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Bikdeli B, Krishnathasan D, Khairani CD, Bejjani A, Davies J, Porio N, Tristani A, Armero A, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Ortiz-Rios MD, Zuluaga-Sánchez V, Achanta A, Jesudasen SJ, Tiu B, Merli GJ, Leiva O, Fanikos J, Grandone E, Sharma A, Rizzo S, Pfeferman MB, Morrison RB, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll B, Goldhaber SZ, Lan Z, Piazza G. Low absolute risk of thrombotic and cardiovascular events in outpatient pregnant women with COVID-19. Thromb Res 2024; 237:209-215. [PMID: 38677791 DOI: 10.1016/j.thromres.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pregnancy may contribute to an excess risk of thrombotic or cardiovascular events. COVID-19 increases the risk of these events, although the risk is relatively limited among outpatients. We sought to determine whether outpatient pregnant women with COVID-19 are at a high risk for cardiovascular or thrombotic events. MATERIALS & METHODS We analyzed pregnant outpatients with COVID-19 from the multicenter CORONA-VTE-Network registry. The main study outcomes were a composite of adjudicated venous or arterial thrombotic events, and a composite of adjudicated cardiovascular events. Events were assessed 90 days after the COVID-19 diagnosis and reported for non-pregnant women ≤45 years, and for men ≤45 years, as points of reference. RESULTS Among 6585 outpatients, 169 were pregnant at diagnosis. By 90-day follow-up, two pregnant women during the third trimester had lower extremity venous thrombosis, one deep and one superficial vein thrombosis. The cumulative incidence of thrombotic events was 1.20 % (95 % confidence interval [CI]: 0.0 to 2.84 %). Respective rates were 0.47 % (95 % CI: 0.14 % to 0.79 %) among non-pregnant women, and 0.49 % (95 % CI: 0.06 % to 0.91 %) among men ≤45 years. No non-thrombotic cardiovascular events occurred in pregnant women. The rates of cardiovascular events were 0.53 % (95 % CI: 0.18 to 0.87) among non-pregnant women, and 0.68 % (95 % CI: 0.18 to 1.18) in men aged ≤45 years. CONCLUSIONS Thrombotic and cardiovascular events are rare among outpatients with COVID-19. Although a higher event rate among outpatient pregnant women cannot be excluded, the absolute event rates are low and do not warrant population-wide cardiovascular interventions to optimize outcomes.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ali A Assi
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Marcos D Ortiz-Rios
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy; Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Samantha Rizzo
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Mariana B Pfeferman
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ruth B Morrison
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett Carroll
- Smith Center for Cardiovascular Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA.
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Wadhera RK, Secemsky EA, Xu J, Yeh RW, Song Y, Goldhaber SZ. Community Socioeconomic Status, Acute Cardiovascular Hospitalizations, and Mortality in Medicare, 2003 to 2019. Circ Cardiovasc Qual Outcomes 2024; 17:e010090. [PMID: 38597091 DOI: 10.1161/circoutcomes.123.010090] [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: 03/27/2023] [Accepted: 01/31/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Socioeconomically disadvantaged communities in the United States disproportionately experience poor cardiovascular outcomes. Little is known about how hospitalizations and mortality for acute cardiovascular conditions have changed among Medicare beneficiaries in socioeconomically disadvantaged and nondisadvantaged communities over the past 2 decades. METHODS Medicare files were linked with the Centers for Disease Control and Prevention's social vulnerability index to examine age-sex standardized hospitalizations for myocardial infarction, heart failure, ischemic stroke, and pulmonary embolism among Medicare fee-for-service beneficiaries ≥65 years of age residing in socioeconomically disadvantaged communities (highest social vulnerability index quintile nationally) and nondisadvantaged communities (all other quintiles) from 2003 to 2019, as well as risk-adjusted 30-day mortality among hospitalized beneficiaries. RESULTS A total of 10 942 483 Medicare beneficiaries ≥65 years of age were hospitalized for myocardial infarction, heart failure, stroke, or pulmonary embolism (mean age, 79.2 [SD, 8.7] years; 53.9% female). Although age-sex standardized myocardial infarction hospitalizations declined in socioeconomically disadvantaged (990-650 per 100 000) and nondisadvantaged communities (950-570 per 100 000) from 2003 to 2019, the gap in hospitalizations between these groups significantly widened (adjusted odds ratio 2003, 1.03 [95% CI, 1.02-1.04]; adjusted odds ratio 2019, 1.14 [95% CI, 1.13-1.16]). There was a similar decline in hospitalizations for heart failure in socioeconomically disadvantaged (2063-1559 per 100 000) and nondisadvantaged communities (1767-1385 per 100 000), as well as for ischemic stroke, but the relative gap did not change for both conditions. In contrast, pulmonary embolism hospitalizations increased in both disadvantaged (146-184 per 100 000) and nondisadvantaged communities (153-184 per 100 000). By 2019, risk-adjusted 30-day mortality was similar between hospitalized beneficiaries from socioeconomically disadvantaged and nondisadvantaged communities for myocardial infarction, heart failure, and ischemic stroke but was higher for pulmonary embolism (odds ratio, 1.10 [95% CI, 1.01-1.20]). CONCLUSIONS Over the past 2 decades, hospitalizations for most acute cardiovascular conditions decreased in both socioeconomically disadvantaged and nondisadvantaged communities, although significant disparities remain, while 30-day mortality is now similar across most conditions.
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Affiliation(s)
- Rishi K Wadhera
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Eric A Secemsky
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Jiaman Xu
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Robert W Yeh
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Yang Song
- Richard and Susan Smith Center for Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA (R.K.W., E.A.S., J.X., R.W.Y., Y.S.)
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Rashedi S, Greason CM, Sadeghipour P, Talasaz AH, O'Donoghue ML, Jimenez D, Monreal M, Anderson CD, Elkind MSV, Kreuziger LMB, Lang IM, Goldhaber SZ, Konstantinides SV, Piazza G, Krumholz HM, Braunwald E, Bikdeli B. Fibrinolytic Agents in Thromboembolic Diseases: Historical Perspectives and Approved Indications. Semin Thromb Hemost 2024. [PMID: 38428841 DOI: 10.1055/s-0044-1781451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
Fibrinolytic agents catalyze the conversion of the inactive proenzyme plasminogen into the active protease plasmin, degrading fibrin within the thrombus and recanalizing occluded vessels. The history of these medications dates to the discovery of the first fibrinolytic compound, streptokinase, from bacterial cultures in 1933. Over time, researchers identified two other plasminogen activators in human samples, namely urokinase and tissue plasminogen activator (tPA). Subsequently, tPA was cloned using recombinant DNA methods to produce alteplase. Several additional derivatives of tPA, such as tenecteplase and reteplase, were developed to extend the plasma half-life of tPA. Over the past decades, fibrinolytic medications have been widely used to manage patients with venous and arterial thromboembolic events. Currently, alteplase is approved by the U.S. Food and Drug Administration (FDA) for use in patients with pulmonary embolism with hemodynamic compromise, ST-segment elevation myocardial infarction (STEMI), acute ischemic stroke, and central venous access device occlusion. Reteplase and tenecteplase have also received FDA approval for treating patients with STEMI. This review provides an overview of the historical background related to fibrinolytic agents and briefly summarizes their approved indications across various thromboembolic diseases.
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Affiliation(s)
- Sina Rashedi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Christie M Greason
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Department of Pharmacotherapy and Outcomes Sciences, Virginia Commonwealth University, Richmond, Virginia
- Department of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, New York, New York
- Department of Pharmacy, New York-Presbyterian Hospital Columbia University Medical Center, New York, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
- Universidad Catolica de Murcia, Murcia, Spain
| | - Christopher D Anderson
- Program in Medical and Population Genetics, Broad Institute of Harvard and the Massachusetts Institute of Technology, Boston, Massachusetts
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, Massachusetts
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Lisa M Baumann Kreuziger
- Medical College of Wisconsin, Milwaukee, Wisconsin
- Blood Research Institute, Versiti, Milwaukee, Wisconsin
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stavros V Konstantinides
- Center for Thrombosis and Haemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Eugene Braunwald
- Division of Cardiovascular Medicine, TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
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5
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Sterling KM, Goldhaber SZ, Sharp AS, Kucher N, Jones N, Maholic R, Meneveau N, Zlotnick D, Sayfo S, Konstantinides SV, Piazza G. Prospective Multicenter International Registry of Ultrasound-Facilitated Catheter-Directed Thrombolysis in Intermediate-High and High-Risk Pulmonary Embolism (KNOCOUT PE). Circ Cardiovasc Interv 2024; 17:e013448. [PMID: 38264938 PMCID: PMC10942169 DOI: 10.1161/circinterventions.123.013448] [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: 07/19/2023] [Accepted: 12/14/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND Prior clinical trials have demonstrated the efficacy of ultrasound-facilitated catheter-directed thrombolysis (USCDT) for the treatment of acute intermediate-risk pulmonary embolism (PE) using reduced thrombolytic doses and shorter infusion durations. However, utilization and safety of such strategies in broader PE populations remain unclear. The KNOCOUT PE (The EKoSoNic Registry of the Treatment and Clinical Outcomes of Patients With Pulmonary Embolism) registry is a multicenter international registry designed to study the treatment of acute PE with USCDT, with focus on safety outcomes. METHODS The KNOCOUT PE prospective cohort included 489 patients (64 sites internationally) with acute intermediate-high or high-risk PE treated with USCDT between March 2018 and June 2020. Principal safety outcomes were independently adjudicated International Society on Thrombosis and Haemostasis major bleeding at 72 hours post-treatment and mortality within 12 months of treatment. Additional outcomes included change in right ventricular/left ventricular ratio and quality of life measures over 12 months. RESULTS Mean alteplase (r-tPA [recombinant tissue-type plasminogen activator]) infusion duration was 10.5 hours. Mean total r-tPA dose was 18.1 mg, with 31.0% of patients receiving ≤12 mg. Major bleeding events within 72 hours occurred in 1.6% (8/489) of patients. One patient experienced worsening of a preexisting subdural hematoma after USCDT and therapeutic anticoagulation, which ultimately required surgery. All-cause mortality at 30 days was 1.0% (5/489). Improvement in PE quality of life score was observed with a 41.1% (243/489, 49.7%) and 44.2% (153/489, 31.3%) mean relative reduction by 3 and 12 months, respectively. CONCLUSIONS In a prospective observational cohort study of patients with intermediate-high and high-risk PE undergoing USCDT, mean r-tPA dose was 18 mg, and the rates of major bleeding and mortality were low. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03426124.
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Affiliation(s)
| | - Samuel Z. Goldhaber
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.Z.G., G.P.)
| | - Andrew S.P. Sharp
- University Hospital of Wales and Cardiff University, United Kingdom (A.S.P.S.)
| | - Nils Kucher
- University Clinic of Angiology, University Hospital Zurich, Switzerland (N.K.)
| | - Noah Jones
- Mount Carmel Health System, Columbus, OH (N.J.)
| | - Robert Maholic
- University of Pittsburgh Medical Center Hamot, Erie, PA (R.M.)
| | | | - David Zlotnick
- University at Buffalo/Great Lakes Cardiovascular, NY (D.Z.)
| | - Sameh Sayfo
- Baylor Scott and White The Heart Hospital Plano, TX (S.S.)
| | | | - Gregory Piazza
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.Z.G., G.P.)
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Goldhaber SZ, Bassand JP, Camm AJ, Virdone S, Pieper K, Cools F, Corbalan R, Gersh BJ, Goto S, Haas S, Misselwitz F, Parkhomenko A, Steffel J, Stepinska J, Turpie AGG, Verheugt FWA, Kayani G, Kakkar AK. Clinical Outcomes in Older Patients with Atrial Fibrillation: Insights from the GARFIELD-AF Registry. Am J Med 2024; 137:128-136.e13. [PMID: 37918777 DOI: 10.1016/j.amjmed.2023.10.027] [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: 07/31/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underutilized in older patients with atrial fibrillation, despite proven clinical benefits. Our objective was to investigate baseline characteristics, treatment patterns, and impact of anticoagulation upon clinical outcomes with respect to age. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed up for 24 months. Adjusted hazard ratios (HR) were obtained via Cox proportional-hazards models with applied weights, to quantify the association of age with clinical outcomes. Comparative effectiveness of OAC vs No OAC and non-vitamin K oral anticoagulants (NOAC) vs vitamin K antagonists (VKA) were assessed using a propensity score with an overlap weighting scheme. RESULTS Of 52,018 patients, 32.6% were 65-74 years of age, 29.3% were 75-84 years, and 7.9% were ≥85 years. OAC treatment was associated with a numerical reduction in all-cause mortality among those aged 65-74 years (HR; 95% confidence interval) (0.86; 0.69-1.06) and aged 75-84 years (0.89; 0.75-1.05) and a significant reduction in patients ≥85 years (0.77; 0.63-0.95) vs no OAC. Similarly, OACs were associated with a decrease in stroke: 65-74 (0.51; 0.35-0.76) and ≥85 years (0.58; 0.34-0.99) and a numerical decrease in 75-84 years (0.84; 0.59-1.18). No increase in major bleeding was observed in patients aged ≥85 treated with OACs. Compared with VKA, NOACs were associated with a significant reduction in all-cause mortality in patients aged <65 and 65-74, with numerical reductions in those aged 75-84 and ≥85 years. CONCLUSIONS Older patients using OACs saw lower all-cause mortality and stroke risk; NOACs had less mortality and major bleeding compared with VKAs.
