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Jolly SS, Lee SF, Mian R, Kedev S, Lavi S, Moreno R, Montalescot G, Hillani A, Henry TD, Asani V, Storey RF, Silvain J, Spratt JCS, d'Entremont MA, Stankovic G, Zafirovska B, Natarajan MK, Sabate M, Shreenivas S, Pinilla-Echeverri N, Sheth T, Altisent OAJ, Ribas N, Skuriat E, Tyrwhitt J, Mehta SR. SYNERGY-Everolimus-Eluting Stent With a Bioabsorbable Polymer in ST-Elevation Myocardial Infarction: CLEAR SYNERGY OASIS-9 Registry. Am J Cardiol 2024; 220:111-117. [PMID: 38447893 DOI: 10.1016/j.amjcard.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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/23/2024] [Accepted: 02/17/2024] [Indexed: 03/08/2024]
Abstract
Our objective was to evaluate the clinical effectiveness of the SYNERGY stent (Boston Scientific Corporation, Marlborough, Massachusetts) in patients with ST-elevation myocardial infarction (STEMI). The only drug-eluting stent approved for treatment of STEMI by the Food and Drug Administration is the Taxus stent (Boston Scientific) which is no longer commercially available, so further data are needed. The CLEAR (Colchicine and spironolactone in patients with myocardial infarction) SYNERGY stent registry was embedded into a larger randomized trial of patients with STEMI (n = 7,000), comparing colchicine versus placebo and spironolactone versus placebo. The primary outcome for the SYNERGY stent registry is major adverse cardiac events (MACE) as defined by cardiovascular death, recurrent MI, or unplanned ischemia-driven target vessel revascularization within 12 months. We estimated a MACE rate of 6.3% at 12 months after primary percutaneous coronary intervention for STEMI based on the Thrombectomy vs percutaneous coronary intervention alone in STEMI (TOTAL) trial. Success was defined as upper bound of confidence interval (CI) to be less than the performance goal of 9.45%. Overall, 733 patients were enrolled from 8 countries with a mean age 60 years, 19.4% diabetes mellitus, 41.3% anterior MI, and median door-to-balloon time of 72 minutes. The MACE rate was 4.8% (95% CI 3.2 to 6.3%) at 12 months which met the success criteria against performance goal of 9.45%. The rates of cardiovascular death, recurrent MI, or target vessel revascularization were 2.7%, 1.9%, 1.0%, respectively. The rates of acute definite stent thrombosis were 0.3%, subacute 0.4%, late 0.4%, and cumulative stent thrombosis of 1.1% at 12 months. In conclusion, the SYNERGY stent in STEMI performed well and was successful compared with the performance goal based on previous trials.
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Affiliation(s)
- Sanjit S Jolly
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada.
| | - Shun Fu Lee
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Rajibul Mian
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Sasko Kedev
- Department of Cardiology, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Shahar Lavi
- Department of Medicine, Western University, London, Ontario, Canada
| | - Raul Moreno
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | | | - Ali Hillani
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Timothy D Henry
- Department of Cardiology, The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, Cincinnati, Ohio
| | - Valon Asani
- Department of Cardiology, Clinical Hospital Tetovo, Tetovo, Macedonia
| | - Robert F Storey
- Department of Cardiology, University of Sheffield, Sheffield, United Kingdom
| | - Johanne Silvain
- Department of Cardiology, Sorbonne University, ACTION Group, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - James C S Spratt
- Department of Cardiology, St. George's University of London, London, England
| | - Marc-André d'Entremont
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada; Department of Cardiology, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Biljana Zafirovska
- Department of Cardiology, University Ss. Cyril and Methodius, Skopje, North Macedonia
| | - Madhu K Natarajan
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Manel Sabate
- Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Satya Shreenivas
- Department of Cardiology, The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital Health Network, Cincinnati, Ohio
| | - Natalia Pinilla-Echeverri
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Tej Sheth
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | | | - Núria Ribas
- Department of Cardiology, Hospital del Mar, Heart Disease Biomedical Research Group 8GRC), IMIM (Hospital del Mar Medical Research Institute), Universitat Pompeu Fabra, Barcelona, Spain
| | - Elizabeth Skuriat
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Jessica Tyrwhitt
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
| | - Shamir R Mehta
- Department of Medicine, Population Health Research Institute McMaster University, Hamilton, Ontario, Canada
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2
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Sirén M, Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumäki J, Tahvanainen M, Koivula K, Wang J, Cairns JA, Niemelä K, Eskola M, Nikus KC, Hernesniemi J. The prognostic significance of single-lead ST-segment resolution in ST-segment elevation myocardial infarction patients treated with primary PCI - A substudy of the randomized TOTAL trial. Am Heart J 2024; 269:149-157. [PMID: 38109987 DOI: 10.1016/j.ahj.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/21/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND ST-segment elevation myocardial infarction (STEMI) is associated with high morbidity and mortality worldwide. Simple electrocardiogram (ECG) tools, including ST-segment resolution (STR) have been developed to identify high-risk STEMI patients after primary percutaneous coronary intervention (PCI). SUBJECTS AND METHODS We evaluated the prognostic impact of STR in the ECG lead with maximal baseline ST-segment elevation (STE) 30-60 minutes after primary PCI in 7,654 STEMI patients included in the TOTAL trial. Incomplete or no STR was defined as < 70% STR and complete STR as ≥ 70% STR. The primary outcome was the composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock, or new or worsening New York Heart Association (NYHA) class IV heart failure at 1-year follow-up. RESULTS Of 7,654 patients, 42.9% had incomplete or no STR and 57.1% had complete STR. The primary outcome occurred in 341 patients (10.4%) in the incomplete or no STR group and in 234 patients (5.4%) in the complete STR group. In Cox regression analysis, adjusted hazard ratio for STR < 70% to predict the primary outcome was 1.56 (95% confidence interval 1.32-1.89; P < .001) (model adjusted for all baseline comorbidities, clinical status during hospitalization, angiographic findings, and procedural techniques). CONCLUSION In a large international study of STEMI patients, STR < 70% 30-60 minutes post primary PCI in the ECG lead with the greatest STE at admission was associated with an increased rate of the composite of cardiovascular death, recurrent MI, cardiogenic shock, or new or worsening NYHA class IV heart failure at 1-year follow-up. Clinicians should pay attention to this simple ECG finding.
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Affiliation(s)
- Marko Sirén
- Faculty of Medicine and Health Technology and Finnish Cardiovascular Research Center, Tampere University, Tampere, Finland.
| | - Joonas Leivo
- Faculty of Medicine and Health Technology and Finnish Cardiovascular Research Center, Tampere University, Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | | | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Jyri Koivumäki
- Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Minna Tahvanainen
- Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Kimmo Koivula
- Internal medicine, South Karelia Central Hospital, Lappeenranta, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
| | - John A Cairns
- The University of British Columbia, Vancouver, Canada
| | - Kari Niemelä
- Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Markku Eskola
- Faculty of Medicine and Health Technology and Finnish Cardiovascular Research Center, Tampere University, Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Kjell C Nikus
- Faculty of Medicine and Health Technology and Finnish Cardiovascular Research Center, Tampere University, Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Jussi Hernesniemi
- Faculty of Medicine and Health Technology and Finnish Cardiovascular Research Center, Tampere University, Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tampere, Finland
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d'Entremont MA, Alrashidi S, Seto AH, Nguyen P, Marquis-Gravel G, Abu-Fadel MS, Juergens C, Tessier P, Lemaire-Paquette S, Heenan L, Skuriat E, Tyrwhitt J, Couture ÉL, Bérubé S, Jolly SS. Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data metaanalysis from the femoral ultrasound trialist collaboration. EUROINTERVENTION 2024; 20:66-74. [PMID: 37800723 PMCID: PMC10758987 DOI: 10.4244/eij-d-22-00809] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/01/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Randomised controlled trials of ultrasound (US)-guided transfemoral access (TFA) for coronary procedures have shown mixed results. AIMS We aimed to compare US-guided versus non-US-guided TFA from randomised data in an individual participant-level data (IPD) meta-analysis. METHODS We completed a systematic review and an IPD meta-analysis of all randomised controlled trials comparing US-guided versus non-US-guided TFA for coronary procedures. We performed a one-stage mixed-model meta-analysis using the intention-to-treat population from included trials. The primary outcome was a composite of major vascular complications or major bleeding within 30 days. RESULTS A total of 2,441 participants (1,208 US-guided, 1,233 non-US-guided) from 4 randomised clinical trials were included. The mean age was 65.5 years, 27.0% were female, and 34.5% underwent a percutaneous coronary intervention. The incidence of major vascular complications or major bleeding (34/1,208 [2.8%] vs 55/1,233 [4.5%]; odds ratio [OR] 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026) was lower in the US-guided TFA group. In the prespecified subgroup of participants who received a vascular closure device, those randomised to US-guided TFA experienced a reduction in the primary outcome (2.1% vs 5.6%; OR 0.36, 95% CI: 0.19-0.69), while no benefit for US guidance was observed in the subgroup without vascular closure devices (4.1% vs 3.3%; OR 1.21, 95% CI: 0.65-2.26; interaction p=0.009). CONCLUSIONS In participants undergoing coronary procedures by TFA, US guidance decreased the composite outcome of major vascular complications or bleeding and may be especially helpful when using vascular closure devices.
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Affiliation(s)
- Marc-André d'Entremont
- Population Health Research Institute, Hamilton, ON, Canada
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
- McMaster University, Hamilton, ON, Canada
| | | | | | - Phong Nguyen
- Western Sydney University, Campbelltown, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | | | - Mazen S Abu-Fadel
- Oklahoma Heart Hospital, Oklahoma City, OK, USA and University of Oklahoma, Norman, OK, USA
| | - Craig Juergens
- University of New South Wales, Sydney, NSW, Australia
- Liverpool Hospital, Liverpool, NSW, Australia
| | - Pierre Tessier
- Hôpital du Sacré-Coeur-de-Montréal, Montreal, QC, Canada
| | | | - Laura Heenan
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Étienne L Couture
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Simon Bérubé
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada
- McMaster University, Hamilton, ON, Canada
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Conen D, Ke Wang M, Popova E, Chan MTV, Landoni G, Cata JP, Reimer C, McLean SR, Srinathan SK, Reyes JCT, Grande AM, Tallada AG, Sessler DI, Fleischmann E, Kabon B, Voltolini L, Cruz P, Maziak DE, Gutiérrez-Soriano L, McIntyre WF, Tandon V, Martínez-Téllez E, Guerra-Londono JJ, DuMerton D, Wong RHL, McGuire AL, Kidane B, Roux DP, Shargall Y, Wells JR, Ofori SN, Vincent J, Xu L, Li Z, Eikelboom JW, Jolly SS, Healey JS, Devereaux PJ. Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial. Lancet 2023; 402:1627-1635. [PMID: 37640035 DOI: 10.1016/s0140-6736(23)01689-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications. METHODS COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125. FINDINGS Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22). INTERPRETATION In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea. FUNDING Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.
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Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ekaterine Popova
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute University San Raffaele, Milan, Italy
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cara Reimer
- Department of Anesthesiology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sean R McLean
- Vancouver Acute Department of Anesthesia and Perioperative Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Patrícia Cruz
- Service of Anesthesiology and Reanimation, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Laura Gutiérrez-Soriano
- Anesthesiology Department, Anesthesiology Research Group, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - William F McIntyre
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Juan Jose Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anna L McGuire
- Division of Thoracic Surgery, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sandra N Ofori
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Lizhen Xu
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Mubashir MM, Rattan V, Jolly SS. Differences in morphology of temporomandibular joint ankylosis of traumatic and infective origin. Int J Oral Maxillofac Surg 2023; 52:1081-1089. [PMID: 36739205 DOI: 10.1016/j.ijom.2023.01.009] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 02/05/2023]
Abstract
The aim of this study was to determine whether there are any differences in morphology between temporomandibular joint ankylosis (TMJA) of traumatic and infective origin. Cone beam computed tomography (CBCT) scans of 25 patients (28 joints) with TMJA of traumatic origin (trauma group) and 15 patients (15 joints) with TMJA of infectious origin (infection group) were included. The following morphological parameters were evaluated on multiple sections of the CBCT scans: lateral juxta-articular bone growth, residual condyle, residual glenoid fossa, ramus thickening, ankylotic mass fusion line, sclerosis of the ankylosed condyle and spongiosa of the glenoid fossa, and mastoid and glenoid fossa air cell obliteration. Lateral juxta-articular bone growth, juxta-articular extension of fusion, and the presence of normal medial residual condyle and residual glenoid fossa were exclusively found in post-traumatic TMJA. There were differences in ramus thickening (82.1% in trauma vs 53.3% in infection), sclerosis of the ankylosed condyle (100% in trauma vs 60% in infection), and sclerosis of the spongiosa of the glenoid fossa (100% in trauma vs 46.7% in infection) between the trauma and infection groups. Mastoid and glenoid fossa air cell obliteration was found more frequently in the infection group (mastoid obliteration: 23.1% in infection vs 4% in trauma; glenoid obliteration: 66.7% in infection vs 55.6% in trauma ). CBCT imaging can be helpful in differentiating between TMJA of traumatic and infectious origin.
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Affiliation(s)
- M M Mubashir
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - V Rattan
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - S S Jolly
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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d'Entremont MA, Marquis-Gravel G, Paradis JM, Bérubé S, Seto AH, Nguyen P, Mehta SR, Couture ÉL, Jolly SS. Strategies to Reduce Transfemoral Access Complications in Contemporary Interventional Cardiology. Can J Cardiol 2023; 39:1392-1396. [PMID: 37211041 DOI: 10.1016/j.cjca.2023.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/11/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Affiliation(s)
- Marc-André d'Entremont
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Simon Bérubé
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Arnold H Seto
- Long Beach VA Medical Center, Long Beach, California, USA
| | - Phong Nguyen
- Western Sydney University, Campbelltown, New South Wales, Australia; University of New South Wales, Liverpool, New South Wales, Australia
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Étienne L Couture
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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7
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Leivo J, Anttonen E, Jolly SS, Džavík V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola M. The prognostic significance of Q waves and T wave inversions in the ECG of patients with STEMI: A substudy of the TOTAL trial. J Electrocardiol 2023; 80:99-105. [PMID: 37295167 DOI: 10.1016/j.jelectrocard.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND The prognostic significance of Q waves and T-wave inversions (TWI) combined and separately in STEMI patients undergoing primary PCI has not been well established in previous studies. METHODS We included 7,831 patients from the TOTAL trial and divided the patients into categories based on Q waves and TWIs in the presenting ECG. The primary outcome was a composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock or new or worsening NYHA class IV heart failure within one year. The study evaluated the effect of Q waves and TWI on the risk of primary outcome and all-cause death, and whether patient benefit of aspiration thrombectomy differed between the ECG categories. RESULTS Patients with Q+TWI+ (Q wave and TWI) pattern had higher risk of primary outcome compared to patients with Q-TWI- pattern [33 (10.5%) vs. 221 (4.2%); adjusted hazard ratio (aHR) 2.10; 95% CI, 1.45-3.04; p<0.001] within 40-days' period. When analyzed separately, patients with Q waves had a higher risk for the primary outcome compared to patients with no Q waves in the first 40 days [aHR 1.80; 95% CI, 1.48-2.19; p<0.001] but there was no additive risk after 40 days. Patients with TWI had a higher risk for primary outcome only after 40 days when compared to patients with no TWI [aHR 1.63; 95% CI, 1.04-2.55; p=0.033]. There was a trend towards a benefit of thrombectomy in patients with the Q+TWI+ pattern. CONCLUSIONS Q waves and TWI combined (Q+TWI+ pattern) in the presenting ECG is associated with unfavourable outcome within 40-days. Q waves tend to affect short-term outcome, while TWI has more effect on long-term outcome.
