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Fischer Q, Pham V, Seret G, Brami P, Picard F, Varenne O. Antiplatelet therapy for treatment of coronary artery disease in older patients. Arch Cardiovasc Dis 2024:S1875-2136(24)00055-X. [PMID: 38658313 DOI: 10.1016/j.acvd.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 04/26/2024]
Abstract
Coronary artery disease in older patients is more frequently diffuse and complex, and is often treated by percutaneous coronary intervention on top of medical therapy. There are currently no specific recommendations for antiplatelet therapy in patients aged≥75 years. Aspirin remains pivotal, and is still indicated as a long-term treatment after percutaneous coronary intervention. In addition, a P2Y12 inhibitor is administered for 6-12 months according to clinical presentation. Age is a minor bleeding risk factor, but because older patients often have several co-morbidities, they are considered as having a high bleeding risk according to different scoring systems. This increased bleeding risk has resulted in different therapeutic strategies for antithrombotic treatment after percutaneous coronary intervention; these include short dual antiplatelet therapy, a switch from potent to less potent antiplatelet therapy or single antiplatelet therapy with a P2Y12 inhibitor instead of aspirin, among others. A patient-centred approach, taking into account health status, functional ability, frailty, cognitive skills, bleeding and ischaemic risks and patient preference, is essential when caring for older adults with coronary artery disease. The present review focuses on the knowledge base, specificities of antiplatelet therapies, a balance between haemorrhagic and ischaemic risk, strategies for antiplatelet therapy and directions for future investigation pertaining to coronary artery disease in older patients.
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Affiliation(s)
- Quentin Fischer
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Vincent Pham
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Gabriel Seret
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Pierre Brami
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Fabien Picard
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Olivier Varenne
- Service de cardiologie, hôpital Cochin, université Paris Cité, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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Ishida M, Shimada R, Takahashi F, Niiyama M, Ishisone T, Matsumoto Y, Taguchi Y, Osaki T, Nishiyama O, Endo H, Sakamoto R, Tanaka K, Koeda Y, Kimura T, Goto I, Ninomiya R, Sasaki W, Itoh T, Morino Y. One-Month Dual Antiplatelet Therapy Followed by P2Y 12 Inhibitor Monotherapy After Biodegradable Polymer Drug-Eluting Stent Implantation - The REIWA Region-Wide Registry. Circ J 2024:CJ-24-0091. [PMID: 38569870 DOI: 10.1253/circj.cj-24-0091] [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] [Indexed: 04/05/2024]
Abstract
BACKGROUND The safety and feasibility of using 1-month dual antiplatelet therapy (DAPT) followed by P2Y12inhibitor monotherapy for patients after percutaneous coronary intervention (PCI) with thin-strut biodegradable polymer drug-eluting stents (BP-DES) in daily clinical practice remain uncertain.Methods and Results: The REIWA region-wide registry is a prospective study conducted in 1 PCI center and 9 local hospitals in northern Japan. A total of 1,202 patients who successfully underwent final PCI using BP-DES (Synergy: n=400; Ultimaster: n=401; Orsiro: n=401), were enrolled in the registry, and received 1-month DAPT followed by P2Y12inhibitor (prasugrel 3.75 mg/day or clopidogrel 75 mg/day) monotherapy. The primary endpoint was a composite of cardiovascular and bleeding events at 12 months, including cardiovascular death, myocardial infarction (MI), definite stent thrombosis (ST), ischemic or hemorrhagic stroke, and Thrombolysis in Myocardial Infarction (TIMI) major or minor bleeding. Based on the results of a previous study, we set the performance goal at 5.0%. Over the 1-year follow-up, the primary endpoint occurred in 3.08% of patients, which was lower than the predefined performance goal (Pnon-inferiority<0.0001). Notably, definite ST occurred in only 1 patient (0.08%) within 1 year (at 258 days). No differences were observed in the primary endpoint between stent types. CONCLUSIONS The REIWA region-wide registry suggests that 1-month DAPT followed by P2Y12inhibitor monotherapy is safe and feasible for Japanese patients with BP-DES.