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Affiliation(s)
| | | | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's University of London, London, UK
| | | | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Ramon Corbalan
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Technical University of Munich, Germany
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7
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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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8
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Bikdeli B, Sadeghipour P, Lou J, Bejjani A, Khairani CD, Rashedi S, Lookstein R, Lansky A, Vedantham S, Sobieszczyk P, Mena-Hurtado C, Aghayev A, Henke P, Mehdipoor G, Tufano A, Chatterjee S, Middeldorp S, Wasan S, Bashir R, Lang IM, Shishehbor MH, Gerhard-Herman M, Giri J, Menard MT, Parikh SA, Mazzolai L, Moores L, Monreal M, Jimenez D, Goldhaber SZ, Krumholz HM, Piazza G. Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review. Semin Thromb Hemost 2024. [PMID: 38176425 DOI: 10.1055/s-0043-1777991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Junyang Lou
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sina Rashedi
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robert Lookstein
- Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Piotr Sobieszczyk
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ayaz Aghayev
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Center for Evidence-based Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Zucker School of Medicine, New York, New York
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suman Wasan
- University of North Carolina, Chapel Hill, North Carolina
| | - Riyaz Bashir
- Departement of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Mehdi H Shishehbor
- University Hospitals Heath System, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Marie Gerhard-Herman
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahil A Parikh
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Lisa Moores
- Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | | | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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9
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Goldhaber SZ. Obesity and Pulmonary Embolism: Can We Dismantle the "Obesity Paradox". Thromb Haemost 2024; 124:58-60. [PMID: 37802123 DOI: 10.1055/a-2187-0966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Affiliation(s)
- Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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10
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Chen AC, Rao AS, Oropallo A, Goldhaber SZ, Fluharty ME, Maheshwari U, Carrier M, Turpie AGG, Pieper K, Kayani G, Kakkar AK. Comparing U.S. and Canadian treatment patterns on venous thromboembolism outcomes in the GARFIELD-VTE registry. Thromb Res 2023; 232:123-132. [PMID: 37976732 DOI: 10.1016/j.thromres.2023.11.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/28/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Economically developed countries continue to find that venous thromboembolism (VTE) is a major cause of morbidity and mortality. OBJECTIVE To compare baseline risk profiles and patient workflow patterns between the United States (U.S.) and Canadian management of VTE patients from 2014 to 2017. METHODS The Global Anticoagulant Registry in the FIELD (GARFIELD-VTE) is a prospective, observational study of 10,679 patients with objectively confirmed VTE, followed for 3 years. In total 1101 patients enrolled in the U.S. and Canada were included in this analysis. RESULTS Median age and body mass index were comparable between the U.S. (60.5; 30.2) and Canadian (59.7; 29) patients. A higher percentage of U.S. patients were black (n = 128, 24.1 %; n = 22, 3.9 %) and had a higher VTE-associated risk profile, including immobilization, hospitalization, and recent surgery. U.S. patients had a higher combined DVT and PE primary diagnoses (20.3 %) and were more likely to be treated in hospitals (77.2 %) than Canadians (13.3 %; 48.1 %). Direct oral anticoagulant therapy (DOAC) was nearly two-fold more frequent in Canadian patients (n = 218, 39.2 %) at the end of 3 years in comparison to the U.S. (n = 118, 23.0 %). Adjusted for sex, recent bleed event, heart failure, chronic immobilization, family history of VTE, history of cancer and prior VTE, and renal insufficiency, the risk of all-cause mortality was 51.9 % higher in patients from the U.S. compared to those in Canada after 3 years. Patients from the U.S. also had a higher likelihood of hospitalization, major bleeding, and recurrent VTE after controlling for prior history and comorbid conditions. CONCLUSION Higher rates of adverse VTE-associated outcomes in the U.S. may be attributed to different baseline risk profiles, facility care, and distribution of specialists and their subsequent treatment strategies. TYPE OF RESEARCH Global, multicentre, non-interventional, prospective registry titled Global Anticoagulant Registry in the FIELD - Venous Thromboembolism (GARFIELD-VTE). KEY FINDINGS 531 U.S. and 557 Canadians patients included in study. DOAC use more frequent in Canadian patients after 3 years than U.S. (39.2 % vs. 23.0 %, respectively). Adjusted for sex, recent bleed event, heart failure, chronic immobilization, family history of VTE, history of cancer and prior VTE, and renal insufficiency, all-cause mortality risk remained higher in U.S. patients vs. Canadian patients after 3 years. U.S. patients had higher likelihood of hospitalization, major bleeding, and recurrent VTE. TAKE-HOME MESSAGE Higher rates of adverse VTE-associated outcomes in the U.S. may be attributed to different baseline risk profiles, facility care, and composition of specialists and their subsequent treatment strategies. TABLE OF CONTENTS SUMMARY Global, multicentre, non-interventional, prospective registry titled Global Anticoagulant Registry in the FIELD - Venous Thromboembolism (GARFIELD-VTE). Higher rates of adverse VTE-associated outcomes were observed in U.S. patients vs Canadian patients, which may be attributed to different baseline risk profiles, facility care, and distribution of specialists and their subsequent treatment strategies.
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Affiliation(s)
- Adrian C Chen
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Department of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Amit S Rao
- Department of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Alisha Oropallo
- Department of Vascular Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Harvard Medical School, Boston, USA
| | | | | | - Marc Carrier
- Department of Medicine, University of Ottawa, Canada
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Nicolajsen CW, Søgaard M, Jensen M, Eldrup N, Larsen TB, Goldhaber SZ, Behrendt CA, Nielsen PB. Antiplatelet Therapy in Patients With Abdominal Aortic Aneurysm Without Symptomatic Atherosclerotic Disease. JAMA Netw Open 2023; 6:e2339715. [PMID: 37878310 PMCID: PMC10600585 DOI: 10.1001/jamanetworkopen.2023.39715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 09/13/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Patients with abdominal aortic aneurysm have a high risk of ischemic events associated with concomitant atherosclerotic cardiovascular disease, and current clinical practice guidelines recommend antiplatelet therapy to mitigate this risk. However, in patients with aneurysms without symptomatic atherosclerosis, the benefit of antiplatelet therapy has been sparsely investigated. Objective To estimate the effect of antiplatelets on the risk of ischemic events and bleeding in individuals with abdominal aneurysms with no symptomatic atherosclerotic vascular disease. Design, Setting, and Participants A comparative effectiveness research study using a target trial emulation framework was performed. Population-based, cross-linked observational data from Danish national health registries containing comprehensive, individual-level information on all Danish citizens were used to evaluate patients who were antiplatelet-naive and diagnosed with abdominal aortic aneurysms, with no record of symptomatic atherosclerotic vascular disease, from January 1, 2010, through August 21, 2021. Exposure Prescription filled for aspirin or clopidogrel. Main Outcomes and Measures Risk of ischemic events (myocardial infarction and/or ischemic stroke) and risk of major bleeding. For target trial emulation, trials were emulated as sequential, contingent on patient eligibility at the time of inclusion, and were evaluated by means of pooled logistic regression models to estimate the intention-to-treat and as-treated effects, expressed as hazard ratio (HR) and event-free survival. Results A total of 6344 patients (65.2% men; age, 72 [IQR, 64-78] years) provided 131 047 trial cases; 3363 of these cases involved initiation of antiplatelet therapy and 127 684 did not. A total of 182 ischemic events occurred among initiators and 5602 ischemic events occurred among noninitiators, corresponding to an intention-to-treat HR of 0.91 (95% CI, 0.73-1.17) and an estimated absolute event-free survival difference of -0.6% (95% CI, -1.7% to 0.5%). After censoring nonadherent person-time, the treatment HR was 0.90 (95% CI, 0.68-1.20), with similar risk difference. For bleeding, the intention-to-treat HR was 1.26 (95% CI, 0.97-1.58) and the event-free survival difference was 1.0%. The treatment HR was 1.21 (95% CI, 0.82-1.72); the risk difference was similar. Conclusions and Relevance In this study, no evidence of effectiveness of antiplatelet therapy to lower the risk of ischemic events and a trend toward higher bleeding risk was noted. The observed differences between the treatment groups were minimal, suggesting limited clinical relevance of antiplatelet treatment.
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Affiliation(s)
- Chalotte W. Nicolajsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
- Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Martin Jensen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | - Torben B. Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Samuel Z. Goldhaber
- Thrombosis Research Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Medical School, Asklepios Clinic Wandsbek, Hamburg, Germany
- Division of Cardiovascular Medicine, Brandenburg Medical School Theodor Fontane, Neuruppin, Germany
| | - Peter B. Nielsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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12
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Sista AK, Vedantham S, Kahn SR, Desai KR, Goldhaber SZ. Research Consensus Panel Follow-up: 8-Year Update on Submassive Pulmonary Embolism. J Vasc Interv Radiol 2023; 34:1658-1663. [PMID: 37394033 DOI: 10.1016/j.jvir.2023.06.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023] Open
Abstract
The 2015 Research Consensus Panel (RCP) on submassive pulmonary embolism (PE) set priorities for research in submassive PE and identified a rigorous randomized trial of catheter-directed therapy plus anticoagulation versus anticoagulation alone as the highest research priority. This update, written 8 years after the RCP was convened, describes the current state of endovascular PE practice and the Pulmonary Embolism-Thrombus Removal with Catheter-Directed Therapy trial, the main output from the RCP.
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Affiliation(s)
- Akhilesh K Sista
- Department of Radiology, Weill Cornell Medicine, New York, New York.
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Susan R Kahn
- Department of Medicine, Jewish General Hospital, Center for Clinical Epidemiology, McGill University, Montreal, Quebec, Canada
| | - Kush R Desai
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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13
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Bassand JP, Virdone S, Camm AJ, Fox KAA, Goldhaber SZ, Goto S, Haas S, Hacke W, Kayani G, Keltai M, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Oral anticoagulation across diabetic subtypes in patients with newly diagnosed atrial fibrillation: A report from the GARFIELD-AF registry. Diabetes Obes Metab 2023; 25:3040-3053. [PMID: 37435777 DOI: 10.1111/dom.15202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
AIMS This study aims to describe both management and prognosis of patients with diabetes mellitus (DM) and newly diagnosed atrial fibrillation (AF), overall as well as by antidiabetic treatment, and to assess the influence of oral anticoagulation (OAC) on outcomes by DM status. METHODS The study population comprised 52 010 newly diagnosed patients with AF, 11 542 DM and 40 468 non-DM, enrolled in the GARFIELD-AF registry. Follow-up was truncated at 2 years after enrolment. Comparative effectiveness of OAC versus no OAC was assessed by DM status using a propensity score overlap weighting scheme and weights were applied to Cox models. RESULTS Patients with DM [39.3% oral antidiabetic drug (OAD), 13.4% insulin ± OAD, 47.2% on no antidiabetic drug] had higher risk profile, OAC use, and rates of clinical outcomes compared with patients without DM. OAC use was associated in patients without DM and patients with DM with lower risk of all-cause mortality [hazard ratio 0.75 (0.69-0.83), 0.74 (0.64-0.86), respectively] and stroke/systemic embolism (SE) [0.69 (0.58-0.83), 0.70 (0.53-0.93), respectively]. The risk of major bleeding with OAC was similarly increased in patients without DM and those with DM [1.40 (1.14-1.71), 1.37 (0.99-1.89), respectively]. Patients with insulin-requiring DM had a higher risk of all-cause mortality and stroke/SE [1.91 (1.63-2.24)], [1.57 (1.06-2.35), respectively] compared with patients without DM, and experienced significant risk reductions of all-cause mortality and stroke/SE with OAC [0.73 (0.53-0.99); 0.50 (0.26-0.97), respectively]. CONCLUSIONS In both patients with DM and patients without DM with AF, OAC was associated with lower risk of all-cause mortality and stroke/SE. Patients with insulin-requiring DM derived significant benefit from OAC.