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Affiliation(s)
- Joonas Leivo
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland.
| | - Eero Anttonen
- Päijät-sote, Primary Health Care, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; Hamilton Health Sciences, P.O. Box 2000, Hamilton, ON L8N 3Z5, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, 6-246A EN, Toronto General Hospital, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Jyri Koivumäki
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Minna Tahvanainen
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Kimmo Koivula
- Internal Medicine, South Karelia Central Hospital, Valto Käkelän katu 1, 53130 Lappeenranta, Finland
| | - Kjell Nikus
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Faculty of Health Sciences, 1280 Main St. W., Hamilton, Ontario L8S4K1, Canada
| | - John A Cairns
- The University of British Columbia, 2329 West Mall, Vancouver, British Columbia V6T1Z4, Canada
| | - Kari Niemelä
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland
| | - Markku Eskola
- Heart Hospital, Tampere University Hospital, Tays Sydänsairaala, PL 2000, 33521 Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Arvo Ylpön katu 34, 33520 Tampere, Finland
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8
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Leong DP, Cirne F, Aghel N, Baro Vila RC, Cavalli GD, Ellis PM, Healey JS, Whitlock R, Khalaf D, Mian H, Jolly SS, Mehta SR, Dent S. Cardiac Interventions in Patients With Active, Advanced Solid and Hematologic Malignancies: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:415-430. [PMID: 37614581 PMCID: PMC10443114 DOI: 10.1016/j.jaccao.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 08/25/2023] Open
Abstract
Invasive cardiac interventions are recommended to treat ST-segment elevation myocardial infarction, non-ST-segment elevation acute coronary syndromes, multivessel coronary disease, severe symptomatic aortic stenosis, and cardiomyopathy. These recommendations are based on randomized controlled trials that historically included few individuals with active, advanced malignancies. Advanced malignancies represent a significant competing risk for mortality, and there is limited evidence to inform the risks and benefits of invasive cardiac interventions in affected patients. We review the benefit conferred by invasive cardiac interventions; the periprocedural considerations; the contemporary survival expectations of patients across several types of active, advanced malignancy; and the literature on cardiovascular interventions in these populations. Our objective is to develop a rational framework to guide clinical recommendations on the use of invasive cardiac interventions in patients with active, advanced cancer.
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Affiliation(s)
- Darryl P. Leong
- The Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Filipe Cirne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nazanin Aghel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Peter M. Ellis
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S. Healey
- The Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Whitlock
- The Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dina Khalaf
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Hira Mian
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Sanjit S. Jolly
- The Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shamir R. Mehta
- The Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, North Carolina, USA
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9
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d'Entremont MA, Alazzoni A, Dzavik V, Sharma V, Overgaard CB, Lemaire-Paquette S, Lamelas P, Cairns JA, Mehta SR, Natarajan MK, Sheth TN, Schwalm JD, Rao SV, Stankovic G, Kedev S, Moreno R, Cantor WJ, Lavi S, Bertrand OF, Nguyen M, Couture ÉL, Jolly SS. No-reflow after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction: an angiographic core laboratory analysis of the TOTAL Trial. EUROINTERVENTION 2023:EIJ-D-23-00112. [PMID: 37382909 PMCID: PMC10397677 DOI: 10.4244/eij-d-23-00112] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND The optimal strategy to prevent no-reflow in ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) is unknown. AIMS We aimed to examine the effect of thrombectomy on the outcome of no-reflow in key subgroups and the adverse clinical outcomes associated with no-reflow. METHODS We performed a post hoc analysis of the TOTAL Trial, a randomised trial of 10,732 patients comparing thrombectomy versus PCI alone. This analysis utilised the angiographic data of 1,800 randomly selected patients. RESULTS No-reflow was diagnosed in 196 of 1,800 eligible patients (10.9%). No-reflow occurred in 95/891 (10.7%) patients randomised to thrombectomy compared with 101/909 (11.1%) in the PCI-alone arm (odds ratio [OR] 0.95, 95% confidence interval [CI]: 0.71-1.28; p-value=0.76). In the subgroup of patients who underwent direct stenting, those randomised to thrombectomy compared with PCI alone experienced less no-reflow (19/371 [5.1%] vs 21/216 [9.7%], OR 0.50, 95% CI: 0.26-0.96). In patients who did not undergo direct stenting, there was no difference between the groups (64/504 [12.7%] vs 75/686 [10.9%)], OR 1.18, 95% CI: 0.82-1.69; interaction p-value=0.02). No-reflow patients had a significantly increased risk of experiencing the primary composite outcome (cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or NYHA Class IV heart failure) at 1 year (adjusted hazard ratio 1.70, 95% CI: 1.13-2.56; p-value=0.01). CONCLUSIONS In patients with STEMI treated by PCI, thrombectomy did not reduce no-reflow in all patients but may be synergistic with direct stenting. No-reflow is associated with increased adverse clinical outcomes.
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Affiliation(s)
- Marc-André d'Entremont
- Sherbrooke University Hospital Center (CHUS), Sherbrooke, QC, Canada
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Vinoda Sharma
- Birmingham City Hospital, University of Birmingham, Birmingham, UK
| | | | | | - Pablo Lamelas
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - John A Cairns
- Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Tej N Sheth
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - John-David Schwalm
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sunil V Rao
- New York University Langone Health, New York, NY, USA
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, University of Belgrade, Belgrade, Serbia
| | - Sasko Kedev
- University Clinic of Cardiology, Ss. Cyril and Methodius University, Skopje, Republic of North Macedonia
| | | | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, ON, Canada
| | - Shahar Lavi
- London Health Sciences Centre, London, ON, Canada
| | | | - Michel Nguyen
- Sherbrooke University Hospital Center (CHUS), Sherbrooke, QC, Canada
| | - Étienne L Couture
- Sherbrooke University Hospital Center (CHUS), Sherbrooke, QC, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
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10
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Eikelboom JW, Belley-Cote E, Whitlock RP, Jolly SS, Wasserman S, Yusuf S. ACT trials: long-term outcomes. Lancet Respir Med 2023; 11:e50. [PMID: 37263712 DOI: 10.1016/s2213-2600(23)00148-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 06/03/2023]
Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Emilie Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Surgery, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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11
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d'Entremont MA, Jolly SS. GPIIb/IIIa inhibitors in primary percutaneous coronary intervention in ST-elevation myocardial infarction - Less is more? Cardiovascular Revascularization Medicine 2023; 51:8-9. [PMID: 37005104 DOI: 10.1016/j.carrev.2023.03.014] [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: 03/17/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023]
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12
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d'Entremont MA, Alrashidi S, Alansari O, Brochu B, Heenan L, Skuriat E, Tyrwhitt J, Raco M, Tsang M, Valettas N, Velianou JL, Sheth TN, Sibbald M, Mehta SR, Pinilla-Echeverri N, Schwalm JD, Natarajan MK, Kelly A, Akl E, Tawadros S, Camargo M, Faidi W, Bauer J, Moxham R, Nkurunziza J, Dutra G, Winter J, Jolly SS. Ultrasound-guided femoral access in patients with vascular closure devices: a prespecified analysis of the randomised UNIVERSAL trial. EUROINTERVENTION 2023; 19:73-79. [PMID: 36876864 PMCID: PMC10174184 DOI: 10.4244/eij-d-22-01130] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Whether ultrasound (US)-guided femoral access compared to femoral access without US guidance decreases access site complications in patients receiving a vascular closure device (VCD) is unclear. AIMS We aimed to compare the safety of VCD in patients undergoing US-guided versus non-US-guided femoral arterial access for coronary procedures. METHODS We performed a prespecified subgroup analysis of the UNIVERSAL trial, a multicentre randomised controlled trial of 1:1 US-guided femoral access versus non-US-guided femoral access, stratified for planned VCD use, for coronary procedures on a background of fluoroscopic landmarking. The primary endpoint was a composite of major Bleeding Academic Research Consortium 2, 3 or 5 bleeding and vascular complications at 30 days. RESULTS Of 621 patients, 328 (52.8%) received a VCD (86% ANGIO-SEAL, 14% ProGlide). In patients who received a VCD, those randomised to US-guided femoral access compared to non-US-guided femoral access experienced a reduction in major bleeding or vascular complications (20/170 [11.8%] vs 37/158 [23.4%], odds ratio [OR] 0.44, 95% confidence interval [CI]: 0.23-0.82). In patients who did not receive a VCD, there was no difference between the US- and non-US-guided femoral access groups, respectively (20/141 [14.2%] vs 13/152 [8.6%], OR 1.76, 95% CI: 0.80-4.03; interaction p=0.004). CONCLUSIONS In patients receiving a VCD after coronary procedures, US-guided femoral access was associated with fewer bleeding and vascular complications compared to femoral access without US guidance. US guidance for femoral access may be particularly beneficial when VCD are used.
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Affiliation(s)
- Marc-André d'Entremont
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Sulaiman Alrashidi
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Omar Alansari
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Bradley Brochu
- CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Laura Heenan
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | - Micheal Raco
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Micheal Tsang
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - James L Velianou
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Tej N Sheth
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Jon David Schwalm
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Andrew Kelly
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Elie Akl
- McGill University Faculty of Medicine and Health Sciences, Montreal, QC, Canada
| | | | | | - Walaa Faidi
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - John Bauer
- Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - James Nkurunziza
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
| | - Gustavo Dutra
- McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Jose Winter
- Clinica Alemana De Santiago, Universidad de Desarrollo, Santiago, Chile
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada.,McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada.,Niagara Health, St. Catharines, ON, Canada
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13
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Manzi MV, Buccheri S, Jolly SS, Zijlstra F, Frobert O, Lagerqvist B, Mahmoud KD, Dzavik V, Barbato E, Sarno G, James S. 532 SEX-RELATED DIFFERENCES IN THROMBUS BURDEN IN ST-ELEVATION MYOCARDIAL INFARCTION PATIENTS UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION. Eur Heart J Suppl 2022. [DOI: 10.1093/eurheartjsupp/suac121.344] [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: 12/23/2022]
Abstract
Abstract
Background
Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated.
Objectives
The aim of this study was to assess the sex-related differences in TB and its clinical implication in patients with STEMI.
Methods
We analyzed individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year.
Results
Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death; 1.52; 95% CI: 1.10-2.12; P=0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, this risk for 1-year CV death was higher only in women with HTB (HR 1.23, 95% CI: 1.18-1.28; P<0.001) who also had an increased risk for all-cause death and ST than men.
Conclusion
In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for stent thrombosis, CV and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.
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Affiliation(s)
- Maria Virginia Manzi
- Departement Of Advanced Biomedical Sciences, University Of Naples Federico Ii
- Departement Of Medical Sciences, Cardiology And Uppsala Clinical Research Center, Uppsala University , Sweden
| | - Sergio Buccheri
- Departement Of Medical Sciences, Cardiology And Uppsala Clinical Research Center, Uppsala University , Sweden
| | - Sanjit S Jolly
- Mcmaster University And The Population Health Research Institute, Hamilton Health Sciences , Hamilton, Ontario , Canada
| | - Felix Zijlstra
- Departement Of Cardiology, Thorax Center, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Ole Frobert
- Departement Of Cardiology, Faculty Of Health, Orebro University , Sweden
| | - Bo Lagerqvist
- Departement Of Medical Sciences, Cardiology And Uppsala Clinical Research Center, Uppsala University , Sweden
| | - Karim D Mahmoud
- Departement Of Cardiology, Thorax Center, Erasmus University Medical Center , Rotterdam , The Netherlands
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network , Toronto, Ontario , Canada
| | - Emanuele Barbato
- Departement Of Advanced Biomedical Sciences, University Of Naples Federico Ii
- Cardiovascular Research Center Aalst , Belgium
| | - Giovanna Sarno
- Departement Of Medical Sciences, Cardiology And Uppsala Clinical Research Center, Uppsala University , Sweden
| | - Stefan James
- Departement Of Medical Sciences, Cardiology And Uppsala Clinical Research Center, Uppsala University , Sweden
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14
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Mehta SR, Pare G, Lonn EM, Jolly SS, Natarajan MK, Pinilla-Echeverri N, Schwalm JD, Sheth TN, Sibbald M, Tsang M, Valettas N, Velianou JL, Lee SF, Ferdous T, Nauman S, Nguyen H, McCready T, McQueen MJ. Effects of routine early treatment with PCSK9 inhibitors in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: a randomised, double-blind, sham-controlled trial. EUROINTERVENTION 2022; 18:e888-e896. [PMID: 36349701 PMCID: PMC9743253 DOI: 10.4244/eij-d-22-00735] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/09/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI), early initiation of high-intensity statin therapy, regardless of low-density lipoprotein (LDL) cholesterol levels, is the standard of practice worldwide. Aims: We sought to determine the effect of a similar early initiation strategy, using a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor added to the high-intensity statin, on LDL cholesterol in acute STEMI. METHODS In a randomised, double-blind trial we assigned 68 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) to early treatment with alirocumab 150 mg subcutaneously or to a matching sham control. The first injection was given before primary PCI regardless of the baseline LDL level, then at 2 and 4 weeks. The primary outcome was the percent reduction in direct LDL cholesterol up to 6 weeks, analysed using a linear mixed model. Results: High-intensity statin use was 97% and 100% in the alirocumab and sham-control groups, respectively. At a median of 45 days, the primary outcome of LDL cholesterol decreased by 72.9% with alirocumab (2.97 mmol/L to 0.75 mmol/L) versus 48.1% with the sham control (2.87 mmol/L to 1.30 mmol/L), for a mean between-group difference of -22.3% (p<0.001). More patients achieved the European Society of Cardiology/European Atherosclerosis Society dyslipidaemia guideline target of LDL ≤1.4 mmol/L in the alirocumab group (92.1% vs 56.7%; p<0.001). Within the first 24 hours, LDL declined slightly more rapidly in the alirocumab group than in the sham-control group (-0.01 mmol/L/hour; p=0.03) with similar between-group mean values. Conclusions: In this randomised trial of routine early initiation of PCSK9 inhibitors in patients undergoing primary PCI for STEMI, alirocumab reduced LDL cholesterol by 22% compared with sham control on a background of high-intensity statin therapy. A large trial is needed to determine if this simplified approach followed by long-term therapy improves cardiovascular outcomes in patients with acute STEMI. (ClinicalTrials.gov: NCT03718286).