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Affiliation(s)
- Masaru Ishida
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Ryutaro Shimada
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
| | - Fumiaki Takahashi
- Division of Medical Engineering, Department of Information Science, Iwate Medical University
| | | | - Takenori Ishisone
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Chubu Hospital
| | - Yuki Matsumoto
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
- Department of Cardiology, Iwate Prefectural Kuji Hospital
| | - Yuya Taguchi
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Miyako Hospital
| | - Takuya Osaki
- Department of Cardiology, Iwate Prefectural Kuji Hospital
| | | | - Hiroshi Endo
- Department of Cardiology, Iwate Prefectural Iwai Hospital
| | | | | | - Yorihiko Koeda
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Takumi Kimura
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Iwao Goto
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Ryo Ninomiya
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
- Department of Cardiology, Iwate Prefectural Ofunato Hospital
| | - Wataru Sasaki
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Tomonori Itoh
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Kodani E, Inoue H, Atarashi H, Okumura K, Yamashita T, Origasa H. Characteristics and outcomes in elderly patients with non-valvular atrial fibrillation and high bleeding risk: subanalysis of the J-RHYTHM Registry. Heart Vessels 2024; 39:330-339. [PMID: 38103100 PMCID: PMC10920444 DOI: 10.1007/s00380-023-02343-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/16/2023] [Indexed: 12/17/2023]
Abstract
Recently, a once-daily dose of edoxaban (15-mg) has been approved for stroke prevention in non-valvular atrial fibrillation (NVAF) patients aged ≥ 80 years, in whom standard oral anticoagulants are not recommended because of high bleeding risk (HBR), based on the ELDERCARE-AF trial. However, information regarding the characteristics and clinical outcomes among such patients is limited. Thus, this study aimed to clarify the characteristics and event rates in elderly patients with NVAF and HBR defined by the ELDERCARE-AF criteria. Of the 7406 NVAF outpatients included in the J-RHYTHM Registry, 60 patients with creatinine clearance (CrCl) < 15 mL/min were excluded. The remaining 7346 patients (age, 69.7 ± 9.9 years; men, 70.9%; warfarin use, 78.7%) were divided into three groups: Group 1, aged < 80 years (n = 6165); Group 2, aged ≥ 80 years without HBR (n = 584); and Group 3, aged ≥ 80 years with HBR (at least one of the followings; CrCl, 15-30 mL/min, history of bleeding, body weight ≤ 45 kg, and antiplatelet use) (n = 597, eligible for 15-mg edoxaban). Patients in Group 3 had a higher prevalence of comorbidities, and therefore, both higher thromboembolic and bleeding risk scores than in the other groups. During the 2-year follow-up period, the incidence rates (per 100 person-years) of thromboembolism in Groups 1, 2, and 3 were 0.7, 1.5, and 2.1 (P < 0.001), major hemorrhage, 0.8, 1.2, and 2.0 (P < 0.001), and all-cause death, 0.8, 2.6, and 4.6 (P < 0.001), respectively. Adjusted hazard ratios of Group 3 were 1.64 (95% confidence interval 0.89-3.04, P = 0.116) for thromboembolism, 1.53 (0.85-2.72, P = 0.154) for major hemorrhage, and 1.84 (1.19-2.85, P = 0.006) for all-cause death compared with Group 1. The NVAF Patients aged ≥ 80 years with HBR defined by the ELDERCARE-AF criteria were certainly at a higher adverse event risk, especially for all-cause death. Clinical trial registration: The J-RHYTHM Registry is registered in the University Hospital Medicine Information Network (UMIN) Clinical Trials Registry (unique identifier: UMIN000001569) http://www.umin.ac.jp/ctr/ .
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Affiliation(s)
- Eitaro Kodani
- Department of Cardiovascular Medicine and Cardiology, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama-shi, Tokyo, 206-8512, Japan.
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
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Kobari Y, Hayashida K. What is the current optimal antithrombotic therapy after transcatheter aortic valve implantation? Current evidence from Japan and the world. J Cardiol 2024; 83:141-148. [PMID: 37524301 DOI: 10.1016/j.jjcc.2023.07.012] [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: 06/07/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
Aortic stenosis (AS) is a major valvular disease that can have a negative impact on patients' prognosis, and its prevalence is increasing due to an aging population worldwide. Transcatheter aortic valve implantation (TAVI) is a well-established therapy for symptomatic severe AS utilized across the entire surgical risk spectrum. Based on the recently published evidence of large, randomized controlled trials (RCTs), the number of patients undergoing TAVI is increasing worldwide. Ischemic and bleeding events are common after TAVI and can have serious consequences both immediately after the procedure and in the long-term. Antiplatelet therapy has been traditionally recommended to prevent thromboembolic events after TAVI. The situation regarding the optimal antithrombotic regimen following TAVI is rapidly changing because many game-changing RCTs have been published. This report provides an overview of the current status and remaining issues in the field of optimal antithrombotic therapy following TAVI, including its possible effect on leaflet thrombosis.
