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Wendelboe A, Weitz JI. Global Health Burden of Venous Thromboembolism. Arterioscler Thromb Vasc Biol 2024; 44:1007-1011. [PMID: 38657032 DOI: 10.1161/atvbaha.124.320151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Aaron Wendelboe
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (A.W.)
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W.)
- Department of Medicine (J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada
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Madarati H, DeYoung V, Singh K, Sparring T, Kwong AC, Fredenburgh JC, Teney C, Koschinsky ML, Boffa MB, Weitz JI, Kretz CA. Optimization of plasma-based BioID identifies plasminogen as a ligand of ADAMTS13. Sci Rep 2024; 14:9073. [PMID: 38643218 PMCID: PMC11032339 DOI: 10.1038/s41598-024-59672-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 04/13/2024] [Indexed: 04/22/2024] Open
Abstract
ADAMTS13, a disintegrin and metalloprotease with a thrombospondin type 1 motif, member 13, regulates the length of Von Willebrand factor (VWF) multimers and their platelet-binding activity. ADAMTS13 is constitutively secreted as an active protease and is not inhibited by circulating protease inhibitors. Therefore, the mechanisms that regulate ADAMTS13 protease activity are unknown. We performed an unbiased proteomics screen to identify ligands of ADAMTS13 by optimizing the application of BioID to plasma. Plasma BioID identified 5 plasma proteins significantly labeled by the ADAMTS13-birA* fusion, including VWF and plasminogen. Glu-plasminogen, Lys-plasminogen, mini-plasminogen, and apo(a) bound ADAMTS13 with high affinity, whereas micro-plasminogen did not. None of the plasminogen variants or apo(a) bound to a C-terminal truncation variant of ADAMTS13 (MDTCS). The binding of plasminogen to ADAMTS13 was attenuated by tranexamic acid or ε-aminocaproic acid, and tranexamic acid protected ADAMTS13 from plasmin degradation. These data demonstrate that plasminogen is an important ligand of ADAMTS13 in plasma by binding to the C-terminus of ADAMTS13. Plasmin proteolytically degrades ADAMTS13 in a lysine-dependent manner, which may contribute to its regulation. Adapting BioID to identify protein-interaction networks in plasma provides a powerful new tool to study protease regulation in the cardiovascular system.
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Affiliation(s)
- Hasam Madarati
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Veronica DeYoung
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Kanwal Singh
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Taylor Sparring
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Andrew C Kwong
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - James C Fredenburgh
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Cherie Teney
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Marlys L Koschinsky
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Robarts Research Institute, The University of Western Ontario, London, ON, Canada
| | - Michael B Boffa
- Department of Biochemistry, Schulich School of Medicine and Dentistry, Robarts Research Institute, The University of Western Ontario, London, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Colin A Kretz
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada.
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Goodman SG, Roy D, Pollack CV, Leblanc K, Kwaku KF, Barnes GD, Bonaca MP, True Hills M, Campello E, Fanikos J, Connors JM, Weitz JI. Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics. Crit Pathw Cardiol 2024:00132577-990000000-00068. [PMID: 38381695 DOI: 10.1097/hpc.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by five times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc.), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for Factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a re-evaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
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Affiliation(s)
- Shaun G Goodman
- Division of Cardiology, St Michael's Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, and Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Denis Roy
- Department of Medicine and Research Center, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Kori Leblanc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kevin F Kwaku
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Marc P Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | | | - Elena Campello
- General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeffrey I Weitz
- McMaster University, Hamilton, ON, Canada, and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
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Eikelboom R, Whitlock RP, Sibilio S, Nguyen F, Perez R, Weitz JI, Belley-Cote E. Direct Oral Anticoagulation Versus Warfarin in Patients with Atrial Fibrillation and Bioprosthetic Heart Valves: a Retrospective, Real-World Cohort Study. Cardiovasc Drugs Ther 2024; 38:109-117. [PMID: 36121587 DOI: 10.1007/s10557-022-07381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In this retrospective cohort study of consecutive patients with atrial fibrillation and surgical or transcatheter bioprosthetic valve, we compared the efficacy and safety of direct oral anticoagulants with warfarin. METHODS Using linked health administrative databases housed at the Institute for Clinical Evaluative Sciences, we identified consecutive patients in Ontario (Canada) 65 years of age or older with AF who underwent bioprosthetic valve replacement between 1 April 2012 and 31 March 2017. We created a time-varying Cox model to examine the relationship between the type of anticoagulant and time to thrombotic or bleeding events after adjustment for baseline risk of thrombosis using the CHA2DS2-VASc score and risk of bleeding using the HAS-BLED scores. We conducted prespecified subgroup analyses according to whether valve implantation was surgical or transcatheter. RESULTS We identified 2245 eligible patients. The mean age was 79 years, 41% were female, and 39% had transcatheter aortic valve replacement. Risk of death or thrombosis was not different between direct oral anticoagulants and warfarin after adjustment for CHA2DS2-VASc score (hazard ratio [HR] 1.02, 95% confidence interval [CI], 0.83-1.25). Risk of death or bleeding was not different between direct oral anticoagulants and warfarin after adjustment for HAS-BLED score (HR 0.89, 95% CI 0.75-1.07). Subgroup analyses of surgical or transcatheter valves were consistent with overall results. CONCLUSIONS In a real-world population of patients with atrial fibrillation and bioprosthetic valve replacement, we found no difference between direct oral anticoagulants and warfarin with regard to the risk of thrombosis or bleeding.
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Affiliation(s)
- Rachel Eikelboom
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada.
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Serena Sibilio
- Dipartimento Di Cardiochirurgia, Istituto Clinico Sant'Ambrogio, Milan, Lombardy, Italy
| | - Francis Nguyen
- Institute for Clinical Evaluative Sciences McMaster, McMaster University, Hamilton, ON, Canada
| | - Richard Perez
- Institute for Clinical Evaluative Sciences McMaster, McMaster University, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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Weitz JI, Tankó LB, Floege J, Fox KAA, Bhatt DL, Thadhani R, Hung J, Pap ÁF, Kubitza D, Winkelmayer WC. Anticoagulation with osocimab in patients with kidney failure undergoing hemodialysis: a randomized phase 2 trial. Nat Med 2024; 30:435-442. [PMID: 38365952 PMCID: PMC10878964 DOI: 10.1038/s41591-023-02794-7] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/22/2023] [Indexed: 02/18/2024]
Abstract
Individuals with kidney failure undergoing hemodialysis are at elevated risk for thromboembolic events. Factor (F) XI, which is in the intrinsic pathway of coagulation, is emerging as an attractive target for new anticoagulants that may be safer than existing agents. Osocimab-an inhibitory FXIa antibody-is a potential treatment option for such patients. We conducted a phase 2b, double-blind, placebo-controlled trial, in which 704 participants (448 male, 256 female) with kidney failure undergoing hemodialysis were randomized to receive lower- or higher-dose osocimab or placebo. In total, 686 participants (436 male, 250 female) received treatment for ≤18 months (planned minimal treatment period of 6 months). The co-primary outcomes were clinically relevant bleeding (a composite of major and clinically relevant nonmajor bleeding) and a composite of the incidence of moderate, severe or serious adverse events. Clinically relevant bleeding occurred in 16/232 (6.9%) and 11/224 (4.9%) participants who received lower- and higher-dose osocimab, respectively, and in 18/230 participants (7.8%) who received a placebo. For the composite adverse event endpoint, incidences were 51%, 47% and 43% in the lower-dose osocimab, higher-dose osocimab and placebo groups, respectively. These results suggest that osocimab is associated with a low risk of bleeding and is generally well tolerated in this population; findings that require confirmation in larger trials. ClinicalTrials.gov identifier, NCT04523220 .
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada.
| | - László B Tankó
- Clinical Development and Operations, Bayer Consumer Care AG, Basel, Switzerland
| | - Jürgen Floege
- Division of Nephrology and Rheumatology, RWTH Aachen University Hospital, Aachen, Germany
| | - Keith A A Fox
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Ravi Thadhani
- Emory University School of Medicine, Atlanta, GA, USA
| | - James Hung
- Clinical Development and Operations, Bayer SA, São Paulo, Brazil
| | - Ákos F Pap
- Clinical Data Sciences and Analytics, Bayer AG, Wuppertal, Germany
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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Chessum JE, Shaya SA, Rajab D, Aftabjahani A, Zhou J, Weitz JI, Gross PL, Kim PY. Thrombin-activatable fibrinolysis inhibitor and sex modulate thrombus stability and pulmonary embolism burden in a murine model. J Thromb Haemost 2024; 22:263-270. [PMID: 37751849 DOI: 10.1016/j.jtha.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Thrombin-activatable fibrinolysis inhibitor (TAFI) levels are positively correlated with the risk of thrombosis. The mechanism of how TAFI affects venous thromboembolism (VTE) remains uncertain. In addition, the role of sex on the risk of VTE has also been studied. However, their association also remains unclear. OBJECTIVES To investigate how TAFI and/or sex affect venous thrombus stability and consequent pulmonary embolism (PE). METHODS Ferric chloride-induced thrombi were formed within the femoral veins of male and female wild-type (WT) or TAFI-knockout (Cpb2-/-) mice. Thrombi were imaged over 2 hours using intravital videomicroscopy to quantify embolization and thrombus size over time. Lungs were examined by immunohistochemistry to quantify (a) emboli and (b) fibrin composition of these emboli. RESULTS Embolization events in female mice were higher than in males (7.9-fold in WT and 3.1-fold in Cpb2-/- mice). Although the maximal thrombus sizes were not different across groups, Cpb2-/- mice had thrombi that were, on average, 24% smaller at the end of the 2-hour experiment than WT mice. Loss of TAFI led to a 4.0- and 2.8-fold increase in PE burden in males and females, respectively, while sex had no influence. Pulmonary emboli in Cpb2-/- mice had higher fibrin composition compared with WT mice. CONCLUSION Female mice had less stable venous thrombi than male mice, suggesting a higher risk of PE in females with deep vein thrombosis. Mice lacking TAFI had more thrombus degradation and higher PE burden than WT mice. These results confirm the role of TAFI in venous thrombosis.
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Affiliation(s)
- James E Chessum
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shana A Shaya
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Dana Rajab
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Ali Aftabjahani
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ji Zhou
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Paul Y Kim
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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8
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Eikelboom JW, Weitz JI. Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials. J Thromb Haemost 2023; 21:3067-3071. [PMID: 37429508 DOI: 10.1016/j.jtha.2023.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.
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Affiliation(s)
- John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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9
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Lee SK, Malik RA, Zhou J, Wang W, Gross PL, Weitz JI, Ramachandran R, Trigatti BL. PAR4 Inhibition Reduces Coronary Artery Atherosclerosis and Myocardial Fibrosis in SR-B1/LDLR Double Knockout Mice. Arterioscler Thromb Vasc Biol 2023; 43:2165-2178. [PMID: 37675637 PMCID: PMC10597419 DOI: 10.1161/atvbaha.123.319767] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND SR-B1 (scavenger receptor class B type 1)/LDLR (low-density lipoprotein receptor) double knockout mice fed a high-fat, high-cholesterol diet containing cholate exhibit coronary artery disease characterized by occlusive coronary artery atherosclerosis, platelet accumulation in coronary arteries, and myocardial fibrosis. Platelets are involved in atherosclerosis development, and PAR (protease-activated receptor) 4 has a prominent role in platelet function in mice. However, the role of PAR4 on coronary artery disease in mice has not been tested. METHODS We tested the effects of a PAR4 inhibitory pepducin (RAG8) on diet-induced aortic sinus and coronary artery atherosclerosis, platelet accumulation in atherosclerotic coronary arteries, and myocardial fibrosis in SR-B1/LDLR double knockout mice. SR-B1/LDLR double knockout mice were fed a high-fat, high-cholesterol diet containing cholate and injected daily with 20 mg/kg of either the RAG8 pepducin or a control reverse-sequence pepducin (SRQ8) for 20 days. RESULTS Platelets from the RAG8-treated mice exhibited reduced thrombin and PAR4 agonist peptide-mediated activation compared with those from control SRQ8-treated mice when tested ex vivo. Although aortic sinus atherosclerosis levels did not differ, RAG8-treated mice exhibited reduced coronary artery atherosclerosis, reduced platelet accumulation in atherosclerotic coronary arteries, and reduced myocardial fibrosis. These protective effects were not accompanied by changes in circulating lipids, inflammatory cytokines, or immune cells. However, RAG8-treated mice exhibited reduced VCAM-1 (vascular cell adhesion molecule 1) protein levels in nonatherosclerotic coronary artery cross sections and reduced leukocyte accumulation in atherosclerotic coronary artery cross sections compared with those from SRQ8-treated mice. CONCLUSIONS The PAR4 inhibitory RAG8 pepducin reduced coronary artery atherosclerosis and myocardial fibrosis in SR-B1/LDLR double knockout mice fed a high-fat, high-cholesterol diet containing cholate. Furthermore, RAG8 reduced VCAM-1 in nonatherosclerotic coronary arteries and reduced leukocyte and platelet accumulation in atherosclerotic coronary arteries. These findings identify PAR4 as an attractive target in reducing coronary artery disease development, and the use of RAG8 may potentially be beneficial in cardiovascular disease.