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Affiliation(s)
- Jean-Pierre Bassand
- University of Besançon Franche-Comté, Besançon, France
- Thrombosis Research Institute, London, UK
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
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14
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Bikdeli B, Muriel A, Wang Y, Piazza G, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Madridano O, Lopez-Saez JB, Mellado M, Brasero AMD, Grandone E, Spagnolo PA, Lu Y, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Gerhard-Herman M, Goldhaber SZ, Bates SM, Jimenez D, Krumholz HM, Monreal M. Sex-Related Differences in Patient Characteristics, Risk Factors, and Symptomatology in Older Adults with Pulmonary Embolism: Findings from the SERIOUS-PE Study. Semin Thromb Hemost 2023; 49:725-735. [PMID: 36868268 DOI: 10.1055/s-0043-1764231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Sex-specific factors are implicated in pulmonary embolism (PE) presentation in young patients, as indicated by increased risk in pregnancy. Whether sex differences exist in PE presentation, comorbidities, and symptomatology in older adults, the age group in which most PEs occur, remains unknown. We identified older adults (aged ≥65 years) with PE in a large international PE registry replete with information about relevant clinical characteristics (RIETE registry, 2001-2021). To provide national data from the United States, we assessed sex differences in clinical characteristics and risk factors of Medicare beneficiaries with PE (2001-2019). The majority of older adults with PE in RIETE (19,294/33,462, 57.7%) and in the Medicare database (551,492/948,823, 58.7%) were women. Compared with men, women with PE less frequently had atherosclerotic diseases, lung disease, cancer, or unprovoked PE, but more frequently had varicose veins, depression, prolonged immobility, or history of hormonal therapy (p < 0.001 for all). Women less often presented with chest pain (37.3 vs. 40.6%) or hemoptysis (2.4 vs. 5.6%) but more often with dyspnea (84.6 vs. 80.9%) (p < 0.001 for all). Measures of clot burden, PE risk stratification, and use of imaging modalities were comparable between women and men. PE is more common in elderly women than in men. Cancer and cardiovascular disease are more common in men, whereas transient provoking factors including trauma, immobility, or hormone therapy are more common in elderly women with PE. Whether such differences correlate with disparities in treatment or differences in short- or long-term clinical outcomes warrants further investigation.
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Affiliation(s)
- Behnood Bikdeli
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Alfonso Muriel
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERESP: Universidad de Alcalá, Madrid, Spain
| | - Yun Wang
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rachel P Rosovsky
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, New York
| | - Michelle L O'Donoghue
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- TIMI Study Group, Brigham and Women's Hospital, Boston, Massachusetts
| | - Olga Madridano
- Department of Internal Medicine, Hospital Universitario Infanta Sofía, Madrid, Spain
| | - Juan Bosco Lopez-Saez
- Department of Internal Medicine, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - Meritxell Mellado
- Department of Angiology and Vascular Surgery, Hospital del Mar, Barcelona, Spain
| | - Ana Maria Diaz Brasero
- Department of Internal Medicine, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza," Foggia, S. Giovanni Rotondo, Italy
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
- Department of Obstetrics Gynaecology and Perinatal Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Primavera A Spagnolo
- Mary Horrigan Connors Center for Women's Health & Gender Biology, Harvard Medical School, Boston, Massachusetts
| | - Yuan Lu
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
| | - Laurent Bertoletti
- Department of Psychiatry, Brigham and Women Hospital, Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
| | | | - Manuel Jesús Núñez
- Department of Internal Medicine, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
| | | | - Marie Gerhard-Herman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Jimenez
- Department of Respiratory, Hospital Ramón y Cajal, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Manuel Monreal
- Chair for the Study of Thromboembolic Disease, Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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15
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Fanikos J, Tawfik Y, Almheiri D, Sylvester K, Buckley LF, Dew C, Dell'Orfano H, Armero A, Bejjani A, Bikdeli B, Campia U, Davies J, Fiumara K, Hogan H, Khairani CD, Krishnathasan D, Lou J, Makawi A, Morrison RH, Porio N, Tristani A, Connors JM, Goldhaber SZ, Piazza G. Anticoagulation-Associated Adverse Drug Events in Hospitalized Patients Across Two Time Periods. Am J Med 2023; 136:927-936.e3. [PMID: 37247752 DOI: 10.1016/j.amjmed.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/05/2023] [Accepted: 05/14/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Anticoagulants often cause adverse drug events (ADEs), comprised of medication errors and adverse drug reactions, in patients. Our study objective was to determine the clinical characteristics, types, severity, cause, and outcomes of anticoagulation-associated ADEs from 2015-2020 (a contemporary period following implementation of an electronic health record, infusion device technology, and anticoagulant dosing nomograms) and to compare them with those of a historical period (2004-2009). METHODS We reviewed all anticoagulant-associated ADEs reported as part of our hospital-wide safety system. Reviewers classified type, severity, root cause, and outcomes for each ADE according to standard definitions. Reviewers also assessed events for patient harm. Patients were followed up to 30 days after the event. RESULTS Despite implementation of enhanced patient safety technology and procedure, ADEs increased in the contemporary period. In the contemporary period, we found 925 patients who had 984 anticoagulation-associated ADEs, including 811 isolated medication errors (82.4%); 13 isolated adverse drug reactions (1.4%); and 160 combined medication errors, adverse drug reactions, or both (16.2%). Unfractionated heparin was the most frequent ADE-related anticoagulant (77.7%, contemporary period vs 58.3%, historical period). The most frequent anticoagulation-associated medication error in the contemporary period was wrong rate or frequency of administration (26.1%, n = 253), with the most frequent root cause being prescribing errors (21.3%, n = 207). The type, root cause, and harm from ADEs were similar between periods. CONCLUSIONS We found that anticoagulation-associated ADEs occurred despite advances in patient safety technologies and practices. Events were common, suggesting marginal improvements in anticoagulant safety over time and ample opportunities for improvement.
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Affiliation(s)
- John Fanikos
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Yahya Tawfik
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Danya Almheiri
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Katelyn Sylvester
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Leo F Buckley
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Chris Dew
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Dell'Orfano
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andre Armero
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Umberto Campia
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Julia Davies
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Karen Fiumara
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Heather Hogan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Candrika Dini Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Darsiya Krishnathasan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Junyang Lou
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alaa Makawi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Ruth H Morrison
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Nicole Porio
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Anthony Tristani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Jean M Connors
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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16
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Bikdeli B, Khairani CD, Krishnathasan D, Bejjani A, Armero A, Tristani A, Davies J, Porio N, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Achanta A, Jesudasen SJ, Tiu BC, Merli GJ, Leiva O, Fanikos J, Sharma A, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll BJ, Lan Z, Goldhaber SZ, Piazza G. Major cardiovascular events after COVID-19, event rates post-vaccination, antiviral or anti-inflammatory therapy, and temporal trends: Rationale and methodology of the CORONA-VTE-Network study. Thromb Res 2023; 228:94-104. [PMID: 37302267 PMCID: PMC10226776 DOI: 10.1016/j.thromres.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular and thrombotic events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to more recent event rates, temporal trends, association between vaccination status and outcomes, and findings within vulnerable subgroups such as older adults (aged 65 years or older), or those undergoing hemodialysis. Sex-informed findings, including results among pregnant and breastfeeding women, as well as adjusted comparisons between male and female adults are similarly understudied. METHODS Adult patients, aged ≥18 years, with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at the participating centers of the registry are eligible for inclusion. A total of 10,000 patients have been included in this multicenter study, with Brigham and Women's Hospital (Boston, MA) serving as the coordinating center. Other sites include Beth Israel Deaconess Medical Center, Anne Arundel Medical Center, University of Virginia Medical Center, University of Colorado Health System, and Thomas Jefferson University Health System. Data elements will be ascertained manually for accuracy. The two main outcomes are 1) a composite of venous or arterial thrombotic events, and 2) a composite of major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Clinical outcomes are adjudicated by independent physicians. Vaccination status and time of inclusion in the study will be ascertained for subgroup-specific analyses. Outcomes are pre-specified to be reported separately for hospitalized patients versus those who were initially receiving outpatient care. Outcomes will be reported at 30-day and 90-day follow-up. Data cleaning at the sites and the data coordinating center and outcomes adjudication process are in-progress. CONCLUSIONS The CORONA-VTE-Network study will share contemporary information related to rates of cardiovascular and thrombotic events in patients with COVID-19 overall, as well as within key subgroups, including by time of inclusion, vaccination status, patients undergoing hemodialysis, the elderly, and sex-informed analyses such as comparison of women and men, or among pregnant and breastfeeding women.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali A Assi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce C Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett J Carroll
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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17
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Piazza G, Hurwitz S, Campia U, Bikdeli B, Lou J, Khairani CD, Bejjani A, Snyder JE, Pfeferman M, Barns B, Rizzo S, Glezer A, Goldhaber SZ. Electronic alerts for ambulatory patients with atrial fibrillation not prescribed anticoagulation: A randomized, controlled trial (AF-ALERT2). Thromb Res 2023; 227:1-7. [PMID: 37182298 DOI: 10.1016/j.thromres.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Despite widely available risk stratification tools, safe and effective anticoagulants, and guideline recommendations, anticoagulation for stroke prevention in atrial fibrillation (AF) is under-prescribed in ambulatory patients. To assess the impact of alert-based computerized decision support (CDS) on anticoagulation prescription in ambulatory patients with AF and high-risk for stroke, we conducted this randomized controlled trial. METHODS Patients with AF and CHA2DS2-VASc score ≥ 2 who were not prescribed anticoagulation and had a clinic visit at Brigham and Women's Hospital were enrolled. Patients were randomly allocated, according to Attending Physician of record, to intervention (alert-based CDS) versus control (no notification). The primary efficacy outcome was the frequency of anticoagulant prescription. RESULTS The CDS tool assigned 395 and 403 patients to the alert and control groups, respectively. Alert patients were more likely to be prescribed anticoagulation within 48 h of the clinic visit (15.4 % vs. 7.7 %, p < 0.001) and at 90 days (17.2 % vs. 9.9 %, p < 0.01). Direct oral anticoagulants were the predominantly prescribed form of anticoagulation. No significant differences were observed in stroke, TIA, or systemic embolic events (0 % vs. 0.8 %, p = 0.09), symptomatic VTE (0.5 % vs. 1 %, p = 0.43), all-cause mortality (2 % vs. 0.7 %, p = 0.12), or major adverse cardiovascular events (2.8 % vs. 2.5 %, p = 0.79) at 90 days. CONCLUSIONS An alert-based CDS strategy increased a primary efficacy outcome of anticoagulation in clinic patients with AF and high-risk for stroke who were not receiving anticoagulation at the time of the office visit. The study was likely underpowered to assess an impact on clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier- NCT02958943.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Behnood Bikdeli
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Yale New Haven Hospital (YNHH), Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Junyang Lou
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mariana Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Briana Barns
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Georgetown University School of Medicine, Washington, DC, USA
| | - Alexandra Glezer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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18
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Camm AJ, Steffel J, Virdone S, Bassand JP, Fox KAA, Goldhaber SZ, Goto S, Haas S, Turpie AGG, Verheugt FWA, Misselwitz F, Herreros RC, Kayani G, Pieper KS, Kakkar AK. Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF. Eur Heart J Open 2023; 3:oead051. [PMID: 37293139 PMCID: PMC10246824 DOI: 10.1093/ehjopen/oead051] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
Aims This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362). Methods and results Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHA2DS2-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease (n = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism. Conclusion In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHA2DS2-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use. Clinical Trial Registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Affiliation(s)
- Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- University of Besançon, Besançon, France
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Sylvia Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
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19
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Talasaz AH, Sadeghipour P, Bakhshandeh H, Sharif-Kashani B, Rashidi F, Beigmohammadi MT, Gohari Moghadam K, Rezaian S, Dabbagh A, Sezavar SH, Farrokhpour M, Abedini A, Aliannejad R, Riahi T, Yadollahzadeh M, Lookzadeh S, Rezaeifar P, Matin S, Tahamtan O, Mohammadi K, Zoghi E, Rahmani H, Hosseini SH, Mousavian SM, Abri H, Sadeghipour P, Baghizadeh E, Rafiee F, Jamalkhani S, Amin A, Mohebbi B, Parhizgar SE, Soleimanzadeh M, Aghakouchakzadeh M, Eslami V, Payandemehr P, Khalili H, Talakoob H, Tojari T, Shafaghi S, Tabrizi S, Kakavand H, Kashefizadeh A, Najafi A, Jiménez D, Gupta A, Madhavan MV, Sethi S, Parikh SA, Monreal M, Hadavand N, Hajighasemi A, Ansarin K, Maleki M, Sadeghian S, Barco S, Siegerink B, Spatz E, Piazza G, Kirtane AJ, Van Tassell BW, Lip GY, Klok E, Goldhaber SZ, Stone G, Krumholz H, Bikdeli B. Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial. Thromb Haemost 2023. [PMID: 36944357 DOI: 10.1055/a-2059-4844] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUNDS In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a non-significant 16% reduction in 30-day composite of venous/arterial thrombosis or death in ICU patients with COVID-19. Thrombo-inflammatory response in COVID-19 may last beyond the first 30 days. METHODS This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this pre-specified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with Post-COVID-19 Functional Scale (PCFS). RESULTS In the primary analysis, 587 patients were included (age: 57 (Q1, Q3: 45, 68) years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio, HR: 0.80, 95% confidence interval, CI: 0.60-1.05, P=0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, Pinteraction=0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (ORordinal, 0.64, 95% CI: 0.41 to 1.01, P=0.05). CONCLUSIONS Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset. (NCT04486508).
