1
|
Chow JK, Bagai A, Tan MK, Har BJ, Yip AMC, Paniagua M, Elbarouni B, Bainey KR, Paradis JM, Maranda R, Cantor WJ, Eisenberg MJ, Dery JP, Madan M, Cieza T, Matteau A, Roth S, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh RC, Kim HH, Robinson SD, Daneault B, Chong AY, Le May MR, Ahooja V, Gregoire JC, Nadeau PL, Laksman Z, Heilbron B, Yung D, Minhas K, Bourgeois R, Overgaard CB, Bonakdar H, Logsetty G, Lavoie AJ, De LaRochelliere R, Mansour S, Spindler C, Yan AT, Goodman SG. Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program. J Cardiol 2023; 82:153-161. [PMID: 36931433 DOI: 10.1016/j.jjcc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
Collapse
Affiliation(s)
| | - Akshay Bagai
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Bryan J Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Basem Elbarouni
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | | | - Warren J Cantor
- University of Toronto, Toronto, Canada; Southlake Regional Health Centre, Newmarket, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Mina Madan
- University of Toronto, Toronto, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Alexis Matteau
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | - Sherryn Roth
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Scarborough Health Network, Toronto, Canada
| | | | | | | | - Ravi Tahiliani
- Central East Regional Cardiac Care Program, Oshawa, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Hahn Hoe Kim
- St. Mary's General Hospital, Kitchener-Waterloo, Canada
| | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, Canada
| | - Benoit Daneault
- Centre hospitalier Universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Canada
| | | | | | | | | | | | | | - Brett Heilbron
- University of British Columbia, Vancouver, Canada; St. Paul's Hospital, Vancouver, Canada
| | - Derek Yung
- Scarborough Health Network, Toronto, Canada
| | - Kunal Minhas
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Ronald Bourgeois
- Moncton Hospital, Dalhousie University Faculty of Medicine, Moncton, Canada
| | | | - Hamid Bonakdar
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Robert De LaRochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Samer Mansour
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | | | - Andrew T Yan
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada.
| | - Shaun G Goodman
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada.
| |
Collapse
|
2
|
Ducharme A, Zieroth S, Ahooja V, Anderson K, Andrade J, Boivin-Proulx LA, Ezekowitz J, Howlett J, Lepage S, Leong D, McDonald MA, O'Meara E, Poon S, Swiggum E, Virani S. Canadian Cardiovascular Society-Canadian Heart Failure Society Focused Clinical Practice Update of Patients With Differing Heart Failure Phenotypes. Can J Cardiol 2023; 39:1030-1040. [PMID: 37169222 DOI: 10.1016/j.cjca.2023.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023] Open
Abstract
A number of societies produce heart failure (HF) management guidelines, comprising official recommendations on the basis of recent research discoveries, but their applicability to specific situations encountered in daily practice might be difficult. In this clinical practice update we aim to provide responses to fundamental questions that face health care providers, like appropriate timing for the introduction and optimization of different classes of medication according to specific patient phenotypes, when second-line therapies and valvular interventions should be considered, and management of difficult clinical scenarios such as cardiorenal syndrome and frailty. A consensus-based methodology was used. Approaches to 5 different phenotypes are presented: (1) The wet HF phenotype is the easiest to manage, decongestion being performed alongside introduction of guideline-directed medical therapy (GDMT); (2) The de novo HF phenotype requires the introduction of the 4 pillars of GDMT, personalizing the order on the basis of the individuals' biological and physiological characteristics; (3) The worsening HF phenotype is a marker of poor prognosis, and therefore should motivate optimization of GDMT, start second-line therapies, and/or reevaluate goals of care/advanced HF therapies; (4) The cardiorenal phenotypes require correct volume assessment, because renal function usually improves with decongestion; and (5) The frail HF phenotype require special attention, careful drug titration, and consideration of cardiac rehabilitation programs. In conclusion, specific common HF phenotypes call for a personalized approach to improve adoption of the HF guidelines into clinical practice.