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Affiliation(s)
- Shamir R Mehta
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Guillaume Pare
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Eva M Lonn
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Jon-David Schwalm
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Tej N Sheth
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Matthew Sibbald
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Michael Tsang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Nicholas Valettas
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - James L Velianou
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
| | - Shun Fu Lee
- Population Health Research Institute, Hamilton, ON, Canada
| | - Tahsin Ferdous
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Helen Nguyen
- Population Health Research Institute, Hamilton, ON, Canada
| | - Tara McCready
- Population Health Research Institute, Hamilton, ON, Canada
| | - Matthew J McQueen
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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15
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Luz Diaz M, Diaz R, Yusufali A, Kumar Sharma S, Tarhuni WM, Hassany M, Avezum A, Harper W, Wasserman S, Almas A, Drapkina O, Felix C, Lopes RD, Berwanger O, Lopez-Jaramillo P, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and the combination of rivaroxaban and aspirin in patients hospitalised with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1169-1177. [PMID: 36228641 PMCID: PMC9635892 DOI: 10.1016/s2213-2600(22)00298-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND COVID-19 disease is accompanied by a dysregulated immune response and hypercoagulability. The Anti-Coronavirus Therapies (ACT) inpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with the combination of rivaroxaban and aspirin for prevention of disease progression in patients hospitalised with COVID-19. METHODS The ACT inpatient, open-label, 2 × 2 factorial, randomised, controlled trial was done at 62 clinical centres in 11 countries. Patients aged at least 18 years with symptomatic, laboratory confirmed COVID-19 who were within 72 h of hospitalisation or worsening clinically if already hospitalised were randomly assigned (1:1) to receive colchicine 1·2 mg followed by 0·6 mg 2 h later and then 0·6 mg twice daily for 28 days versus usual care; and in a second (1:1) randomisation, to the combination of rivaroxaban 2·5 mg twice daily plus aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome, assessed at 45 days in the intention-to-treat population, for the colchicine randomisation was the composite of the need for high-flow oxygen, mechanical ventilation, or death; and for the rivaroxaban plus aspirin randomisation was the composite of major thrombosis (myocardial infarction, stroke, acute limb ischaemia, or pulmonary embolism), the need for high-flow oxygen, mechanical ventilation, or death. The trial is registered at www. CLINICALTRIALS gov, NCT04324463 and is ongoing. FINDINGS Between Oct 2, 2020, and Feb 10, 2022, at 62 sites in 11 countries, 2749 patients were randomly assigned to colchicine or control and the combination of rivaroxaban and aspirin or to the control. 2611 patients were included in the analysis of colchicine (n=1304) versus control (n=1307); 2119 patients were included in the analysis of rivaroxaban and aspirin (n=1063) versus control (n=1056). Follow-up was more than 98% complete. Overall, 368 (28·2%) of 1304 patients allocated to colchicine and 356 (27·2%) of 1307 allocated to control had a primary outcome (hazard ratio [HR] 1·04, 95% CI 0·90-1·21, p=0·58); and 281 (26·4%) of 1063 patients allocated to the combination of rivaroxaban and aspirin and 300 (28·4%) of 1056 allocated to control had a primary outcome (HR 0·92, 95% CI 0·78-1·09, p=0·32). Results were consistent in subgroups defined by vaccination status, disease severity at baseline, and timing of randomisation in relation to onset of symptoms. There was no increase in the number of patients who had at least one serious adverse event for colchicine versus control groups (87 [6·7%] of 1304 vs 90 [6·9%] of 1307) or with rivaroxaban and aspirin versus control groups (85 [8·0%] vs 91 [8·6%]). Among patients assigned to colchicine, 8 (0·61%) had adverse events that led to discontinuation of study drug, mostly gastrointestinal in nature. 17 (1·6%) patients assigned to the combination of rivaroxaban and aspirin had bleeding compared with seven (0·66%) of those allocated to control (p=0·042); the number of serious bleeding events was two (0·19%) versus six (0·57%), respectively (p=0·18). No patients assigned to rivaroxaban and aspirin had serious adverse events that led to discontinuation of study drug. INTERPRETATION Among patients hospitalised with COVID-19, neither colchicine nor the combination of rivaroxaban and aspirin prevent disease progression or death. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada,Correspondence to: Prof John W Eikelboom, Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Maria Luz Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - William Harper
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Aysha Almas
- Section of Internal Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Oxana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | | | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Tarhuni WM, Hassany M, Kontsevaya A, Harper W, Sharma SK, Lopez-Jaramillo P, Dans AL, Palileo-Villanueva LM, Avezum A, Pais P, Xavier D, Felix C, Yusufali A, Lopes RD, Berwanger O, Ali Z, Wasserman S, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and aspirin in community patients with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1160-1168. [PMID: 36228639 PMCID: PMC9635862 DOI: 10.1016/s2213-2600(22)00299-5] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The large number of patients worldwide infected with the SARS-CoV-2 virus has overwhelmed health-care systems globally. The Anti-Coronavirus Therapies (ACT) outpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin for prevention of disease progression in community patients with COVID-19. METHODS The ACT outpatient, open-label, 2 × 2 factorial, randomised, controlled trial, was done at 48 clinical sites in 11 countries. Patients in the community aged 30 years and older with symptomatic, laboratory confirmed COVID-19 who were within 7 days of diagnosis and at high risk of disease progression were randomly assigned (1:1) to receive colchicine 0·6 mg twice daily for 3 days and then 0·6 mg once daily for 25 days versus usual care, and in a second (1:1) randomisation to receive aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome was assessed at 45 days in the intention-to-treat population; for the colchicine randomisation it was hospitalisation or death, and for the aspirin randomisation it was major thrombosis, hospitalisation, or death. The ACT outpatient trial is registered at ClinicalTrials.gov, NCT04324463 and is ongoing. FINDINGS Between Aug 27, 2020, and Feb 10, 2022, 3917 patients were randomly assigned to colchicine or control and to aspirin or control; after excluding 36 patients due to administrative reasons 3881 individuals were included in the analysis (n=1939 colchicine vs n=1942 control; n=1945 aspirin vs 1936 control). Follow-up was more than 99% complete. Overall event rates were 5 (0·1%) of 3881 for major thrombosis, 123 (3·2%) of 3881 for hospitalisation, and 23 (0·6%) of 3881 for death; 66 (3·4%) of 1939 patients allocated to colchicine and 65 (3·3%) of 1942 patients allocated to control experienced hospitalisation or death (hazard ratio [HR] 1·02, 95% CI 0·72-1·43, p=0·93); and 59 (3·0%) of 1945 of patients allocated to aspirin and 73 (3·8%) of 1936 patients allocated to control experienced major thrombosis, hospitalisation, or death (HR 0·80, 95% CI 0·57-1·13, p=0·21). Results for the primary outcome were consistent in all prespecified subgroups, including according to baseline vaccination status, timing of randomisation in relation to onset of symptoms (post-hoc analysis), and timing of enrolment according to the phase of the pandemic (post-hoc analysis). There were more serious adverse events with colchicine than with control (34 patients [1·8%] of 1939 vs 27 [1·4%] of 1942) but none in either group that led to discontinuation of study interventions. There was no increase in serious adverse events with aspirin versus control (31 [1·6%] vs 31 [1·6%]) and none that led to discontinuation of study interventions. INTERPRETATION The results provide no support for the use of colchicine or aspirin to prevent disease progression or death in outpatients with COVID-19. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, and Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Anna Kontsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Antonio L Dans
- UP College of Medicine, University of the Philippines Manila, Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Prem Pais
- St John's Research Institute, Bangalore, India
| | - Denis Xavier
- St John's Medical College, St John's Research Institute, Bangalore, India
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | - Zeeshan Ali
- Jinnah Sindh Medical University and Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
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Jolly SS, AlRashidi S, d’Entremont MA, Alansari O, Brochu B, Heenan L, Skuriat E, Tyrwhitt J, Raco M, Tsang M, Valettas N, Velianou JL, Sheth T, Sibbald M, Mehta SR, Pinilla-Echeverri N, Schwalm JD, Natarajan MK, Kelly A, Akl E, Tawadros S, Camargo M, Faidi W, Bauer J, Moxham R, Nkurunziza J, Dutra G, Winter J. Routine Ultrasonography Guidance for Femoral Vascular Access for Cardiac Procedures: The UNIVERSAL Randomized Clinical Trial. JAMA Cardiol 2022; 7:1110-1118. [PMID: 36116089 PMCID: PMC9483833 DOI: 10.1001/jamacardio.2022.3399] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [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: 08/10/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022]
Abstract
Importance A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared with radial access. Strategies to make femoral access safer are needed. Objective To determine whether routinely using ultrasonography guidance for femoral arterial access for coronary angiography/intervention reduces bleeding or vascular complications. Design, Setting, and Participants The Routine Ultrasound Guidance for Vascular Access for Cardiac Procedures (UNIVERSAL) randomized clinical trial is a multicenter, prospective, open-label trial of ultrasonography-guided femoral access vs no ultrasonography for coronary angiography or intervention with planned femoral access. Patients were randomized from June 26, 2018, to April 26, 2022. Patients with ST-elevation myocardial infarction were not eligible. Interventions Ultrasonography guidance vs no ultrasonography guidance for femoral arterial access on a background of fluoroscopic landmarking. Main Outcomes and Measures The primary composite outcome is the composite of major bleeding based on the Bleeding Academic Research Consortium 2, 3, or 5 criteria or major vascular complications within 30 days. Results A total of 621 patients were randomized at 2 centers in Canada (mean [SD] age, 71 [10.24] years; 158 [25.4%] female). The primary outcome occurred in 40 of 311 patients (12.9%) in the ultrasonography group vs 50 of 310 patients (16.1%) without ultrasonography (odds ratio, 0.77 [95% CI, 0.49-1.20]; P = .25). The rates of Bleeding Academic Research Consortium 2, 3, or 5 bleeding were 10.0% (31 of 311) vs 10.7% (33 of 310) (odds ratio, 0.93 [95% CI, 0.55-1.56]; P = .78). The rates of major vascular complications were 6.4% (20 of 311) vs 9.4% (29 of 310) (odds ratio, 0.67 [95% CI, 0.37-1.20]; P = .18). Ultrasonography improved first-pass success (277 of 311 [86.6%] vs 222 of 310 [70.0%]; odds ratio, 2.76 [95% CI, 1.85-4.12]; P < .001) and reduced the number of arterial puncture attempts (mean [SD], 1.2 [0.5] vs 1.4 [0.8]; mean difference, -0.26 [95% CI, -0.37 to -0.16]; P < .001) and venipuncture (10 of 311 [3.1%] vs 37 of 310 [11.7%]; odds ratio, 0.24 [95% CI, 0.12-0.50]; P < .001) with similar times to access (mean [SD], 114 [185] vs 129 [206] seconds; mean difference, -15.1 [95% CI, -45.9 to 15.8]; P = .34). All prerandomization prespecified subgroups were consistent with the overall finding. Conclusions and Relevance In this randomized clinical trial, use of ultrasonography for femoral access did not reduce bleeding or vascular complications. However, ultrasonography did reduce the risk of venipuncture and number of attempts. Larger trials may be required to demonstrate additional potential benefits of ultrasonography-guided access. Trial Registration ClinicalTrials.gov Identifier: NCT03537118.
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Affiliation(s)
- Sanjit S. Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Sulaiman AlRashidi
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Marc-André d’Entremont
- Population Health Research Institute, Hamilton, Ontario, Canada
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Omar Alansari
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Bradley Brochu
- CK Hui Heart Centre, Royal Alexandra Hospital Edmonton, Edmonton, Alberta, Canada
| | - Laura Heenan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Michael Raco
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Michael Tsang
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - James L. Velianou
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Shamir R. Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Jon David Schwalm
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Madhu K. Natarajan
- Population Health Research Institute, Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Andrew Kelly
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Elie Akl
- McGill University Faculty of Medicine and Health Sciences, Montreal, Quebec, Canada
| | | | | | - Walaa Faidi
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John Bauer
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - James Nkurunziza
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
- Niagara Health, St Catherines, Ontario, Canada
| | - Gustavo Dutra
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jose Winter
- Departamento de enfermedades cardiovasculares, Clínica Alemana De Santiago, Universidad del Desarrollo, Chile
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Mehta SR, Wang J, Wood DA, Spertus JA, Cohen DJ, Mehran R, Storey RF, Steg PG, Pinilla-Echeverri N, Sheth T, Bainey KR, Bangalore S, Cantor WJ, Faxon DP, Feldman LJ, Jolly SS, Kunadian V, Lavi S, Lopez-Sendon J, Madan M, Moreno R, Rao SV, Rodés-Cabau J, Stanković G, Bangdiwala SI, Cairns JA. Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction: Results From the COMPLETE Randomized Clinical Trial. JAMA Cardiol 2022; 7:1091-1099. [PMID: 36129696 PMCID: PMC9494273 DOI: 10.1001/jamacardio.2022.3032] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/25/2022] [Indexed: 01/09/2023]
Abstract
Importance In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown. Objective To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD. Design, Setting, and Participants This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021. Interventions Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization. Main Outcomes and Measures Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end. Results Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02). Conclusions and Relevance In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.
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Affiliation(s)
- Shamir R. Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - David A. Wood
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri–Kansas City, Kansas City
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital, Roslyn, New York
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Philippe Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - David P. Faxon
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laurent J. Feldman
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Sanjit S. Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Shahar Lavi
- Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jose Lopez-Sendon
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Raul Moreno
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | | | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Quebec, Canada
| | - Goran Stanković
- Serbia to Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Shrikant I. Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John A. Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
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19
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Manzi MV, Buccheri S, Jolly SS, Zijlstra F, Frøbert O, Lagerqvist B, Mahmoud KD, Džavík V, Barbato E, Sarno G, James S. Sex-Related Differences in Thrombus Burden in STEMI Patients Undergoing Primary Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2022; 15:2066-2076. [PMID: 36265938 DOI: 10.1016/j.jcin.2022.08.013] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Women have a worse prognosis after ST-segment elevation myocardial infarction (STEMI) than men. The prognostic role of thrombus burden (TB) in influencing the sex-related differences in clinical outcomes after STEMI has not been clearly investigated. OBJECTIVES The aim of this study was to assess the sex-related differences in TB and its clinical implications in patients with STEMI. METHODS Individual patient data from the 3 major randomized clinical trials of manual thrombus aspiration were analyzed, encompassing a total of 19,047 patients with STEMI, of whom 13,885 (76.1%) were men and 4,371 (23.9%) were women. The primary outcome of interest was 1-year cardiovascular (CV) death. The secondary outcomes of interest were recurrent myocardial infarction, heart failure, all-cause mortality, stroke, stent thrombosis (ST), and target vessel revascularization at 1 year. RESULTS Patients with high TB (HTB) had worse 1-year outcomes compared with those presenting with low TB (adjusted HR for CV death: 1.52; 95% CI: 1.10-2.12; P = 0.01). In unadjusted analyses, female sex was associated with an increased risk for 1-year CV death regardless of TB. After adjustment, the risk for 1-year CV death was higher only in women with HTB (HR: 1.23; 95% CI: 1.18-1.28; P < 0.001), who also had an increased risk for all-cause death and ST than men. CONCLUSIONS In patients with STEMI, angiographic evidence of HTB negatively affected prognosis. Among patients with HTB, women had an excess risk for ST, CV, and all-cause mortality than men. Further investigations are warranted to better understand the pathophysiological mechanisms leading to excess mortality in women with STEMI and HTB.
