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Broughton N, Comer K, Casey-Gillman O, Moore L, Antoniou S, Patel R, Fhadil S, Wright P, Ozkor M, Guttmann O, Baumbach A, Wragg A, Jain AJ, Choudry F, Mathur A, Rathod KS, Jones DA. An exploration of the early discharge approach for low-risk STEMI patients following primary percutaneous coronary intervention. Am J Cardiovasc Dis 2023; 13:32-42. [PMID: 37213314 PMCID: PMC10193248] [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] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/17/2023] [Indexed: 05/23/2023]
Abstract
Recently, there has been growing interest in the early discharge strategy for low-risk patients who have undergone primary percutaneous coronary intervention (PCI) to treat ST-segment elevation myocardial infarction (STEMI). So far findings have suggested there are multiple advantages of shorter hospital stays, including that it could be a safe way to be more cost- and resource-efficient, reduce cases of hospital-acquired infection and boost patient satisfaction. However, there are remaining concerns surrounding safety, patient education, adequate follow-up and the generalisability of the findings from current studies which are mostly small-scale. By assessing the current research, we describe the advantages, disadvantages and challenges of early hospital discharge for STEMI and discuss the factors that determine if a patient can be considered low risk. If it is feasible to safely employ a strategy like this, the implications for healthcare systems worldwide could be extremely beneficial, particularly in lower-income economies and when we consider the detrimental impacts of the recent COVID-19 pandemic on healthcare systems.
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Affiliation(s)
- Nicole Broughton
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
| | - Katrina Comer
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Oliver Casey-Gillman
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Lizze Moore
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Riyaz Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Muhiddin Ozkor
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Oliver Guttmann
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Andrew Wragg
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Ajay J Jain
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Fizzah Choudry
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Krishnaraj S Rathod
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of LondonLondon EC1A 7BE, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
- Department of Cardiology, Barts Heart Centre, Barts Health NHS TrustLondon EC1A 7BE, UK
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Schellhase E, Stanko M, Kinstler N, Miller ML, Antoniou S, Fhadil S, Patel M, Wright P. Analysis of Pharmacy Cardiac Optimization Clinic for Patients with New Onset Atrial Fibrillation Detected via Cardiac Implantable Electronic Device Clinic. Pharmacy (Basel) 2023; 11:pharmacy11020048. [PMID: 36961026 PMCID: PMC10037589 DOI: 10.3390/pharmacy11020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/21/2023] [Accepted: 02/25/2023] [Indexed: 03/08/2023] Open
Abstract
For patients with cardiac implantable electronic devices (CIEDs), arrythmias such as atrial fibrillation (AF) can be detected and actions taken to rapidly assess and initiate treatment where appropriate. Actions include timely initiation of anticoagulation, review of blood pressure, and optimization of cholesterol/lipids to prevent unfavorable outcomes, such as stroke and other cardiovascular complications. Delays to initiating anticoagulation can have devastating consequences. We sought to implement a virtual clinic, where a pharmacist reviews patient referrals from a CIED clinic after detecting AF from the CIED. Anticoagulation choice is determined by patient-specific factors, and a shared patient-provider decision to start oral anticoagulation is made. In addition, blood pressure readings and medications are assessed with lipid-lowering therapies for optimization. A total of 315 patients have been admitted through this clinic and anticoagulated over a two-year span; in addition, 322 successful interventions were made for optimization of cardiac therapy. Rapid initiation of anticoagulation within five days of referral was likely to have reduced unfavorable outcomes, such as stroke and other cardiovascular optimizations, leading to improved patient outcomes.
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Affiliation(s)
- Ellen Schellhase
- Purdue University College of Pharmacy, West Lafayette, IN 47907, USA
| | - Madeline Stanko
- Purdue University College of Pharmacy, West Lafayette, IN 47907, USA
| | - Natalie Kinstler
- Purdue University College of Pharmacy, West Lafayette, IN 47907, USA
| | - Monica L Miller
- Purdue University College of Pharmacy, West Lafayette, IN 47907, USA
| | | | | | - Mital Patel
- St. Bartholomew's Hospital, London EC1A 7BE, UK
| | - Paul Wright
- St. Bartholomew's Hospital, London EC1A 7BE, UK
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Manjooran S, Rathod K, Wright P, Antoniou S, Fhadil S, Wragg A, Ozkor M, Baumach A, Mathur A, Jones D. Low dose rivaroxaban therapy in aspirin allergic patients undergoing percutaneous coronary intervention. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1237] [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: 11/13/2022] Open
Abstract
Abstract
Aspirin in combination with a P2Y12 inhibitor is the mainstay of treatment post percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, patients who are allergic to or intolerant to aspirin pose a therapeutic challenge especially when encountered in the setting of acute coronary syndrome. Aspirin desensitization strategies have been used in clinical practice to build tolerance prior to coronary intervention but clearly are not practical in the setting of ACS or significant symptomatic CAD. Low dose rivaroxaban (2.5 mg twice a day) has been previously shown to be safe in combination with a P2Y12 inhibitor post ACS compared to aspirin. We therefore sought to see if low dose rivaroxaban is a safe and effective alternative to aspirin in patients post PCI who are unable to take aspirin.This study aims to compare the efficacy (Major adverse cardiovascular events (MACE)) and safety (Bleeding events as defined by Bleeding Academic Research Consortium (BARC) criteria) in patients with confirmed aspirin allergy who were treated with low dose rivaroxaban therapy in place of aspirin in combination with P2Y12 inhibitors post PCI.