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Affiliation(s)
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Babak Sharif-Kashani
- Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | | | - Mohammad Taghi Beigmohammadi
- Anesthesiology and Intensive Care, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Keivan Gohari Moghadam
- Department of Internal Medicine, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Somayeh Rezaian
- Alborz University of Medicine Science, Karaj, Iran., Tehran, Iran (the Islamic Republic of)
| | - Ali Dabbagh
- Cardiac Anesthesiology, Anesthesiology Research Center, Tehran, Iran (the Islamic Republic of)
| | - Seyed Hashem Sezavar
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Mohsen Farrokhpour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Atefeh Abedini
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Rasoul Aliannejad
- Department of Pulmonary and Critical Care, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Taghi Riahi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Mahdi Yadollahzadeh
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Somayeh Lookzadeh
- Chronic Respiratory Disease Research Center, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Parisa Rezaeifar
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Samira Matin
- Tuberclosis and Lung Diseases Research Center, Tabriz, Iran (the Islamic Republic of)
| | - Ooria Tahamtan
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Keyhan Mohammadi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Elnaz Zoghi
- School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hamid Rahmani
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed Hossein Hosseini
- School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed Masoud Mousavian
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Homa Abri
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Pardis Sadeghipour
- Firouzgar hospital, Department of internal medicine, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Elahe Baghizadeh
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Farnaz Rafiee
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Sepehr Jamalkhani
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Seyed Ehsan Parhizgar
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | - Mahshid Soleimanzadeh
- Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | | | - Vahid Eslami
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Pooya Payandemehr
- Sina hospital, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hossein Khalili
- Department of Pharmacotherapy, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hamed Talakoob
- Cardiovascular Research Center, Alborz University of Medical Sciences, Karaj, Iran, Tehran, Iran (the Islamic Republic of)
| | - Taranom Tojari
- Department of Biotechnology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran., Tehran, Iran (the Islamic Republic of)
| | - Shadi Shafaghi
- Lung Transplantion Research Center, Department of Cardiology, National Research Institute of Tuberculosls and Lung Diseases (NRITLD), Shahid Beheshti University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Sanaz Tabrizi
- Rasoul-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Hessam Kakavand
- School of pharmacy, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Alireza Kashefizadeh
- Shahid Dr. Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran., Tehran, Iran (the Islamic Republic of)
| | - Atabak Najafi
- Sina Hospital, Tehran, Iran (the Islamic Republic of)
| | - David Jiménez
- Respiratory Division, Medicine Department, Ramón y Cajal Hospital, IRYCIS and Alcalá de Henares University, Madrid, Spain
| | - Aakriti Gupta
- Cardiovascular Research Foundation, New York, United States
| | | | - Sanjum Sethi
- Columbia University Irving Medical Center, New York, United States
| | - Sahil A Parikh
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York, United States
| | - Manuel Monreal
- Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Naser Hadavand
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | | | - Khalil Ansarin
- Tuberculosis and lung diseases research center, Tabriz University of Medical Sciences, Tabriz, Iran, Tabriz, Iran (the Islamic Republic of)
| | - Majid Maleki
- Rajaie Cardiovascular Medical and Research Center, Tehran, Iran (the Islamic Republic of)
| | | | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Bob Siegerink
- Leiden University Medical Center Department of Clinical Epidemiology, Leiden, Netherlands
| | - Erica Spatz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | - Ajay J Kirtane
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, United States
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, United States
| | - Gregory Yh Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool Institute of Ageing and Chronic Disease, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Erik Klok
- Dept. of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Gregg Stone
- Cardiovascular Research Foundation, New York, United States
| | - Harlan Krumholz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Behnood Bikdeli
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
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20
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Bikdeli B, Lo YC, Khairani C, Bejjani A, Jiménez D, Barco S, Mahajan S, Caraballo C, Secemsky E, Klok E, Hunsaker A, Aghayev A, Muriel A, Wang Y, Hussain M, Appah-Sampong A, Lu Y, Lin Z, Aneja S, Khera R, Goldhaber SZ, Zhou L, Monreal M, Krumholz H, Piazza G. Developing Validated Tools to Identify Pulmonary Embolism in Electronic Databases: Rationale and Design of the PE-EHR+ Study. Thromb Haemost 2023; 123:649-662. [PMID: 36809777 DOI: 10.1055/a-2039-3222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Contemporary pulmonary embolism (PE) research relies on data from electronic health records (EHRs) and administrative databases that use International Classification of Diseases (ICD) codes. Natural language processing (NLP) tools can be used for automated chart review and patient identification. However, there remains uncertainty with the validity of ICD-10 codes or NLP algorithms for patient identification. METHODS The PE-EHR+ study has been designed to validate ICD-10 codes as Principal Discharge Diagnosis, or Secondary Discharge Diagnoses, as well as NLP tools set out in prior studies to identify patients with PE within EHRs. Manual chart review by two independent abstractors by predefined criteria will be the reference standard. Sensitivity, specificity, and positive and negative predictive values will be determined. We will assess the discriminatory function of code subgroups for intermediate- and high-risk PE. In addition, accuracy of NLP algorithms to identify PE from radiology reports will be assessed. RESULTS A total of 1,734 patients from the Mass General Brigham health system have been identified. These include 578 with ICD-10 Principal Discharge Diagnosis codes for PE, 578 with codes in the secondary position, and 578 without PE codes during the index hospitalization. A smaller subset of patients will also be identified from the Yale-New Haven Health System. Data validation and analyses will be forthcoming. CONCLUSIONS The PE-EHR+ study will help validate efficient tools for identification of patients with PE in EHRs, improving the reliability of efficient observational studies or randomized trials of patients with PE using electronic databases.
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Affiliation(s)
- Behnood Bikdeli
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Ying-Chih Lo
- Brigham and Women's Hospital, Boston, United States
| | | | | | - David Jiménez
- Respiratory Division, Medicine Department, Ramón y Cajal Hospital, IRYCIS and Alcalá de Henares University, Madrid, Spain
| | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Cesar Caraballo
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Eric Secemsky
- Beth Israel Deaconess Medical Center, Boston, United States
| | - Erik Klok
- Dept. of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Netherlands.,Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Ayaz Aghayev
- Brigham and Women's Hospital, Boston, United States
| | | | - Yun Wang
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | | | - Yuan Lu
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Zhenqui Lin
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | - Sanjay Aneja
- Yale School of Medicine, New Haven, United States
| | - Rohan Khera
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
| | | | - Li Zhou
- Brigham and Women's Hospital, Boston, United States
| | - Manuel Monreal
- Universidad Catolica San Antonio de Murcia Facultad de Ciencias de la Salud, Barcelona, Spain
| | - Harlan Krumholz
- Yale University Center for Outcomes Research and Evaluation, New Haven, United States
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21
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Nicolajsen CW, Nielsen PB, Jensen M, Eldrup N, Larsen TB, Lip GYH, Goldhaber SZ, Søgaard M. Stroke and Myocardial Infarction in Patients with Abdominal Aortic Aneurysm and New-Onset Atrial Fibrillation. Thromb Haemost 2023; 123:555-564. [PMID: 36626930 DOI: 10.1055/a-2009-8954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE We investigated the association between new-onset atrial fibrillation (AF) and risk of stroke and myocardial infarction (MI) in patients with abdominal aortic aneurysmal (AAA) disease. METHODS Observational crossover study using Danish nationwide data, including patients with AAA and incident AF between 1997 and 2018. We estimated the 1-year risk of stroke and MI and the within-individual odds ratios (ORs) of ischemic events before and after an AF diagnosis, stratified by year of AF diagnosis (1997-2010 and 2011-2018), and supplemented with analyses on changes in use of antithrombotic therapy. RESULTS A total of 3,035 AAA patients were included: 1,040 diagnosed during 1997 to 2010, and 1,995 during 2011 to 2018 (22.2% females, median age 78 years; median CHA2DS2-VASc score 4; interquartile range: 3-5). One-year risk of ischemic events after AF was 5.9% (confidence interval [CI] 95%: 4.6-7.5%) and 4.5% (CI 95%: 3.7-5.5%) for stroke and 5.4% (CI 95%: 4.2-6.9%) and 4.0% (CI 95%: 3.2-4.9%) for MI during 1997 to 2010 and 2011 to 2018, respectively. The OR of ischemic stroke before and after incident AF was 2.8 (CI 95%: 1.6-5.2) during 1997 to 2010; and 2.4 (CI 95%: 1.5 to 3.9) during 2011 to 2018, and 3.5 (CI 95%: 1.7-7.5) and 1.5 (CI 95%: 0.9-2.4) for MI. One-year proportion of prescription claims for oral anticoagulants after AF changed from 66.1% in 1997 to 2010 to 82.6% in 2011 to 2018, while antiplatelet prescription claims changed from 80.8 to 60.9%. CONCLUSION Cardiovascular prognosis has improved in patients with prevalent AAA disease and new-onset AF in concordance with optimization of antithrombotic therapy over time. A diagnosis of AF conferred residual risk of stroke and MI.
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Affiliation(s)
- Chalotte W Nicolajsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Vascular Surgery, Viborg Regional Hospital, Viborg, Denmark
| | - Peter B Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Copenhagen University, Copenhagen, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Thrombosis Research Group, Brigham and Women's Hospital, Boston, Massachusetts, United States.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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22
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Rizzo SM, Tavakol S, Bi WL, Li S, Secemsky EA, Campia U, Piazza G, Goldhaber SZ, Schmaier AA. Meningioma resection and venous thromboembolism incidence, management, and outcomes. Res Pract Thromb Haemost 2023; 7:100121. [PMID: 37063769 PMCID: PMC10099298 DOI: 10.1016/j.rpth.2023.100121] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/24/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023] Open
Abstract
Background Meningioma resection is associated with the risk of venous thromboembolism (VTE). Objectives To determine the incidence and risk factors for VTE following meningioma resection and VTE outcomes based on the type and timing of anticoagulation. Methods From 2011 to 2019, 901 consecutive patients underwent meningioma resection. We retrospectively evaluated the postoperative incidence of VTE and bleeding. For VTE, we determined the treatment strategy and rate of VTE complications and bleeding. Results Pharmacologic prophylaxis was administered to 665 (73.8%) patients. The cumulative incidence for total postoperative VTE was 8.7% (95% CI: 6.9%-10.6%), and for symptomatic VTE was 6.0% (95% CI: 4.6%-7.7%). A multivariable model identified the following independent predictors of symptomatic VTE: history of VTE, obesity, and lack of pharmacologic prophylaxis. Following postoperative VTE, 58 (74.3%) patients received therapeutic anticoagulation either initially (33.3%) or after a median delay of 23.5 days (41.0%). Symptomatic recurrent VTE occurred in 13 (16.6%) patients. Following VTE, the use of subtherapeutic anticoagulation was associated with a lower rate of total VTE extension than no anticoagulation (17.5% vs 42.9%, OR 0.28, 95% CI: 0.09-0.93). In total, 14 patients (1.6%) experienced clinically relevant bleeding: 4 received therapeutic anticoagulants, 8 received prophylactic anticoagulation, and 2 received no anticoagulation. Among patients with VTE, 4 (5.1%) experienced bleeding. Conclusion Recognition of risk factors for VTE following meningioma resection may help improve approaches to thromboprophylaxis. The management of postoperative VTE is highly variable, but most VTE patients are ultimately treated with therapeutic anticoagulants.