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Affiliation(s)
- Maria Virginia Manzi
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy.
| | - Sergio Buccheri
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Felix Zijlstra
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ole Frøbert
- Department of Cardiology, Faculty of Health, Örebro University, Örebro, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Karim D Mahmoud
- Department of Cardiology, Thorax Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Emanuele Barbato
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy; Cardiovascular Research Center Aalst, Belgium
| | - Giovanna Sarno
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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20
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Alrashidi S, d’Entremont MA, Alansari O, Winter J, Brochu B, Heenan L, Skuriat E, Tyrwhitt J, Raco M, Tsang MB, Valettas N, Velianou J, Sheth T, Sibbald M, Mehta SR, Pinilla-Echeverri N, Schwalm JD, Natarajan MK, Kelly A, Akl E, Tawadros S, Camargo M, Faidi W, Dutra G, Jolly SS. Design and Rationale of Routine Ultrasou Nd Gu Idance for Vascular Acc Ess fo R Cardiac Procedure s: A Randomized Tria L (UNIVERSAL). CJC Open 2022; 4:1074-1080. [PMID: 36562014 PMCID: PMC9764117 DOI: 10.1016/j.cjco.2022.08.011] [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] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/22/2022] [Indexed: 12/25/2022] Open
Abstract
Background A significant limitation of femoral artery access for cardiac interventions is the increased risk of vascular complications and bleeding compared to radial access. Ultrasound (US)-guided femoral access may reduce major vascular complications and bleeding. We aim to determine whether routinely using US guidance for femoral arterial access for coronary angiography or intervention will reduce Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding or major vascular complications. Methods The Ultrasound Guidance for Vascular Access for Cardiac Procedures: A Randomized Trial (UNIVERSAL) is a multicentre, prospective, open-label, randomized trial with blinded outcomes assessment. Patients undergoing coronary angiography with or without intervention via a femoral approach with fluoroscopic guidance will be randomized 1:1 to US-guided femoral access, compared to no US. The primary outcome is the composite of major bleeding based on the BARC 2, 3, or 5 criteria or major vascular complications within 30 days. The trial is designed to have 80% power and a 2-sided alpha level of 5% to detect a 50% relative risk reduction for the primary outcome based on a control event rate of 14%. Results We completed enrollment on April 29, 2022, with 621 randomized patients. The patients had a mean age of 71 years (25.4% female), with a high rate of comorbidities, as follows: 45% had a prior percutaneous coronary intervention; 57% had previous coronary artery bypass surgery; and 18% had peripheral vascular disease. Conclusions The UNIVERSAL trial will be one of the largest randomized trials of US-guided femoral access and has the potential to change guidelines and increase US uptake for coronary procedures worldwide.
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Affiliation(s)
- Sulaiman Alrashidi
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Marc-André d’Entremont
- Population Health Research Institute, Hamilton, Ontario, Canada,Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Omar Alansari
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Jose Winter
- Clinica Alemana de Santiago, Santiago, Chile
| | - Bradley Brochu
- CK Hui Heart Centre, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Laura Heenan
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Michael Raco
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Michael B. Tsang
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - James Velianou
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Tej Sheth
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Shamir R. Mehta
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Natalia Pinilla-Echeverri
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jon David Schwalm
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Madhu K. Natarajan
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Andrew Kelly
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada
| | - Elie Akl
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | - Walaa Faidi
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gustavo Dutra
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S. Jolly
- McMaster University, Hamilton, Ontario, Canada,Hamilton Health Sciences, Hamilton, Ontario, Canada,Niagara Health, St. Catharines, Ontario, Canada,Population Health Research Institute, Hamilton, Ontario, Canada,Corresponding author: Dr Sanjit S. Jolly, Population Health Research Institute, Hamilton General Hospital, 237 Barton St. East, Hamilton, Ontario L8L 2X2, Canada. Tel.: +1-905-521-2100 ext. 40309.
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21
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Gargiulo G, Giacoppo D, Jolly SS, Cairns J, Le May M, Bernat I, Romagnoli E, Rao SV, van Leeuwen MAH, Mehta SR, Bertand OF, Wells GA, Meijers TA, Siontis GCM, Esposito G, Windecker S, Jüni P, Valgimigli M. Impact on Mortality and Major Bleeding of Radial Versus Femoral Artery Access for Coronary Angiography or Percutaneous Coronary Intervention: a Meta-analysis of Individual Patient Data from Seven Multicenter Randomized Clinical Trials. Circulation 2022; 146:1329-1343. [PMID: 36036610 DOI: 10.1161/circulationaha.122.061527] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In some randomized controlled trials (RCTs), transradial (TRA) compared with transfemoral access (TFA) was associated with lower mortality in coronary artery disease patients undergoing invasive management. We analyzed the effects of TRA versus TFA across multicenter RCTs and whether these associations are modified by patient or operator characteristics. METHODS We performed an individual patient data meta-analysis of multicenter RCTs comparing TRA versus TFA among patients undergoing coronary angiography with or without percutaneous coronary intervention (PCI) (PROSPERO; CRD42018109664). The primary outcome was all-cause mortality and the co-primary outcome was major bleeding at 30 days. The primary analysis was conducted by one-stage mixed-effects models based on the intention-to-treat cohort. The impact of access-site on mortality and major bleeding was further assessed by multivariable analysis. The relationship among access-site, bleeding, and mortality was investigated by natural effect model mediation analysis with multivariable adjustment. RESULTS A total of 21,600 patients (TRA=10,775 vs. TFA=10,825) from 7 RCTs were included. Median age was 63.9 years, 31.9% were female, 95% presented with acute coronary syndrome (ACS), and 75.2% underwent PCI. All-cause mortality (1.6% vs. 2.1%; HR 0.77, 95% CI 0.63-0.95, p=0.012) and major bleeding (1.5% vs. 2.7%; OR 0.55, 95% CI 0.45- 0.67, p<0.001) were lower with TRA. Subgroup analyses for mortality showed consistent results, except for baseline hemoglobin (pinteraction=0.033), indicating that the benefit of TRA was substantial in patients with significant anemia, while it was not significant in patients with milder or no baseline anemia. After adjustment, TRA remained associated with 24% and 51% relative risk reduction of all-cause mortality and major bleeding. A mediation analysis showed that the benefit of TRA on mortality was only partially driven by major bleeding prevention, and ancillary mechanisms are required to fully explain the causal association. CONCLUSIONS TRA is associated with lower all-cause mortality and major bleeding at 30 days, compared with TFA. The effect on mortality was driven by patients with anemia. The reduction in major bleeding only partially explains the mortality benefit.
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Affiliation(s)
- Giuseppe Gargiulo
- 1Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy
| | - Daniele Giacoppo
- Cardiology Department, Alto Vicentino Hospital, Santorso, Italy; 3Cardiovascular Research Institute, Mater Private Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland; ISAResearch Center, Deutsches Herzzentrum München, Technisches Universität München, Munich, Germany
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | - John Cairns
- University of British Columbia, Vancouver, Canada
| | - Michel Le May
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ivo Bernat
- University Hospital and Faculty of Medicine Pilsen, Charles University, Czech Republic
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - George A Wells
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thomas A Meijers
- Department of Cardiology, Isala Heart Center, Zwolle, the Netherlands
| | | | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University Federico II of Naples, Naples, Italy
| | - Stephan Windecker
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marco Valgimigli
- Department of Cardiology, University Hospital of Bern, Bern, Switzerland; Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
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22
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Alkhalil M, Kuzemczak M, Zhao R, Kavvouras C, Cantor WJ, Overgaard CB, Lavi S, Sharma V, Chowdhary S, Stanković G, Kedev S, Bernat I, Bhindi R, Sheth T, Niemela K, Jolly SS, Džavík V. Prognostic Role of Residual Thrombus Burden Following Thrombectomy: Insights From the TOTAL Trial. Circ Cardiovasc Interv 2022; 15:e011336. [PMID: 35580203 DOI: 10.1161/circinterventions.121.011336] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It is unclear whether more effective forms of thrombus removal than current aspiration catheters would lead to improved outcomes. We sought to evaluate the prognostic role of residual thrombus burden (rTB), after manual thrombectomy, in patients undergoing primary percutaneous coronary intervention with routine manual thrombectomy in the TOTAL trial (Thrombectomy Versus PCI Alone). METHODS This is a single-arm analysis of patients from the TOTAL trial who underwent routine manual aspiration thrombectomy. The rTB was quantified by an angiographic core laboratory using the Thrombolysis in Myocardial Infarction criteria and validated using existing optical coherent tomography data. Large rTB was defined as grade ≥3. The primary outcome was death from cardiovascular causes, recurrent myocardial infarction, cardiogenic shock, or new or worsening heart failure within 180 days. RESULTS Of 5033 patients randomized to routine thrombectomy, 2869 patients had quantifiable rTB (1014 [35%] had large rTB). Patients with large rTB were more likely to have hypertension, previous percutaneous coronary intervention, myocardial infarction, or Killip class III on presentation but less likely to have Killip class I. The primary outcome occurred more frequently in patients with large rTB, even after adjustment for known risk predictors (8.6% versus 4.6%; adjusted hazard ratio, 1.83 [95% CI, 1.34-2.48]). These patients also had a higher risk of cardiovascular death (adjusted hazard ratio, 1.83 [95% CI, 1.13-2.95]), cardiogenic shock (adjusted hazard ratio, 2.02 [95% CI, 1.08-3.76]), and heart failure (adjusted hazard ratio, 1.74 [95% CI, 1.02-2.96]) but not myocardial infarction or stroke. CONCLUSIONS Large rTB is a common finding in primary percutaneous coronary intervention and is associated with increased risk of adverse cardiovascular outcomes, including cardiovascular death. Future technologies offering better thrombus removal than current devices may decrease or even eliminate the risk associated with rTB. This, potentially, can turn into a strategic option to be studied in clinical trials. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01149044.
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Affiliation(s)
- Mohammad Alkhalil
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.).,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, United Kingdom (M.A.).,Translational and Clinical Research Institute, Newcastle University, United Kingdom (M.A.)
| | - Michał Kuzemczak
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.).,Division of Emergency Medicine, Poznan University of Medical Sciences, Poland (M.K.).,Department of Invasive Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland (M.K.)
| | - Robin Zhao
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | - Charalampos Kavvouras
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.)
| | - Warren J Cantor
- Division of Cardiology, University of Toronto and Southlake Regional Health Centre, Canada (W.J.C., C.B.O.)
| | - Christopher B Overgaard
- Division of Cardiology, University of Toronto and Southlake Regional Health Centre, Canada (W.J.C., C.B.O.)
| | - Shahar Lavi
- London Health Sciences Centre, Canada (S.L.)
| | - Vinoda Sharma
- Cardiology Department, Sandwell and West Birmingham Hospitals NHS Trust, United Kingdom (V.S.)
| | - Saqib Chowdhary
- Cardiology Department, Wythenshawe Hospital, Manchester, United Kingdom (S.C.)
| | - Goran Stanković
- Department of Cardiology, University of Belgrade, Serbia (G.S.)
| | - Saško Kedev
- University Clinic of Cardiology, Ss. Cyril and Methodius University, Skopje, Macedonia (S.K.)
| | - Ivo Bernat
- University Hospital and Faculty of Medicine Pilsen, Czech Republic (I.B.)
| | - Ravinay Bhindi
- Royal North Shore Hospital, University of Sydney, Australia (R.B.)
| | - Tej Sheth
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | | | - Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton, Canada (R.Z., T.S., S.S.J.)
| | - Vladimír Džavík
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Canada (M.A., M.K., C.K., V.D.)
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23
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d'Entremont MA, Couture ÉL, Connelly K, Walling A, Jolly SS, Valettas N, Tsang MB, Mampuya W, Poirier P, Huynh T. Management of the master endurance athlete with stable coronary artery disease. Can J Cardiol 2022; 38:1450-1453. [PMID: 35489669 DOI: 10.1016/j.cjca.2022.04.013] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/05/2022] [Accepted: 04/17/2022] [Indexed: 11/02/2022] Open
Abstract
Master endurance athletes are individuals > 35 years of age who either train for or participate in competitions. Considering the potential burden of coronary artery disease in this population, clinicians should be aware of the inherent dangers of exercise. A tailored approach with shared decision-making, balancing risks and benefits of exercise, is recommended to ensure safe exercise in these individuals.
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Affiliation(s)
| | - Étienne L Couture
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke (QC), Canada
| | - Kim Connelly
- Keenan Research Center, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto (ON), Canada; Department of Physiology, University of Toronto, Toronto (ON), Canada; Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto (ON), Canada
| | - Ann Walling
- Sir Mortimer B. Davis Jewish General Hospital, Montreal (QC), Canada
| | - Sanjit S Jolly
- McGill Health University Center, Montreal (QC), Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton Health Sciences, Hamilton (ON), Canada
| | - Nicholas Valettas
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton Health Sciences, Hamilton (ON), Canada
| | - Micheal B Tsang
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton Health Sciences, Hamilton (ON), Canada
| | - Warner Mampuya
- Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke (QC), Canada
| | - Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Québec (QC), Canada
| | - Thao Huynh
- McGill Health University Center, Montreal (QC), Canada.