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Affiliation(s)
- Samuel K. Lee
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
- Department of Biochemistry and Biomedical Sciences McMaster University, Hamilton, Ontario, Canada (S.K.L., W.W., J.I.W., B.L.T.)
| | - Rida A. Malik
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (R.A.M., J.Z., P.L.G., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
| | - Ji Zhou
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (R.A.M., J.Z., P.L.G., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
| | - Wei Wang
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
- Department of Biochemistry and Biomedical Sciences McMaster University, Hamilton, Ontario, Canada (S.K.L., W.W., J.I.W., B.L.T.)
| | - Peter L. Gross
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (R.A.M., J.Z., P.L.G., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
| | - Jeffrey I. Weitz
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Department of Medicine (R.A.M., J.Z., P.L.G., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
- Department of Biochemistry and Biomedical Sciences McMaster University, Hamilton, Ontario, Canada (S.K.L., W.W., J.I.W., B.L.T.)
| | - Rithwik Ramachandran
- Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada (R.R.)
| | - Bernardo L. Trigatti
- Thrombosis and Atherosclerosis Research Institute (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.), McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Ontario, Canada (S.K.L., R.A.M., J.Z., W.W., P.L.G., J.I.W., B.L.T.)
- Department of Biochemistry and Biomedical Sciences McMaster University, Hamilton, Ontario, Canada (S.K.L., W.W., J.I.W., B.L.T.)
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10
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Field TS, Dizonno V, Almekhlafi MA, Bala F, Alhabli I, Wong H, Norena M, Villaluna MK, King-Azote P, Ratnaweera N, Mancini S, Van Gaal SC, Wilson LK, Graham BR, Sposato LA, Blacquiere D, Dewar BM, Boulos MI, Buck BH, Odier C, Perera KS, Pikula A, Tkach A, Medvedev G, Canfield C, Mortenson WB, Nadeau JO, Alshimemeri S, Benavente OR, Demchuk AM, Dowlatshahi D, Lanthier S, Lee AYY, Mandzia J, Suryanarayan D, Weitz JI, Hill MD. Study of Rivaroxaban for Cerebral Venous Thrombosis: A Randomized Controlled Feasibility Trial Comparing Anticoagulation With Rivaroxaban to Standard-of-Care in Symptomatic Cerebral Venous Thrombosis. Stroke 2023; 54:2724-2736. [PMID: 37675613 PMCID: PMC10615774 DOI: 10.1161/strokeaha.123.044113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/14/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Emerging data suggest that direct oral anticoagulants may be a suitable choice for anticoagulation for cerebral venous thrombosis (CVT). However, conducting high-quality trials in CVT is challenging as it is a rare disease with low rates of adverse outcomes such as major bleeding and functional dependence. To facilitate the design of future CVT trials, SECRET (Study of Rivaroxaban for Cerebral Venous Thrombosis) assessed (1) the feasibility of recruitment, (2) the safety of rivaroxaban compared with standard-of-care anticoagulation, and (3) patient-centered functional outcomes. METHODS This was a phase II, prospective, open-label blinded-end point 1:1 randomized trial conducted at 12 Canadian centers. Participants were aged ≥18 years, within 14 days of a new diagnosis of symptomatic CVT, and suitable for oral anticoagulation; they were randomized to receive rivaroxaban 20 mg daily, or standard-of-care anticoagulation (warfarin, target international normalized ratio, 2.0-3.0, or low-molecular-weight heparin) for 180 days, with optional extension up to 365 days. Primary outcomes were annual rate of recruitment (feasibility); and a composite of symptomatic intracranial hemorrhage, major extracranial hemorrhage, or mortality at 180 days (safety). Secondary outcomes included recurrent venous thromboembolism, recanalization, clinically relevant nonmajor bleeding, and functional and patient-reported outcomes (modified Rankin Scale, quality of life, headache, mood, fatigue, and cognition) at days 180 and 365. RESULTS Fifty-five participants were randomized. The rate of recruitment was 21.3 participants/year; 57% of eligible candidates consented. Median age was 48.0 years (interquartile range, 38.5-73.2); 66% were female. There was 1 primary event (symptomatic intracranial hemorrhage), 2 clinically relevant nonmajor bleeding events, and 1 recurrent CVT by day 180, all in the rivaroxaban group. All participants in both arms had at least partial recanalization by day 180. At enrollment, both groups on average reported reduced quality of life, low mood, fatigue, and headache with impaired cognitive performance. All metrics improved markedly by day 180. CONCLUSIONS Recruitment targets were reached, but many eligible participants declined randomization. There were numerically more bleeding events in patients taking rivaroxaban compared with control, but rates of bleeding and recurrent venous thromboembolism were low overall and in keeping with previous studies. Participants had symptoms affecting their well-being at enrollment but improved over time. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03178864.
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Affiliation(s)
- Thalia S Field
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Vanessa Dizonno
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Fouzi Bala
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
- Department of Radiology, Tours University Hospital, France (F.B.)
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Hubert Wong
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Monica Norena
- School of Population and Public Health, and Centre for Health Outcomes and Evaluative Sciences (H.W., M.N.), University of British Columbia, Canada
| | - Maria Karina Villaluna
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Princess King-Azote
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Namali Ratnaweera
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Steven Mancini
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Stephen C Van Gaal
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Laura K Wilson
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Brett R Graham
- Division of Neurology, University of Saskatchewan College of Medicine, Saskatoon, Canada (B.R.G.)
| | - Luciano A Sposato
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Dylan Blacquiere
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Brian M Dewar
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Mark I Boulos
- Sunnybrook Research Institute, Division of Neurology (M.I.B.), University Health Network, University of Toronto, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada (B.H.B.)
| | - Celine Odier
- Département de Neurosciences, Centre Hospitalier d'Université de Montréal, Université de Montréal, Canada (C.O.)
| | - Kanjana S Perera
- Population Health Research Institute and Division of Neurology, McMaster University, Hamilton, Canada (K.S.P.)
| | - Aleksandra Pikula
- Krembil Brain Institute (A.P.), University Health Network, University of Toronto, Canada
| | - Aleksander Tkach
- Kelowna General Hospital, Interior Health Authority, Canada (A.T.)
| | - George Medvedev
- Royal Columbian Hospital, Fraser Health Authority, New Westminster, Canada (G.M.)
| | - Carolyn Canfield
- Department of Family Practice, Innovation Support Unit (C.C.), University of British Columbia, Vancouver, Canada
| | - W Ben Mortenson
- Department of Occupational Science and Occupational Therapy (W.B.M.), University of British Columbia, Vancouver, Canada
| | | | | | - Oscar R Benavente
- Vancouver Stroke Program, Division of Neurology (T.S.F., V.D., M.K.V., P.K-A., N.R., S.M., S.C.V.G., L.K.W., O.R.B.), University of British Columbia, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
| | - Dar Dowlatshahi
- Ottawa Stroke Program, Ottawa Hospital Research institute, University of Ottawa, Canada (D.B., B.M.D., D.D.)
| | - Sylvain Lanthier
- Hôpital de Sacre-Coeur de Montréal, Département de Neurosciences, Université de Montréal, Canada (S.L.)
| | - Agnes Y Y Lee
- Division of Hematology (A.Y.Y.L.), University of British Columbia, Vancouver, Canada
| | - Jennifer Mandzia
- Department of Clinical Neurosciences, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada (L.A.S., J.M.)
| | - Deepa Suryanarayan
- Division of Hematology, Cumming School of Medicine (D.S.), University of British Columbia, Vancouver, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada (J.I.W.)
| | - Michael D Hill
- Department of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (M.A.A., F.B., I.A., A.M.D., M.D.H.)
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11
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Chan NC, Weitz JI. New Therapeutic Targets for the Prevention and Treatment of Venous Thromboembolism With a Focus on Factor XI Inhibitors. Arterioscler Thromb Vasc Biol 2023; 43:1755-1763. [PMID: 37650326 DOI: 10.1161/atvbaha.123.318781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/16/2023] [Indexed: 09/01/2023]
Abstract
FXI (factor XI) and FXII (factor XII) have emerged as targets for new anticoagulants that have the potential to be both more efficacious and safer than the currently available direct oral anticoagulants for the prevention and treatment of venous thromboembolism. In this review, we discuss the role of FXI and FXII in the pathogenesis of venous thromboembolism, explain why FXI is a better target, and explain why FXI inhibitors have potential advantages over currently available anticoagulants. Finally, we describe the FXI inhibitors under development and discuss their potential to address unmet needs in venous thromboembolism management.
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Affiliation(s)
- Noel C Chan
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (N.C.C., J.I.W.)
- Department of Medicine (N.C.C., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada (N.C.C.)
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (N.C.C., J.I.W.)
- Department of Medicine (N.C.C., J.I.W.), McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada
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12
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Malik RA, Liao P, Zhou J, Hussain R, Fredenburgh JC, Hettrick L, Revenko AS, Weitz JI. Histidine-rich glycoprotein attenuates catheter thrombosis. Blood Adv 2023; 7:5651-5660. [PMID: 37042966 PMCID: PMC10546346 DOI: 10.1182/bloodadvances.2022009236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/13/2023] Open
Abstract
Factor XII (FXII) knockdown attenuates catheter thrombosis in rabbits. Because histidine-rich glycoprotein (HRG) modulates FXIIa activity, we hypothesized that HRG depletion would promote catheter thrombosis. To test this, rabbits were given either antisense oligonucleotides (ASOs) against HRG or FXII, a control ASO, or saline. The activated partial thromboplastin time (aPTT), prothrombin time (PT), and catheter-induced thrombin generation were determined in blood collected before and after treatment. Compared with the controls, the HRG- and FXII-directed ASOs reduced hepatic messenger RNA and plasma levels of HRG and FXII, respectively, by >90%. Although HRG knockdown shortened the aPTT by 2.5 fold, FXII knockdown prolonged it by fourfold; neither of the ASOs affected the PT. Catheter segments shortened the lag time and increased peak thrombin in the plasma from control rabbits; effects were significantly enhanced and attenuated in the plasma from rabbits given the HRG- and FXII-directed ASOs, respectively. Catheters were then inserted into the right external jugular vein of the rabbits, and the time for catheter occlusion was determined. The catheter occlusion times with the control ASO or saline were 62 ± 8 minutes and 60 ± 11 minutes, respectively. The occlusion time was significantly reduced to 34 ± 9 minutes, with HRG knockdown and significantly prolonged to 128 ± 19 minutes with FXII knockdown. HRG levels are decreased with sepsis or cancer, and such patients are prone to catheter thrombosis. Because HRG modulates catheter thrombosis, our findings suggest that HRG supplementation may prevent this problem.
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Affiliation(s)
- Rida A. Malik
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Peng Liao
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ji Zhou
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Rawaa Hussain
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - James C. Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lisa Hettrick
- Department of Pulmonary and Oncology Drug Discovery, Ionis Pharmaceuticals Inc, Carlsbad, CA
| | - Alexey S. Revenko
- Department of Pulmonary and Oncology Drug Discovery, Ionis Pharmaceuticals Inc, Carlsbad, CA
| | - Jeffrey I. Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
- Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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13
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Wang TF, Khorana AA, Agnelli G, Bloomfield D, Bonaca MP, Büller HR, Connors JM, Goto S, Jing ZC, Kakkar AK, Khder Y, Raskob GE, Soff GA, Verhamme P, Weitz JI, Carrier M. Treatment of Cancer-Associated Thrombosis: Recent Advances, Unmet Needs, and Future Direction. Oncologist 2023; 28:555-564. [PMID: 37171998 PMCID: PMC10322141 DOI: 10.1093/oncolo/oyad116] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 03/24/2023] [Indexed: 05/14/2023] Open
Abstract
Cancer-associated thrombosis, with the incidence rising over the years, is associated with significant morbidity and mortality in patients with cancer. Recent advances in the treatment of cancer-associated venous thromboembolism (VTE) include the introduction of direct oral anticoagulants (DOACs), which provide a more convenient and effective option than low-molecular-weight heparin (LMWH). Nonetheless, important unmet needs remain including an increased risk of bleeding in certain patient subgroups such as those with gastroesophageal cancer, concerns about drug-drug interactions, and management of patients with severe renal impairment. Although DOACs are more convenient than LMWH, persistence can decline over time. Factor XI inhibitors have potential safety advantages over DOACs because factor XI appears to be essential for thrombosis but not hemostasis. In phase II trials, some factor XI inhibitors were superior to enoxaparin for the prevention of VTE after knee replacement surgery without increasing the risk of bleeding. Ongoing trials are assessing the efficacy and safety of factor XI inhibitors for the treatment of cancer-associated VTE.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Alok A Khorana
- Department of Hematology and Medical Oncology Taussig Cancer Institute Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Marc P Bonaca
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- CPC Clinical Research, Aurora, CO, USA
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jean M Connors
- Hematology Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Zhi-Cheng Jing
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City, OK, USA
| | - Gerald A Soff
- General Hematology Service, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, KU Leuven, Leuven, Belgium
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa Hospital Research Institute, Ottawa, Canada
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14
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Fredenburgh JC, Weitz JI. News at XI: moving beyond factor Xa inhibitors. J Thromb Haemost 2023; 21:1692-1702. [PMID: 37116752 DOI: 10.1016/j.jtha.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 04/30/2023]
Abstract
Oral anticoagulants are a mainstay for the prevention and treatment of arterial and venous thrombosis. Direct oral anticoagulants (DOACs) have replaced vitamin K antagonists for many indications. Currently available DOACs include dabigatran, which inhibits thrombin, and apixaban, edoxaban, and rivaroxaban, which inhibit factor (F) Xa. A new class of DOACs is under development. These new DOACs, which include asundexian and milvexian, inhibit FXIa, which is positioned in the intrinsic pathway of coagulation. Anticoagulants that target FXIa have the potential to be safer than the current DOACs because there is emerging evidence that FXI is essential for thrombosis but mostly dispensable for hemostasis. In addition to the oral inhibitors of FXIa, parenteral inhibitors are also under development. These include fesomersen, an antisense oligonucleotide that reduces the hepatic synthesis of FXI; abelacimab, an antibody that binds to FXI and blocks its activation; and osocimab, an FXIa inhibitory antibody. Focusing on these new agents, this article describes the unmet needs in oral anticoagulation therapy, explains why FXI is a promising target for new oral anticoagulants, reviews phase 2 clinical data on new agents, describes ongoing phase 3 trials, and provides a perspective on the opportunities and challenges for FXI inhibitors.