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Affiliation(s)
- Samantha M. Rizzo
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Sherwin Tavakol
- Brigham and Women’s Hospital, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Wenya Linda Bi
- Brigham and Women’s Hospital, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Siling Li
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eric A. Secemsky
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Umberto Campia
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z. Goldhaber
- Brigham and Women’s Hospital, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Alec A. Schmaier
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Division of Hemostasis and Thrombosis, Harvard Medical School, Boston, Massachusetts, USA
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23
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Chi G, Violi F, Pignatelli P, Vestri A, Spagnoli A, Loffredo L, Hernandez AF, Hull RD, Cohen AT, Harrington RA, Goldhaber SZ, Gibson CM. External validation of the ADA score for predicting thrombosis among acutely ill hospitalized medical patients from the APEX Trial. J Thromb Thrombolysis 2023; 55:211-221. [PMID: 36566304 PMCID: PMC9789884 DOI: 10.1007/s11239-022-02757-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
The ADA (Age-D-dimer-Albumin) score was developed to identify hospitalized patients at an increased risk for thrombosis in the coronavirus infectious disease-19 (COVID-19) setting. The study aimed to validate the ADA score for predicting thrombosis in a non-COVID-19 medically ill population from the APEX trial. The APEX trial was a multinational, randomized trial that evaluated the efficacy and safety of betrixaban vs. enoxaparin among acutely ill hospitalized patients at risk for venous thromboembolism. The study endpoints included the composite of arterial or venous thrombosis and its components. Metrics of model calibration and discrimination were computed for assessing the performance of the ADA score as compared to the IMPROVE score, a well-validated VTE risk assessment model. Among 7,119 medical inpatients, 209 (2.9%) had a thrombosis event up to 77 days of follow-up. The ADA score demonstrated good calibration for both arterial and venous thrombosis, whereas the IMPROVE score had adequate calibration for venous thrombosis (p > 0.05 from the Hosmer-Lemeshow test). For discriminating arterial and venous thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.620 [95% CI: 0.582 to 0.657] vs. 0.590 [95% CI: 0.556 to 0.624]; ∆ c statistic = 0.030 [95% CI: -0.022 to 0.081]; p = 0.255). Similarly, for discriminating arterial thrombosis, there was no significant difference between the ADA vs. IMPROVE score (c statistic = 0.582 [95% CI: 0.534 to 0.629] vs. 0.609 [95% CI: 0.564 to 0.653]; ∆ c statistic = -0.027 [95% CI: -0.091 to 0.036]; p = 0.397). For discriminating venous thrombosis, the ADA score was modestly superior to the IMPROVE score (c statistic = 0.664 [95% CI: 0.607 to 0.722] vs. 0.573 [95% CI: 0.521 to 0.624]; ∆ c statistic = 0.091 [95% CI: 0.011 to 0.172]; p = 0.026). The ADA score had a higher sensitivity (0.579 [95% CI: 0.512 to 0.646]; vs. 0.440 [95% CI: 0.373 to 0.507]) but lower specificity (0.625 [95% CI: 0.614 to 0.637] vs. 0.747 [95% CI: 0.737 to 0.758]) than the IMPROVE score for predicting thrombosis. Among acutely ill hospitalized medical patients enrolled in the APEX trial, the ADA score demonstrated good calibration but suboptimal discrimination for predicting thrombosis. The findings support the use of either the ADA or IMPROVE score for thrombosis risk assessment. The applicability of the ADA score to non-COVID-19 populations warrants further research.Clinical Trial Registration: http://www.clinicaltrials.gov . Unique identifier: NCT01583218.
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Affiliation(s)
- Gerald Chi
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
| | - Francesco Violi
- I Clinica Medica, Sapienza University of Rome, and Medicina Cardiocentro, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Sapienza University of Rome, and Medicina Cardiocentro, Naples, Italy
| | - Annarita Vestri
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandra Spagnoli
- BioMedical Statistics Section, Department of Public health and Infectious Disease, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Loffredo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Russell D Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, King's College, London, UK
| | - Robert A Harrington
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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24
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Taqueti VR, Shah AM, Everett BM, Pradhan AD, Piazza G, Bibbo C, Hainer J, Morgan V, Carolina do A. H. de Souza A, Skali H, Blankstein R, Dorbala S, Goldhaber SZ, Le May MR, Chow BJ, deKemp RA, Hage FG, Beanlands RS, Libby P, Glynn RJ, Solomon SD, Ridker PM, Di Carli MF. Coronary Flow Reserve, Inflammation, and Myocardial Strain: The CIRT-CFR Trial. JACC Basic Transl Sci 2023; 8:141-151. [PMID: 36908662 PMCID: PMC9998473 DOI: 10.1016/j.jacbts.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/17/2022] [Indexed: 12/24/2022]
Abstract
Inflammation is a key determinant of cardiovascular outcomes, but its role in heart failure is uncertain. In patients with cardiometabolic disease enrolled in the prospective, multicenter ancillary study of CIRT (Cardiovascular Inflammation Reduction Trial), CIRT-CFR (Coronary Flow Reserve to Assess Cardiovascular Inflammation), impaired coronary flow reserve was independently associated with increased inflammation and myocardial strain despite well-controlled lipid, glycemic, and hemodynamic profiles. Inflammation modified the relationship between CFR and myocardial strain, disrupting the association between cardiac blood flow and function. Future studies are needed to investigate whether an early inflammation-mediated reduction in CFR capturing microvascular ischemia may lead to heart failure in patients with cardiometabolic disease. (Cardiovascular Inflammation Reduction Trial [CIRT]; NCT01594333; Coronary Flow Reserve to Assess Cardiovascular Inflammation [CIRT-CFR]; NCT02786134).
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Key Words
- BMI, body mass index
- CAD, coronary artery disease
- CFR, coronary flow reserve
- CT, computed tomography
- GLS, global longitudinal strain
- HDL, high-density lipoprotein cholesterol
- HFpEF, heart failure with preserved ejection fraction
- IL, interleukin
- LDL, low-density lipoprotein cholesterol
- LDM, low-dose methotrexate
- LVEF, left ventricular ejection fraction
- MBF, myocardial blood flow
- MI, myocardial infarction
- NHLBI, National Heart, Lung, and Blood Institute
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- PET, positron emission tomography
- cardiometabolic disease
- cardiovascular trial coronary flow reserve
- coronary microvascular dysfunction
- heart failure
- hsCRP, high-sensitivity C-reactive protein
- hsTNT, high-sensitivity troponin T
- inflammation
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Affiliation(s)
- Viviany R. Taqueti
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amil M. Shah
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendan M. Everett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aruna D. Pradhan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Courtney Bibbo
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Victoria Morgan
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ana Carolina do A. H. de Souza
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hicham Skali
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michel R. Le May
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Benjamin J.W. Chow
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Robert A. deKemp
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Fadi G. Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Rob S. Beanlands
- Division of Cardiology, University of Ottawa Heart Institute, National Cardiac Positron Emission Tomography (PET) Centre, Ottawa, Canada
| | - Peter Libby
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J. Glynn
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Scott D. Solomon
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Ridker
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Center for Cardiovascular Disease Prevention, Division of Preventive Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F. Di Carli
- Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Chopard R, Campia U, Jering KS, Almarzooq ZI, Snyder JE, Rizzo S, Waxman AB, Goldhaber SZ, Piazza G. Guideline adherence and clinical outcomes of patients with acute pulmonary embolism evaluated by a multidisciplinary response team at a quaternary care center. Thromb Res 2023; 222:113-116. [PMID: 36640566 DOI: 10.1016/j.thromres.2022.12.018] [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: 07/26/2022] [Revised: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 12/31/2022]
Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, Besançon, France; EA3920, University of Burgundy Franche-Comté, Besançon, France; F-CRIN, INNOVTE network, Saint-Etienne, France.
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karola S Jering
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zaid I Almarzooq
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Elizabeth Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Rizzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aaron B Waxman
- Division of Pulmonary and Critical Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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26
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O'Toole RV, Stein DM, O'Hara NN, Frey KP, Taylor TJ, Scharfstein DO, Carlini AR, Sudini K, Degani Y, Slobogean GP, Haut ER, Obremskey W, Firoozabadi R, Bosse MJ, Goldhaber SZ, Marvel D, Castillo RC. Aspirin or Low-Molecular-Weight Heparin for Thromboprophylaxis after a Fracture. N Engl J Med 2023; 388:203-213. [PMID: 36652352 DOI: 10.1056/nejmoa2205973] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [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: 01/19/2023]
Abstract
BACKGROUND Clinical guidelines recommend low-molecular-weight heparin for thromboprophylaxis in patients with fractures, but trials of its effectiveness as compared with aspirin are lacking. METHODS In this pragmatic, multicenter, randomized, noninferiority trial, we enrolled patients 18 years of age or older who had a fracture of an extremity (anywhere from hip to midfoot or shoulder to wrist) that had been treated operatively or who had any pelvic or acetabular fracture. Patients were randomly assigned to receive low-molecular-weight heparin (enoxaparin) at a dose of 30 mg twice daily or aspirin at a dose of 81 mg twice daily while they were in the hospital. After hospital discharge, the patients continued to receive thromboprophylaxis according to the clinical protocols of each hospital. The primary outcome was death from any cause at 90 days. Secondary outcomes were nonfatal pulmonary embolism, deep-vein thrombosis, and bleeding complications. RESULTS A total of 12,211 patients were randomly assigned to receive aspirin (6101 patients) or low-molecular-weight heparin (6110 patients). Patients had a mean (±SD) age of 44.6±17.8 years, 0.7% had a history of venous thromboembolism, and 2.5% had a history of cancer. Patients received a mean of 8.8±10.6 in-hospital thromboprophylaxis doses and were prescribed a median 21-day supply of thromboprophylaxis at discharge. Death occurred in 47 patients (0.78%) in the aspirin group and in 45 patients (0.73%) in the low-molecular-weight-heparin group (difference, 0.05 percentage points; 96.2% confidence interval, -0.27 to 0.38; P<0.001 for a noninferiority margin of 0.75 percentage points). Deep-vein thrombosis occurred in 2.51% of patients in the aspirin group and 1.71% in the low-molecular-weight-heparin group (difference, 0.80 percentage points; 95% CI, 0.28 to 1.31). The incidence of pulmonary embolism (1.49% in each group), bleeding complications, and other serious adverse events were similar in the two groups. CONCLUSIONS In patients with extremity fractures that had been treated operatively or with any pelvic or acetabular fracture, thromboprophylaxis with aspirin was noninferior to low-molecular-weight heparin in preventing death and was associated with low incidences of deep-vein thrombosis and pulmonary embolism and low 90-day mortality. (Funded by the Patient-Centered Outcomes Research Institute; PREVENT CLOT ClinicalTrials.gov number, NCT02984384.).
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Affiliation(s)
- Robert V O'Toole
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Deborah M Stein
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Nathan N O'Hara
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Katherine P Frey
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Tara J Taylor
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Daniel O Scharfstein
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Anthony R Carlini
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Kuladeep Sudini
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Yasmin Degani
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Gerard P Slobogean
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Elliott R Haut
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - William Obremskey
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Reza Firoozabadi
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Michael J Bosse
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Samuel Z Goldhaber
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Debra Marvel
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
| | - Renan C Castillo
- From the Departments of Orthopedics (R.V.O., N.N.O., Y.D., G.P.S.) and Surgery (D.M.S.), R Adams Cowley Shock Trauma Center, the University of Maryland School of Medicine, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health (K.P.F., T.J.T., A.R.C., K.S., R.C.C.), the Department of Surgery, John Hopkins Hospital (E.R.H.), and the PREVENT CLOT Patient and Stakeholder Committee (D.M.) - all in Baltimore; the Department of Population Health Science, University of Utah, Salt Lake City (D.O.S.); the Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville (W.O.); the Department of Orthopaedics and Sports Medicine, University of Washington, Seattle (R.F.); the Department of Orthopaedic Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC (M.J.B.); and the Department of Medicine, Harvard Medical School, Boston (S.Z.G.)