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Breen TJ, Raphael CE, Ingraham B, Lane C, Huxley S, Roger VL, Jaffe A, Lewis B, Sandoval YB, Prasad A, Rihal CS, Gulati R, Singh M. Incidence and outcomes of high bleeding risk patients with type 1 and type 2 myocardial infarction in a community-based cohort: Application of the Academic Research Consortium High Bleeding Risk Criteria. Int J Cardiol 2024; 396:131565. [PMID: 37913957 PMCID: PMC10841724 DOI: 10.1016/j.ijcard.2023.131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/29/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND AIMS The incidence and outcomes of high bleeding risk (HBR) patients in a community cohort according to the Academic Research Consortium (ARC) criteria is not known. We hypothesized that HBR is common and associated with worse outcomes for all-comers with myocardial infarction. METHODS We prospectively collected all patients with cardiac troponin T > 99th percentile upper limit of normal (≥0.01 ng/mL) in Olmsted County between 2003 and 2012. Events were retrospectively classified as type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI), or myocardial injury. Patients were further classified as HBR based on the "ARC-HBR definition." Outcomes included all-cause mortality, cardiovascular mortality, recurrent MI, stroke, and major bleeding. RESULTS 2419 patients were included in the final study; 1365 were classified as T1MI and 1054 as T2MI. Patients were followed for a median of 5.5 years. ARC-HBR was more common in T2MI than T1MI (73% vs 46%, p < 0.001). Among patients with T1MI, HBR was associated with higher all-cause mortality (HR 3.7, 95% CI 3.2-4.5, p < 0.001), cardiovascular mortality (4.7, 3.6-6.3, p < 0.001), recurrent MI (2.1, 1.6-2.7, p < 0.001), stroke (4.9, 2.9-8.4, p < 0.001), and major bleeding (6.5, 3.7-11.4, p < 0.001). For T2MI, HBR was similarly associated with higher all-cause mortality (HR 2.1, 95% CI 1.8-2.5, p < 0.001), cardiovascular mortality (2.7, 1.8-4.0, p < 0.001), recurrent MI (1.7, 1.1-2.6, p = 0.02) and major bleeding (HR 15.6, 3.8-63.8, p < 0.001). CONCLUSION HBR is common among unselected patients with T1MI and T2MI and is associated with increased overall and cardiovascular mortality, recurrent cardiovascular events, and major bleeding on long-term follow up.
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Affiliation(s)
- Thomas J Breen
- Department of Cardiovascular Medicine, Yale University, 20 York Street, New Haven, CT 06510, United States of America.
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brenden Ingraham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Conor Lane
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Sam Huxley
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Veronique L Roger
- Division of Intramural Research, National Heart Lung and Blood Institute, Bethesda, MD 20814, United States of America
| | - Allan Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Bradley Lewis
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Yader B Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
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Obayashi Y, Natsuaki M, Watanabe H, Morimoto T, Yamamoto K, Nishikawa R, Ando K, Suwa S, Isawa T, Takenaka H, Ishikawa T, Tokuyama H, Sakamoto H, Fujita T, Nanasato M, Okayama H, Nishikura T, Kirigaya H, Nishida K, Ono K, Kimura T. Aspirin-free strategy for percutaneous coronary intervention in acute coronary syndrome based on the subtypes of acute coronary syndrome and high bleeding risk: the STOPDAPT-3 trial. Eur Heart J Cardiovasc Pharmacother 2024:pvae009. [PMID: 38285607 DOI: 10.1093/ehjcvp/pvae009] [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] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND AND AIMS High bleeding risk (HBR) and acute coronary syndrome (ACS) subtypes are critical in determining bleeding and cardiovascular event risk after percutaneous coronary intervention (PCI). METHODS In 4476 ACS patients enrolled in the STOPDAPT-3, where the no-aspirin and dual antiplatelet therapy (DAPT) strategies after PCI were randomly compared, the pre-specified subgroup analyses were conducted based on HBR/non-HBR and ST-segment elevation myocardial infarction (STEMI)/non-ST-segment elevation ACS (NSTE-ACS). The co-primary bleeding endpoint was BARC type 3 or 5, and the co-primary cardiovascular endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis, or ischemic stroke at 1 month. RESULTS Irrespective of the subgroups, the effect of no-aspirin compared with DAPT was not significant for the bleeding endpoint (HBR [N = 1803]: 7.27% and 7.91%, HR 0.91, 95%CI 0.65-1.28; non-HBR [N = 2673]: 3.40% and 3.65%, HR 0.93, 95%CI 0.62-1.39; Pinteraction = 0.94; STEMI [N = 2553]: 6.58% and 6.56%, HR 1.00, 95% CI 0.74-1.35; NSTE-ACS [N = 1923]: 2.94% and 3.64%, HR 0.80, 95%CI 0.49-1.32; Pinteraction = 0.45), and for the cardiovascular endpoint (HBR: 7.87% and 5.75%, HR 1.39, 95%CI 0.97-1.99; non-HBR: 2.56% and 2.67%, HR 0.96, 95%CI 0.60-1.53; Pinteraction = 0.22; STEMI: 6.07% and 5.46%, HR 1.11, 95%CI 0.81-1.54; NSTE-ACS: 3.03% and 1.71%, HR 1.78, 95%CI 0.97-3.27; Pinteraction = 0.18). CONCLUSIONS In patients with ACS undergoing PCI, the no-aspirin strategy compared to the DAPT strategy failed to reduce major bleeding events irrespective of HBR and ACS subtypes. The numerical excess risk of the no-aspirin strategy relative to the DAPT strategy for cardiovascular events was observed in patients with HBR and in patients with NSTE-ACS.