Methods
This was a single center observational study which looked at 50 cases of patients with aspirin allergy (47 cases) or significant confirmed aspirin intolerance (3 cases) who underwent PCI between December 2017 and February 2022. Patients were advised to take low dose rivaroxaban 2.5 mg twice a day as an alternative to aspirin 75 mg once a day. A comparator group of 50 matched patients without aspirin allergy who underwent PCI during the same time period and treated with standard aspirin therapy (75mg) along with a P2Y12 inhibitor. Outcomes over follow-up were MACE (mortality, myocardial infarction, stroke, and unscheduled revascularisation) and bleeding events defined by–BARC criteria.
Results
The median age of the aspirin allergy cohort was 62 years old with typical comorbidities associated with CAD. The cohort included a case mix of ACS and stable angina.The P2Y12 inhibitor in the majority of cases (76%) was Clopidogrel; Ticagrelor was used in 20% of cases and Prasugrel in 4% cases. No differences existed between the rivaroxaban and matched patient groups. The median follow-up as 626 days (Interquartile range 237–549). The duration of low dose rivaroxaban therapy was for 12 months with a P2Y12 in 72%, 1–3 months for 22% and finally continued long term (with P2Y12 discontinuation at 12 months) in 6%. No difference existed in the incidence of MACE between the low dose rivaroxaban group (12%) compared to the matched cohort (10% p=0.266). No difference in bleeding outcomes (any bleeding event BARC type >0) were seen (14% in rivaroxaban and 16% in control, p=0.329).
Conclusions
This study provides more supporting evidence that low dose rivaroxaban therapy is an alternative to aspirin when used in combination with a P2Y12 inhibitor post PCI.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Manjooran
- Barts Heart Centre , London , United Kingdom
| | - K Rathod
- Barts Heart Centre , London , United Kingdom
| | - P Wright
- Barts Heart Centre , London , United Kingdom
| | - S Antoniou
- Barts Heart Centre , London , United Kingdom
| | - S Fhadil
- Barts Heart Centre , London , United Kingdom
| | - A Wragg
- Barts Heart Centre , London , United Kingdom
| | - M Ozkor
- Barts Heart Centre , London , United Kingdom
| | - A Baumach
- Barts Heart Centre , London , United Kingdom
| | - A Mathur
- Barts Heart Centre , London , United Kingdom
| | - D Jones
- Barts Heart Centre , London , United Kingdom
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Rathod KS, Comer K, Casey-Gillman O, Moore L, Mills G, Ferguson G, Antoniou S, Patel R, Fhadil S, Damani T, Wright P, Ozkor M, Das D, Guttmann OP, Baumbach A, Archbold RA, Wragg A, Jain AK, Choudry FA, Mathur A, Jones DA. Early Hospital Discharge Following PCI for Patients With STEMI. J Am Coll Cardiol 2021; 78:2550-2560. [PMID: 34915986 DOI: 10.1016/j.jacc.2021.09.1379] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 08/06/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care. OBJECTIVES This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients. METHODS Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in <48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months. RESULTS The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (>30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for >48 hours (>48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses. CONCLUSIONS Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.
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Affiliation(s)
- Krishnaraj S Rathod
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Katrina Comer
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Oliver Casey-Gillman
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Lizzie Moore
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Gordon Mills
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Gordon Ferguson
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Riyaz Patel
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Tasleem Damani
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mick Ozkor
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Debashish Das
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Oliver P Guttmann
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - R Andrew Archbold
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Andrew Wragg
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ajay K Jain
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Fizzah A Choudry
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Willian Harvey Research Institute, Queen Mary University of London, London, United Kingdom; Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
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5
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Patel M, Fhadil S, Zemrak F, Wright P, Rochford C, Jones S, Earley M, Antoniou S. Pharmacist-led medicines optimisation clinic for implantable cardiac device patients. Eur J Cardiovasc Nurs 2021. [DOI: 10.1093/eurjcn/zvab060.009] [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: 11/12/2022]
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background/Introduction: Cardiac implantable electronic devices (CIED) enhance detection of atrial fibrillation (AF), providing a comprehensive measure of AF burden. Patients with device-detected AF are usually referred for anticoagulation to their local anticoagulation clinic or General Practitioner (GP), which often delays time to initiation, potentially increasing the risk of stroke. In addition, AF is associated with increased risk of cardiovascular disease and mortality. Optimising blood pressure, cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.