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Affiliation(s)
- James C Fredenburgh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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15
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Barnes GD, Ageno W, Castellucci LA, Chiasakul T, Eslick R, Ferreiro JL, Gailani D, Gorog DA, Lip GYH, Raffini L, Rezende SM, Weitz JI, Cuker A. Recommendation on the nomenclature for anticoagulants: updated communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Commitee on the Control of Anticoagulation. J Thromb Haemost 2023; 21:1381-1384. [PMID: 36796485 PMCID: PMC10629847 DOI: 10.1016/j.jtha.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Oral anticoagulation therapy has evolved beyond vitamin K antagonists to include oral direct thrombin inhibitors and factor Xa inhibitors. Collectively known as "direct oral anticoagulants," this class of medications represents the current standard of care for the prevention and treatment of common thrombotic disorders, including atrial fibrillation and venous thromboembolism. Medications that target factors XI/XIa and XII/XIIa are currently under investigation for several thrombotic and nonthrombotic conditions. Given that these emerging medications will likely have distinct risk-benefit profiles to the current direct oral anticoagulants, may have different routes of administration, and could be used for unique clinical conditions (e.g., hereditary angioedema), the International Society on Thrombosis and Haemostasis Subcommittee on Control of Anticoagulation assembled a writing group to make recommendations on the nomenclature of anticoagulant medications. With input from the broader thrombosis community, the writing group recommends that anticoagulant medications be described by the route of administration and specific targets (e.g., oral factor XIa inhibitor).
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada. https://twitter.com/LanaCastellucci
| | - Thita Chiasakul
- Department of Medicine, Research Unit in Translational Hematology, Division of Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. https://twitter.com/JoyThitaC
| | - Renee Eslick
- Department of Haematology, Canberra Health Services, Garran, Australia. https://twitter.com/Renee_Eslick
| | - José L Ferreiro
- Department of Cardiology, Bellvitge University Hospital, and Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), CIBERCV, L'Hospitalet de Llobregat, Spain
| | - David Gailani
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Leslie Raffini
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/CukerMD
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van Es N, De Caterina R, Weitz JI. Reversal agents for current and forthcoming direct oral anticoagulants. Eur Heart J 2023; 44:1795-1806. [PMID: 36988142 DOI: 10.1093/eurheartj/ehad123] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/28/2022] [Accepted: 02/17/2023] [Indexed: 03/30/2023] Open
Abstract
Over the past 20 years, there has been a shift from vitamin K antagonists to direct oral anticoagulants (DOACs), which include the thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban, edoxaban, and rivaroxaban. Although DOACs are associated with less serious bleeding than vitamin K antagonists, bleeding still occurs with DOACs, particularly in the elderly and in those with comorbidities. Reversal of the anticoagulant effects of the DOACs may be needed in patients with serious bleeding and in those requiring urgent surgery or intervention. Reversal can be effected with specific agents, such as idarucizumab for dabigatran and andexanet alfa for apixaban, edoxaban, and rivaroxaban, or with non-specific agents, such as prothrombin complex concentrates, activated prothrombin complex concentrate, and recombinant activated factor VII. This paper (i) provides an update on when and how to reverse the DOACs, (ii) describes new reversal agents under development, and (iii) provides a strategic framework for the reversal of the factor XI inhibitors currently under investigation in phase three clinical trials.
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Affiliation(s)
- Nick van Es
- Department of Vascular Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Raffaele De Caterina
- Chair and Postgraduate School of Cardiology, University of Pisa, Lungarno Antonio Pacinotti, 43, 56126 Pisa, Italy
- Cardiology Division, Pisa University Hospital, 56100 Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Via Leonardo Petruzzi, 42, 65013 Città Sant'Angelo-Pescara, Italy
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, 1200 Main St W, Hamilton, ON, Canada L8N 3Z5
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada L8S 4L8
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON, Canada L8L 2X2
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17
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Guan Z, Wang R, Hussain RH, Fredenburgh JC, Jaffer IH, Weitz JI. Rivaroxaban and apixaban are less effective than enoxaparin for the prevention of catheter-induced clotting in vitro. J Thromb Haemost 2023; 21:76-82. [PMID: 36695399 DOI: 10.1016/j.jtha.2022.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/17/2022] [Accepted: 10/29/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Central venous catheters are prone to clotting, particularly in patients with cancer. Although low-molecular-weight heparin and direct oral anticoagulants, such as apixaban and rivaroxaban, have been evaluated for the prevention of catheter thrombosis, their efficacy remains uncertain. OBJECTIVES Compare apixaban and rivaroxaban with enoxaparin for the prevention of catheter-induced clotting in vitro. METHODS To address this uncertainty, we used a well-established microplate-based assay to compare the effects of enoxaparin, apixaban, and rivaroxaban on catheter-induced thrombosis and thrombin generation in human plasma. RESULTS Consistent with our previous findings, catheter segments shortened the clotting time and promoted thrombin generation. When compared at concentrations with similar anti-factor Xa activity as enoxaparin, apixaban and rivaroxaban were >20-fold less potent than enoxaparin for the prevention of catheter-induced clotting and thrombin generation. CONCLUSION The prevention of catheter thrombosis in patients with cancer is challenging. Clinical trials are needed to compare the efficacy of low-molecular-weight heparin with that of direct oral anticoagulants both for the prevention and treatment of catheter thrombosis.
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Affiliation(s)
- Zeyu Guan
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Roxanna Wang
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Rawaa H Hussain
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Iqbal H Jaffer
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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18
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W., J.W.E.).,Departments of Medicine (J.I.W., J.W.E.), McMaster University, Hamilton, Ontario, Canada.,Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W., J.W.E.).,Departments of Medicine (J.I.W., J.W.E.), McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (J.W.E.)
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19
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Afonso E, Bayat F, Ladouceur L, Khan S, Martínez-Gómez A, Weitz JI, Hosseinidoust Z, Tiemblo P, García N, Didar TF. Highly Stable Hierarchically Structured All-Polymeric Lubricant-Infused Films Prevent Thrombosis and Repel Multidrug-Resistant Pathogens. ACS Appl Mater Interfaces 2022; 14:53535-53545. [PMID: 36413608 DOI: 10.1021/acsami.2c17309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Thrombus formation and infections caused by bacterial adhesion are the most common causes of failure in blood-contacting medical devices. Reducing the interaction of pathogens using repellent surfaces has proven to be a successful strategy in preventing device failure. However, designing scale-up methodologies to create large-scale repellent surfaces remains challenging. To address this need, we have created an all-polymeric lubricant-infused system using an industrially viable swelling-coagulation solvent (S-C) method. This induces hierarchically structured micro/nano features onto the surface, enabling improved lubricant infusion. Poly(3,3,3-trifluoropropylmethylsiloxane) (PTFS) was used as the lubricant of choice, a previously unexplored omniphobic nonvolatile silicone oil. This resulted in all-polymeric liquid-infused surfaces that are transparent and flexible with long-term stability. Repellent properties have been demonstrated using human whole blood and methicillin-resistant Staphylococcus aureus (MRSA) bacteria matrices, with lubricated surfaces showing 93% reduction in blood stains and 96.7% reduction in bacterial adherence. The developed material has the potential to prevent blood and pathogenic contamination for a range biomedical devices within healthcare settings.
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Affiliation(s)
- Elisabet Afonso
- Department of Physical Chemistry of Polymers, Institute of Polymer Science and Technology, Spanish Research Council, Madrid 28006, Spain
| | - Fereshteh Bayat
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
| | - Liane Ladouceur
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | - Shadman Khan
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
| | - Aránzazu Martínez-Gómez
- Department of Physical Chemistry of Polymers, Institute of Polymer Science and Technology, Spanish Research Council, Madrid 28006, Spain
| | - Jeffrey I Weitz
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
- Department of Medicine, 1280 Main St W, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, 1280 Main St W, Hamilton, Ontario L8S 4L8, Canada
- Thrombosis & Atherosclerosis Research Institute (TaARI), 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Zeinab Hosseinidoust
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
- Department of Chemical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
- Michael DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario L98 4L8, Canada
| | - Pilar Tiemblo
- Department of Physical Chemistry of Polymers, Institute of Polymer Science and Technology, Spanish Research Council, Madrid 28006, Spain
| | - Nuria García
- Department of Physical Chemistry of Polymers, Institute of Polymer Science and Technology, Spanish Research Council, Madrid 28006, Spain
| | - Tohid F Didar
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario L9S 8L7, Canada
- Department of Mechanical Engineering, McMaster University, Hamilton, Ontario L8S 4L8, Canada
- Michael DeGroote Institute for Infectious Disease Research, McMaster University, Hamilton, Ontario L98 4L8, Canada
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20
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Weitz JI, Szekanecz Z, Charles-Schoeman C, Vranic I, Sahin B, Paciga SA, Wang Z, Hyde C, Martin DA. Biomarkers to predict risk of venous thromboembolism in patients with rheumatoid arthritis receiving tofacitinib or tumour necrosis factor inhibitors. RMD Open 2022; 8:rmdopen-2022-002571. [PMID: 36323490 PMCID: PMC9639150 DOI: 10.1136/rmdopen-2022-002571] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 07/25/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE In the ORAL (Oral Rheumatoid Arthritis triaL) Surveillance study of patients with rheumatoid arthritis aged ≥50 years with ≥1 additional cardiovascular risk factor, incidence of pulmonary embolism was higher with tofacitinib 10 mg two times per day than with tumour necrosis factor inhibitors (TNFi). This exploratory post hoc analysis examined whether biomarkers explained the associations of tofacitinib versus TNFi with venous thromboembolism (VTE). METHODS ORAL Surveillance was a prospective, open-label, event-driven, non-inferiority, postauthorisation safety study. Patients were randomised 1:1:1 to receive tofacitinib 5 mg or 10 mg two times per day or a TNFi. For this analysis, 294 soluble, proteomic, genetic and antibody biomarkers (of which 79 had a known role in inflammation, coagulation, vascular biology or Janus kinase signalling) were quantified in serum collected at baseline, month 12 and study end. RESULTS Overall, 4362 patients were randomised and treated. The exploratory biomarker data set included 285 patients (57 VTE cases; 228 matched controls). D-dimer was quantified in 3732 patients (54 VTE cases; 3678 controls). No biomarker demonstrated a clear mechanistic association with the increased risk of VTE for tofacitinib versus TNFi. Month 12 D-dimer levels were positively associated with risk of a subsequent VTE within the tofacitinib 5 mg and 10 mg two times per day arms. CONCLUSIONS Overall, this post hoc analysis did not identify biomarkers that explained the increased VTE risk for tofacitinib versus TNFi. Individual VTE risk should be considered when making decisions about initiation or maintenance of tofacitinib treatment. TRIAL REGISTRATION NUMBER NCT02092467; ClinicalTrials.gov.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Zoltán Szekanecz
- Division of Rheumatology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Christina Charles-Schoeman
- Division of Rheumatology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | | | - Burak Sahin
- Immunology & Inflammation Medical Affairs, Pfizer Inc, Istanbul, Turkey
| | | | - Zhenyu Wang
- Immunology & Inflammation Research, Pfizer Inc, Cambridge, Massachusetts, USA
| | - Craig Hyde
- Biostatistics, Pfizer Inc, Groton, Connecticut, USA
| | - David A Martin
- Immunology & Inflammation Research, Pfizer Inc, Cambridge, Massachusetts, USA