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24
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Eikelboom J, Rangarajan S, Jolly SS, Belley-Cote EP, Whitlock R, Beresh H, Lewis G, Xu L, Chan N, Bangdiwala S, Diaz R, Orlandini A, Hassany M, Tarhuni WM, Yusufali AM, Sharma SK, Konstsevaya A, Jaramillo PL, Avezum A, Dans AL, Wasserman S, Camilo F, Kazmi K, Pais P, Xavier D, Lopes RD, Berwanger O, Nkeshimana M, Harper W, Loeb M, Choudhri S, Farkouh ME, Bosch J, Anand SS, Yusuf S. The Anti-Coronavirus Therapy (ACT) trials: design, baseline characteristics, and challenges. CJC Open 2022; 4:568-576. [PMID: 35252829 PMCID: PMC8887957 DOI: 10.1016/j.cjco.2022.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 12/14/2022] Open
Abstract
Background Effective treatments for COVID-19 are urgently needed, but conducting randomized trials during the pandemic has been challenging. Methods The Anti-Coronavirus Therapy (ACT) trials are parallel factorial international trials that aimed to enroll 3500 outpatients and 2500 inpatients with symptomatic COVID-19. The outpatient trial is evaluating colchicine vs usual care, and aspirin vs usual care. The primary outcome for the colchicine randomization is hospitalization or death, and for the aspirin randomization, it is major thrombosis, hospitalization, or death. The inpatient trial is evaluating colchicine vs usual care, and the combination of rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily vs usual care. The primary outcome for the colchicine randomization is need for high-flow oxygen, need for mechanical ventilation, or death, and for the rivaroxaban plus aspirin randomization, it is major thrombotic events, need for high-flow oxygen, need for mechanical ventilation, or death. Results At the completion of enrollment on February 10, 2022, the outpatient trial had enrolled 3917 patients, and the inpatient trial had enrolled 2611 patients. Challenges encountered included lack of preliminary data about the interventions under evaluation, uncertainties related to the expected event rates, delays in regulatory and ethics approvals, and in obtaining study interventions, as well as the changing pattern of the COVID-19 pandemic. Conclusions The ACT trials will determine the efficacy of anti-inflammatory therapy with colchicine, and antithrombotic therapy with aspirin given alone or in combination with rivaroxaban, across the spectrum of mild, moderate, and severe COVID-19. Lessons learned from the conduct of these trials will inform planning of future trials.
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Affiliation(s)
- John Eikelboom
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard Whitlock
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Heather Beresh
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Gayle Lewis
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Noel Chan
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Shrikant Bangdiwala
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Rafael Diaz
- ECLA (Estudios Clínicos Latino America) ICR (Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Andres Orlandini
- ECLA (Estudios Clínicos Latino America) ICR (Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Wadea M Tarhuni
- Dept of Medicine, University of Saskatchewan, Saskatoon , Canada.,Dept of Medicine, Western University, Clinical Skills Building London, Canada.,Windsor Cardiac Centre, Windsor, Canada
| | - A M Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, UAE
| | | | - Anna Konstsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russian Federation
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Felix Camilo
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Khawar Kazmi
- National Institute of Cardiovascular Diseases, Rafique Shaheed Road, Karachi, Pakistan
| | - Prem Pais
- St. John's Research Institute, Bangalore, India
| | - Denis Xavier
- St. John's Medical College, St. John's Research Institute, Bangalore, India
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, North Carolina, USA
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein, São Paulo, Brazil.,Global Cardiovascular Coalition, Alameda Campinas, São Paulo, Brazil
| | - Menelas Nkeshimana
- Centre Hospitalier Universitaire de Kigali, Rwanda.,University of Rwanda, Dept. Of Internal Medicine, Kigali, Rwanda
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University. Hamilton, Canada
| | - Shurjeel Choudhri
- Bayer Inc., Medical & Scientific Affairs, Pharmaceuticals, Mississauga, Canada
| | | | - Jackie Bosch
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Sonia S Anand
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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Graham JJ, Bagai A, Wijeysundera H, Weisz G, Rinfret S, Dick A, Jolly SS, Schaempert E, Mansour S, Dzavik V, Henriques JPS, Elbarouni B, Vo MN, Teefy P, Goodhart D, Mancini GBJ, Strauss BH, Buller CE. Collagenase to facilitate guidewire crossing in chronic total occlusion PCI-The Total Occlusion Study in Coronary Arteries-5 (TOSCA-5) trial. Catheter Cardiovasc Interv 2022; 99:1065-1073. [PMID: 35077606 DOI: 10.1002/ccd.30101] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/29/2021] [Accepted: 01/09/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Chronic total occlusions (CTO) are common and are associated with lower percutaneous coronary intervention (PCI) success rates, often due to failure of antegrade guidewire crossing. Local, intralesional delivery of collagenase (MZ-004) may facilitate guidewire crossing in CTO. AIMS To evaluate the effect of MZ-004 in facilitating antegrade wire crossing in CTO angioplasty. METHODS A total of 76 patients undergoing CTO PCI were enrolled at 13 international sites: 38 in the randomized training stage (collagenase [MZ-004] 900 or 1200 μg) and 38 in the placebo-controlled stage (MZ-004 900 or 1200 μg or placebo). Patients received the MZ-004 or identical volume saline (placebo group) in a double-blind design, injected via microcatheter directly into the proximal cap of the CTO. The following day patients underwent CTO PCI using antegrade wire techniques only. RESULTS Patients were generally similar except for a trend for higher Japanese chronic total occlusion (J-CTO) score in the MZ-004 group (MZ-004 J-CTO score 1.9 vs. 1.4, p = 0.07). There was a numerical increase in the rates of guidewire crossing in the MZ-004 groups compared to placebo (74% vs. 63%, p = 0.52). Guidewire crossing with a soft-tip guidewire (≤1.5 g tip load) was significantly higher in the MZ-004 groups (0% in placebo, 17% in 900 μg, and 29% in 1200 μg MZ-004 group, p = 0.03). Rates of the major adverse cardiovascular event were similar between groups. CONCLUSION Local delivery of MZ-004 into coronary CTOs appears safe and may facilitate CTO crossing, particularly with softer tipped guidewires. These data support the development of a pivotal trial to further evaluate this agent.
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Affiliation(s)
- John J Graham
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Harindra Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Giora Weisz
- Department of Cardiology, Shaare Zedek Medical Center, Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Stéphane Rinfret
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Alexander Dick
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Samer Mansour
- Division of Cardiology, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jose P S Henriques
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Basem Elbarouni
- St. Boniface General Hospital Winnipeg, Winnipeg, Manitoba, Canada
| | - Minh N Vo
- St. Boniface General Hospital Winnipeg, Winnipeg, Manitoba, Canada
| | - Patrick Teefy
- Department of Medicine, Cardiology Division, London Health Sciences Centre, University Hospital, London, Ontario, Canada
| | - David Goodhart
- Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - G B John Mancini
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Christopher E Buller
- Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Anttonen E, Punkka O, Leivo J, Jolly SS, Džavík V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola M. The Association of Atrial Fibrillation Before Percutaneous Coronary Intervention With 1-Year Outcome in ST-Elevation Myocardial Infarction Patients. CJC Open 2021; 3:1221-1229. [PMID: 34888505 PMCID: PMC8636243 DOI: 10.1016/j.cjco.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 04/01/2021] [Accepted: 06/01/2021] [Indexed: 11/18/2022] Open
Abstract
Background We aimed to determine the association of atrial fibrillation (AF) with 1-year outcome in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI). Methods Patients (n = 8830) enrolled in the Trial of Routine Aspiration Thrombectomy with PCI vs PCI Alone in Patients With STEMI (TOTAL) were followed for 1 year. The primary outcome was a composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening class IV heart failure. The presence or absence of AF was determined from a single pre-PCI electrocardiogram. Results Patients with AF (n = 437; 4.9%) were older, and more often had a history of stroke, hypertension, or myocardial infarction. The rate of the primary outcome was higher in the AF group than in the sinus rhythm (SR) group (17.4% vs 7.4%, P < 0.001), as was the rate of cardiovascular death (9.8% vs 3.3%, P < 0.001). In multivariable analysis, AF was independently predictive of the primary outcome (adjusted hazard ratio [aHR] 1.68; 95% confidence interval [CI], 1.30-2.16, P < 0.001), cardiovascular death (aHR 1.69; 95% CI, 1.19-2.40, P = 0.003), all-cause mortality (aHR 1.63; 95% CI, 1.18-2.24, P = 0.003), and severe heart failure (aHR 1.96; 95% CI, 1.25-3.07, P = 0.003). Among patients who were in SR, the primary outcome occurred in 307 of 4252 (7.2%) in the thrombectomy group and 310 of 4141 (7.5%) in the PCI alone group, and among those with AF, these rates were respectively 42 of 218 (19.3%) and 34 of 219 (15.5%) (Pinteraction = 0.26). Conclusions In STEMI patients, AF on the pre-PCI electrocardiogram is associated with a higher risk of the primary composite cardiovascular outcome, all-cause and cardiovascular death, and severe heart failure during 1-year follow-up than it is in patients with SR.
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Affiliation(s)
- Eero Anttonen
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Olli Punkka
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Corresponding author: Olli Punkka, MD, Faculty of Medicine and Health Technology, University of Tampere, Finland, Arvo Ylpön katu 34, Tampere 33520, Finland. Tel.: +358505294566.
| | - Joonas Leivo
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Sanjit S. Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jyri Koivumäki
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Minna Tahvanainen
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Kimmo Koivula
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
- Internal Medicine Department, Helsinki University Hospital, Helsinki, Finland
| | - Kjell Nikus
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John A. Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kari Niemelä
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
| | - Markku Eskola
- Heart Centre, Department of Cardiology, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
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27
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Diaz R, Orlandini A, Castellana N, Caccavo A, Corral P, Corral G, Chacón C, Lamelas P, Botto F, Díaz ML, Domínguez JM, Pascual A, Rovito C, Galatte A, Scarafia F, Sued O, Gutierrez O, Jolly SS, Miró JM, Eikelboom J, Loeb M, Maggioni AP, Bhatt DL, Yusuf S. Effect of Colchicine vs Usual Care Alone on Intubation and 28-Day Mortality in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2141328. [PMID: 34964849 PMCID: PMC8717104 DOI: 10.1001/jamanetworkopen.2021.41328] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Hospitalized patients with COVID-19 pneumonia have high rates of morbidity and mortality. OBJECTIVE To assess the efficacy of colchicine in hospitalized patients with COVID-19 pneumonia. DESIGN, SETTING, AND PARTICIPANTS The Estudios Clínicos Latino América (ECLA) Population Health Research Institute (PHRI) COLCOVID trial was a multicenter, open-label, randomized clinical trial performed from April 17, 2020, to March 28, 2021, in adults with confirmed or suspected SARS-CoV-2 infection followed for up to 28 days. Participants received colchicine vs usual care if they were hospitalized with COVID-19 symptoms and had severe acute respiratory syndrome or oxygen desaturation. The main exclusion criteria were clear indications or contraindications for colchicine, chronic kidney disease, and negative results on a reverse transcription-polymerase chain reaction test for SARS-CoV-2 before randomization. Data were analyzed from June 20 to July 25, 2021. INTERVENTIONS Patients were assigned in a 1:1 ratio to usual care or usual care plus colchicine. Colchicine was administered orally in a loading dose of 1.5 mg immediately after randomization, followed by 0.5 mg orally within 2 hours of the initial dose and 0.5 mg orally twice a day for 14 days or discharge, whichever occurred first. MAIN OUTCOMES AND MEASURES The first coprimary outcome was the composite of a new requirement for mechanical ventilation or death evaluated at 28 days. The second coprimary outcome was death at 28 days. RESULTS A total of 1279 hospitalized patients (mean [SD] age, 61.8 [14.6] years; 449 [35.1%] women and 830 [64.9%] men) were randomized, including 639 patients in the usual care group and 640 patients in the colchicine group. Corticosteroids were used in 1171 patients (91.5%). The coprimary outcome of mechanical ventilation or 28-day death occurred in 160 patients (25.0%) in the colchicine group and 184 patients (28.8%) in the usual care group (hazard ratio [HR], 0.83; 95% CI, 0.67-1.02; P = .08). The second coprimary outcome, 28-day death, occurred in 131 patients (20.5%) in the colchicine group and 142 patients (22.2%) in the usual care group (HR, 0.88; 95% CI, 0.70-1.12). Diarrhea was the most frequent adverse effect of colchicine, reported in 68 patients (11.3%). CONCLUSIONS AND RELEVANCE This randomized clinical trial found that compared with usual care, colchicine did not significantly reduce mechanical ventilation or 28-day mortality in patients hospitalized with COVID-19 pneumonia. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04328480.
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Affiliation(s)
- Rafael Diaz
- Estudios Clínicos Latino América, Rosario, Argentina
- Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Andrés Orlandini
- Estudios Clínicos Latino América, Rosario, Argentina
- Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Noelia Castellana
- Estudios Clínicos Latino América, Rosario, Argentina
- Universidad Nacional de Rosario, Rosario, Argentina
| | - Alberto Caccavo
- Hospital de Coronel Suárez Raúl Alfredo Caccavo, Universidad Provincial del Sudoeste, Buenos Aires, Argentina
| | - Pablo Corral
- Departamento de Investigación, Facultad de Medicina, Universidad FASTA, Buenos Aires, Argentina
| | | | - Carolina Chacón
- Estudios Clínicos Latino América, Rosario, Argentina
- Universidad Abierta Interamericana, Rosario, Argentina
- Unidad Coronaria de Sanatorio Delta de Rosario, Rosario, Argentina
- Comite de Epidemiologia y Prevención Cardiovasculr de la Federación Argentina de Cardiologia, Rosario, Argentina
| | - Pablo Lamelas
- Health Research Methods, Evidence, and Impact, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Botto
- Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
| | - María Luz Díaz
- Estudios Clínicos Latino América, Rosario, Argentina
- Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Juan Manuel Domínguez
- Estudios Clínicos Latino América, Rosario, Argentina
- Instituto Cardiovascular de Rosario, Rosario, Argentina
- Heart Failure and Heart Transplant Unit, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Carla Rovito
- Estudios Clínicos Latino América, Rosario, Argentina
| | | | - Franco Scarafia
- Estudios Clínicos Latino América, Rosario, Argentina
- Statistics Department, Universidad Nacional de Rosario, Rosario, Argentina
| | - Omar Sued
- Fundación Huésped, Buenos Aires, Argentina
| | | | - Sanjit S. Jolly
- Division of Cardiology, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - José M. Miró
- Infectious Diseases Service, Hospital Clínic, Instituto de Investigaciones Biomédicas August Pi i Sunyer, University of Barcelona, Barcelona, Spain
| | - John Eikelboom
- Medicine, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Mark Loeb
- Health Research Methods, Evidence, and Impact, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
- Departments of Pathology and Molecular Medicine, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Aldo Pietro Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Salim Yusuf
- Division of Cardiology, Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Canada
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Fiolet ATL, Opstal TSJ, Mosterd A, Eikelboom JW, Jolly SS, Keech AC, Kelly P, Tong DC, Layland J, Nidorf SM, Thompson PL, Budgeon C, Tijssen JGP, Cornel JH. Efficacy and safety of low-dose colchicine in patients with coronary disease: a systematic review and meta-analysis of randomized trials. Eur Heart J 2021; 42:2765-2775. [PMID: 33769515 DOI: 10.1093/eurheartj/ehab115] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Recent randomized trials demonstrated a benefit of low-dose colchicine added to guideline-based treatment in patients with recent myocardial infarction or chronic coronary disease. We performed a systematic review and meta-analysis to obtain best estimates of the effects of colchicine on major adverse cardiovascular events (MACE). METHODS AND RESULTS We searched the literature for randomized clinical trials of long-term colchicine in patients with atherosclerosis published up to 1 September 2020. The primary efficacy endpoint was MACE, the composite of myocardial infarction, stroke, or cardiovascular death. We combined the results of five trials that included 11 816 patients. The primary endpoint occurred in 578 patients. Colchicine reduced the risk for the primary endpoint by 25% [relative risk (RR) 0.75, 95% confidence interval (CI) 0.61-0.92; P = 0.005], myocardial infarction by 22% (RR 0.78, 95% CI 0.64-0.94; P = 0.010), stroke by 46% (RR 0.54, 95% CI 0.34-0.86; P = 0.009), and coronary revascularization by 23% (RR 0.77, 95% CI 0.66-0.90; P < 0.001). We observed no difference in all-cause death (RR 1.08, 95% CI 0.71-1.62; P = 0.73), with a lower incidence of cardiovascular death (RR 0.82, 95% CI 0.55-1.23; P = 0.34) counterbalanced by a higher incidence of non-cardiovascular death (RR 1.38, 95% CI 0.99-1.92; P = 0.060). CONCLUSION Our meta-analysis indicates that low-dose colchicine reduced the risk of MACE as well as that of myocardial infarction, stroke, and the need for coronary revascularization in a broad spectrum of patients with coronary disease. There was no difference in all-cause mortality and fewer cardiovascular deaths were counterbalanced by more non-cardiovascular deaths.
