring. METHODS We undertook a pooled analysis of 7329 patients with nonvalvular atrial fibrillation from the Stroke Prevention Using Oral Thrombin Inhibitor in Atrial Fibrillation III and V trials to compare bleeding outcomes in patients who received ximelagatran, 36 mg twice daily, or warfarin sodium (target international normalized ratio, 2.0-3.0). We determined annual risk of bleeding (any, major), case-fatality rate, time course and anatomic sites of major bleeding, and risk factors for major bleeding with ximelagatran and warfarin treatment. RESULTS Annual incidence of any bleeding was 31.75% with ximelagatran and 38.82% with warfarin (relative risk reduction, 18.2%; 95% confidence interval [CI], 13.0-23.1; P<.001). Annual incidence of major bleeding was 2.01% with ximelagatran and 2.68% with warfarin (relative risk reduction, 25.1%; 95% CI, 3.2-42.1; P = .03). Case-fatality rate of bleeding was comparable in ximelagatran- and warfarin-treated patients (8.16% vs 8.09%; P = .98). Cumulative incidence of major bleeding was higher with warfarin than ximelagatran after 24 months of treatment (4.7% vs 3.7%; P = .04). Anatomic sites of bleeding were comparable with both treatments. Risk factors for bleeding with ximelagatran were as follows (hazard ratios and 95% CIs in parentheses): diabetes mellitus (1.81; 1.19-2.77; P = .006), previous stroke or transient ischemic attack (1.78; 1.16-2.73; P = .008), age 75 years or greater (1.70; 1.33-2.18; P<.001), and aspirin use (1.68; 1.08-2.59; P = .02). Risk factors for bleeding in warfarin-treated patients were previous liver disease (4.88; 1.55-15.39; P = .007); aspirin use (2.41; 1.69-3.43; P<.001); and age 75 years or greater (1.26; 1.03-1.52; P = .02). CONCLUSIONS Treatment with ximelagatran, 36 mg twice daily, is associated with a lower risk of bleeding than warfarin in patients with nonvalvular atrial fibrillation. Aspirin use and increasing age were associated with an increased risk of bleeding in ximelagatran- and warfarin-treated patients.
Collapse
Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | | | | | | | | | | |
Collapse
|
40
|
Abstract
OBJECTIVES Negative feedback regulation of pancreatic proteases controls pancreatic secretion in most species and pancreatic growth in rodents. Its mechanism involves the inhibition of intraluminal proteases, resulting in sustained elevation of plasma cholecystokinin (CCK) concentrations, producing a chronic trophic stimulus to the pancreas that leads to the formation of pancreatic nodules and adenomas. Ximelagatran, whose active form, melagatran, inhibits both thrombin and the serine protease trypsin, is under clinical development as an oral anticoagulant. Recent data indicate species differences in the expression of CCK receptor subtypes in the pancreas. CCK1 receptors are abundant in rat pancreas but are either absent or present at very low levels in human pancreas. As part of the clinical studies, we examined whether long-term ximelagatran administration causes CCK release and exerts possible trophic effects on the pancreas in humans. METHODS One hundred thirty patients requiring anticoagulation treatment for atrial fibrillation randomly received, in a double-blind fashion, either 36 mg oral ximelagatran twice daily or warfarin dose adjusted to an international normalized ratio of 2.0 to 3.0. Before enrollment and after 12 months of treatment, computed tomography scans of the pancreas were performed, and pancreas volumes were quantified using the summation-of-areas technique. Three months after the initiation of drug treatment, plasma CCK concentrations were measured by radioimmunoassay 120 minutes after the patients drank 240 mL of a mixed liquid meal (Ensure). RESULTS After 3 months of treatment, plasma CCK concentrations did not differ between the ximelagatran and warfarin groups, 15 +/- 18 and 11 +/- 17 pmol/L (X +/- SD; P = 0.22), respectively. The initial average pancreas volumes were 82 +/- 31 and 88 +/- 28 mL in the ximelagatran and warfarin groups, respectively, and decreased to 70 +/- 25 and 75 +/- 28 mL, respectively, after 12 months of treatment. Although the decrease in pancreas volume with time was significant in each group (P = 0.0001), the magnitude of the volume reduction was similar in the 2 groups. CONCLUSION In contrast to rats, in which long-term oral administration of ximelagatran stimulates pancreatic growth and adenoma formation, in humans, ximelagatran does not increase plasma CCK concentrations and has no demonstrable trophic effect on the human pancreas.
Collapse
Affiliation(s)
- Rodger A Liddle
- Department of Medicine, Duke University, Durham VA Medical Centers, Durham, NC, USA.