Collapse
Affiliation(s)
- Anique Ducharme
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Shelley Zieroth
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vineeta Ahooja
- Department of Medicine, The Heart Health Institute, Scarborough, Ontario, Canada
| | - Kim Anderson
- Department of Medicine, Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Jason Andrade
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Justin Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Howlett
- Department of Medicine, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Serge Lepage
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Derek Leong
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael A McDonald
- Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Eileen O'Meara
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Stephanie Poon
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Swiggum
- Department of Medicine, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Sean Virani
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
3
|
Gupta M, Mancini GJ, Wani RJ, Ahooja V, Bergeron J, Manjoo P, Pandey AS, Reiner M, Beltran J, Oliveira T, Mackinnon ES. Real-world Insights into Evolocumab Use in Patients with Hyperlipidemia: Canadian Analysis from the ZERBINI Study. CJC Open 2022; 4:558-567. [PMID: 35734519 PMCID: PMC9207771 DOI: 10.1016/j.cjco.2022.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/07/2022] [Indexed: 01/24/2023] Open
Abstract
Background The 2021 Canadian Cardiovascular Society guidelines recommend proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor therapy in patients with atherosclerotic cardiovascular disease whose low-density lipoprotein cholesterol (LDL-C) concentration remains ≥ 1.8 mmol/L despite maximally tolerated statin therapy. This retrospective and prospective observational study characterizes Canadian patients treated with evolocumab and describes its effectiveness and safety. Methods Between August 2017 and July 2019, a total of 131 patients initiated on evolocumab therapy were enrolled at 15 sites in Canada. Data were extracted from medical records every 3 months between 6 months prior to, and for 12 months following evolocumab therapy initiation, until July 6, 2020. Baseline and prospectively collected data are reported as available. Results A total of 131 patients were enrolled (59.5% male; mean age [standard deviation (SD)] 64.7 ± 10.6 years), most with a diagnosis of atherosclerotic cardiovascular disease and/or familial hypercholesterolemia (93.4%). Mean (± SD) LDL-C concentration at baseline was 3.7 (± 1.7) mmol/L (n = 119), with 58.0% of patients receiving a statin (36.6% high intensity). Mean (± SD) LDL-C concentration after evolocumab treatment was 1.6 (± 1.0) mmol/L (n = 120), representing a 58.7% decrease from baseline (n = 109). This level remained stable over 12 months. An LDL-C concentration < 1.8 mmol/L was achieved by 77.5% of patients. Persistence was 92%, and no serious treatment-emergent adverse events were reported. Conclusions These findings provide real-world evidence of guideline-recommended initiation of evolocumab therapy, as well as confirmation of its effectiveness and safety in a Canadian population. Evolocumab therapy can address a healthcare gap in the management of dyslipidemia, by increasing the proportion of patients achieving LDL-C goals recommended to lower cardiovascular risk.
Collapse
Affiliation(s)
- Milan Gupta
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Canadian Collaborative Research Network, Hamilton, Ontario, Canada
| | - G.B. John Mancini
- Centre for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Vineeta Ahooja
- Heart Health Institute, Scarborough and Ajax, Ontario, Canada
| | - Jean Bergeron
- Department of Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
- Department of Laboratory Medicine, Centre Hospitalier Universitaire de Québec-Université Laval, Québec, Québec, Canada
| | - Priya Manjoo
- Department of Endocrinology, University of British Columbia, Vancouver, British Columbia, Canada
- Cardiometabolic Collaborative Clinic, Vancouver Island Health Authority, Vancouver, British Columbia, Canada
| | - A. Shekhar Pandey
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Cambridge Cardiac Care Centre, Cambridge, Ontario, Canada
| | | | | | | | - Erin S. Mackinnon
- Amgen Canada Inc., Mississauga, Ontario, Canada
- Corresponding author: Dr Erin Mackinnon, 6775 Financial Dr, Suite 100, Mississauga, Ontario L5N 0A4, Canada. Tel.: +1-647-919-0453.
| |
Collapse
|
4
|
Goodman S, Bagai A, Tan M, Andrade J, Spindler C, Malek-Marzban P, Har B, Yip A, Paniagua M, Elbarouni B, Bainey K, Paradis J, Maranda R, Cantor W, Doucet M, Khan R, Eisenberg M, Dery J, Schwalm J, Madan M, Lam A, Hameed A, Noronha L, Cieza T, Matteau A, Roth S, So D, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh R, Kim H, Robinson S, Daneault B, Chong A, Le May M, Ahooja V, Gregoire J, Nadeau P, Laksman Z, Heilbron B, Bonakdar H, Yung D, Yan A. ANTITHROMBOTIC THERAPIES IN CANADIAN ATRIAL FIBRILLATION PATIENTS WITH CONCOMITANT CORONARY ARTERY DISEASE: INSIGHTS FROM THE CONNECT AF+PCI-I AND -II PROGRAMS. Can J Cardiol 2021. [DOI: 10.1016/j.cjca.2021.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
5
|
Abstract
Background We studied care gap in patients with familial hypercholesterolemia (FH) with respect to lipid‐lowering therapy. Methods and Results We enrolled patients with cardiovascular disease (CVD) or FH and low‐density lipoprotein‐cholesterol >2.0 mmol/L despite maximally tolerated statin therapy. During follow‐up physicians received online reminders of treatment recommendations of 2009 patients (median age, 63 years, 42% women), 52.4% had CVD only, 31.7% FH only, and 15.9% both CVD and FH. Patients with FH were younger and more likely to be women and non‐White with significantly higher baseline low‐density lipoprotein‐cholesterol level (mmol/L) as compared with patients with CVD (FH 3.92±1.48 versus CVD 2.96±0.94, P<0.0001). Patients with FH received less statin (70.6% versus 79.2%, P=0.0001) at baseline but not ezetimibe (28.1% versus 20.4%, P=0.0003). Among patients with FH only, 45.3% were at low‐density lipoprotein target (≥ 50% reduction from pre‐treatment level or low‐density lipoprotein <2.5 mmol/L) at baseline and increasing to 65.8% and 73.6% by visit 2 and 3, respectively. Among patients with CVD only, none were at recommended level (≤2.0 mmol/L) at baseline and 44.3% and 53.3% were at recommended level on second and third visit, respectively. When primary end point was analyzed as a difference between baseline and last available follow‐up observation, only 22.0% of patients with FH only achieved it as compared with 45.8% with CVD only (P<0.0001) and 55.2% with both FH+CVD (P<0.0001). Conclusions There is significant treatment inertia in patients with FH including those with CVD. Education focused on patients with FH should continue to be undertaken.