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Affiliation(s)
- Aernoud T L Fiolet
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands
| | - Tjerk S J Opstal
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arend Mosterd
- Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands.,Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands.,Julius Centre for Health Sciences and Primary Care, Utrecht University Medical Centre, Utrecht, The Netherlands
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Division of Cardiology, Department of Medicine, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Anthony C Keech
- Sydney Medical School, National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Australia
| | - Peter Kelly
- Mater University and Health Research Board (HRB) Stroke Clinical Trials Network Ireland, University College Dublin, Ireland
| | - David C Tong
- Cardiology, Department of Medicine, Peninsula Health, Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia.,Department of Cardiology, St. Vincent's Hospital Melbourne, VIC, Australia
| | - Jamie Layland
- Cardiology, Department of Medicine, Peninsula Health, Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia.,Department of Cardiology, St. Vincent's Hospital Melbourne, VIC, Australia.,Peninsula Clinical School, Central Clinical School, Monash University, VIC, Australia
| | - Stefan M Nidorf
- Heart and Vascular Research Institute of Western Australia, Perth, Australia.,GenesisCare Western Australia, Perth, Australia
| | - Peter L Thompson
- Heart and Vascular Research Institute of Western Australia, Perth, Australia.,Sir Charles Gairdner Hospital, Perth, Australia.,School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Charley Budgeon
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Jan G P Tijssen
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands.,Cardialysis BV, Rotterdam, The Netherlands
| | - Jan H Cornel
- Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands.,Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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29
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Kofler T, Kurmann R, Lehnick D, Cioffi GM, Chandran S, Attinger-Toller A, Toggweiler S, Kobza R, Moccetti F, Cuculi F, Jolly SS, Bossard M. Colchicine in Patients With Coronary Artery Disease: A Systematic Review and Meta-Analysis of Randomized Trials. J Am Heart Assoc 2021; 10:e021198. [PMID: 34369166 PMCID: PMC8475038 DOI: 10.1161/jaha.121.021198] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Inflammation plays a pivotal role in coronary artery disease (CAD). The anti‐inflammatory drug colchicine seems to reduce ischemic events in patients with CAD. So far there is equipoise about its safety and impact on mortality. Methods and Results To evaluate the utility of colchicine in patients with acute and chronic CAD, we performed a systematic review and meta‐analysis. MEDLINE, EMBASE, Cochrane CENTRAL and conference abstracts were searched from January 1975 to October 2020. Randomized trials assessing colchicine compared with placebo/standard therapy in patients with CAD were included. Data were combined using random‐effects models. The reliability of the available data was tested using trial sequential analyses . Of 3108 citations, 13 randomized trials (n=13 125) were included. Colchicine versus placebo/standard therapy in patients with CAD reduced risk of myocardial infarction (odds ratio [OR] 0.64; 95% CI, 0.46–0.90; P=0.01; I2 41%) and stroke/transient ischemic attack (OR 0.50; 95% CI, 0.31–0.81; P=0.005; I2 0%). But treatment with colchicine compared with placebo/standard therapy had no influence on all‐cause and cardiovascular mortality (OR 0.96; 95% CI, 0.65–1.41; P=0.83; I2 24%; and OR 0.82; 95% CI, 0.55–1.22; P=0.45; I2 0%, respectively). Colchicine increased the risk for gastrointestinal side effects (P<0.001). According to trial sequential analyses, there is only sufficient evidence for a myocardial infarction risk reduction with colchicine. Conclusions Among patients with CAD, colchicine reduces the risk of myocardial infarction and stroke, but has a higher rate of gastrointestinal upset with no influence on all‐cause mortality.
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Affiliation(s)
- Thomas Kofler
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Reto Kurmann
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Dirk Lehnick
- Department of Biostatistics and Methodology CTU-CS University of Lucerne Lucerne Switzerland
| | | | - Sujay Chandran
- Royal Sussex County Hospital Sussex Worthing United Kingdom
| | | | - Stefan Toggweiler
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Richard Kobza
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Federico Moccetti
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Florim Cuculi
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
| | - Sanjit S Jolly
- McMaster UniversityHamilton Health Sciences Hamilton Ontario Canada
| | - Matthias Bossard
- Cardiology Division Heart Center Luzerner Kantonsspital Lucerne Switzerland
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30
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Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola M. The prognostic significance of grade of ischemia in the ECG in patients with ST-elevation myocardial infarction: A substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial). J Electrocardiol 2021; 68:65-71. [PMID: 34365136 DOI: 10.1016/j.jelectrocard.2021.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The importance of the grade of ischemia (GI) ECG classification in the risk assessment of patients with STEMI has been shown previously. Grade 3 ischemia (G3I) is defined as ST-elevation with distortion of the terminal portion of the QRS complex in two or more adjacent leads, while Grade 2 ischemia (G2I) is defined as ST-elevation without QRS distortion. Our aim was to evaluate the prognostic impact of the GI classification on the outcome in patients with STEMI. METHODS 7,211 patients from the TOTAL trial were included in our study. The primary outcome was a composite of cardiovascular death, recurrent myocardial infarction (MI), cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year. RESULTS The primary outcome occurred in 153 of 1,563 patients (9.8%) in the G3I group vs. 364 of 5,648 patients (6.4%) in the G2I group (adjusted HR 1.27; 95% CI, 1.04 - 1.55; p=0.022). The rate of cardiovascular death (4.8% vs. 2.5%; adjusted HR 1.48; 95% CI 1.09 - 2.00; p=0.013) was also higher in patients with G3I. CONCLUSIONS G3I in the presenting ECG was associated with an increased rate of the composite of cardiovascular death, recurrent MI, cardiogenic shock, or NYHA class IV heart failure within one year compared to patients with G2I. Patients with G3I also had a higher cardiovascular death compared to patients with G2I.
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Affiliation(s)
- Joonas Leivo
- Internal medicine, Kanta-Häme Central Hospital, Hämeenlinna, Ahvenistontie 20, 13530 Hämeenlinna, Finland; Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Arvo Ylpön katu 34, 33520 Tampere, Finland.
| | - Eero Anttonen
- Päijät-sote, Primary health care, Lahti, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, Hamilton, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; Hamilton Health Sciences, Hamilton, P.O. Box 2000, Hamilton, ON L8N 3Z5, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, R. Fraser Elliott Building, 1st Floor 190 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Jyri Koivumäki
- Heart Center, Department of Cardiology, Tampere University Hospital, Tays Sydänkeskus Oy, PL 2000, 33521 Tampere, Finland
| | - Minna Tahvanainen
- Heart Center, Department of Cardiology, Tampere University Hospital, Tays Sydänkeskus Oy, PL 2000, 33521 Tampere, Finland
| | - Kimmo Koivula
- Internal medicine, South Karelia Central Hospital, Valto Käkelän katu 1, Lappeenranta 53130, Finland
| | - Kjell Nikus
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Arvo Ylpön katu 34, 33520 Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tays Sydänkeskus Oy, PL 2000, 33521 Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Department of Medicine, McMaster University, Hamilton, 1280 Main Street West, Hamilton, Ontario L8S4L8, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Faculty of Health Sciences, 1280 Main St. W., Hamilton, Ontario L8S4K1, Canada
| | - John A Cairns
- The University of British Columbia, 2329 West Mall, Vancouver, British Columbia V6T1Z4, Canada
| | - Kari Niemelä
- Heart Center, Department of Cardiology, Tampere University Hospital, Tays Sydänkeskus Oy, PL 2000, 33521 Tampere, Finland
| | - Markku Eskola
- Faculty of Medicine and Health Technology, Tampere University and Finnish Cardiovascular Research Center, Tampere, Arvo Ylpön katu 34, 33520 Tampere, Finland; Heart Center, Department of Cardiology, Tampere University Hospital, Tays Sydänkeskus Oy, PL 2000, 33521 Tampere, Finland
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Jolly SS, Nolan J. Radial First in ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2021; 14:e010595. [PMID: 33685218 DOI: 10.1161/circinterventions.121.010595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada (S.S.J.), Staffordshire, United Kingdom
| | - James Nolan
- Keele Cardiovascular Research Group (J.N.), Staffordshire, United Kingdom
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Iqbal MB, Moore PT, Nadra IJ, Robinson SD, Fretz E, Ding L, Fung A, Aymong E, Chan AW, Hodge S, Webb J, Sheth T, Jolly SS, Mehta SR, Sathananthan J, Wood DA, Della Siega A. Complete revascularization in stable multivessel coronary artery disease: A real world analysis from the British Columbia Cardiac Registry. Catheter Cardiovasc Interv 2021; 99:627-638. [PMID: 33660326 DOI: 10.1002/ccd.29564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/24/2021] [Accepted: 02/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than half of patients undergoing percutaneous coronary intervention (PCI) have multivessel disease (MVD). The prognostic significance of PCI in stable patients has recently been debated, but little data exists about the potential benefit of complete revascularization (CR) in stable MVD. We investigated the prognostic benefit of CR in patients undergoing PCI for stable disease. METHODS We compared CR versus incomplete revascularization (IR) in 8,436 patients with MVD. The primary outcome was all-cause mortality at 5 years. RESULTS A total of 1,399 patients (17%) underwent CR during the index PCI procedure for stable disease. CR was associated with lower mortality (6.2 vs. 10.7%, p < .001) and lower repeat revascularization at 5 years (12.7 vs. 18.4%, p < .001). Multivariable-adjusted analyses indicated that CR was associated with lower mortality (HR = 0.73, 95% CI: 0.58-0.91, p = .005) and repeat revascularization at 5 years (HR = 0.78, 95% CI: 0.66-0.93, p = .005). These findings were also confirmed in propensity-matched cohorts. Subgroup analyses indicated that CR conferred survival in older patients, male patients, absence of renal disease, greater angina (CCS Class III-IV) and heart failure (NYHA Class III-IV) symptoms, and greater burden of coronary disease. In sensitivity analyses where patients with subsequent repeat revascularization events were excluded, CR remained a strong predictor for lower mortality (HR = 0.69, 95% CI: 0.54-0.89, p = .004). CONCLUSIONS In this study of stable patients with MVD, CR was an independent predictor of long-term survival. This benefit was specifically seen in higher risk patient groups and indicates that CR may benefit selected stable patients with MVD.
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Affiliation(s)
- M Bilal Iqbal
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter T Moore
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Imad J Nadra
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Simon D Robinson
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Fretz
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Lillian Ding
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Anthony Fung
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Eve Aymong
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Albert W Chan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Royal Columbian Hospital, Vancouver, British Columbia, Canada
| | - Steven Hodge
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - John Webb
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Tej Sheth
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Anthony Della Siega
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Moxham R, Džavík V, Cairns J, Natarajan MK, Bainey KR, Akl E, Tsang MB, Lavi S, Cantor WJ, Madan M, Liu YY, Jolly SS. Association of Thrombus Aspiration With Time and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction: A Post Hoc Analysis of the Randomized TOTAL Trial. JAMA Netw Open 2021; 4:e213505. [PMID: 33769510 PMCID: PMC7998077 DOI: 10.1001/jamanetworkopen.2021.3505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Patients with shorter ischemic times have a greater viable myocardium and may derive greater benefit from thrombus aspiration. OBJECTIVE To study the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction (STEMI) based on time. DESIGN, SETTING, AND PARTICIPANTS The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients with STEMI) trial was an international randomized clinical trial of 10 732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021. INTERVENTIONS Thrombus aspiration vs PCI alone. MAIN OUTCOMES AND MEASURES Post hoc subgroup analyses were performed for total ischemic time and first medical contact (FMC)-to-device time for the primary outcomes (cardiovascular [CV] mortality, myocardial Infarction [MI], cardiogenic shock, and New York Heart Association class IV heart failure) and angiographically determined distal embolization. In addition, a multivariable analysis was performed to assess the association of total ischemic time and FMC-to-device time with CV mortality at 1 year. RESULTS The study randomized 10 732 patients, and 9986 underwent primary PCI and had time data available (7737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (<2 hours: odds ratio [OR], 0.23 [95% CI, 0.09-0.62]; 2-6 hours: OR, 0.54 [95% CI, 0.39-0.73]; >6 hours: OR, 0.70 [95% CI, 0.33-1.50]; P = .12 for interaction). However, for the primary composite outcome, there was no benefit based on (1) total ischemic time (<2 hours: hazard ratio [HR], 0.77 [95% CI, 0.46-1.28]; 2-6 hours: HR, 1.03 [95% CI, 0.85-1.25]; >6 hours: HR, 0.87 [95% CI, 0.60-1.27]; P = .46 for interaction) or (2) FMC-to-device time (<60 minutes: HR, 1.14 [95% CI, 0.66-1.95]; 60-90 minutes: HR, 0.94 [95% CI, 0.67-1.32]; >90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; P = .54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26 [95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45 [95% CI, 1.18-1.79]) were independently associated with CV mortality. CONCLUSIONS AND RELEVANCE This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01149044.