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27
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Khairani CD, Bejjani A, Piazza G, Jimenez D, Monreal M, Chatterjee S, Pengo V, Woller SC, Cortes-Hernandez J, Connors JM, Kanthi Y, Krumholz HM, Middeldorp S, Falanga A, Cushman M, Goldhaber SZ, Garcia DA, Bikdeli B. Direct Oral Anticoagulants vs Vitamin K Antagonists in Patients With Antiphospholipid Syndromes: Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2023; 81:16-30. [PMID: 36328154 PMCID: PMC9812926 DOI: 10.1016/j.jacc.2022.10.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/05/2022] [Accepted: 10/12/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) for patients with thrombotic antiphospholipid syndrome remain controversial. OBJECTIVES The authors performed a systematic review and meta-analysis of randomized controlled trials that compared DOACs with vitamin K antagonists (VKAs). METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials through April 9, 2022. The 2 main efficacy outcomes were a composite of arterial thrombotic events and venous thromboembolic events (VTEs). The main safety outcome was major bleeding. Random effects models with inverse variance were used. RESULTS Our search retrieved 253 studies. Four open-label randomized controlled trials involving 472 patients were included (mean control-arm time-in-therapeutic-range 60%). All had proper random sequence generation and adequate allocation concealment. Overall, the use of DOACs compared with VKAs was associated with increased odds of subsequent arterial thrombotic events (OR: 5.43; 95% CI: 1.87-15.75; P < 0.001, I2 = 0%), especially stroke, and the composite of arterial thrombotic events or VTE (OR: 4.46; 95% CI: 1.12-17.84; P = 0.03, I2 = 0%). The odds of subsequent VTE (OR: 1.20; 95% CI: 0.31-4.55; P = 0.79, I2 = 0%), or major bleeding (OR: 1.02; 95% CI: 0.42-2.47; P = 0.97; I2 = 0%) were not significantly different between the 2 groups. Most findings were consistent within subgroups. CONCLUSIONS Patients with thrombotic antiphospholipid syndrome randomized to DOACs compared with VKAs appear to have increased risk for arterial thrombosis. No significant differences were observed between patients randomized to DOACs vs VKAs in the risk of subsequent VTE or major bleeding.
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Affiliation(s)
- Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Manuel Monreal
- Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - Saurav Chatterjee
- Division of Cardiology, St Luke's-Roosevelt Hospital Center of the Mount Sinai Health System, New York, New York, USA
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy
| | - Scott C Woller
- Department of Medicine, Intermountain Medical Center, Murray, Utah, USA; Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yogendra Kanthi
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Harlan M Krumholz
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut, USA
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna Falanga
- University of Milan Bicocca, School of Medicine, Milan, Italy; Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Cardiovascular Research Foundation, New York, New York, USA.
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28
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Sadeghipour P, Jenab Y, Moosavi J, Hosseini K, Mohebbi B, Hosseinsabet A, Chatterjee S, Pouraliakbar H, Shirani S, Shishehbor MH, Alizadehasl A, Farrashi M, Rezvani MA, Rafiee F, Jalali A, Rashedi S, Shafe O, Giri J, Monreal M, Jimenez D, Lang I, Maleki M, Goldhaber SZ, Krumholz HM, Piazza G, Bikdeli B. Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial. JAMA Cardiol 2022; 7:1189-1197. [PMID: 36260302 PMCID: PMC9582964 DOI: 10.1001/jamacardio.2022.3591] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2023]
Abstract
Importance The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration ClinicalTrials.gov Identifier: NCT05172115.
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Affiliation(s)
- Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Yaser Jenab
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinsabet
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Northshore-LIJ Hospitals of Northwell Health, New York, New York
- Zucker School of Medicine, New York, New York
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Shapour Shirani
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehdi H. Shishehbor
- University Hospitals, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Azin Alizadehasl
- Cardio-Oncology Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Melody Farrashi
- Echocardiography Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Rezvani
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnaz Rafiee
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sina Rashedi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Shafe
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia
| | - Manuel Monreal
- Faculty of Health Sciences, Universidad Católica San Antonio de Murcia, Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal, Madrid, Spain
- Medicine Department, Universidad de Alcalá, Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Irene Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Majid Maleki
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular, Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Samuel Z. Goldhaber
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Yale New Haven Hospital Center for Outcomes Research & Evaluation, Yale, New Haven, Connecticut
- Cardiovascular Research Foundation, New York, New York
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29
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Farmakis I, Valerio L, Mavromanoli AC, Bikdeli B, Connors JM, Giannakoulas G, Goldhaber SZ, Hobohm L, Hunt BJ, Keller K, Klok FA, Spyropoulos AC, Kucher N, Konstantinides S, Barco S. Mortality related to pulmonary embolism in the United States before and during the COVID-19 pandemic: an analysis of the CDC Multiple Cause of Death database. Eur Heart J 2022. [PMCID: PMC9619500 DOI: 10.1093/eurheartj/ehac544.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background The COVID-19 pandemic caused a large number of excess deaths. COVID-19 emerged as a prothrombotic disease often complicated by pulmonary embolism (PE). In light of this, we hypothesized that PE-related mortality rates (stable before the pandemic) would be characterized by an increasing trend following the COVID-19 outbreak. Purpose To investigate the mortality rates associated with PE among deaths with or without COVID-19 during the 2020 pandemic in the United States (US). Methods For this retrospective epidemiological study, we analyzed public medically certified vital registration data (death certificates encompassing underlying and multiple causes of death) from the Mortality Multiple Cause-of-Death database provided by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2018–20). We investigated the time trends in monthly PE-related crude mortality rates for 2018–2019 and for 2020 (the latter associated vs. not associated with COVID-19), utilizing annual national population totals from the US Census Bureau. Second, we calculated the PE-related proportionate mortality among COVID-19 deaths (overall and limited to autopsy-based diagnosis). We performed subgroup analyses based on age groups, sex and race. Results During 2020, 49,423 deaths in association with PE were reported, vs. 39,450 in 2019 and 38,215 in 2018. The crude PE-related mortality rate without COVID-19 was 13.3 per 100,000 population in 2020 compared to 11.7 in 2018 and 12.0 in 2019 (Figure 1A). The PE-related mortality rate with COVID-19 was 1.6 per 100,000 population in 2020. Among non-COVID-19-related deaths, the crude PE-related mortality rate was higher in women; among COVID-19-related deaths, it was higher in men. PE-related mortality rates were approximately two-fold higher among black (vs. white) general population irrespective of COVID-19 status (Figures 1B and 1C). Among COVID-19 deaths, PE-related deaths corresponded to 1.4% of total; the value rose to 6.0% when an autopsy was performed. This figure was higher in men and its time evolution is depicted in Figure 2A. The proportionate mortality of PE in COVID-19 deaths was higher for younger age groups (15–44 years) compared to non-COVID-19-related deaths (Figure 2B). Conclusion In 2020, an overall 20%-increase in PE-related mortality was reported, not being limited to patients with COVID-19. Our findings could be interpreted in the context of undiagnosed COVID-19 cases, uncounted late sequelae, and possibly sedentary lifestyle and avoidance of healthcare facilities during the pandemic that may have prevented timely diagnosis and treatment of other diseases. Whether vaccination programs had an impact on PE-associated mortality in the year 2021, remains to be determined. Funding Acknowledgement Type of funding sources: None.
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Affiliation(s)
- I Farmakis
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - L Valerio
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | | | - B Bikdeli
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - J M Connors
- Brigham and Women's Hospital, Hematology Division , Boston , United States of America
| | - G Giannakoulas
- AHEPA University General Hospital, Department of Cardiology , Thessaloniki , Greece
| | - S Z Goldhaber
- Brigham and Women's Hospital, Cardiovascular Medicine Division , Boston , United States of America
| | - L Hobohm
- Center for Thrombosis and Hemostasis , Mainz , Germany
| | - B J Hunt
- Guy's & St Thomas' NHS Foundation Trust, St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group , London , United Kingdom
| | - K Keller
- University Medical Center Mainz, Department of Cardiology , Mainz , Germany
| | - F A Klok
- Leiden University Medical Center, Department of Medicine - Thrombosis and Hemostasis , Leiden , The Netherlands
| | - A C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell , Hempstead , United States of America
| | - N Kucher
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
| | | | - S Barco
- University Hospital Zurich, Department of Angiology , Zurich , Switzerland
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30
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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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31
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Albertsen IE, Konstantinides S, Piazza G, Goldhaber SZ, Larsen TB, Søgaard M, Brønnum Nielsen P. Risk of recurrent venous thromboembolism in selected subgroups of men: a Danish nationwide cohort study. TH Open 2022; 6:e378-e386. [DOI: 10.1055/a-1949-9404] [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: 01/03/2022] [Accepted: 09/19/2022] [Indexed: 10/14/2022] Open
Abstract
Background
Although men are considered at high risk for recurrent venous thromboembolism (VTE), sex-specific data on prognostic factors are lacking. We estimated the cumulative recurrence risks associated with clinical characteristics and comorbidities known or suspected to be associated with the developing of VTE recurrence: major surgery, trauma, history of cancer, rheumatic disorder, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, diabetes, chronic renal disease, varicose veins, alcohol-related diseases, and arterial hypertension.
Methods
We linked nationwide Danish health registries to identify all incident VTE in- and outpatients in men from 2008 through 2018. Recurrent VTE risk two years after anticoagulant discontinuation was calculated using the Aalen-Johansen estimator, stratified by age above/below 50 years.
Results
The study included 13,932 men with VTE, of whom 21% (n=2,898) were aged < 50 years. For men aged < 50 years with at least one of the clinical characteristics, two-year recurrence risk ranged from 6% (major surgery) to 16% (history of cancer). For men ≥ 50 years with at least one of the characteristics, recurrence risk ranged from 7% (major surgery) to 12% (ischemic heart disease, chronic obstructive pulmonary disease, and chronic renal disease). Men aged < 50 and ≥ 50 years without the clinical characteristics all had a recurrence risk of 10%.
Discussion
We demonstrated a two-year recurrence risk of at least 6%, regardless of age category and disease status, in this nationwide cohort of men with VTE. The recurrence risk must be balanced against bleeding risk. However, the high recurrence risk across all subgroups might ultimately lead to greater emphasis on male sex in future guidelines focusing on optimized secondary VTE prevention.
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Affiliation(s)
- Ida Ehlers Albertsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Stavros Konstantinides
- Centre for Thrombosis and Haemostasis, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany
- University Medical Centre, Johannes Gutenberg University Mainz, Germany
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, United States
| | | | | | - Mette Søgaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Klok FA, Piazza G, Sharp ASP, Ní Ainle F, Jaff MR, Chauhan N, Patel B, Barco S, Goldhaber SZ, Kucher N, Lang IM, Schmidtmann I, Sterling KM, Becker D, Martin N, Rosenfield K, Konstantinides SV. Ultrasound-facilitated, catheter-directed thrombolysis vs anticoagulation alone for acute intermediate-high-risk pulmonary embolism: Rationale and design of the HI-PEITHO study. Am Heart J 2022; 251:43-53. [PMID: 35588898 DOI: 10.1016/j.ahj.2022.05.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/13/2022] [Accepted: 05/13/2022] [Indexed: 05/21/2023]
Abstract
BACKGROUND Due to the bleeding risk of full-dose systemic thrombolysis and the lack of major trials focusing on the clinical benefits of catheter-directed treatment, heparin antiocoagulation remains the standard of care for patients with intermediate-high-risk pulmonary embolism (PE). METHODS AND RESULTS The Higher-Risk Pulmonary Embolism Thrombolysis (HI-PEITHO) study (ClinicalTrials.gov Identifier: NCT04790370) is a multinational multicenter randomized controlled parallel-group comparison trial. Patients with: (1) confirmed acute PE; (2) evidence of right ventricular (RV) dysfunction on imaging; (3) a positive cardiac troponin test; and (4) clinical criteria indicating an elevated risk of early death or imminent hemodynamic collapse, will be randomized 1:1 to treatment with a standardized protocol of ultrasound-facilitated catheter-directed thrombolysis plus anticoagulation, vs anticoagulation alone. The primary outcome is a composite of PE-related mortality, cardiorespiratory decompensation or collapse, or non-fatal symptomatic and objectively confirmed PE recurrence, within 7 days of randomization. Further assessments cover, apart from bleeding complications, a broad spectrum of functional and patient-reported outcomes including quality of life indicators, functional status and the utilization of health care resources over a 12-month follow-up period. The trial plans to include 406 patients, but the adaptive design permits a sample size increase depending on the results of the predefined interim analysis. As of May 11, 2022, 27 subjects have been enrolled. The trial is funded by Boston Scientific Corporation and through collaborative research agreements with University of Mainz and The PERT Consortium. CONCLUSIONS Regardless of the outcome, HI-PEITHO will establish the first-line treatment in intermediate-high risk PE patients with imminent hemodynamic collapse. The trial is expected to inform international guidelines and set the standard for evaluation of catheter-directed reperfusion options in the future.