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21
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Poole L, Casari C, Manevski SD, Eslick R, Weitz JI, Al Moosawi M, Armstrong P, Campbell R, Chiasakul T, Iding A, Kohli S, Poole L, Potere N, Sayar Z, Skeith L. Challenges facing early career women in thrombosis and hemostasis—meeting the needs of the next generation. J Thromb Haemost 2022. [DOI: 10.1111/jth.15895] [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: 11/29/2022]
Affiliation(s)
- Lauren Poole
- Department of Pharmacology, Robert Wood Johnson Medical School Rutgers University Piscataway New Jersey USA
| | - Caterina Casari
- HITh, UMR_S1176, Institut National de la Santé et de la Recherche Médicale University Paris‐Saclay Le Kremlin‐Bicêtre France
| | - Sofija Dunjic Manevski
- Laboratory for Molecular Biology, Institute of Molecular Genetics and Genetic Engineering University of Belgrade Beograd Serbia
| | - Renee Eslick
- Department of Haematology Canberra Health Services Canberra ACT Australia
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22
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Raskob GE, Ageno W, Albers G, Elliott CG, Halperin J, Maynard G, Steg PG, Weitz JI, Albanese J, Yuan Z, Levitan B, Lu W, Suh EY, Spiro T, Lipardi C, Barnathan ES, Spyropoulos AC. Benefit-Risk Assessment of Rivaroxaban for Extended Thromboprophylaxis After Hospitalization for Medical Illness. J Am Heart Assoc 2022; 11:e026229. [PMID: 36205248 DOI: 10.1161/jaha.122.026229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 11/16/2022]
Abstract
Background Venous thromboembolism (VTE) often occurs after hospitalization in medically ill patients, but the population benefit-risk of extended thromboprophylaxis remains uncertain. Methods and Results The MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) study (NCT02111564) was a randomized double-blind trial that compared thromboprophylaxis with rivaroxaban 10 mg daily versus placebo for 45 days after hospital discharge in medically ill patients with a creatinine clearance ≥50 mL/min. The benefit-risk balance in this population was quantified by calculating the between-treatment rate differences in efficacy and safety end points per 10 000 patients treated. Clinical characteristics of the study population were consistent with a hospitalized medical population at risk for VTE. Treating 10 000 patients with rivaroxaban resulted in 32.5 fewer symptomatic VTE and VTE-related deaths but was associated with 8 additional major bleeding events. The treatment benefit was driven by the prevention of nonfatal symptomatic VTE (26 fewer events). There was no between-treatment difference in the composite of critical site or fatal bleeding. Conclusions Extending thromboprophylaxis with rivaroxaban for 45 days after hospitalization provides a positive benefit-risk balance in medically ill patients at risk for VTE who are not at high risk for bleeding. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT02111564.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | - Gregory Albers
- Stanford Stroke Center Stanford University Medical Center Stanford CA
| | - C Gregory Elliott
- Department of Medicine Intermountain Medical Center and the University of Utah Salt Lake City UT
| | | | | | - Philippe Gabriel Steg
- Universite Paris-Cite Assistance Publique-Hôpitauxde Paris, and INSERM U-1148 Paris France.,Imperial College, Royal Brompton Hospital London United Kingdom
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | | | - Zhong Yuan
- Janssen Research & Development, LLC Titusville NJ
| | | | - Wentao Lu
- Janssen Research & Development, LLC Raritan NJ
| | | | - Theodore Spiro
- Clinical Development Pharmaceuticals, Bayer U.S. LLC Whippany NJ
| | | | | | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell The Feinstein Institute for Medical Research, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lennox Hill Hospital New York NY
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23
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Haas S, Farjat AE, Pieper K, Ageno W, Angchaisuksiri P, Bounameaux H, Goldhaber SZ, Goto S, Mantovani L, Prandoni P, Schellong S, Turpie AG, Weitz JI, MacCallum P, Cate HT, Panchenko E, Carrier M, Jerjes-Sanchez C, Gibbs H, Jansky P, Kayani G, Kakkar AK. On-treatment Comparative Effectiveness of Vitamin K Antagonists and Direct Oral Anticoagulants in GARFIELD-VTE, and Focus on Cancer and Renal Disease. TH Open 2022; 6:e354-e364. [DOI: 10.1055/s-0042-1757744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) provide a safe, effective alternative to vitamin K antagonists (VKAs) for venous thromboembolism (VTE) treatment, as shown via intention-to-treat comparative effectiveness analysis. However, on-treatment analysis is imperative in observational studies because anticoagulation choice and duration are at investigators' discretion.
Objectives The aim of the study is to compare the effectiveness of DOACs and VKAs on 12-month outcomes in VTE patients using on-treatment analysis.
Methods The Global Anticoagulant Registry in the FIELD - VTE (GARFIELD-VTE) is a world-wide, prospective, non-interventional study observing treatment of VTE in routine clinical practice.
Results In total, 8,034 patients received VKAs (n = 3,043, 37.9%) or DOACs (n = 4,991, 62.1%). After adjustment for baseline characteristics and follow-up bleeding events, and accounting for possible time-varying confounding, all-cause mortality was significantly lower with DOACs than VKAs (hazard ratio: 0.58 [95% confidence interval 0.42–0.79]). Furthermore, patients receiving VKAs were more likely to die of VTE complications (4.9 vs. 2.2%) or bleeding (4.9 vs. 0.0%). There was no significant difference in rates of recurrent VTE (hazard ratio: 0.74 [0.55–1.01]), major bleeding (hazard ratio: 0.76 [0.47–1.24]), or overall bleeding (hazard ratio: 0.87 [0.72–1.05]) with DOACs or VKAs. Unadjusted analyses suggested that VKA patients with active cancer or renal insufficiency were more likely to die than patients treated with DOAC (52.51 [37.33–73.86] vs. 26.52 [19.37–36.29] and 9.97 [7.51–13.23] vs. 4.70 [3.25–6.81] per 100 person-years, respectively).
Conclusion DOACs and VKAs had similar rates of recurrent VTE and major bleeding. However, DOACs were associated with reduced all-cause mortality and a lower likelihood of death from VTE or bleeding compared with VKAs.
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Affiliation(s)
- Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Karen Pieper
- Thrombosis Research Institute, London, United Kingdom
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | | | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, United States
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | - Lorenzo Mantovani
- Center for Public Health Research, University of Milan-Bicocca, Monza, Italy
| | | | - Sebastian Schellong
- Department of Health Sciences, Medical Department 2, Municipal Hospital Dresden, Germany
| | | | - Jeffrey I. Weitz
- Department of Haematology, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Peter MacCallum
- Thrombosis Research Institute, London, United Kingdom
- Queen Mary University of London, London, United Kingdom
| | - Hugo ten Cate
- Department of Vascular Medicine and Internal Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht; Maastricht, The Netherlands
| | - Elizaveta Panchenko
- National Medical Research Center of Cardiology of Ministry of Health of the Russian Federation, Moscow, Russian Federation
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital, Ottawa, Canada
| | - Carlos Jerjes-Sanchez
- Tecnológico de Monterrey. Escuela de Medicina y Ciencias de la Salud., Monterrey, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, Sa Pedro Garza Garcia, Mexico
| | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Australia
| | - Petr Jansky
- Motol University Hospital, Department of Cardiovascular Surgery, Prague, Czech Republic
| | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom
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24
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Bonaca MP, Antman EM, Cunningham JW, Wiviott SD, Murphy SA, Halperin JL, Weitz JI, Grosso MA, Lanz HJ, Braunwald E, Giugliano RP, Ruff CT. Ischaemic and bleeding risk in atrial fibrillation with and without peripheral artery disease and efficacy and safety of full- and half-dose edoxaban vs. warfarin: insights from ENGAGE AF-TIMI 48. Eur Heart J Cardiovasc Pharmacother 2022; 8:695-706. [PMID: 34962979 DOI: 10.1093/ehjcvp/pvab089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 10/13/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS In patients with atrial fibrillation (AF), peripheral artery disease (PAD) is associated with higher rates of stroke and bleeding. Both higher dose edoxaban (60/30 mg) and lower dose edoxaban (30/15 mg) were non-inferior to warfarin for stroke and systemic embolism (SSE) and significantly reduced major bleeding in AF patients in the global study to assess the safety and effectiveness of edoxaban vs standard practice of dosing with warfarin in patients with atrial fibrillation (ENGAGE AF-TIMI 48) trial. Whether the efficacy and safety of these dosing strategies vs. warfarin are consistent in patients with AF and PAD has not been described. METHODS AND RESULTS Of 21 105 patients with AF randomized to warfarin, edoxaban 60/30 mg, or edoxaban 30/15 mg, 841 were identified with PAD. Endpoints included major adverse cardiovascular events (MACEs), SSE, and major bleeding. Patients with PAD had higher risk of MACEs [adjusted hazard ratio (HRadj) 1.33, 95% confidence interval (CI) 1.12-1.57, P = 0.001] and cardiovascular (CV) death (HRadj 1.49, 95% CI 1.21-1.83, P < 0.001) than those without PAD, but not major bleeding. The efficacy of edoxaban 60/30 mg vs. warfarin was consistent regardless of PAD (SSE HR; PAD 1.16, 95% CI 0.42-3.20; no-PAD 0.86, 95% CI 0.74-1.02, P-interaction 0.57) as was major bleeding (PAD 0.96, 95% CI 0.54-1.70; no-PAD 0.80, 95% CI 0.70-0.91, P-interaction 0.54). Edoxaban 30/15 mg was inferior for SSE, with significant heterogeneity when stratified by PAD status (P-interaction 0.039). CONCLUSION Patients with AF and PAD are at heightened risk of MACEs and CV death vs. those without PAD. The efficacy and safety of edoxaban 60/30 mg vs. warfarin in AF are consistent regardless of PAD; however, edoxaban 30/15 mg is inferior for stroke prevention in AF patients with PAD. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00781391.
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Affiliation(s)
- Marc P Bonaca
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- CPC Clinical Research, University of Colorado School of Medicine, 13199 E. Montview Blvd., Suite 200, Aurora, CO 80045, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan L Halperin
- Cardiovascular Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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25
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Weitz JI, Peyvandi F. ISTH Biennial Impact Report: Looking back and looking forward. J Thromb Haemost 2022; 20:1515-1517. [PMID: 35754017 DOI: 10.1111/jth.15749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Flora Peyvandi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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26
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Spyropoulos AC, Goldin M, Ageno W, Albers GW, Elliott CG, Hiatt WR, Halperin JL, Maynard G, Steg PG, Weitz JI, Spiro TE, Lu W, Marsigliano J, Raskob GE, Barnathan ES. Rivaroxaban Plus Aspirin for Extended Thromboprophylaxis in Acutely Ill Medical Patients: Insights from the MARINER Trial. TH Open 2022; 6:e177-e183. [PMID: 36046208 PMCID: PMC9273326 DOI: 10.1055/s-0042-1750379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/25/2022] [Indexed: 11/18/2022] Open
Abstract
Background
The MARINER trial evaluated whether postdischarge thromboprophylaxis with rivaroxaban could reduce the primary outcome of symptomatic venous thromboembolism (VTE) or VTE-related death in acutely ill medical patients at risk for VTE. Although aspirin use was not randomized, approximately half of the enrolled patients were receiving aspirin at baseline. We hypothesized that thromboprophylaxis with once-daily rivaroxaban (10 mg or, if creatinine clearance was 30–49 mL/min, 7.5 mg) plus aspirin (R/A) would be superior to placebo without aspirin (no thromboprophylaxis [no TP]).
Methods
We compared the primary and major secondary outcomes in the intention-to-treat population in four subgroups defined at baseline: (1) R/A (
N
= 3,159); (2) rivaroxaban alone (
N
= 2,848); (3) aspirin alone (
N
= 3,046); and (4) no TP (
N
= 2,966). Major bleeding (MB) and nonmajor clinically relevant (NMCR) bleeding were assessed in the safety population on treatment plus 2 days.
Results
Patients on R/A had reduced symptomatic VTE and VTE-related death compared with no TP (0.76 vs 1.28%,
p
= 0.042), and experienced less symptomatic VTE and all-cause mortality (
p
= 0.005) and all-cause mortality alone (
p
= 0.01) compared with no TP. Event incidences for rivaroxaban alone (0.91%) or aspirin alone (0.92%) were similar. MB was low in all groups but lowest in the no TP group. NMCR bleeding was increased with R/A compared with no TP (
p
= 0.009).
Limitations
Aspirin use was not randomized.
Conclusion
Extended postdischarge thromboprophylaxis with R/A was associated with less symptomatic VTE and VTE-related death compared with no TP in previously hospitalized medical patients at risk for VTE. NMCR bleeding was increased with R/A compared with no TP. These post hoc findings need confirmation in a prospective trial.