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Affiliation(s)
- Rachel Moxham
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - John Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Madhu K. Natarajan
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Elie Akl
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael B. Tsang
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shahar Lavi
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Warren J. Cantor
- Southlake Regional Health Center, University of Toronto, Toronto, Ontario, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yan Yun Liu
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S. Jolly
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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Popat SP, Rattan V, Rai S, Jolly SS, Malhotra S. Nutritional intervention during maxillomandibular fixation of jaw fractures prevents weight loss and improves quality of life. Br J Oral Maxillofac Surg 2020; 59:478-484. [PMID: 33589311 DOI: 10.1016/j.bjoms.2020.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/15/2020] [Indexed: 11/17/2022]
Abstract
Maxillomandibular fixation (MMF) for the management of jaw fractures leads to compromised nutritional intake and consequent weight loss and poor quality of life (QoL). The present study aimed to evaluate the effectiveness of a home-based dietary plan to prevent weight loss, and its effect on the QoL of patients who underwent four weeks of MMF for the treatment of maxillofacial fractures. A total of 50 patients were randomised into nutritional intervention (Group1) and non-intervention groups (Group 2). Patients in Group1 were counselled by a dietitian and given a diet plan. Patients in Group 2 were advised to take a liquid diet of their own choice in the form of shakes, juices, and milk, along with protein supplements. Patients in Group1 lost significantly less weight than those in Group 2 (p=0.001) at week four of follow up. Group1 patients had significantly better oral health-related QoL in the 'physical pain' domain during the two weeks of MMF, and in the 'physical discomfort' and 'psychological disability' domains two weeks after the release of MMF. They had significantly better nutrition-related QoL in all the domains during the two weeks of MMF and, except for the 'physical' domain, also during the two weeks after its release. Individual home-based diet plans effectively helped the patients maintain their weight and improved QoL.
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Affiliation(s)
- S P Popat
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - V Rattan
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - S Rai
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - S S Jolly
- Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - S Malhotra
- Department of Dietetics, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Cantor WJ, Lavi S, Džavík V, Cairns J, Cheema AN, Della Siega A, Moreno R, Stankovic G, Kedev S, Natarajan MK, Levi Y, Yuan F, Jolly SS. Upstream anticoagulation for patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention: Insights from the TOTAL trial. Catheter Cardiovasc Interv 2020; 96:519-525. [PMID: 31613046 DOI: 10.1002/ccd.28540] [Citation(s) in RCA: 2] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/22/2019] [Accepted: 10/01/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes. BACKGROUND For patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of anticoagulant administration remains uncertain. METHODS Patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant prior to randomization and PCI. Baseline and procedural characteristics were compared. For one-year clinical outcomes, Cox proportional modeling adjusted on a propensity score was used to analyze differences between groups. Angiographic endpoints were analyzed by logistic regression models adjusted for propensity scores. RESULTS In the trial, 10,064 patients were enrolled and underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%).The most common anticoagulant was intravenous unfractionated heparin (5,188, 81%). Patients who received preprocedural anticoagulation had higher rates of TIMI-2-3 or TIMI-3 flow and lower grades of thrombus prior to PCI. Pretreatment with anticoagulation was associated with lower use of bailout thrombectomy, GP IIb/IIIa inhibitors, and intra-aortic balloon pump. After adjustment, preprocedural anticoagulation was associated with lower rates of CABG and minor bleeding at 1 year but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure. CONCLUSIONS Preprocedural anticoagulation is associated with improved flow and reduced thrombus in the IRA prior to PCI, less bailout thrombectomy during PCI but no difference in death, recurrent infarction, or heart failure at 1 year.
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Affiliation(s)
- Warren J Cantor
- Division of Cardiology, Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shahar Lavi
- University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - John Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Goran Stankovic
- Clinical Center of Serbia and Department of Cardiology, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Sasko Kedev
- University Clinic of Cardiology, Sts. Cyril and Methodius University, Skopje, Macedonia
| | - Madhu K Natarajan
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yaniv Levi
- University of Western Ontario, London Health Sciences Centre, London, Ontario, Canada
| | - Fei Yuan
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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36
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Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumäki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemelä K, Eskola MJ. The high-risk ECG pattern of ST-elevation myocardial infarction: A substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial). Int J Cardiol 2020; 319:40-45. [PMID: 32470531 DOI: 10.1016/j.ijcard.2020.05.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Useful tools for risk assessment in patients with STEMI are needed. We evaluated the prognostic impact of the evolving myocardial infarction (EMI) and the preinfarction syndrome (PIS) ECG patterns and determined their correlation with angiographic findings and treatment strategy. METHODS This substudy of the randomized Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI (TOTAL) included 7860 patients with STEMI and either the EMI or the PIS ECG pattern. The primary outcome was a composite of death from cardiovascular causes, recurrent MI, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year. RESULTS The primary outcome occurred in 271 of 2618 patients (10.4%) in the EMI group vs. 322 of 5242 patients (6.1%) in the PIS group [AdjustedHR, 1.54; 95% CI, 1.30 to 1.82; p < .001]. The primary outcome occurred in the thrombectomy and PCI alone groups in 131 of 1306 (10.0%) and 140 of 1312 (10.7%) patients with EMI [HR 0.94; 95% CI, 0.74-1.19] and 162 of 2633 (6.2%) and 160 of 2609 (6.1%) patients with PIS [HR 1.00; 95% CI, 0.81-1.25], respectively (pinteraction = 0.679). CONCLUSIONS Patients with the EMI ECG pattern proved to have an increased rate of the primary outcome within one year compared to the PIS pattern. Routine manual thrombectomy did not reduce the risk of primary outcome within the different dynamic ECG patterns. The PIS/EMI dynamic ECG classification could help to triage patients in case of simultaneous STEMI patients with immediate need for pPCI.
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Affiliation(s)
- Joonas Leivo
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland.
| | - Eero Anttonen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Hamilton Health Sciences, Hamilton, Canada
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Jyri Koivumäki
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Minna Tahvanainen
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Kimmo Koivula
- Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland; Internal medicine, Helsinki University Hospital, Finland
| | - Kjell Nikus
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
| | - Jia Wang
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada; David Braley Cardiac, Vascular and Stroke Research Institute, Hamilton, Canada
| | | | - Kari Niemelä
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland
| | - Markku J Eskola
- Heart Center, Department of Cardiology, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finnish Cardiovascular Research Center, Tampere, Finland
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Wood DA, Cairns JA, Wang J, Mehran R, Storey RF, Nguyen H, Meeks B, Kunadian V, Tanguay JF, Kim HH, Cheema A, Dehghani P, Natarajan MK, Jolly SS, Amerena J, Keltai M, James S, Hlinomaz O, Niemela K, AlHabib K, Lewis BS, Nguyen M, Sarma J, Dzavik V, Della Siega A, Mehta SR. Timing of Staged Nonculprit Artery Revascularization in Patients With ST-Segment Elevation Myocardial Infarction: COMPLETE Trial. J Am Coll Cardiol 2020; 74:2713-2723. [PMID: 31779786 DOI: 10.1016/j.jacc.2019.09.051] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD). OBJECTIVES The purpose of this study was to determine the effect of nonculprit-lesion PCI timing on major CV outcomes and also the time course of the benefit of complete revascularization. METHODS Following culprit-lesion PCI, 4,041 patients with STEMI and multivessel CAD were randomized to staged nonculprit-lesion PCI or culprit-lesion only PCI. Randomization was stratified according to investigator-planned timing of nonculprit-lesion PCI: during or after the index hospitalization. The first coprimary outcome was the composite of CV death or myocardial infarction (MI). In pre-specified analyses, hazard ratios (HRs) were calculated for each time stratum. Landmark analyses of the entire population were performed within 45 days and after 45 days. RESULTS For nonculprit-lesion PCI planned during the index hospitalization (actual time: median 1 day), CV death or MI was reduced with complete revascularization compared with culprit-lesion only PCI (HR: 0.77; 95% confidence interval [CI]: 0.59 to 1.00). For nonculprit lesion PCI planned to occur after hospital discharge (actual time: median 23 days), CV death or MI was also reduced with complete revascularization (HR: 0.69; 95% CI: 0.49 to 0.97; interaction p = 0.62). Landmark analyses demonstrated an HR of 0.86 (95% CI: 0.59 to 1.24) during the first 45 days and 0.69 (95% CI: 0.54 to 0.89) from 45 days to the end of follow-up for intended nonculprit lesion PCI versus culprit lesion only PCI. CONCLUSIONS Among STEMI patients with multivessel disease, the benefit of complete revascularization over culprit-lesion only PCI was consistent irrespective of the investigator-determined timing of nonculprit-lesion intervention. The benefit of complete revascularization on hard clinical outcomes emerged mainly over the long term.
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Affiliation(s)
- David A Wood
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada.
| | - John A Cairns
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Helen Nguyen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brandi Meeks
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vijay Kunadian
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Hahn-Ho Kim
- St Mary's General Hospital, Kitchener, Ontario, Canada
| | - Asim Cheema
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Matyas Keltai
- Hungarian Institute of Cardiology, Budapest, Hungary
| | - Stefan James
- Uppsala Clinical Research Centre and Department of Medical Sciences, Uppsala, Sweden
| | - Ota Hlinomaz
- University Hospital St Anne, Brno, Czech Republic
| | - Kari Niemela
- Heart Centre, Tampere University Hospital, Tampere, Finland
| | - Khalid AlHabib
- Department of Cardiac Services, King Fahad Cardiac Center, Saudi Arabia
| | - Basil S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Michel Nguyen
- Division of Cardiology, Centre Hospitalier, Universitaire de Sherbrooke, Quebec, Quebec, Canada
| | - Jaydeep Sarma
- North West Heart Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anthony Della Siega
- Department of Cardiac Services, Victoria Heart Institute Foundation, Victoria, British Columbia, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
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Rymer JA, Kaltenbach LA, Kochar A, Hess CN, Gilchrist IC, Messenger JC, Harrington RA, Jolly SS, Jacobs AK, Abbott JD, Wojdyla DM, Krucoff MW, Rao SV. Comparison of Rates of Bleeding and Vascular Complications Before, During, and After Trial Enrollment in the SAFE-PCI Trial for Women. Circ Cardiovasc Interv 2020; 12:e007086. [PMID: 31014090 DOI: 10.1161/circinterventions.118.007086] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND SAFE-PCI for Women (Study of Access Site for Enhancement of PCI for Women), a randomized controlled trial comparing radial and femoral access in women undergoing cardiac catheterization or percutaneous coronary intervention (PCI), was terminated early for lower than expected event rates. Whether this was because of patient selection or better access site practice among trial patients is unknown. METHODS AND RESULTS SAFE-PCI was conducted within the National Cardiovascular Data Registry CathPCI registry. Using the National Cardiovascular Research Infrastructure Identification, PCI date, and age, patients enrolled in SAFE-PCI were compared with trial-eligible female CathPCI registry patients 1 year before, during, and 1 year after SAFE-PCI enrollment. Patient and procedure characteristics, predicted bleeding and mortality, and post-PCI bleeding were compared between groups. Enrolled SAFE-PCI patients and registry patients from the 3 time periods were linked to Centers for Medicare and Medicaid Services data to compare 30-day death and unplanned revascularization rates. At 54 SAFE-PCI sites, there were 496 SAFE-PCI trial patients with a PCI visit within the CathPCI registry. There were 24 958 registry patients from 1 year before and 1 year after SAFE-PCI enrollment and 15 904 trial-eligible registry patients during trial enrollment. Trial patients were younger, had lower predicted bleeding and mortality, and had lower rates of post-PCI bleeding within 72 hours compared with registry patients. Among 12 212 Centers for Medicare and Medicaid Services-linked patients, there were no significant differences in 30-day death and unplanned revascularization among the 4 groups. CONCLUSIONS Lower predicted risk of bleeding and mortality among SAFE-PCI trial patients compared with registry patients suggests that lower-risk patients were selectively enrolled for the trial. These data demonstrate how registry-based randomized trials may offer methods for enrollment feedback to curb selection bias in recruitment. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01406236.
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Affiliation(s)
- Jennifer A Rymer
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Lisa A Kaltenbach
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W.)
| | - Ajar Kochar
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Connie N Hess
- Division of Cardiology, University of Colorado School of Medicine, Aurora (C.N.H., J.C.M.)
| | - Ian C Gilchrist
- Department of Medicine, Penn State University, Hershey, PA (I.C.G.)
| | - John C Messenger
- Division of Cardiology, University of Colorado School of Medicine, Aurora (C.N.H., J.C.M.)
| | | | - Sanjit S Jolly
- Department of Medicine, McMaster University, Hamilton, ON (S.S.J.)
| | | | - J Dawn Abbott
- Division of Cardiovascular Medicine, Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI (J.D.A.)
| | - Daniel M Wojdyla
- Division of Cardiology, Duke Clinical Research Institute, Durham, NC (L.A.K., D.M.W.)
| | - Mitchell W Krucoff
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
| | - Sunil V Rao
- Department of Medicine, Duke University Medical Center, Durham, NC (J.A.R., A.K., M.W.K., S.V.R)
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Abstract
Considerable evidence supports transradial angiography and intervention in patients with acute coronary syndrome, with an emphasis on decreasing major bleeding and access site vascular complications. Patients undergoing invasive treatment are at greatest risk of bleeding and have the most to gain. The radial advantage has consistently been shown to translate into reduced mortality in pooled data analyses. The benefits of transradial access have been demonstrated across the acute coronary syndrome spectrum and in both sexes. A radial-first strategy should be the default approach and continuous efforts should be made to increase operator expertise of transradial access in these patients.
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Affiliation(s)
- Elie Akl
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Mohammed K Rashid
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Ahmad Alshatti
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Department of Medicine, Division of Cardiology, McMaster University, Room C3-118, DBCVSRI Building, 237 Barton Street East, Hamilton, ON L8L 2X2, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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40
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Mahmoud KD, Jolly SS, James S, Džavík V, Cairns JA, Olivecrona GK, Renlund H, Gao P, Lagerqvist B, Alazzoni A, Kedev S, Stankovic G, Meeks B, Frøbert O, Zijlstra F. Clinical impact of direct stenting and interaction with thrombus aspiration in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: Thrombectomy Trialists Collaboration. Eur Heart J 2019; 39:2472-2479. [PMID: 29688419 DOI: 10.1093/eurheartj/ehy219] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/04/2018] [Indexed: 11/12/2022] Open
Abstract
Aims Preliminary studies suggest that direct stenting (DS) during percutaneous coronary intervention (PCI) may reduce microvascular obstruction and improve clinical outcome. Thrombus aspiration may facilitate DS. We assessed the impact of DS on clinical outcome and myocardial reperfusion and its interaction with thrombus aspiration among ST-segment elevation myocardial infarction (STEMI) patients undergoing PCI. Methods and results Patient-level data from the three largest randomized trials on routine manual thrombus aspiration vs. PCI only were merged. A 1:1 propensity matched population was created to compare DS and conventional stenting. Synergy between DS and thrombus aspiration was assessed with interaction P-values in the final models. In the unmatched population (n = 17 329), 32% underwent DS and 68% underwent conventional stenting. Direct stenting rates were higher in patients randomized to thrombus aspiration as compared with PCI only (41% vs. 22%; P < 0.001). Patients undergoing DS required less contrast (162 mL vs. 172 mL; P < 0.001) and had shorter fluoroscopy time (11.1 min vs. 13.3 min; P < 0.001). After propensity matching (n = 10 944), no significant differences were seen between DS and conventional stenting with respect to 30-day cardiovascular death [1.7% vs. 1.9%; hazard ratio 0.88, 95% confidence interval (CI) 0.55-1.41; P = 0.60; Pinteraction = 0.96) and 30-day stroke or transient ischaemic attack (0.6% vs. 0.4%; odds ratio 1.02; 95% CI 0.14-7.54; P = 0.99; Pinteraction = 0.81). One-year results were similar. No significant differences were seen in electrocardiographic and angiographic myocardial reperfusion measures. Conclusion Direct stenting rates were higher in patients randomized to thrombus aspiration. Clinical outcomes and myocardial reperfusion measures did not differ significantly between DS and conventional stenting and there was no interaction with thrombus aspiration.