Purpose
To develop and evaluate an innovative pathway to allow Specialist Cardiac Pharmacists to promptly assess and initiate anticoagulation in patients with device-detected AF, and additionally address risk factors for prevention of cardiovascular disease.
Methods
As part of a quality improvement initiative, a pathway was developed where patients with AF identified on CIED who require anticoagulation are referred for assessment and management to a pharmacist-led optimisation clinic. Specialist Cardiac Pharmacists contact patients within 5 days of referral to discuss and initiate or optimise treatment for AF, blood pressure, cholesterol and lifestyle choices. Patients deemed inappropriate for anticoagulation were referred back to the medical team for further assessment. All patients received a follow-up telephone consultation at 4-6 weeks to assess tolerability, adherence and response to treatment.
Results
Between September 2020 and February 2021, 22 patients were referred to the optimisation clinic. Mean age was 74.32 +/- 12.34 years and 77% were men. Mean CHA2DS2VASc was 3.4 +/- 0.8 and mean HASBLED was 1.2 +/- 0.6. The average time from referral to anticoagulation was 3 days compared to 4 weeks prior to implementation of the pathway. All patients were assessed and appropriately anticoagulated, whereas approximately 15% of patients were still not anticoagulated at 3 months prior to implementation of the pathway despite referral to their local clinic. All patients had their blood pressure and cholesterol reviewed, which were optimised in 23% and 41% of patients respectively. All patients confirmed adherence and suffered no adverse effects on follow-up.
Conclusion(s): We report the safe and successful implementation of a pharmacist-led medicines optimisation clinic. This has significantly reduced time to anticoagulation without compromising safety, as well as assuring all patients are appropriately anticoagulated. In addition, over half of patients required blood pressure and/or cholesterol optimisation to reduce the risk of cardiovascular disease, a service not previously provided for this cohort of patients.
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Affiliation(s)
- M Patel
- Barts Heart Centre, Pharmacy, Greater London, United Kingdom of Great Britain & Northern Ireland
| | - S Fhadil
- Barts Heart Centre, Pharmacy, Greater London, United Kingdom of Great Britain & Northern Ireland
| | - F Zemrak
- Barts Heart Centre, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - P Wright
- Barts Heart Centre, Pharmacy, Greater London, United Kingdom of Great Britain & Northern Ireland
| | - C Rochford
- Barts Heart Centre, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - S Jones
- Barts Heart Centre, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - M Earley
- Barts Heart Centre, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - S Antoniou
- Barts Heart Centre, Pharmacy, Greater London, United Kingdom of Great Britain & Northern Ireland
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Jones DA, Wright P, Alizadeh MA, Fhadil S, Rathod KS, Guttmann O, Knight C, Timmis A, Baumbach A, Wragg A, Mathur A, Antoniou S. The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction. European Heart Journal - Cardiovascular Pharmacotherapy 2020; 7:398-404. [PMID: 32730627 DOI: 10.1093/ehjcvp/pvaa096] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/08/2020] [Accepted: 07/23/2020] [Indexed: 12/23/2022]
Abstract
Abstract
Aim
Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI.
Methods and results
This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388).
Conclusion
These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.
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Affiliation(s)
- Daniel A Jones
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Paul Wright
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Momin A Alizadeh
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Sadeer Fhadil
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
| | - Krishnaraj S Rathod
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Oliver Guttmann
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Charles Knight
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Adam Timmis
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Andreas Baumbach
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Andrew Wragg
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Anthony Mathur
- Barts Interventional Group, Interventional Cardiology, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
- Charterhouse Square Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1M 6BQ, UK
| | - Sotiris Antoniou
- Department of Pharmacy, Barts Heart Centre, St Bartholomew's Hospital, 2nd Floor, King George V Building, West Smithfield, London EC1A 7BE, UK
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7
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Alizadeh M, Antoniou S, Fhadil S, Rathod R, Guttmann O, Knight C, Timmis A, Wragg A, Mathur A, Jones DA, Baumbach A, Weeraman D, Beirne A. P6426The use of direct oral anti-coagulations (DOACs) compared to vitamin k antagonist in patients with left ventricular thrombus after acute myocardial infarction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.1020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI.
Methods and results
This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome.
Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia).
Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388).
Conclusion
This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data.
Acknowledgement/Funding
None
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Affiliation(s)
- M Alizadeh
- Barts Health NHS Trust, London, United Kingdom
| | - S Antoniou
- Barts Health NHS Trust, London, United Kingdom
| | - S Fhadil
- Barts Health NHS Trust, London, United Kingdom
| | - R Rathod
- Barts Health NHS Trust, London, United Kingdom
| | - O Guttmann
- Barts Health NHS Trust, London, United Kingdom
| | - C Knight
- Barts Health NHS Trust, London, United Kingdom
| | - A Timmis
- Barts Health NHS Trust, London, United Kingdom
| | - A Wragg
- Barts Health NHS Trust, London, United Kingdom
| | - A Mathur
- Barts Health NHS Trust, London, United Kingdom
| | - D A Jones
- Barts Health NHS Trust, London, United Kingdom
| | - A Baumbach
- Barts Health NHS Trust, London, United Kingdom
| | - D Weeraman
- Barts Health NHS Trust, London, United Kingdom
| | - A Beirne
- Barts Health NHS Trust, London, United Kingdom
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Abstract
Postpartum cardiomyopathy (PPCM) is a rare condition that develops near the end of pregnancy or in the months after giving birth, manifesting as heart failure secondary to left ventricular systolic dysfunction. Clinical progression varies considerably, with both end-stage heart failure occurring within days and spontaneous recovery seen. Treatment pathways for heart failure are well established, but the evidence about the safety of medicines passed to infants during breastfeeding is scarce and mainly poor; this often leads to an incorrect decision that a mother should not breastfeed. Given its benefits to both mother and infant, breastfeeding should not routinely be ruled out if the mother is taking heart failure medication but the consequences for the infant need to be considered. An informed risk assessment to minimise potential harm to the infant can be carried out using the evidence that is available along with a consideration of drug properties, adverse effects, paediatric use and pharmacokinetics. In most cases, risks can be managed and infants can be monitored for potential problems. Breastfeeding can be encouraged in women with cardiac dysfunction with PPCM although treatment for the mother takes priority with breastfeeding compatibility being the secondary consideration. International research is continuing to establish efficacy and safety of pharmacotherapy in PPCM.
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9
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Fhadil S, Timmis A, Ruparelia N, Wright P, Patel R, Sud P, Robson J, Antoniou S. 71 Up-titration of secondary prevention following acute coronary syndrome (acs). Heart 2017. [DOI: 10.1136/heartjnl-2017-311726.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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10
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Fhadil S, Wright P, Antoniou S. CP-051 An audit to determine the impact of pharmacist medication reconciliation on discharge (MROD) within a tertiary cardiac centre: Abstract CP-051 Table 1. Eur J Hosp Pharm 2016. [DOI: 10.1136/ejhpharm-2016-000875.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Gulamhussein MA, Patrini D, Pararajasingham J, Fhadil S, Wright P, Roberts N, Panagiotopoulos N. An evaluation of anticoagulation initiation post cardiac surgery in a tertiary cardiac centre. J Cardiothorac Surg 2015. [PMCID: PMC4693859 DOI: 10.1186/1749-8090-10-s1-a145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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12
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Woo WL, Panagiotopoulos N, Gvinianidze L, Fhadil S, Borg E, Falzon M, Lawrence D. Primary synovial sarcoma of the lung: can haemothorax be the first manifestation? J Thorac Dis 2015; 6:E249-51. [PMID: 25590001 DOI: 10.3978/j.issn.2072-1439.2014.11.01] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 09/09/2014] [Indexed: 11/14/2022]
Abstract
Primary pulmonary synovial sarcomas represent a rare clinical entity and account for approximately 0.5% of lung malignancies. We report the case of a 30-year-old male who presented clinically with haemothorax. Imaging revealed a complex collection obscuring a multi-lobulated mass in the right lower lobe of the lung. He underwent a right thoracotomy for evacuation of collection and surgical resection of his pulmonary mass. Histological analysis confirmed a grade 3 monophasic fibrous synovial sarcoma of the lung with infiltration to adjacent pleura, causing his initial haemothorax. Postoperative period was uneventful and patient was referred to the oncology team for further management. Primary pulmonary synovial sarcoma, though rare, should remain an important differential when considering lung malignancies, as complete surgical resection is the mainstay of treatment.
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Affiliation(s)
- Wen Ling Woo
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Nikolaos Panagiotopoulos
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Lasha Gvinianidze
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Sadeer Fhadil
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Elaine Borg
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - Mary Falzon
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
| | - David Lawrence
- 1 Department of Cardiothoracic Surgery, 2 Department of Histopathology, University College London Hospitals (UCLH), London, UK
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