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Affiliation(s)
- Alex C. Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, New York, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
| | - Mark Goldin
- Northwell Health, Great Neck, New York, United States
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- University of Insubria, Varese, Italy
| | - Gregory W. Albers
- Stanford Stroke Center, Stanford Medical Center, Stanford University, Palo Alto, California, United States
| | - C. Gregory Elliott
- Department of Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, Utah, United States
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine
- CPC Clinical Research, Aurora, Colorado, United States
| | - Jonathan L. Halperin
- Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, United States
| | - Gregory Maynard
- University of California at Davis, Sacramento, California, United States
| | - P. Gabriel Steg
- Université de Paris, Assistance Publique–Hôpitaux de Paris, and INSERM U-1148, Paris, France
| | - Jeffrey I. Weitz
- McMaster University
- The Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | - Wentao Lu
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
| | - Jessica Marsigliano
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
| | - Gary E. Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Elliot S. Barnathan
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, New Jersey, United States
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27
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Li Y, Li Y, Prince E, Weitz JI, Panyukov S, Ramachandran A, Rubinstein M, Kumacheva E. Fibrous hydrogels under biaxial confinement. Nat Commun 2022; 13:3264. [PMID: 35672320 PMCID: PMC9174476 DOI: 10.1038/s41467-022-30980-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/19/2022] [Indexed: 11/09/2022] Open
Abstract
Confinement of fibrous hydrogels in narrow capillaries is of great importance in biological and biomedical systems. Stretching and uniaxial compression of fibrous hydrogels have been extensively studied; however, their response to biaxial confinement in capillaries remains unexplored. Here, we show experimentally and theoretically that due to the asymmetry in the mechanical properties of the constituent filaments that are soft upon compression and stiff upon extension, filamentous gels respond to confinement in a qualitatively different manner than flexible-strand gels. Under strong confinement, fibrous gels exhibit a weak elongation and an asymptotic decrease to zero of their biaxial Poisson’s ratio, which results in strong gel densification and a weak flux of liquid through the gel. These results shed light on the resistance of strained occlusive clots to lysis with therapeutic agents and stimulate the development of effective endovascular plugs from gels with fibrous structures for stopping vascular bleeding or suppressing blood supply to tumors. Studies of the confinement of filamentous hydrogels such as fibrin, a major component of blood clots, can shed light on the resistance of strained occlusive clots to lysis with therapeutic agents. Here, the authors show the mechanism of the response of fibrous hydrogels to confinement.
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28
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Bikdeli B, Zahedi Tajrishi F, Sadeghipour P, Talasaz AH, Fanikos J, Lippi G, Siegal DM, Eikelboom JW, Monreal M, Jimenez D, Connors JM, Ageno W, Barnes GD, Piazza G, Angiolillo DJ, Parikh SA, Kirtane AJ, Lopes RD, Bhatt DL, Weitz JI, Mehran R, Krumholz HM, Goldhaber SZ, Lip GYH. Efficacy and Safety Considerations With Dose-Reduced Direct Oral Anticoagulants: A Review. JAMA Cardiol 2022; 7:747-759. [PMID: 35648414 DOI: 10.1001/jamacardio.2022.1292] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance Dose-reduced regimens of direct oral anticoagulants (DOACs) may be used for 2 main purposes: dose-adjusted treatment intended as full-intensity anticoagulation (eg, for stroke prevention in atrial fibrillation [AF] in patients requiring dose reduction) or low-intensity treatment (eg, extended-duration treatment of venous thromboembolism [VTE]). We reviewed randomized clinical trials (RCTs) to understand the scenarios in which dose-adjusted or low-intensity DOACs were tested and reviewed the labeled indications by regulatory authorities, using data from large registries to assess whether the use of dose-reduced DOACs in routine practice aligned with the findings of RCTs. Observations Among 4191 screened publications, 35 RCTs that used dose-adjusted DOACs were identified for dabigatran, apixaban, rivaroxaban, and edoxaban. Of these 35 RCTs, 29 were related to stroke prevention in AF. Efficacy and safety results for dose-adjusted DOACs in large RCTs of AF were similar to those found for full-dose DOACs. To our knowledge, dabigatran, apixaban, and rivaroxaban have not been studied as dose-adjusted therapy for acute VTE treatment. Low-intensity DOACs were identified in 37 RCTs. Low-intensity DOACs may be used for extended-duration treatment of VTE (apixaban and rivaroxaban), primary prevention in orthopedic surgeries (dabigatran, apixaban, and rivaroxaban), primary prevention in ambulatory high-risk cancer patients (apixaban and rivaroxaban) or (postdischarge) high-risk medical patients (rivaroxaban), in stable atherosclerotic vascular disease, or after a recent revascularization for peripheral artery disease in conjunction with aspirin (rivaroxaban). Minor variations exist between regulatory authorities in different regions regarding criteria for dose adjustment of DOACs. Data from large registries indicated that dose-reduced DOACs were used occasionally with doses or for clinical scenarios different from those studied in RCTs or recommended by regulatory authorities. Conclusions and Relevance Dose adjustment and low-intensity treatment are 2 different forms of dose-reduced DOACs. Dose adjustment is mostly relevant for AF and should be done based on the approved criteria. Dose adjustment of DOACs should not be used for acute VTE treatment in most cases. In contrast, low-intensity DOACs may be used for primary or secondary VTE prevention for studied and approved indications. Attention should be given to routine practice patterns to align the daily clinical practice with existing evidence of safety and efficacy.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut.,Cardiovascular Research Foundation, New York, New York
| | - Farbod Zahedi Tajrishi
- Cardiac Primary Prevention Research Center, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran.,Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.,Virginia Commonwealth University, Richmond
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Sahil A Parikh
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, New York.,Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.,Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Deepak L Bhatt
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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29
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Spyropoulos AC, Raskob GE, Cohen AT, Ageno W, Weitz JI, Spiro TE, Lu W, Lipardi C, Albers GW, Elliott CG, Halperin JL, Hiatt WR, Maynard G, Steg PG, Sugarmann C, Barnathan ES. Association of Bleeding Severity with Mortality in Extended Thromboprophylaxis of Medically Ill Patients in the MAGELLAN and MARINER Trials. Circulation 2022; 145:1471-1479. [PMID: 35389229 DOI: 10.1161/circulationaha.121.057847] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Extended thromboprophylaxis has not been widely implemented in acutely ill medical patients due to bleeding concerns. The MAGELLAN and MARINER trials evaluated whether rivaroxaban compared with enoxaparin or placebo could prevent venous thromboembolism (VTE) without increased bleeding. We hypothesized that patients with major bleeding (MB) but not those with non-major clinically relevant bleeding (NMCRB), would be at an increased risk of all-cause mortality (ACM). Methods: We evaluated all bleeding events in patients taking at least one dose of study drug and their association with ACM in 4 mutually exclusive groups: (1) no bleeding, or first event was (2) NMCRB, (3) MB, or (4) trivial bleeding. Using a Cox proportional hazards model adjusted for differences in baseline characteristics associated with ACM, we assessed the risk of ACM after such events. Results: Compared to patients with no bleeding, the risk of ACM for patients with NMCRB was not increased in MARINER (HR 0.43, p=0.235) but was increased in MAGELLAN (HR 1.74 p=0.021). MB was associated with a higher incidence of ACM in both studies, while trivial bleeding was not associated with ACM in either study. Conclusions: Patients with MB had an increased risk of ACM, while NMCRB was not consistently associated with an increased risk of death. These results inform the risk-benefit calculus of extended thromboprophylaxis in medically ill patients.
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Affiliation(s)
- Alex C Spyropoulos
- The Feinstein Institute for Medical Research, Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Gary E Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Alexander T Cohen
- Department of Hematological Medicine, Guys and St Thomas/NHS Foundation Trust, King's College London, London, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy and University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Wentao Lu
- Biostatistics Department, Janssen Research and Development LLC, Raritan, NJ
| | - Concetta Lipardi
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Gregory W Albers
- Director Stanford Stroke Center, Stanford Medical Center, Stanford University, Palo Alto, CA
| | - C Gregory Elliott
- Departments of Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | | | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO
| | | | - P Gabriel Steg
- Université de Paris, INSERM UMR-1148 F- 75018 Paris, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Chiara Sugarmann
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Elliot S Barnathan
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
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30
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Khan S, Jarad NA, Ladouceur L, Rachwalski K, Bot V, Shakeri A, Maclachlan R, Sakib S, Weitz JI, Brown ED, Soleymani L, Didar TF. Transparent and Highly Flexible Hierarchically Structured Polydimethylsiloxane Surfaces Suppress Bacterial Attachment and Thrombosis Under Static and Dynamic Conditions. Small 2022; 18:e2108112. [PMID: 35224860 DOI: 10.1002/smll.202108112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 12/30/2021] [Indexed: 06/14/2023]
Abstract
The surface fouling of biomedical devices has been an ongoing issue in healthcare. Bacterial and blood adhesion in particular, severely impede the performance of such tools, leading to poor patient outcomes. Various structural and chemical modifications have been shown to reduce fouling, but all existing strategies lack the combination of physical, chemical, and economic traits necessary for widespread use. Herein, a lubricant infused, hierarchically micro- and nanostructured polydimethylsiloxane surface is presented. The surface is easy to produce and exhibits the high flexibility and optical transparency necessary for incorporation into various biomedical tools. Tests involving two clinically relevant, priority pathogens show up to a 98.5% reduction in the biofilm formation of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. With blood, the surface reduces staining by 95% and suppresses thrombin generation to background levels. Furthermore, the surface shows applicability within applications such as catheters, extracorporeal circuits, and microfluidic devices, through its effectiveness in dynamic conditions. The perfusion of bacterial media shows up to 96.5% reduction in bacterial adhesion. Similarly, a 95.8% reduction in fibrin networks is observed following whole blood perfusion. This substrate stands to hold high applicability within biomedical systems as a means to prevent fouling, thus improving performance.
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Affiliation(s)
- Shadman Khan
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
| | - Noor Abu Jarad
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
| | - Liane Ladouceur
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
| | - Kenneth Rachwalski
- Department of Biochemistry and Biomedical Sciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Veronica Bot
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
| | - Amid Shakeri
- Department of Mechanical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
| | - Roderick Maclachlan
- Department of Engineering Physics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L7, Canada
| | - Sadman Sakib
- Department of Engineering Physics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L7, Canada
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis & Atherosclerosis Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada
| | - Eric D Brown
- Department of Biochemistry and Biomedical Sciences, McMaster University, 1280 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Leyla Soleymani
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
- Department of Engineering Physics, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4L7, Canada
| | - Tohid F Didar
- School of Biomedical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
- Department of Mechanical Engineering, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4L7, Canada
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31
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Truong TK, Malik RA, Yao X, Fredenburgh JC, Stafford AR, Madarati HM, Kretz CA, Weitz JI. Identification of the histidine-rich glycoprotein domains responsible for contact pathway inhibition. J Thromb Haemost 2022; 20:821-832. [PMID: 34967109 DOI: 10.1111/jth.15631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 12/27/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previously, we showed that histidine-rich glycoprotein (HRG) binds factor (F) XIIa with high affinity, inhibits FXII autoactivation and FXIIa-mediated activation of FXI, and attenuates ferric chloride-induced arterial thrombosis in mice. Therefore, HRG downregulates the contact pathway in vitro and in vivo. OBJECTIVE To identify the domains on HRG responsible for contact pathway inhibition. METHODS Recombinant HRG domain constructs (N-terminal [N1, N2, and N1N2], proline-rich regions, histidine-rich region [HRR], and C-terminal) were expressed and purified. The affinities of plasma-derived HRG, HRG domain constructs, and synthetic HRR peptides for FXII, FXIIa, β-FXIIa, and polyphosphate (polyP) were determined using surface plasmon resonance, and their effects on polyP-induced FXII autoactivation, FXIIa-mediated activation of FXI and prekallikrein, the activated partial thromboplastin time (APTT), and thrombin generation were examined. RESULTS HRG and HRG domain constructs bind FXIIa, but not FXII or β-FXII. HRR, N1, and N1N2 bind FXIIa with affinities comparable with that of HRG, whereas the remaining domains bind with lower affinity. Synthetic HRR peptides bind FXIIa and polyP with high affinity. HRG and HRR significantly inhibit FXII autoactivation and prolong the APTT. Like HRG, synthetic HRR peptides inhibit FXII autoactivation, attenuate FXIIa-mediated activation of prekallikrein and FXI, prolong the APTT, and attenuate thrombin generation. CONCLUSION The interaction of HRG with FXIIa and polyP is predominantly mediated by the HRR domain. Like intact HRG, HRR downregulates the contact pathway and contributes to HRG-mediated down regulation of coagulation.
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Affiliation(s)
- Tammy K Truong
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Rida A Malik
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Xintong Yao
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - James C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alan R Stafford
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hasam M Madarati
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Colin A Kretz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
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32
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Bhatt DL, Pollack CV, Mazer CD, Angiolillo DJ, Steg PG, James SK, Weitz JI, Ramnath R, Arnold SE, Mays MC, Umstead BR, White B, Hickey LL, Jennings LK, Curry BJ, Lee JS, Verma S. Bentracimab for Ticagrelor Reversal in Patients Undergoing Urgent Surgery. NEJM Evid 2022; 1:EVIDoa2100047. [PMID: 38319214 DOI: 10.1056/evidoa2100047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Bentracimab for Ticagrelor Reversal in Patients Undergoing Urgent SurgeryTicagrelor is a reversible oral P2Y12 platelet inhibitor used in patients with many forms of heart and vascular disease. Because patients receiving ticagrelor may bleed or need emergent surgery, bentracimab was studied as a ticagrelor reversal agent. In this study in 150 patients, treatment had a significant salutary impact on laboratory measured platelet function. Adjudicated hemostasis was achieved in over 90% of patients, most of whom had cardiac surgery; thrombotic events occurred in just over 5% of treated patients.