| | | | | | | | | | | |
Collapse
|
41
|
Schwann NM, Horrow J. Failing to Reject the Null Hypothesis Does Not Mean that the Null Hypothesis Is True. Anesth Analg 2005; 100:1869. [PMID: 15920250 DOI: 10.1213/01.ane.0000156679.52332.42] [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: 11/05/2022]
Affiliation(s)
- Nanette M Schwann
- Allentown Anesthesia Associates, Vice Chair for Research, Department of Anesthesiology, Lehigh Valley Hospital and Health Network, Allentown, PA, (Schwann) Department of Anesthesiology, Drexel University College of Medicine, Philadelphia, PA (Horrow)
| | | |
Collapse
|
42
|
Juul-Möller S, Persson M, Gage B, Labovitz A, Zabalgoita M, Baruch L, Horrow J. Endothelial stress is a predictor for ischemic stroke in patients with non-valvular atrial fibrillation. Heart Rhythm 2005. [DOI: 10.1016/j.hrthm.2005.02.363] [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: 11/26/2022]
|
43
|
Albers GW, Diener HC, Frison L, Grind M, Nevinson M, Partridge S, Halperin JL, Horrow J, Olsson SB, Petersen P, Vahanian A. Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial. JAMA 2005; 293:690-8. [PMID: 15701910 DOI: 10.1001/jama.293.6.690] [Citation(s) in RCA: 534] [Impact Index Per Article: 28.1] [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] [Indexed: 01/26/2023]
Abstract
CONTEXT In patients with nonvalvular atrial fibrillation, warfarin prevents ischemic stroke, but dose adjustment, coagulation monitoring, and bleeding limit its use. OBJECTIVE To compare the efficacy of the oral direct thrombin inhibitor ximelagatran with warfarin for prevention of stroke and systemic embolism. DESIGN, SETTING, AND PARTICIPANTS Double-blind, randomized, multicenter trial (2000-2001) conducted at 409 North American sites, involving 3922 patients with nonvalvular atrial fibrillation and additional stroke risk factors. INTERVENTIONS Adjusted-dose warfarin (aiming for an international normalized ratio [INR] 2.0 to 3.0) or fixed-dose oral ximelagatran, 36 mg twice daily. MAIN OUTCOME MEASURES The primary end point was all strokes (ischemic or hemorrhagic) and systemic embolic events. The primary analysis was based on demonstrating noninferiority within an absolute margin of 2.0% per year according to the intention-to-treat model. RESULTS During 6405 patient-years (mean 20 months) of follow-up, 88 patients experienced primary events. The mean (SD) INR with warfarin (2.4 [0.8]) was within target during 68% of the treatment period. The primary event rate with ximelagatran was 1.6% per year and with warfarin was 1.2% per year (absolute difference, 0.45% per year; 95% confidence interval, -0.13% to 1.03% per year; P<.001 for the predefined noninferiority hypothesis). When all-cause mortality was included in addition to stroke and systemic embolic events, the rate difference was 0.10% per year (95% confidence interval, -0.97% to 1.2% per year; P = .86). There was no difference between treatment groups in rates of major bleeding, but total bleeding (major and minor) was lower with ximelagatran (37% vs 47% per year; 95% confidence interval for the difference, -14% to -6.0% per year; P<.001). Serum alanine aminotransferase levels rose to greater than 3 times the upper limit of normal in 6.0% of patients treated with ximelagatran, usually within 6 months and typically declined whether or not treatment continued; however, one case of documented fatal liver disease and one other suggestive case occurred. CONCLUSIONS The results establish the efficacy of fixed-dose oral ximelagatran without coagulation monitoring compared with well-controlled warfarin for prevention of thromboembolism in patients with atrial fibrillation requiring chronic anticoagulant therapy, but the potential for hepatotoxicity requires further investigation.
Collapse
|
44
|
Horrow J. Can You Reheparinize After Heparinase-I? Anesth Analg 2002. [DOI: 10.1097/00000539-200208000-00065] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
45
|
Horrow J, Strong MD, Van Riper DF. Tranexamic acid after bypass: too late to help? J Thorac Cardiovasc Surg 1994; 107:1375-7. [PMID: 8176987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
46
|
Parmet JL, Horrow J, Rosenberg H. Fat embolism syndrome. N Engl J Med 1994; 330:642-3. [PMID: 8302355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
|
47
|
Affiliation(s)
- G H Pharo
- Department of Anesthesiology, Hahnemann University, Philadelphia, PA 19102-1192
| | | | | | | |
Collapse
|
48
|
Abstract
Seventeen adults received the antifibrinolytic drug tranexamic acid during cardiac surgery utilizing extracorporeal circulation (ECC). In 8 patients, drug administration began prior to skin incision (pre-ECC); infusions commenced after ECC and protamine administration in another 9 patients (post-ECC). Compared with the post-ECC group, the pre-ECC group exhibited less bleeding via mediastinal drains (420 vs. 655 mL/12 h median, P = 0.024), decreased frequency of the presence (greater than or equal to 10 micrograms/mL) of fibrin split products (P less than 0.05), and greater platelet dense granule content of adenosine diphosphate after surgery (15.47 vs. 4.05 nmoles/mg protein median, P = 0.021). Follow-up in vitro study of tranexamic acid inhibition of plasmin-induced platelet activation utilizing normal human platelet rich plasma and porcine plasmin revealed a 13-fold lower concentration of tranexamic acid for 50% inhibition when plasmin was preincubated with the drug (1.2 micrograms/mL, 95% CI = 1.13-1.60 micrograms/mL) compared to when platelet rich plasma was preincubated with the drug (16 micrograms/mL, 95% CI = 7.3-99. micrograms/mL). Plasmin inactivated with tranexamic acid retained its ability to inhibit thrombin-induced platelet activation, thus suggesting that tranexamic acid inhibits plasmin's catalytic activity and not its binding to platelets. Both clot lysis and platelet dysfunction may contribute to bleeding after ECC. Tranexamic acid blocks plasmin-induced partial platelet activation during ECC, thus preserving platelet function and promoting hemostasis after ECC.
Collapse
Affiliation(s)
- G Soslau
- Department of Anesthesiology, Hahnemann University, Philadelphia, PA 19102-1192
| | | | | |
Collapse
|
49
|
|