Collapse
Affiliation(s)
| | | | - Mary Tan
- Canadian Heart Research Centre Toronto ON Canada
| | - Shaun G Goodman
- Canadian Heart Research Centre Toronto ON Canada.,St Michael's HospitalUniversity of Toronto Toronto ON Canada
| | | | - Jean Grégoire
- Université de MontréalInstitut de cardiologie de Montréal Montreal QC Canada
| | - Peter J Lin
- Canadian Heart Research Centre Toronto ON Canada
| | - James A Stone
- Cumming School of Medicine University of Calgary Calgary Canada.,Libin Cardiovascular Institute of Alberta Alberta Canada
| | - Lawrence A Leiter
- Li Ka Shing Knowledge InstituteSt. Michael's HospitalUniversity of Toronto Toronto ON Canada
| |
Collapse
|
6
|
Affiliation(s)
- Carolyn S. P. Lam
- National Heart Centre SingaporeSingapore
- Duke‐National University of Singapore Medical SchoolSingapore
- University Medical Centre GroningenGroningenthe Netherlands
- The George Institute for Global HealthNewtownAustralia
| | | | | | - Subodh Verma
- Division of Cardiac SurgeryKeenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's HospitalUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
7
|
Ahooja V, Thatai D. Multivessel coronary vasospasm mimicking triple-vessel obstructive coronary artery disease. J Invasive Cardiol 2007; 19:E178-81. [PMID: 17620681] [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] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Spontaneous coronary artery spasm is an important cause of morbidity both in patients with atherosclerotic coronary artery disease and in those with Prinzmetal's angina. Coronary vasospasm tends to occur in focal areas in the coronary tree and can be readily induced by the use of various agents. Spontaneous severe multivessel spasm, mimicking severe obstructive coronary artery disease, has been infrequently described. The therapeutic dilemma in such a clinical situation is highlighted in our current case where an unnecessary coronary artery bypass graft surgery (CABG) was performed due to the lack of clinical suspicion of spasm. This patient presented 5 years after triple-vessel CABG with an episode of rest angina, and was initially found to have severe obstruction of all three native coronary arteries with patent grafts to the right coronary and left anterior descending arteries. After nitroglycerin injection, all three native vessels appeared large and normal. This report raises the question of whether the routine use of intracoronary nitroglycerin, largely abandoned over the past 20 years, should be revisited, at least for certain patient populations such as those with rest angina.
Collapse
Affiliation(s)
- Vineeta Ahooja
- Division of Cardiology, Wayne State University, Detroit Medical Center, Detroit, MI, USA
| | | |
Collapse
|
8
|
Abstract
Chronic left ventricular systolic dysfunction is a well recognized problem with an increasingly significant impact on healthcare in the form of congestive heart failure (CHF). Advances in medicine have led to improved survival after myocardial infarction (MI) and as a result, an increased prevalence of left ventricular systolic dysfunction. An increased incidence of thromboembolism, especially stroke, in patients with left ventricular systolic dysfunction is also well recognized. Pharmacological strategies to prevent stroke have been proposed in numerous studies. For example, anticoagulation in patients with atrial fibrillation and heart failure has been shown to reduce mortality rates and the incidence of stroke; however, its role in patients with left ventricular dysfunction and normal sinus rhythm is unclear and utilization of anticoagulation in these patients varies widely. The role of aspirin to prevent thromboembolism in patients with CHF is controversial. The relatively new pharmacological agent ximelagatran, which has an advantage of unmonitored oral administration has the potential to change the anticoagulation strategy in patients with heart failure. Important trials to define optimal therapy for reducing the risk of thromboembolism and death in patients with left ventricular systolic dysfunction and sinus rhythm include the recently reported WATCH (Warfarin and Antiplatelet Therapy in Chronic Heart failure) trial and the WARCEF (Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction) trial, which is currently underway. The WATCH trial failed to outline significant differences between aspirin (acetylsalicylic acid), warfarin, and clopidogrel in the primary composite endpoint of all-cause mortality, nonfatal MI, and nonfatal stroke. Combined data from WATCH and WARCEF may provide sufficient statistical power to clarify outcomes such as stroke and death in patients with reduced cardiac ejection fraction. The pooled data may also help define optimal preventative measures for thromboembolism in patients with left ventricular systolic dysfunction and sinus rhythm.
Collapse
Affiliation(s)
- Deepak Thatai
- Department of Cardiology, Veteran Affairs Medical Center, Detroit, Michigan 48201, USA.
| | | | | |
Collapse
|