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Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi School of Medicine, Jackson
| | | | | | - Ph Gabriel Steg
- INSERM UMR1148, University of Paris, Paris
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris
| | - Stefan K James
- Cardiology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | | | | | | - John S Lee
- PhaseBio Pharmaceuticals, Inc., Malvern, PA
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33
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Goldin M, Koulas I, Weitz JI, Spyropoulos A. State-of-the-art-mini review: Dual pathway inhibition to reduce arterial and venous thromboembolism. Thromb Haemost 2022; 122:1279-1287. [DOI: 10.1055/a-1778-1083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Venous thromboembolism (VTE) and arterial thromboembolism (ATE) are linked by the common mechanism of thrombin generation. Historically these entities have been treated as separate pathophysiologic processes requiring different treatments: VTE, as the formation of fibrin-/coagulation-factor-derived thrombus in low flow vasculature, requiring anticoagulants; versus ATE, as largely platelet-derived thrombus in high flow vasculature, requiring antiplatelet agents. Observational studies have elucidated shared risk factors and co-morbidities predisposing individuals with VTE to ATE, and vice versa, and have bolstered the strategy of dual pathway inhibition (DPI) – the combination of low dose anticoagulants with antiplatelet agents – to reduce thrombotic outcomes on both sides of the vasculature. Randomized clinical trials have evaluated the efficacy and safety of such regimens - mostly rivaroxaban and aspirin - in high-risk groups of patients, including those with recent acute or chronic coronary syndrome, as well as those with peripheral artery disease with or without revascularization. Studies of extended VTE prophylaxis in acutely ill medical patients have also contributed to the evidence evaluating DPI. The totality of available data supports the concept that DPI can reduce major and fatal thromboembolic outcomes, including stroke, myocardial infarction, VTE, and cardiovascular death in key patient cohorts, with acceptable risk of bleeding. Further data are needed to refine which patients derive the best net clinical benefit from such an approach. At the same time, other novel agents such as contact pathway inhibitors that reduce thrombin generation without affecting hemostasis - and thus maximize safety - should be assessed in appropriate populations.
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Affiliation(s)
- Mark Goldin
- Medicine, Northwell Health, New Hyde Park, United States
| | - Ioannis Koulas
- Northwell Health Feinstein Institutes for Medical Research, Manhasset, United States
| | - Jeffrey I Weitz
- The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada
| | - Alex Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, Hofstra, Northwell School of Medicine, NY, United States
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Cohen O, Ageno W, Farjat AE, Turpie AGG, Weitz JI, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Management strategies and clinical outcomes in patients with inferior vena cava thrombosis: Data from GARFIELD-VTE. J Thromb Haemost 2022; 20:366-374. [PMID: 34714962 PMCID: PMC9299483 DOI: 10.1111/jth.15574] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 10/08/2021] [Accepted: 10/25/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Inferior vena cava (IVC) thrombosis is a rare form of venous thromboembolism (VTE). The optimal treatment strategies and outcomes are unclear in patients with this presentation. OBJECTIVE We aimed to compare baseline characteristics, treatment patterns and 24-month outcomes in IVC thrombosis patients (n = 100) with lower extremity deep vein thrombosis (LEDVT) patients (n = 7629). METHODS GARFIELD-VTE is a prospective, observational registry of 10 868 patients with objectively diagnosed VTE from 415 sites in 28 countries. RESULTS IVC thrombosis patients were younger (51.9 vs. 59.8 years), more frequently had active cancer (26.0% vs. 8.9%) or history of cancer (21.0% vs. 12.2%), and less frequently had recent trauma or surgery than LEDVT patients. IVC thrombosis was more frequently treated with parenteral anticoagulants alone (35.1% vs. 15.9%), whereas patients with LEDVT more commonly received vitamin K antagonists (32.0% vs. 25.8%) or direct oral anticoagulants (49.0% vs. 35.1%). Thrombolysis (11.0% vs. 3.6%) and surgical/mechanical interventions (4.0% vs. 1.4%) were more frequent in IVC thrombosis. At 24-months, the rate per 100 person-years (95% confidence interval) of all-cause mortality was higher in patients with IVC thrombosis than LEDVT (13.28 [8.57-20.58] vs. 4.91 [4.55-5.3]); the incidence of cancer-associated mortality was comparable as was the incidence of VTE recurrence (4.11 [1.85-9.15] vs. 4.18 [3.84-4.55]). Major bleeding was slightly higher in IVC thrombosis (2.03 [0.66-6.31] vs. 1.66 [1.45-1.89]). CONCLUSION In summary, IVC thrombosis patients have higher all-cause mortality rates than those with LEDVT, a finding only partly attributable to malignancy.
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Affiliation(s)
- Omri Cohen
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
- National Hemophilia CenterInstitute of Thrombosis and HemostasisSheba Medical CenterTel‐HashomerIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | | | | | - Jeffrey I. Weitz
- McMaster UniversityHamiltonOntarioCanada
- Thrombosis and Atherosclerosis Research InstituteHamiltonOntarioCanada
| | - Sylvia Haas
- Formerly Technical University of MunichMunichGermany
| | - Shinya Goto
- Department of Medicine (Cardiology)Tokai University School of MedicineIseharaJapan
| | | | | | - Harry Gibbs
- Vascular LaboratoryThe Alfred HospitalMelbourneVictoriaAustralia
| | - Peter MacCallum
- Thrombosis Research InstituteLondonUK
- Queen Mary University of LondonLondonUK
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Ladouceur L, Shakeri A, Khan S, Rincon AR, Kasapgil E, Weitz JI, Soleymani L, Didar TF. Producing Fluorine- and Lubricant-Free Flexible Pathogen- and Blood-Repellent Surfaces Using Polysiloxane-Based Hierarchical Structures. ACS Appl Mater Interfaces 2022; 14:3864-3874. [PMID: 35040309 DOI: 10.1021/acsami.1c21672] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
High-touch surfaces are known to be a major route for the spread of pathogens in healthcare and public settings. Antimicrobial coatings have, therefore, garnered significant attention to help mitigate the transmission of infectious diseases via the surface route. Among antimicrobial coatings, pathogen-repellent surfaces provide unique advantages in terms of safety in public settings such as instant repellency, affordability, biocompatibility, and long-term stability. While there have been many advances in the fabrication of biorepellent surfaces in the past two decades, this area of research continues to suffer challenges in scalability, cost, compatibility with high-touch applications, and performance for pathogen repellency. These features are critical for high-touch surfaces to be used in public settings. Additionally, the environmental impact of manufacturing repellent surfaces remains a challenge, mainly due to the use of fluorinated coatings. Here, we present a flexible hierarchical coating with straightforward and cost-effective manufacturing without the use of fluorine or a lubricant. Hierarchical surfaces were prepared through the growth of polysiloxane nanostructures using n-propyltrichlorosilane (n-PTCS) on activated polyolefin (PO), followed by heat shrinking to induce microscale wrinkles. The developed coatings demonstrated repellency, with contact angles over 153° and sliding angles <1°. In assays mimicking touch, these hierarchical surfaces demonstrated a 97.5% reduction in transmission of Escherichia coli (E.coli), demonstrating their potential as antimicrobial coatings to mitigate the spread of infectious diseases. Additionally, the developed surfaces displayed a 93% reduction in blood staining after incubation with human whole blood, confirming repellent properties that reduce bacterial deposition.
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Affiliation(s)
- Liane Ladouceur
- Department of Mechanical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
| | - Amid Shakeri
- Department of Mechanical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
| | - Shadman Khan
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
| | - Alejandra Rey Rincon
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Department of Engineering Physics, McMaster University, 1280 Main Street West, Hamilton L8S 4L7, Canada
| | - Esra Kasapgil
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Department of Biomedical Engineering, Faculty of Engineering and Architecture, University of Bakircay, TR-35665 Menemen, Izmir, Turkey
| | - Jeffrey I Weitz
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Department of Biochemistry and Biomedical Sciences, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Thrombosis & Atherosclerosis Research Institute (TaARI), 237 Barton Street East, Hamilton, Ontario, Canada L8L 2X2
| | - Leyla Soleymani
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Department of Engineering Physics, McMaster University, 1280 Main Street West, Hamilton L8S 4L7, Canada
| | - Tohid F Didar
- Department of Mechanical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- School of Biomedical Engineering, McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
- Institute for Infectious Disease Research (IIDR), McMaster University, 1280 Main St W, Hamilton, Ontario, Canada L8S 4L8
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Weitz JI, Strony J, Ageno W, Gailani D, Hylek EM, Lassen MR, Mahaffey KW, Notani RS, Roberts R, Segers A, Raskob GE. Milvexian for the Prevention of Venous Thromboembolism. N Engl J Med 2021; 385:2161-2172. [PMID: 34780683 PMCID: PMC9540352 DOI: 10.1056/nejmoa2113194] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Factor XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism may be more effective and result in less bleeding than conventional anticoagulants. Additional data are needed regarding the efficacy and safety of milvexian, an oral factor XIa inhibitor. METHODS In this parallel-group, phase 2 trial, we randomly assigned 1242 patients undergoing knee arthroplasty to receive one of seven postoperative regimens of milvexian (25 mg, 50 mg, 100 mg, or 200 mg twice daily or 25 mg, 50 mg, or 200 mg once daily) or enoxaparin (40 mg once daily). The primary efficacy outcome was venous thromboembolism (which was a composite of asymptomatic deep-vein thrombosis, confirmed symptomatic venous thromboembolism, or death from any cause). The principal safety outcome was bleeding. RESULTS Among the patients receiving milvexian twice daily, venous thromboembolism developed in 27 of 129 (21%) taking 25 mg, in 14 of 124 (11%) taking 50 mg, in 12 of 134 (9%) taking 100 mg, and in 10 of 131 (8%) taking 200 mg. Among those receiving milvexian once daily, venous thromboembolism developed in 7 of 28 (25%) taking 25 mg, in 30 of 127 (24%) taking 50 mg, and in 8 of 123 (7%) taking 200 mg, as compared with 54 of 252 patients (21%) taking enoxaparin. The dose-response relationship with twice-daily milvexian was significant (one-sided P<0.001), and the 12% incidence of venous thromboembolism with twice-daily milvexian was significantly lower than the prespecified benchmark of 30% (one-sided P<0.001). Bleeding of any severity occurred in 38 of 923 patients (4%) taking milvexian and in 12 of 296 patients (4%) taking enoxaparin; major or clinically relevant nonmajor bleeding occurred in 1% and 2%, respectively; and serious adverse events were reported in 2% and 4%, respectively. CONCLUSIONS Postoperative factor XIa inhibition with oral milvexian in patients undergoing knee arthroplasty was effective for the prevention of venous thromboembolism and was associated with a low risk of bleeding. (Funded by Bristol Myers Squibb and Janssen Research and Development; AXIOMATIC-TKR ClinicalTrials.gov number, NCT03891524.).
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Affiliation(s)
- Jeffrey I Weitz
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - John Strony
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Walter Ageno
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - David Gailani
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Elaine M Hylek
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Michael R Lassen
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Kenneth W Mahaffey
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Ravi S Notani
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Robin Roberts
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Annelise Segers
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
| | - Gary E Raskob
- From the Thrombosis and Atherosclerosis Research Institute and McMaster University (J.I.W., R.R.) - both in Hamilton, ON, Canada; Janssen Research and Development, Raritan, NJ (J.S., R.S.N.); the University of Insubria, Varese, Italy (W.A.); Vanderbilt University Medical Center, Nashville (D.G.); Boston University School of Medicine, Boston (E.M.H.); Gildhøj Private Hospital, Copenhagen (M.R.L.); Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, CA (K.W.M.); International Trial Expertise Advisory and Services, Amsterdam (A.S.); and Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.)
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Bounameaux H, Haas S, Farjat AE, Ageno W, Weitz JI, Goldhaber SZ, Turpie AGG, Goto S, Angchaisuksiri P, Nielsen JD, Kayani G, Schellong S, Mantovani LG, Prandoni P, Kakkar AK. Corrigendum to "Comparative effectiveness of oral anticoagulants in venous thromboembolism: GARFIELD-VTE" [Thromb. Res. 2020 Jul; 191:103-112]. Thromb Res 2021; 216:129. [PMID: 34863582 DOI: 10.1016/j.thromres.2021.11.023] [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: 11/15/2022]
Affiliation(s)
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | | | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Japan
| | | | | | - Gloria Kayani
- Thrombosis Research Institute, London, United Kingdom
| | | | - Lorenzo G Mantovani
- IRCCS Multimedica, Sesto San Giovanni, Italy; University of Milano-Bicocca, Milan, Italy
| | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, United Kingdom; University College London, London, United Kingdom
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Talasaz AH, Sadeghipour P, Aghakouchakzadeh M, Kakavand H, Ariannejad H, Connors JM, Hunt BJ, Berger JS, Van Tassell BW, Middeldorp S, Piazza G, Weitz JI, Cushman M, Lip GYH, Goldhaber SZ, Bikdeli B. Use of novel antithrombotic agents for COVID-19: Systematic summary of ongoing randomized controlled trials. J Thromb Haemost 2021; 19:3080-3089. [PMID: 34538017 PMCID: PMC8646701 DOI: 10.1111/jth.15533] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/16/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with macro- and micro-thromboses, which are triggered by endothelial cell activation, coagulopathy, and uncontrolled inflammatory response. Conventional antithrombotic agents are under assessment in dozens of randomized controlled trials (RCTs) in patients with COVID-19, with preliminary results not demonstrating benefit in several studies. OBJECTIVES Given the possibility that more novel agents with antithrombotic effects may have a potential utility for management of patients with COVID-19, we assessed ongoing RCTs including these agents with their potential mechanism of action in this population. METHODS We searched clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform to identify RCTs of novel antithrombotic agents in patients with COVID-19. RESULTS Based on a systematic literature search, 27 RCTs with 10 novel antithrombotic agents (including nafamostat, dociparstat, rNAPc2, and defibrotide) were identified. The results from these trials have not been disseminated yet. The studied drugs in the ongoing or completed RCTs include agents affecting the coagulation cascade, drugs affecting endothelial activation, and mixed acting agents. Their postulated antithrombotic mechanisms of action and their potential impact on patient management are summarized. CONCLUSION Some novel antithrombotic agents have pleiotropic anti-inflammatory and antiviral effects, which may help reduce the viral load or fibrosis, and improve oxygenation. Results from ongoing RCTs will elucidate their actual role in the management of patients with COVID-19.