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Affiliation(s)
- Karim D Mahmoud
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, The Netherlands.,Department of Cardiology, Sint Franciscus Gasthuis, Kleiweg 500, BA Rotterdam, The Netherlands
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stefan James
- Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Henrik Renlund
- Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Peggy Gao
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Bo Lagerqvist
- Department of Medical Science, Uppsala University and Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Ashraf Alazzoni
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Sasko Kedev
- University Clinic of Cardiology, Sts. Cyril and Methodius University, Skopje, Macedonia
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Brandi Meeks
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ole Frøbert
- Department of Cardiology, Södra Grev Rosengatan, Örebro University, Faculty of Health, Örebro, Sweden
| | - Felix Zijlstra
- Department of Cardiology, Thorax Center, Erasmus Medical Center, Rotterdam, The Netherlands
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41
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Maes F, Jolly SS, Cairns J, Delarochellière R, Côté M, Dzavik V, Rodés-Cabau J. Plaque Sealing With Drug-Eluting Stents Versus Medical Therapy for Treating Intermediate Non-Obstructive Saphenous Vein Graft Lesions: A Pooled Analysis of the VELETI and VELETI II Trials. J Invasive Cardiol 2019; 31:E308-E315. [PMID: 31671060] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND The presence of intermediate "non-obstructive" saphenous vein graft (SVG) lesions is a strong predictor of cardiac events. We wanted to assess the efficacy of sealing these SVG lesions with drug-eluting stent (DES) implantation for reducing major adverse cardiac event (MACE) rate. METHODS The present analysis is based on the pooled data from the VELETI and VELETI II randomized trials. Patients with at least 1 intermediate SVG lesion (30%-60% diameter stenosis) were randomized to DES implantation (SVG-DES) or medical treatment (SVG-MT). The primary outcome was the first occurrence of MACE, defined as the composite of cardiac death, myocardial infarction, or coronary revascularization related to the target SVG. RESULTS A total of 182 patients were included (mean age, 70 ± 9 years), with 90 and 92 patients allocated to the SVG-DES and SVG-MT groups, respectively. After a mean follow-up of 4 ± 1 years, patients in the SVG-MT group exhibited a higher rate of MACE related to the target SVG (23.9% vs 17.8% in the SVG-DES group; P=.04) and MACE related to the target SVG lesion (21.7% vs 12.2% in the SVG-DES group; P<.01). In the multivariable analysis, a higher total cholesterol value at baseline (P=.04) was the only independent predictor of SVG disease progression leading to clinical events. CONCLUSIONS In patients with prior coronary artery bypass grafting and intermediate non-obstructive SVG lesions, plaque sealing with DES reduced the incidence of MACE related to SVG disease progression. A higher cholesterol level was the main predictor of SVG disease progression leading to clinical events in these patients.
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Affiliation(s)
| | | | | | | | | | | | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, 2725 Chemin Ste-Foy, G1V 4G5, Quebec City, Quebec, Canada.
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Leivo J, Anttonen E, Jolly SS, Dzavik V, Koivumaki J, Tahvanainen M, Koivula K, Nikus K, Wang J, Cairns JA, Niemela K, Eskola M. 3037The prognostic significance of grade of ischemia in patients with STEMI: a substudy of the randomized trial of primary PCI with or without routine manual thrombectomy (TOTAL trial). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The importance of grade of ischemia (GI) classification in the risk assessment of patients with ST-elevation myocardial infarction has been shown previously. Grade 3 ischemia (G3I) is defined by the Sclarovsky-Birnbaum grading system as ECG with ST-elevation and distortion of the terminal portion of the QRS complex in two or more adjacent leads, while grade 2 ischemia (G2I) is defined as ECG with ST-elevation without QRS distortion.
Methods
In a substudy of the international, multicenter, prospective, randomized Trial of Routine Aspiration Thrombectomy with PCI versus PCI Alone in Patients with STEMI (TOTAL), we studied the prognostic impact of the grade of ischemia classification on the outcome in patients with STEMI (n=7,211). The primary outcome was a composite of death from cardiovascular causes, recurrent MI, cardiogenic shock, or New York Heart Association (NYHA) class IV heart failure within one year.
Results
The primary outcome occurred in 153 of 1,563 patients (9.8%) in the G3I group vs. 364 of 5,648 patients (6.4%) in the G2I group (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.29 to 1.88; p<0.001). The rates of cardiovascular death (4.8% with G3I vs. 2.5% with G2I; HR, 1.92; 95% CI, 1.45 to 2.54; p<0.001) and all-cause mortality (5.2% with G3I vs. 3.3% with G2I; HR, 1.62; 95% CI, 1.25 to 2.10; p<0.001) were also higher in patients with G3I. The rate of stroke or TIA were similar within the two groups (1.1% with G3I vs. 1.0% with G2I; HR, 1.13; 95% CI, 0.66 to 1.95; p=0.650). The grade of ischemia (G3I vs G2I) was shown to be an independent predictor of primary outcome in adjusted multivariable analysis (adjusted HR, 1.43; 95% CI, 1.18 to 1.74; p<0.001).
Conclusions
STEMI patients with G3I in the presenting ECG proved to have an increased rate of cardiovascular death, recurrent MI, cardiogenic shock, or NYHA class IV heart failure within one year compared to patients with G2I.
Acknowledgement/Funding
Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, The unit of Heart Center Co. [Z60064]
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Affiliation(s)
- J Leivo
- University of Tampere, Faculty of Medicine and Health Technology, Tampere, Finland
| | - E Anttonen
- University of Tampere, Faculty of Medicine and Health Technology, Tampere, Finland
| | - S S Jolly
- Population Health Research Institute, Hamilton, Canada
| | - V Dzavik
- University Health Network, Peter Munk Cardiac Centre, Toronto, Canada
| | - J Koivumaki
- Tampere University Hospital, Heart Center, Department of Cardiology, Tampere, Finland
| | - M Tahvanainen
- Tampere University Hospital, Heart Center, Department of Cardiology, Tampere, Finland
| | - K Koivula
- Helsinki University Central Hospital, Helsinki, Finland
| | - K Nikus
- Tampere University Hospital, Heart Center, Department of Cardiology, Tampere, Finland
| | - J Wang
- Population Health Research Institute, Hamilton, Canada
| | - J A Cairns
- University of British Columbia, Vancouver, Canada
| | - K Niemela
- Tampere University Hospital, Heart Center, Department of Cardiology, Tampere, Finland
| | - M Eskola
- Tampere University Hospital, Heart Center, Department of Cardiology, Tampere, Finland
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43
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Rashid MK, Sahami N, Singh K, Winter J, Sheth T, Jolly SS. Ultrasound Guidance in Femoral Artery Catheterization: A Systematic Review and a Meta-Analysis of Randomized Controlled Trials. J Invasive Cardiol 2019; 31:E192-E198. [PMID: 31257213] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND During percutaneous cardiac procedures, the use of radial access is growing, but femoral access remains needed for large-bore, high-risk procedures. Methods are needed to make femoral access safer. In this systematic review and meta-analysis of randomized-controlled trials (RCTs), we assess whether ultrasound guidance is associated with a decreased risk of vascular complications during femoral artery catheterization. METHODS Medline, Embase, and Cochrane Central were searched from inception to April 2018. RCTs assessing the use of ultrasound among adult patients undergoing a femoral artery catheterization were included. The primary outcome was vascular-access related complications. Secondary outcomes included major and minor vascular access bleeding, success rate, venipuncture, number of attempts, and successful placement into the common femoral artery. RESULTS Five RCTs (n = 1553) met the inclusion criteria, with two trials using blinded outcome assessment. Ultrasound use was associated with a reduction in the rate of vascular-access related complications (1.9% vs 4.3%; odds ratio [OR], 0.44; 95% confidence interval [CI], 0.24-0.81; P<.01). This was primarily driven by a reduction in local hematomas; once hematomas were excluded, the association was no longer significant (0.6% vs 1.7%; OR, 0.39; 95% CI, 0.15-1.07; P=.07). There was no significant reduction in major bleeding (0.3% vs 1.3%; OR, 0.28; 95% CI, 0.07-0.1.16; P=.08) or minor bleeding (1.4% vs 2.8%; OR, 0.50; 95% CI, 0.24-1.05; P=.07). CONCLUSIONS Ultrasound guidance during femoral artery catheterization is associated with a decreased risk of vascular complications, primarily driven by a reduction in local hematomas. Larger trials are needed to determine the effect of ultrasound on major bleeding and vascular complications (excluding hematomas).
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Affiliation(s)
| | | | | | | | | | - Sanjit S Jolly
- Cardiology Division, Hamilton Health Sciences, Hamilton General Hospital Site, Population Health Research Institute (PHRI), McMaster University, 237 Barton Street East, Hamilton, Ontario, Canada L8L 2X2.
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Welsh RC, Sidhu RS, Cairns JA, Lavi S, Kedev S, Moreno R, Cantor WJ, Stankovic G, Meeks B, Yuan F, Džavík V, Jolly SS. Outcomes Among Clopidogrel, Prasugrel, and Ticagrelor in ST-Elevation Myocardial Infarction Patients Who Underwent Primary Percutaneous Coronary Intervention From the TOTAL Trial. Can J Cardiol 2019; 35:1377-1385. [PMID: 31492492 DOI: 10.1016/j.cjca.2019.04.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/18/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Robust comparisons between oral P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) in ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention are lacking. We sought to evaluate outcomes on the basis of P2Y12 inhibitor therapy in patients from the Thrombectomy With PCI Versus PCI Alone in Patients With STEMI Undergoing Primary PCI (TOTAL) trial. METHODS We grouped 9932 patients according to P2Y12 inhibitor at hospital discharge: clopidogrel (n = 6500; 65.5%), prasugrel (n = 1244; 12.5%), or ticagrelor (n = 2188; 22.0%). The primary composite end point of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or New York Heart Association class IV heart failure was examined at 1 year. Secondary efficacy and safety end points were also assessed. Cox proportional hazard ratios were determined and adjusted for confounders via propensity scoring. RESULTS Baseline characteristics differing between the 3 groups were mainly age 75 years or older, diabetes, and previous stroke. After adjustment, ticagrelor use was associated with a lower rate of the primary composite outcome compared with clopidogrel (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.57-0.91; P < 0.02) and prasugrel (aHR, 0.65; 95% CI, 0.48-0.89; P = 0.02). Prasugrel use was not associated with a lower rate of the primary outcome compared with clopidogrel (aHR, 1.09; 95% CI, 0.86-1.39; P > 0.99). Neither prasugrel nor ticagrelor were associated with increased risk of stroke compared with clopidogrel. Compared with clopidogrel, ticagrelor was associated with significantly lower rates of major bleeding. CONCLUSIONS In this observational analysis of STEMI patients who underwent primary percutaneous coronary intervention, ticagrelor was associated with improved outcomes compared with clopidogrel and prasugrel. An appropriately powered randomized trial is needed to confirm these findings.
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Affiliation(s)
- Robert C Welsh
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada.
| | - Robinder S Sidhu
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; University of Alberta, Edmonton, Alberta, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Shahar Lavi
- London Health Sciences Centre, London, Ontario, Canada
| | - Sasko Kedev
- University Clinic of Cardiology, Sts Curil and Methodius University, Skopje, Macedonia
| | | | - Warren J Cantor
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | | | - Brandi Meeks
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Fei Yuan
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Sanjit S Jolly
- McMaster University and the Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
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45
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Allahwala UK, Jolly SS, Džavík V, Cairns JA, Kedev S, Balasubramanian K, Stankovic G, Moreno R, Valettas N, Bertrand O, Lavi S, Velianou JL, Sheth T, Meeks B, Brilakis ES, Bhindi R. The Presence of a CTO in a Non-Infarct-Related Artery During a STEMI Treated With Contemporary Primary PCI Is Associated With Increased Rates of Early and Late Cardiovascular Morbidity and Mortality: The CTO-TOTAL Substudy. JACC Cardiovasc Interv 2019; 11:709-711. [PMID: 29622151 DOI: 10.1016/j.jcin.2017.12.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 12/22/2022]
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46
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Jolly SS, Gao P, Cairns JA, Yusuf S, Bhatt DL, Wyse DG, Wells GA, Džavík V. Risks of Overinterpreting Interim Data: Lessons From the TOTAL Trial (Thrombectomy With PCI Versus PCI Alone in Patients With STEMI). Circulation 2019; 137:206-209. [PMID: 29311352 DOI: 10.1161/circulationaha.117.030656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sanjit S Jolly
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - Peggy Gao
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - John A Cairns
- University of British Columbia, Vancouver, Canada (J.A.C.)
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Canada (S.S.J., P.G., S.Y.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.L.B.)
| | - D George Wyse
- Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Canada (D.G.W.)
| | | | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (V.D.)
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47
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Jolly SS. Reply: Thrombus Aspiration in Hyperglycemic Patients With High Inflammation Levels in Coronary Thrombus. J Am Coll Cardiol 2019; 73:532. [PMID: 30704590 DOI: 10.1016/j.jacc.2018.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 11/26/2018] [Indexed: 11/17/2022]
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48
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Affiliation(s)
- Sanjit S Jolly
- Departments of Medicine and Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shamir R Mehta
- Departments of Medicine and Health Research Methods, Evidence, and Impact, Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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49
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Jolly SS, Valgimigli M. Transradial left main PCI is safe and effective. EUROINTERVENTION 2018; 14:1073-1075. [PMID: 30451691 DOI: 10.4244/eijv14i10a192] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sanjit S Jolly
- Department of Medicine, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
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50
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Affiliation(s)
- Rodrigo Bagur
- Cardiology Division, London Health Sciences Centre, Western University, Ontario, Canada (R.B.)
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, United Kingdom (R.B.)
| | - Sanjit S. Jolly
- Cardiology Division, Hamilton Health Sciences, McMaster University, Ontario, Canada (S.S.J.)
- Population Health Research Institute, Hamilton, Ontario, Canada (S.S.J.)
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