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Affiliation(s)
- Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Fionnuala Ní Ainle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | | | | | | | - Stefano Barco
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland; Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Nils Kucher
- Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Irene M Lang
- Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Keith M Sterling
- Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, VA
| | - Dorothea Becker
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Nadine Martin
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Kenneth Rosenfield
- Division of Vascular Medicine and Intervention, Massachusetts General Hospital, Boston, MA
| | - Stavros V Konstantinides
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
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Farmakis IT, Valerio L, Bikdeli B, Connors JM, Giannakoulas G, Goldhaber SZ, Hobohm L, Hunt BJ, Keller K, Spyropoulos AC, Barco S. Annual mortality related to pulmonary embolism in the US before and during the COVID-19 pandemic. J Am Coll Cardiol 2022; 80:1579-1581. [PMID: 36038034 PMCID: PMC9412135 DOI: 10.1016/j.jacc.2022.08.721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/27/2022] [Accepted: 08/10/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Jean M Connors
- Brigham and Women's Hospital, Hematology Division, Harvard Medical School, Boston, United States
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Beverley J Hunt
- St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Cardiology, University Medical Center Mainz, Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Alex C Spyropoulos
- Department of Medicine, Lenox Hill Hospital at Northwell Health and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
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Camm CF, Virdone S, Goto S, Bassand JP, van Eickels M, Haas S, Gersh BJ, Pieper K, Fox KAA, Misselwitz F, Turpie AGG, Goldhaber SZ, Verheugt F, Camm J, Kayani G, Panchenko E, Oh S, Luciardi HL, Sawhney JPS, Connolly SJ, Angchaisuksiri P, ten Cate H, Eikelboom JW, Kakkar AK. Association of body mass index with outcomes in patients with newly diagnosed atrial fibrillation: GARFIELD-AF. Open Heart 2022. [PMCID: PMC9362832 DOI: 10.1136/openhrt-2022-002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective While greater body mass index (BMI) is associated with increased risk of developing atrial fibrillation (AF), the impact of BMI on outcomes in newly diagnosed AF is unclear. We examine the influence of BMI on outcomes and whether this is modified by sex and evaluate the effect of non-vitamin K oral anticoagulants (NOACs) in patients with high BMI. Methods GARFIELD-AF is a prospective registry of 52 057 newly diagnosed AF patients. The study population comprised 40 482 participants: 703 underweight (BMI <18.5 kg/m2), 13 095 normal (BMI=18.5–24.9 kg/m2), 15 043 overweight (BMI=25.0–29.9 kg/m2), 7560 obese (BMI=30.0–34.9 kg/m2) and 4081 extremely obese (BMI ≥35.0 kg/m2). Restricted cubic splines quantified the association of BMI with outcomes. Comparative effectiveness of NOACs and vitamin K antagonists (VKAs) by BMI was performed using propensity score overlap-weighted Cox models. Results The median age of participants was 71.0 years (Q1; Q3 62.0; 78.0), and 55.6% were male. Those with high BMI were younger, more often had vascular disease, hypertension and diabetes. Within 2-year follow-up, a U-shaped relationship between BMI and all-cause mortality was observed, with BMI of ~30 kg/m2 associated with the lowest risk. The association with new/worsening heart failure was similar. Only low BMI was associated with major bleeding and no association emerged for non-haemorrhagic stroke. BMI was similarly associated with outcomes in men and women. BMI did not impact the lower rate of all-cause mortality of NOACs compared with VKAs. Conclusions In the GARFIELD-AF registry, underweight and extremely obese AF patients have increased risk of mortality and new/worsening heart failure compared with normal or obese patients.
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35
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Leiva O, Campia U, Snyder J, Barns BM, Rizzo S, Khairani CD, Brunner A, Al-Samkari H, Leaf RK, Rosovsky R, Goodarzi K, Bornikova L, Fathi A, Goldhaber SZ, Hobbs G, Piazza G. Patients with myeloproliferative neoplasms and COVID-19 have increased rates of arterial thrombosis. Res Pract Thromb Haemost 2022; 6:e12752. [PMID: 35979196 PMCID: PMC9372283 DOI: 10.1002/rth2.12752] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background Both coronavirus disease‐2019 (COVID‐19) and myeloproliferative neoplasms (MPNs) are associated with systemic inflammation and risk of thrombosis. Risk of thrombosis in patients with COVID with and without MPNs has not been extensively studied. Methods Retrospective cohort study of 44 patients with MPNs and 1114 patients without MPNs positive for SARS‐COV‐2. Outcomes were arterial thrombosis (AT), venous thromboembolism (VTE), bleeding, and death. Time‐to‐event analysis was performed using competing risk regression model and Cox proportional hazards. Results AT occurred more frequently in patients with MPN (7% vs. 1%, p = 0.03). Rates of VTE (7% vs. 5%, p = 0.73), bleeding (7% vs. 2%, p = 0.06), and death (9% vs. 6%, p = 0.32) were similar. MPN patients were older and had more cardiovascular comorbidities. After time‐to‐event competing‐risk regression adjusting for age, MPN patients had higher risk of AT (subdivision hazards ratio 3.95, 95% CI 1.09–14.39) but not VTE, bleeding, or death. Conclusions Among patients with COVID‐19, MPN patients had higher risk of arterial thrombosis but not VTE, bleeding, and death compared with non‐MPN patients. Larger studies are needed to confirm our findings given the limited sample size.
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Affiliation(s)
- Orly Leiva
- Division of Cardiovascular Medicine, Department of Medicine New York University Langone Health New York City New York USA.,Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Julia Snyder
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Briana M Barns
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Samantha Rizzo
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Andrew Brunner
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Hanny Al-Samkari
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Rebecca Karp Leaf
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Rachel Rosovsky
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Katayoon Goodarzi
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Larissa Bornikova
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Amir Fathi
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
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Nicolajsen CW, Søgaard M, Eldrup N, Jensen M, Larsen TB, Goldhaber SZ, Nielsen PB. Temporal trends in abdominal aortic aneurysmal disease: a nationwide cohort study on cardiovascular morbidity and medical cardioprotective therapy. Eur J Prev Cardiol 2022; 29:1957-1964. [DOI: 10.1093/eurjpc/zwac105] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/27/2022] [Accepted: 05/17/2022] [Indexed: 01/04/2023]
Abstract
Abstract
Aims
Abdominal aortic aneurysmal disease is associated with increased risk of cardiovascular morbidity and death, which potentially can be reduced with cardioprotective medical therapy. The aim of this study was to observe temporal trends in prevalence and incidence of cardiovascular comorbidity as well as use of medical cardioprotective treatment in patients diagnosed with abdominal aortic aneurysmal disease.
Methods and results
This was a population-based cohort study based on data from national health registries, including all patients diagnosed with abdominal aortic aneurysms between 1998 and 2018. Data were stratified into four time periods (1999–2003, 2004–2008, 2009–2013, and 2014–2018) to illustrate trends over time. Outcome measures were (i) cardiovascular comorbidity and medical cardioprotective therapy at time of diagnosis, (ii) new admissions for atherosclerotic cardiovascular disease, and (iii) all-cause mortality after 2-year follow-up. The study cohort included 33 296 individuals. Mean age was 74 years. Prevalence of atherosclerotic cardiovascular comorbidity at diagnosis decreased from 41.5 to 32.6%. Use of statins increased from 17.9 to 66.9%, antiplatelets from 45.6 to 63.3%, and combined therapy with both antiplatelets and statins from 11.3 to 44.8%, and from 12.1 to 50.7% when anticoagulant therapy was included. Developments in medication use plateaued after 2013. Prevalence and incidence of atherosclerotic cardiovascular disease decreased through all four time periods. The same applied to all-cause mortality, which decreased from 24.3 to 12.4 deaths (per 100 person-years).
Conclusion
In patients diagnosed with abdominal aortic aneurysm, cardiovascular comorbidity at diagnosis, risk of future cardiovascular events, and all-cause mortality is decreasing. Nevertheless, cardiovascular burden and mortality rates remain substantial, and medical cardioprotective therapy can be further improved.
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Affiliation(s)
- Chalotte W. Nicolajsen
- Department of Clinical Medicine, Faculty of Health, Aalborg Thrombosis Research Unit, Aalborg University , Sdr. Skovvej 15, 9000 Aalborg , Denmark
- Department of Cardiology, Aalborg University Hospital , Aalborg , Denmark
| | - Mette Søgaard
- Department of Clinical Medicine, Faculty of Health, Aalborg Thrombosis Research Unit, Aalborg University , Sdr. Skovvej 15, 9000 Aalborg , Denmark
- Department of Cardiology, Aalborg University Hospital , Aalborg , Denmark
| | - Nikolaj Eldrup
- Department of Vascular Surgery, Rigshospitalet , Copenhagen , Denmark
| | - Martin Jensen
- Department of Clinical Medicine, Faculty of Health, Aalborg Thrombosis Research Unit, Aalborg University , Sdr. Skovvej 15, 9000 Aalborg , Denmark
| | - Torben B. Larsen
- Department of Clinical Medicine, Faculty of Health, Aalborg Thrombosis Research Unit, Aalborg University , Sdr. Skovvej 15, 9000 Aalborg , Denmark
- Department of Cardiology, Aalborg University Hospital , Aalborg , Denmark
| | - Samuel Z. Goldhaber
- Thrombosis Research Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital , Boston, MA , USA
- Department of Medicine, Harvard Medical School , Boston, MA , USA
| | - Peter B. Nielsen
- Department of Clinical Medicine, Faculty of Health, Aalborg Thrombosis Research Unit, Aalborg University , Sdr. Skovvej 15, 9000 Aalborg , Denmark
- Department of Cardiology, Aalborg University Hospital , Aalborg , Denmark
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Romero JE, Goldhaber SZ. Uninterrupted Oral Anticoagulation During Catheter Ablation of Ventricular Tachycardia: Is the Riskier Option the Safest? JACC Clin Electrophysiol 2022; 8:749-753. [PMID: 35738851 DOI: 10.1016/j.jacep.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Jorge E Romero
- Cardiac Arrhythmia Center, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Samuel Z Goldhaber
- Thrombosis Research Group and Section of Vascular Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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38
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Bikdeli B, Piazza G, Jimenez D, Muriel A, Wang Y, Khairani CD, Rosovsky RP, Mehdipoor G, O'Donoghue ML, Spagnolo P, Dreyer RP, Bertoletti L, López-Jiménez L, Núñez MJ, Blanco-Molina Á, Bates SM, Gerhard-Herman M, Goldhaber SZ, Monreal M, Krumholz HM. Sex Differences in PrEsentation, Risk Factors, Drug and Interventional Therapies, and OUtcomes of Elderly PatientS with Pulmonary Embolism: Rationale and design of the SERIOUS-PE study. Thromb Res 2022; 214:122-131. [DOI: 10.1016/j.thromres.2022.04.019] [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] [Received: 03/03/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/16/2022]
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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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40
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Sylvester KW, Chen A, Lewin A, Fanikos J, Goldhaber SZ, Connors JM. Optimization of DOAC management services in a centralized anticoagulation clinic. Res Pract Thromb Haemost 2022; 6:e12696. [PMID: 35541695 PMCID: PMC9069544 DOI: 10.1002/rth2.12696] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background In 2017, the Brigham and Women’s Hospital Anticoagulation Management Service (BWH AMS) expanded services to patients on direct oral anticoagulants (DOACs). We have since updated our DOAC management plan and adjusted the workflow of our clinic. Objectives This report describes how our DOAC management has evolved and describes key interventions made. Additionally, we report on the results of a survey completed by referring physicians that assessed perspectives regarding centralized DOAC management by BWH AMS pharmacists. Methods An analysis was completed of all patients referred to the BWH AMS and the number of interventions completed and documented in our anticoagulation management software. A survey with eight questions was sent to 110 referring physicians (selected based on referring to the AMS within the past 1.5 years). Results Over 4 years, 1622 patients on DOACs were referred to the BWH AMS, amounting to 3154 DOAC encounters. A total of 212 interventions for medication procurement, 171 dose adjustment interventions, and 603 coordinated procedure plans were completed. Of the 32 physicians who responded to the survey, many believed that the quality and safety of anticoagulation therapy was improved with BWH AMS management. Despite provider satisfaction with pharmacist‐led care in DOACs, physicians expressed concerns regarding the lack of provider awareness of the clinic and possible duplicative efforts. Conclusion We plan to evolve the DOAC clinic model to optimize its clinical and operational value and to improve our delivery of care using electronic tools to move toward a population management approach for DOAC management.