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Affiliation(s)
- Azita H Talasaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacotherapy and Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Aghakouchakzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hessam Kakavand
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Ariannejad
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jean M Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Beverley J Hunt
- Haemostasis and Thrombosis Centre, St Thomas' Hospital, London, UK
| | - Jeffrey S Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, Center for the Prevention of Cardiovascular Disease, New York University School of Medicine, New York, New York, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Mary Cushman
- Department of Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, Vermont, USA
- Department of Pathology and Laboratory Medicine, University of Vermont Larner College of Medicine and University of Vermont Medical Center, Burlington, Vermont, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut, USA
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Bosch FTM, Mulder FI, Huisman MV, Zwicker JI, Di Nisio M, Carrier M, Segers A, Verhamme P, Middeldorp S, Weitz JI, Grosso MA, Duggal A, Büller HR, Wang T, Garcia D, Kamphuisen PW, Raskob GE, van Es N. Risk factors for gastrointestinal bleeding in patients with gastrointestinal cancer using edoxaban. J Thromb Haemost 2021; 19:3008-3017. [PMID: 34455706 PMCID: PMC9292167 DOI: 10.1111/jth.15516] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In the Hokusai VTE Cancer study, the risk of major bleeding was 2.9% higher in the edoxaban group compared with the dalteparin group, mainly due to more gastrointestinal bleedings in patients with gastrointestinal cancer. The identification of risk factors for gastrointestinal bleeding may help to guide the use of DOACs in these patients. OBJECTIVES To evaluate risk factors for gastrointestinal bleeding in patients with gastrointestinal cancer receiving edoxaban. PATIENTS/METHODS In this nested case-control study in patients with gastrointestinal cancer randomized to edoxaban in the Hokusai VTE Cancer study, cases (patients with clinically relevant gastrointestinal bleeding during treatment) were randomly matched to three controls (patients who had no gastrointestinal bleeding). Data for the 4-week period prior to bleeding were retrospectively collected. Odds ratios (ORs) were calculated in a crude conditional logistic regression model and a multivariable model adjusted for age, sex, and cancer type. RESULTS Twenty-four cases and 64 matched controls were included. In the multivariable analysis, advanced cancer, defined as regionally advanced or metastatic cancer (OR 3.6, 95% CI 1.01-12.6) and low hemoglobin levels (OR 4.8, 95% CI 1.5-16.0) were significantly associated with bleeding. There was no significant difference in patients with resected tumors (OR 0.4, 95% CI 0.1-1.4), or in patients on chemotherapy (OR 1.3, 95% CI 0.5-3.5). CONCLUSION Advanced cancer and low hemoglobin levels were associated with an increased risk of gastrointestinal bleeding in patients with gastrointestinal cancer receiving edoxaban. We were unable to identify other risk factors, mainly due to limited statistical power.
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Affiliation(s)
- Floris T. M. Bosch
- Department of Internal MedicineTergooi HospitalHilversumThe Netherlands
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceMedical CentersAmsterdam UniversityUniversity of AmsterdamAmsterdamThe Netherlands
| | - Frits I. Mulder
- Department of Internal MedicineTergooi HospitalHilversumThe Netherlands
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceMedical CentersAmsterdam UniversityUniversity of AmsterdamAmsterdamThe Netherlands
| | - Menno V. Huisman
- Department of Medicine‐Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Jeffrey I. Zwicker
- Division of Hemostasis and ThrombosisDivision of Hematology and OncologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
| | - Marcello Di Nisio
- Department of Medicine and Ageing SciencesUniversity G. D'AnnunzioChietiItaly
| | - Marc Carrier
- Department of MedicineOttawa Hospital Research Institute at the University of OttawaOttawaONCanada
| | - Annelise Segers
- ITREASAcademic Research OrganizationAmsterdamthe Netherlands
| | - Peter Verhamme
- Department of Vascular Medicine and HemostasisUniversity Hospitals LeuvenLeuvenBelgium
| | - Saskia Middeldorp
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Jeffrey I. Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research InstituteHamiltonONCanada
| | | | - Anil Duggal
- Daiichi Sankyo Pharma DevelopmentBasking RidgeNJUSA
| | - Harry R. Büller
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceMedical CentersAmsterdam UniversityUniversity of AmsterdamAmsterdamThe Netherlands
| | - Tzu‐Fei Wang
- Department of MedicineOttawa Hospital Research Institute at the University of OttawaOttawaONCanada
| | - David Garcia
- Division of HematologyDepartment of MedicineUniversity of WashingtonSeattleWAUSA
| | - Pieter Willem Kamphuisen
- Department of Internal MedicineTergooi HospitalHilversumThe Netherlands
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceMedical CentersAmsterdam UniversityUniversity of AmsterdamAmsterdamThe Netherlands
| | - Gary E. Raskob
- College of Public HealthUniversity of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Nick van Es
- Department of Vascular MedicineAmsterdam Cardiovascular ScienceMedical CentersAmsterdam UniversityUniversity of AmsterdamAmsterdamThe Netherlands
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Weitz JI, Farjat AE, Ageno W, Turpie AGG, Haas S, Goto S, Goldhaber SZ, Angchaisuksiri P, Gibbs H, MacCallum P, Carrier M, Kayani G, Schellong S, Bounameaux H, Mantovani LG, Prandoni P, Kakkar AK. Influence of body mass index on clinical outcomes in venous thromboembolism: Insights from GARFIELD-VTE. J Thromb Haemost 2021; 19:3031-3043. [PMID: 34487616 DOI: 10.1111/jth.15520] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is limited information on the influence of body mass index (BMI) on clinical outcomes in patients with venous thromboembolism (VTE). OBJECTIVES Investigate the influence of BMI on baseline characteristics, treatment patterns, and 24-month outcomes in VTE patients. METHODS GARFIELD-VTE is a prospective, non-interventional study of 10 869 patients with objectively confirmed VTE. Patients were grouped according to BMI: <18.5 (underweight; n = 214); 18.5-24.9 (normal; n = 2866); 25.0-29.9 (overweight; n = 3326); ≥30 (obese; n = 3073). RESULTS Compared with patients with a normal BMI, obese patients were more frequently Caucasian (77.4% vs. 57.9%), treated in the outpatient setting (30.4% vs. 23.1%), and had previous VTE (17.5% vs. 11.7%). Active cancer was associated with lower BMI (underweight: 30.4%, normal: 13.5%, overweight: 9.4%, obese: 7.0%). At baseline, overweight and obese patients less often received parenteral therapy alone (16.7% and 14.4%) compared with those with an underweight or normal BMI (30.8% and 21.6%). Obese patients more commonly remained on anticoagulants for ≥2-years compared to those with a normal BMI (52.3% vs. 37.7%). After 24-months, the risk of all-cause mortality was lower in overweight and obese patients than in those with normal BMI (adjusted hazard ratio [95% CI]; 0.75 [0.63-0.89] and 0.59 [0.49-0.72], respectively). Underweight patients more often experienced major bleeding (2.45 [1.41-4.26]) and all-cause mortality (1.90 [1.43-2.53]) than patients with a normal BMI. Recurrent VTE was comparable among groups. CONCLUSION Underweight VTE patients have the highest risk of mortality and major bleeding. The risk of mortality in obese VTE patients is lower than that in VTE patients with a normal BMI.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Harry Gibbs
- Vascular Laboratory, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter MacCallum
- Thrombosis Research Institute, London, UK
- Queen Mary University of London, UK
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Henri Bounameaux
- University Hospital of Geneva and Faculty of Medicine, Geneva, Switzerland
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41
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Spyropoulos AC, Goldin M, Giannis D, Diab W, Wang J, Khanijo S, Mignatti A, Gianos E, Cohen M, Sharifova G, Lund JM, Tafur A, Lewis PA, Cohoon KP, Rahman H, Sison CP, Lesser ML, Ochani K, Agrawal N, Hsia J, Anderson VE, Bonaca M, Halperin JL, Weitz JI. Efficacy and Safety of Therapeutic-Dose Heparin vs Standard Prophylactic or Intermediate-Dose Heparins for Thromboprophylaxis in High-risk Hospitalized Patients With COVID-19: The HEP-COVID Randomized Clinical Trial. JAMA Intern Med 2021; 181:1612-1620. [PMID: 34617959 PMCID: PMC8498934 DOI: 10.1001/jamainternmed.2021.6203] [Citation(s) in RCA: 273] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Hospitalized patients with COVID-19 are at risk for venous and arterial thromboembolism and death. Optimal thromboprophylaxis dosing in high-risk patients is unknown. OBJECTIVE To evaluate the effects of therapeutic-dose low-molecular-weight heparin (LMWH) vs institutional standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The HEP-COVID multicenter randomized clinical trial recruited hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater from May 8, 2020, through May 14, 2021, at 12 academic centers in the US. INTERVENTIONS Patients were randomized to institutional standard prophylactic or intermediate-dose LMWH or unfractionated heparin vs therapeutic-dose enoxaparin, 1 mg/kg subcutaneous, twice daily if creatinine clearance was 30 mL/min/1.73 m2 or greater (0.5 mg/kg twice daily if creatinine clearance was 15-29 mL/min/1.73 m2) throughout hospitalization. Patients were stratified at the time of randomization based on intensive care unit (ICU) or non-ICU status. MAIN OUTCOMES AND MEASURES The primary efficacy outcome was venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause, and the principal safety outcome was major bleeding at 30 ± 2 days. Data were collected and adjudicated locally by blinded investigators via imaging, laboratory, and health record data. RESULTS Of 257 patients randomized, 253 were included in the analysis (mean [SD] age, 66.7 [14.0] years; men, 136 [53.8%]; women, 117 [46.2%]); 249 patients (98.4%) met inclusion criteria based on D-dimer elevation and 83 patients (32.8%) were stratified as ICU-level care. There were 124 patients (49%) in the standard-dose vs 129 patients (51%) in the therapeutic-dose group. The primary efficacy outcome was met in 52 of 124 patients (41.9%) (28.2% VTE, 3.2% ATE, 25.0% death) with standard-dose heparins vs 37 of 129 patients (28.7%) (11.7% VTE, 3.2% ATE, 19.4% death) with therapeutic-dose LMWH (relative risk [RR], 0.68; 95% CI, 0.49-0.96; P = .03), including a reduction in thromboembolism (29.0% vs 10.9%; RR, 0.37; 95% CI, 0.21-0.66; P < .001). The incidence of major bleeding was 1.6% with standard-dose vs 4.7% with therapeutic-dose heparins (RR, 2.88; 95% CI, 0.59-14.02; P = .17). The primary efficacy outcome was reduced in non-ICU patients (36.1% vs 16.7%; RR, 0.46; 95% CI, 0.27-0.81; P = .004) but not ICU patients (55.3% vs 51.1%; RR, 0.92; 95% CI, 0.62-1.39; P = .71). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, therapeutic-dose LMWH reduced major thromboembolism and death compared with institutional standard heparin thromboprophylaxis among inpatients with COVID-19 with very elevated D-dimer levels. The treatment effect was not seen in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04401293.
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Affiliation(s)
- Alex C Spyropoulos
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Mark Goldin
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Dimitrios Giannis
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Wassim Diab
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Janice Wang
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Sameer Khanijo
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Andrea Mignatti
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Eugenia Gianos
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Department of Cardiology, Lenox Hill Hospital, Northwell Health, New York, New York
| | - Marc Cohen
- Department of Medicine, Newark Beth Israel Medical Center, Newark, New Jersey
| | - Gulru Sharifova
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | | | - Alfonso Tafur
- Department of Medicine, Cardiovascular Institute, NorthShore University HealthSystem, Evanston, Illinois.,Division of Cardiology, Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | | | - Kevin P Cohoon
- Division of Cardiovascular Medicine, Department of Medicine, Froedtert & the Medical College of Wisconsin, Milwaukee
| | - Husneara Rahman
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Cristina P Sison
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Martin L Lesser
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York.,Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York.,Biostatistics Unit, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Kanta Ochani
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Nirav Agrawal
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York
| | - Judith Hsia
- Colorado Prevention Center (CPC) Clinical Research, Aurora.,Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Aurora
| | | | - Marc Bonaca
- Colorado Prevention Center (CPC) Clinical Research, Aurora.,Division of Cardiology, University of Colorado School of Medicine, University of Colorado, Aurora
| | - Jonathan L Halperin
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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Khan F, Rahman A, Tritschler T, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Becattini C, Agnelli G, Brighton T, Lensing AW, Pinede L, Parpia S, Geersing GJ, Takada T, Bradbury C, Andreozzi GM, Palareti G, Prandoni P, Buller HR, Mallick R, Hutton B, Thavorn K, Le Gal G, Rodger M, Fergusson DA. Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis. Thromb Haemost 2021; 122:1186-1197. [PMID: 34753191 DOI: 10.1055/a-1690-8728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. OBJECTIVES To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies. RESULTS Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%). CONCLUSIONS Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | | | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Timothy Brighton
- Prince of Wales Hospital and Community Health Services, Randwick, Australia
| | | | - Laurent Pinede
- Infirmerie Protestante de Lyon, Caluire et Cuire, France
| | | | | | | | - Charlotte Bradbury
- University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | - H R Buller
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- ICES @uOttawa, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
| | - Marc Rodger
- Medicine, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
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Ageno W, Lopes RD, Goldin M, Yusen RD, Albers GW, Elliott GC, Halperin JL, Hiatt WR, Maynard G, Steg PG, Weitz JI, Suh E, Lu W, Barnathan ES, Raskob GE, Spyropoulos AC. Rivaroxaban for extended thromboprophylaxis in acutely ill medical patients 75 years of age or older. J Thromb Haemost 2021; 19:2772-2780. [PMID: 34314574 PMCID: PMC9292378 DOI: 10.1111/jth.15477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/07/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although older patients are at increased risk for venous thromboembolism (VTE), thromboprophylaxis is underused because of bleeding concerns. The MARINER trial evaluated whether rivaroxaban reduced symptomatic postdischarge VTE in acutely ill medical patients. OBJECTIVES We hypothesized that rivaroxaban would have a favorable benefit/risk profile in patients ≥75 years of age. METHODS Patients were randomized in a double-blind manner at hospital discharge to rivaroxaban (10 mg/day for creatinine clearance ≥50 ml/min; 7.5 mg/day for ≥30-<50 ml/min) or placebo for 45 days. Using a Cox proportional hazard model including treatment as a covariate, we compared the risk of the primary efficacy outcome (symptomatic VTE plus VTE-related death in the intention-to-treat population) and safety outcome (International Society on Thrombosis and Haemostasis major bleeding in the safety population) in the prespecified subgroups of patients ≥ and <75 years of age. RESULTS The primary event rate in patients ≥75 years of age was 2-fold higher than that in those <75 years. The incidence of the primary efficacy outcomes in both age groups was numerically lower with rivaroxaban than with placebo (≥75: 1.2% and 1.6%, HR 0.73, 95% CI 0.43-1.22; <75 0.6% and 0.8%, HR 0.78, 95% CI 0.46-1.32; interaction p-value for age group = .85). The incidence of major bleeding was low and similar in the two age and treatment groups (interaction p value for age group = .35). CONCLUSION Symptomatic VTE and VTE-related death occur frequently in older patients with acute medical illness. The benefit/risk profile of rivaroxaban in patients ≥75 years of age appears consistent with that observed in the general population.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | - Renato D. Lopes
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNCUSA
| | - Mark Goldin
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill HospitalThe Feinstein Institute for Medical Research and Zucker School of Medicine at Hofstra/NorthwellNew YorkNYUSA
| | - Roger D. Yusen
- Division of Pulmonary and Critical Care MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Gregory W. Albers
- Director Stanford Stroke CenterStanford Medical CenterStanford UniversityPalo AltoCAUSA
| | - Gregory C. Elliott
- Departments of MedicineUniversity of Utah and Intermountain HealthcareSalt Lake CityUTUSA
| | | | - William R. Hiatt
- Division of CardiologyUniversity of Colorado School of Medicine, and CPC Clinical ResearchAuroraCOUSA
| | | | | | - Jeffrey I. Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research InstituteHamiltonONCanada
| | - Eunyoung Suh
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Wentao Lu
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Elliot S. Barnathan
- Cardiovascular Clinical DevelopmentJanssen Research and Development, LLCRaritan, NJUSA
| | - Gary E. Raskob
- Hudson College of Public HealthThe University of Oklahoma Health Sciences CenterOklahoma CityOKUSA
| | - Alex C. Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill HospitalThe Feinstein Institute for Medical Research and Zucker School of Medicine at Hofstra/NorthwellNew YorkNYUSA
- Department of Obstetrics and GynecologyI.M. Sechenov First Moscow State Medical UniversityMoscowRussia
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44
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Shi M, Thavorn K, Hutton B, Le Gal G, Rodger M, Fergusson D. Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2801-2813. [PMID: 34379859 DOI: 10.1111/jth.15491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain. OBJECTIVES To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE. METHODS MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results. RESULTS Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%). CONCLUSIONS In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Kimpton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Philip S Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | | | | | | | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Benilde Cosmi
- Department of Specialty, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Letizia Marconi
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Antonio Palla
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Siragusa
- Department Pro.Mi.Se., University of Palermo, Palermo, Italy
| | | | - Sameer Parpia
- Departments of Oncology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
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45
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Chan NC, Weitz JI. In pregnant women with suspected VTE and low/intermediate or unlikely pretest probability, D-dimer rules out VTE at 3 mo. Ann Intern Med 2021; 174:JC130. [PMID: 34724403 DOI: 10.7326/acpj202111160-130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Bellesini M, Robert-Ebadi H, Combescure C, et al. D-dimer to rule out venous thromboembolism during pregnancy: a systematic review and meta-analysis. J Thromb Haemost. 2021;19:2454-67. 34161671.
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Affiliation(s)
- Noel C Chan
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada (N.C.C., J.I.W.)
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada (N.C.C., J.I.W.)
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46
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Affiliation(s)
- Noel C Chan
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
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Eikelboom J, Floege J, Thadhani R, Weitz JI, Winkelmayer WC. Anticoagulation in patients with kidney failure on dialysis: factor XI as a therapeutic target. Kidney Int 2021; 100:1199-1207. [PMID: 34600964 DOI: 10.1016/j.kint.2021.08.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 05/27/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease is present in almost 10% of the world population and is associated with excess mortality and morbidity. Reduced glomerular filtration rate and the presence and extent of proteinuria, key domains of chronic kidney disease, have both been shown to be strong and independent risk factors for cardiovascular disease. Patients with kidney failure requiring dialysis are at highest risk for cardiovascular events (e.g., stroke or myocardial infarction), and of developing chronic cardiovascular conditions, such as heart failure. Despite the high burden of cardiovascular disease, there is a paucity of evidence supporting therapies to reduce this risk. Although long-term anticoagulant treatment has the potential to prevent thromboembolism in persons with kidney failure on dialysis, this possibility remains understudied. The limited data available on anticoagulation in patients with kidney failure has focused on vitamin K antagonists or direct oral anticoagulants that inhibit thrombin or factor (F) Xa. The risk of bleeding is a major concern with these agents. However, FXI is emerging as a potential safer target for new anticoagulants because FXI plays a greater part in thrombosis than in hemostasis. In this article, we (i) explain the rationale for considering anticoagulation therapy in patients with kidney failure to reduce atherothrombotic events, (ii) highlight the limitations of current anticoagulants in this patient population, (iii) explain the potential benefits of FXI inhibitors, and (iv) summarize ongoing studies investigating FXI inhibition in patients with kidney failure on dialysis.
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Affiliation(s)
- John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA.
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Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Thavorn K, Hutton B, Le Gal G, Fergusson DA, Rodger MA. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420-1429. [PMID: 34516270 DOI: 10.7326/m21-1094] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [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: 11/22/2022] Open
Abstract
BACKGROUND The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. PURPOSE To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021. STUDY SELECTION Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment. DATA EXTRACTION Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies. DATA SYNTHESIS Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs. LIMITATION Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs. CONCLUSION In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).
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Affiliation(s)
- Faizan Khan
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Tobias Tritschler
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | - Miriam Kimpton
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Philip S Wells
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Clive Kearon
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Harry R Büller
- Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (H.R.B.)
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma (G.E.R.)
| | | | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Gualtiero Palareti
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Cristina Legnani
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Paul A Kyrle
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Sabine Eichinger
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Lisbeth Eischer
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | | | | | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Benilde Cosmi
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy (B.C.)
| | - Drahomir Aujesky
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | | | | | | | | | - Sameer Parpia
- McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | | | | | | | - Kednapa Thavorn
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Brian Hutton
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Dean A Fergusson
- University of Ottawa, Ottawa Hospital Research Institute, and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, and McGill University, Montreal, Quebec, Canada (M.A.R.)
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Abstract
BACKGROUND The role of factor XI in the pathogenesis of postoperative venous thromboembolism is uncertain. Abelacimab is a monoclonal antibody that binds to factor XI and locks it in the zymogen (inactive precursor) conformation. METHODS In this open-label, parallel-group trial, we randomly assigned 412 patients who were undergoing total knee arthroplasty to receive one of three regimens of abelacimab (30 mg, 75 mg, or 150 mg) administered postoperatively in a single intravenous dose or to receive 40 mg of enoxaparin administered subcutaneously once daily. The primary efficacy outcome was venous thromboembolism, detected by mandatory venography of the leg involved in the operation or objective confirmation of symptomatic events. The principal safety outcome was a composite of major or clinically relevant nonmajor bleeding up to 30 days after surgery. RESULTS Venous thromboembolism occurred in 13 of 102 patients (13%) in the 30-mg abelacimab group, 5 of 99 patients (5%) in the 75-mg abelacimab group, and 4 of 98 patients (4%) in the 150-mg abelacimab group, as compared with 22 of 101 patients (22%) in the enoxaparin group. The 30-mg abelacimab regimen was noninferior to enoxaparin, and the 75-mg and 150-mg abelacimab regimens were superior to enoxaparin (P<0.001). Bleeding occurred in 2%, 2%, and none of the patients in the 30-mg, 75-mg, and 150-mg abelacimab groups, respectively, and in none of the patients in the enoxaparin group. CONCLUSIONS This trial showed that factor XI is important for the development of postoperative venous thromboembolism. Factor XI inhibition with a single intravenous dose of abelacimab after total knee arthroplasty was effective for the prevention of venous thromboembolism and was associated with a low risk of bleeding. (Funded by Anthos Therapeutics; ANT-005 TKA EudraCT number, 2019-003756-37.).
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/therapeutic use
- Anticoagulants/administration & dosage
- Anticoagulants/adverse effects
- Anticoagulants/therapeutic use
- Arthroplasty, Replacement, Knee
- Dose-Response Relationship, Drug
- Enoxaparin/adverse effects
- Enoxaparin/therapeutic use
- Factor XI/antagonists & inhibitors
- Factor XI/metabolism
- Female
- Hemorrhage/chemically induced
- Humans
- Infusions, Intravenous
- Injections, Subcutaneous
- Male
- Middle Aged
- Partial Thromboplastin Time
- Postoperative Complications/prevention & control
- Venous Thromboembolism/prevention & control
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Affiliation(s)
- Peter Verhamme
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - B Alexander Yi
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Annelise Segers
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Janeen Salter
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Daniel Bloomfield
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Harry R Büller
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Gary E Raskob
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
| | - Jeffrey I Weitz
- From KU Leuven Department of Cardiovascular Sciences, Vascular Medicine and Hemostasis, Leuven, Belgium (P.V.); Anthos Therapeutics, Cambridge, MA (B.A.Y., J.S., D.B.); International Trial Expertise Advisory and Services (A.S.) and the Department of Vascular Medicine, Academic Medical Center, University of Amsterdam (H.R.B.) - both in Amsterdam; Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City (G.E.R.); and the Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada (J.I.W.)
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50
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Hsu C, Hutt E, Bloomfield DM, Gailani D, Weitz JI. Factor XI Inhibition to Uncouple Thrombosis From Hemostasis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:625-631. [PMID: 34353538 DOI: 10.1016/j.jacc.2021.06.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [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: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
Hemostasis and thrombosis are believed to be so intricately linked that any strategies that reduce thrombosis will have an inevitable impact on hemostasis. Consequently, bleeding is viewed as an unavoidable side effect of anticoagulant therapy. Emerging evidence suggests that factor XI is important for thrombosis but has a minor role in hemostasis. This information raises the possibility that anticoagulants that target factor XI will be safer than currently available agents. The authors provide a visual representation of the coagulation pathways that distinguishes between the steps involved in thrombosis and hemostasis to explain why factor XI inhibitors may serve as hemostasis-sparing anticoagulants. A safer class of anticoagulants would provide opportunities for treatment of a wider range of patients, including those at high risk for bleeding. Ongoing clinical studies will determine the extent to which factor XI inhibitors attenuate thrombosis without disruption of hemostasis.
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Affiliation(s)
- Charles Hsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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