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Affiliation(s)
- Katelyn W. Sylvester
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - Alisia Chen
- Bouve College of Health Sciences Northeastern University Boston Massachusetts USA
| | - Andrea Lewin
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - John Fanikos
- Department of Pharmacy Services Brigham and Women’s Hospital Boston Massachusetts USA
| | - Samuel Z. Goldhaber
- Division of Cardiovascular Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Jean M. Connors
- Division of Hematology Brigham and Women’s Hospital Boston Massachusetts USA
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Bejjani A, Khairani CD, Goldhaber SZ, Piazza G, Campia U. Abstract 549: Impact Of ST Segment Elevation On In-hospital Mortality And Stroke In Acute Aortic Syndromes. Arterioscler Thromb Vasc Biol 2022. [DOI: 10.1161/atvb.42.suppl_1.549] [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: 12/02/2022]
Abstract
Background:
Acute aortic syndromes (AAS) may present with a wide variety of electrocardiographic findings. We aimed to study the prevalence of ST segment elevation on ECG in patients presenting with AAS and to assess its association with in-hospital mortality and complications.
Methods:
Retrospective analysis of all patients who presented to our tertiary care center with AAS from July 2012 to October 2020. ST segment elevation was defined as being reported on the first ECG reading upon admission.
Results:
Of 338 patients presenting with AAS, 23 (6.8%) had ST segment elevation on their initial ECG. There was no difference in age among patients who had ST segment elevation compared to those who did not (63.3 ± 15.9 vs. 68.2 ± 15.1 respectively, p = 0.135). The rate of ST segment elevation was similar between females and males (8.2% vs. 5.9% respectively, p = 0.508) and between Stanford type A and type B AAS (6.7% vs. 6.9% respectively, p = 1.000). Patients presenting with ST segment elevation had a 3-fold increase in the risk of in-hospital mortality (unadjusted OR 3.37) and a 4-fold increase in the risk of in-hospital stroke (unadjusted OR 4.27) compared to those without. After adjusting for age, sex, atrial fibrillation on initial ECG, and type of AAS, ST segment elevation remained independently associated with mortality (adjusted OR 6.06) and stroke (adjusted OR 5.33).
Conclusion:
In patients presenting with AAS, ST segment elevation on the initial ECG was independently associated with in-hospital mortality and stroke.
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Abunimer AM, Lak AM, Calvachi P, Smith TR, Aglio LS, Almefty KK, Dunn IF, Bi WL, Goldhaber SZ, Al-Mefty O. Early Detection and Management of Venous Thrombosis in Skull Base Surgery: Role of Routine Doppler Ultrasound Monitoring. Neurosurgery 2022; 91:115-122. [PMID: 35383697 DOI: 10.1227/neu.0000000000001936] [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: 08/17/2021] [Accepted: 01/08/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), encompassing deep venous thrombosis (DVT) and pulmonary embolism (PE), causes postoperative morbidity and mortality in neurosurgical patients. The use of pharmacological prophylaxis for DVT prevention in the immediate postoperative period carries increased risk of intracranial hemorrhage, especially after skull base surgeries. OBJECTIVE To investigate the impact of routine Doppler ultrasound monitoring in prevention and tiered management of VTE after skull base surgery. METHODS We retrospectively analyzed a large cohort of consecutive adult patients who were prospectively and uniformly managed with routine monitoring by Doppler ultrasound for DVT after resection of a skull base tumor. RESULTS A total of 389 patients who underwent 459 surgeries for intracranial tumor resection were analyzed. Skull base meningioma was the most common pathology. Forty-four (9.59%) postoperative VTEs were detected: 9 (1.96%) with PE with or without DVT and 35 (7.63%) with DVT alone. Four cases of subsegmental PE were diagnosed without evidence of lower extremity DVT, possibly in the setting of peripherally inserted central catheters maintenance. One patient had a preoperative proximal DVT and underwent a prophylactic inferior vena cava filter but expired from PE after discharge. Prior history of VTE (risk ratio [RR] 5.13; 95% CI 2.76-7.18; P < .01), anesthesia duration (RR 1.14; 95% CI 1.03-1.27; P = .02), and blood transfusion (RR 1.95; 95% CI 1.01-3.37; P = .04) were associated with VTE development on multivariate analysis. CONCLUSION Routine postoperative venous ultrasound monitoring detects asymptomatic DVT guiding management. This is an alternative strategy to prescribing pharmacological VTE prophylaxis immediately after lengthy surgeries for intracranial tumors. Peripherally inserted central catheters were associated with subsegmental PE.
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Affiliation(s)
- Abdullah M Abunimer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Asad M Lak
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Paola Calvachi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda S Aglio
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ian F Dunn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ossama Al-Mefty
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Pellegrini VD, Eikelboom JW, Evarts CM, Franklin PD, Garvin KL, Goldhaber SZ, Iorio R, Lambourne CA, Magaziner J, Magder L. Randomised comparative effectiveness trial of Pulmonary Embolism Prevention after hiP and kneE Replacement (PEPPER): the PEPPER trial protocol. BMJ Open 2022; 12:e060000. [PMID: 35260464 PMCID: PMC8905949 DOI: 10.1136/bmjopen-2021-060000] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION More than 1 million elective total hip and knee replacements are performed annually in the USA with 2% risk of clinical pulmonary embolism (PE), 0.1%-0.5% fatal PE, and over 1000 deaths. Antithrombotic prophylaxis is standard of care but evidence is limited and conflicting. We will compare effectiveness of three commonly used chemoprophylaxis agents to prevent all-cause mortality (ACM) and clinical venous thromboembolism (VTE) while avoiding bleeding complications. METHODS AND ANALYSIS Pulmonary Embolism Prevention after HiP and KneE Replacement is a large randomised pragmatic comparative effectiveness trial with non-inferiority design and target enrolment of 20 000 patients comparing aspirin (81 mg two times a day), low-intensity warfarin (INR (International Normalized Ratio) target 1.7-2.2) and rivaroxaban (10 mg/day). The primary effectiveness outcome is aggregate of VTE and ACM, primary safety outcome is clinical bleeding complications, and patient-reported outcomes are determined at 1, 3 and 6 months. Primary data analysis is per protocol, as preferred for non-inferiority trials, with secondary analyses adherent to intention-to-treat principles. All non-fatal outcomes are captured from patient and clinical reports with independent blinded adjudication. Study design and oversight are by a multidisciplinary stakeholder team including a 10-patient advisory board. ETHICS AND DISSEMINATION The Institutional Review Board of the Medical University of South Carolina provides central regulatory oversight. Patients aged 21 or older undergoing primary or revision hip or knee replacement are block randomised by site and procedure; those on chronic anticoagulation are excluded. Recruitment commenced at 30 North American centres in December 2016. Enrolment currently exceeds 13 500 patients, representing 33% of those eligible at participating sites, and is projected to conclude in July 2024; COVID-19 may force an extension. Results will inform antithrombotic choice by patients and other stakeholders for various risk cohorts, and will be disseminated through academic publications, meeting presentations and communications to advocacy groups and patient participants. TRIAL REGISTRATION NCT02810704.
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Affiliation(s)
| | | | - C McCollister Evarts
- Orthopaedics and Physical Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Patricia D Franklin
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kevin L Garvin
- Orthopaedics and Physical Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Richard Iorio
- Orthopaedics, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carol Ann Lambourne
- Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jay Magaziner
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence Magder
- Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Albertsen IE, Konstantinides SV, Piazza G, Goldhaber SZ, Larsen TB, Soegaard M, Nielsen PB. RISK OF RECURRENT VENOUS THROMBOEMBOLISM IN SUBGROUPS OF MEN: A NATIONWIDE COHORT STUDY. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02507-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
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Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Bikdeli B, Khairani CD, Barns BM, Rosovsky RP, Jimenez D, Monreal M, Sylvester KW, Middeldorp S, Bates SM, Krumholz HM, Goldhaber SZ, Hunt BJ, Piazza G. Women's representation in venous thromboembolism randomized trials and registries: The illustrative example of direct oral anticoagulants for acute treatment. Contemp Clin Trials 2022; 115:106714. [PMID: 35202841 DOI: 10.1016/j.cct.2022.106714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/22/2022]
Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA.
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Briana M Barns
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - Katelyn W Sylvester
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - Saskia Middeldorp
- Department of Internal Medicine &, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Shannon M Bates
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Health Policy and Administration, Yale School of Public Health, New Haven, CT, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
| | - Beverley J Hunt
- Haemostasis and Thrombosis Centre, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Boston, MA, USA
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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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Fox KAA, Virdone S, Bassand JP, Camm AJ, Goto S, Goldhaber SZ, Haas S, Kayani G, Koretsune Y, Misselwitz F, Oh S, Piccini JP, Parkhomenko A, Sawhney JPS, Stepinska J, Turpie AGG, Verheugt FWA, Kakkar AK. Do baseline characteristics and treatments account for geographical disparities in the outcomes of patients with newly diagnosed atrial fibrillation? The prospective GARFIELD-AF registry. BMJ Open 2022; 12:e049933. [PMID: 34996784 PMCID: PMC8744109 DOI: 10.1136/bmjopen-2021-049933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE In patients with newly diagnosed atrial fibrillation (AF), do baseline risk factors and stroke prevention strategies account for the geographically diverse outcomes. DESIGN Global Anticoagulant Registry in the FIELD-Atrial Fibrillation is a prospective multinational non-interventional registry of patients with newly diagnosed AF (n=52 018 patients). SETTING Investigator sites (n=1317) were representative of the care settings/locations in each of the 35 participating countries. Treatment decisions were all determined by the local responsible clinicians. PARTICIPANTS The patients (18 years and over) with newly diagnosed AF had at least 1 investigator-determined stroke risk factor and patients were not required to meet specific thresholds of risk score for anticoagulant treatment. MAIN OUTCOMES AND MEASURES Observed 1-year event rates and risk-standardised rates were derived. RESULTS Rates of death, non-haemorrhagic stroke/systemic embolism and major bleeding varied more than three-to-four fold across countries even after adjustment for baseline factors and antithrombotic treatments. Rates of anticoagulation and antithrombotic treatment varied widely. Patients from countries with the highest rates of cardiovascular mortality and stroke were among the least likely to receive oral anticoagulants. Beyond anticoagulant treatment, variations in the treatment of comorbidities and lifestyle factors may have contributed to the variations in outcomes. Countries with the lowest healthcare Access and Quality indices (India, Ukraine, Argentina, Brazil) had the highest risk-standardised mortality. CONCLUSION The variability in outcomes across countries for patients with newly diagnosed AF is not accounted for by baseline characteristics and antithrombotic treatments. Residual mortality rates were correlated with Healthcare Access and Quality indices. The findings suggest the management of patients with AF needs to not only address guideline indicated and sustained anticoagulation, but also the treatment of comorbidities and lifestyle factors. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- Department of Cardiology, University of Besançon, Besancon, France
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine Graduate School of Medicine, Isehara, Japan
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munchen, Germany
| | | | | | | | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Jongno-gu, Korea (the Republic of)
| | | | - Alex Parkhomenko
- National Scientific Center M D Strazhesko Institute of Cardiology, The National Academy of Medical Sciences of Ukraine, Kiiv, Ukraine
| | | | - Janina Stepinska
- Institute of Cardiology, Intensive Cardiac therapy clinic, Warsaw, Poland
| | | | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
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Kalayci A, Gibson CM, Hernandez AF, Hull RD, Cohen AT, Fitzgerald C, Hussain SD, Chi G, Alkhalfan F, Harrington RA, Goldhaber SZ. Inverse relationship between body mass index and risk of venous thromboembolism among medically ill hospitalized patients: Observations from the APEX trial. Thromb Res 2022; 211:63-69. [DOI: 10.1016/j.thromres.2022.01.016] [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] [Received: 06/16/2021] [Revised: 01/02/2022] [Accepted: 01/17/2022] [Indexed: 11/29/2022]
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50
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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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