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Affiliation(s)
- Yuki Obayashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ko Yamamoto
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyusyu, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Tsuyoshi Isawa
- Department of Cardiology, Sendai Kousei Hospital, Sendai, Japan
| | | | - Tetsuya Ishikawa
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Hideo Tokuyama
- Department of Cardiology, Kawaguchi Cardiovascular and Respiratory Hospital, Kawaguchi, Japan
| | - Hiroki Sakamoto
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Takanari Fujita
- Division of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Tenjin Nishikura
- Department of Cardiology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hidekuni Kirigaya
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Koji Nishida
- Division of Cardiology, Chikamori Hospital, Kochi, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
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Ciou WS, Wang CC, Lin FJ, Chao TF, Lin SY. Comparison of different direct oral anticoagulant regimens in atrial fibrillation patients with high bleeding risk. Heart Rhythm 2024:S1547-5271(24)00079-1. [PMID: 38266751 DOI: 10.1016/j.hrthm.2024.01.025] [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: 09/16/2023] [Revised: 01/09/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND The optimal dose of direct oral anticoagulants (DOACs) to prevent ischemic stroke (IS) and systemic thromboembolism (STE) in atrial fibrillation (AF) patients with a predisposing bleeding risk remains unclear. OBJECTIVE The purpose of this study was to compare the effectiveness and safety of different DOAC dosage regimens in AF patients with high bleeding risk but low thrombosis risk. METHODS This retrospective observational study was conducted with the National Health Insurance claims database in Taiwan to include AF patients aged 20 up to 75 years, under DOAC therapy, with CHA2DS2-VASc score of 1 for males and 2 for females and HAS-BLED score ≥3. Standard-dose regimen was defined as dabigatran 300 mg, rivaroxaban 20 mg, apixaban 10 mg, or edoxaban 60 mg per day. Any other lower-dose regimen were defined as the low-dose regimen. The primary outcomes were IS and major bleeding (MB). The secondary outcomes were STE, gastrointestinal bleeding, intracranial hemorrhage, and cardiovascular death. RESULTS A total of 964 patients were included (52.1% standard-dose regimen). Median HAS-BLED score was 3 [interquartile range 3-3]. Compared with standard-dose group, patients in the low-dose group had a significantly increased risk of IS (adjusted hazard ratio [aHR] 5.13; 95% confidence interval 1.37-19.22) and STE (aHR 3.14 [1.05-9.37]) but similar risk of MB (aHR 0.45 [0.12-1.67]). The risks of other hemorrhage and cardiovascular death were similar between the 2 dose groups. CONCLUSION Among patients with a predominant bleeding risk but relatively low thrombosis risk, the low-dose DOAC regimen is not a more appropriate selection than standard-dose regimen.
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Affiliation(s)
- Wei-Siang Ciou
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chuan Wang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Lin CF, Tsai CL, Chang YH, Lin DY, Chien LN. Sex-based differences in ischemic cardiovascular and bleeding outcomes following implantation of drug-eluting stent in patients at high bleeding risk. Hellenic J Cardiol 2024:S1109-9666(24)00001-0. [PMID: 38218375 DOI: 10.1016/j.hjc.2024.01.001] [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: 08/08/2023] [Revised: 11/28/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Patients with high bleeding risk (HBR) may exhibit uncertain adherence to dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) implantation. The current population-based cohort study aimed to investigate the sex-based differences in adverse outcomes among the HBR population by analyzing the National Health Insurance Research Database in Taiwan. METHODS Patients who had HBR features defined by the Academic Research Consortium (ARC) and received DES implantation between January 1, 2007, and December 31, 2017, were enrolled. Propensity score matching was adopted to select 3,981 pairs with similar clinical cardiovascular risks but different sexes. A competing risk model was performed to evaluate the risk of adverse ischemic events (cardiac death, nonfatal myocardial infarction, and ischemic stroke) and any bleeding events in both sexes. Noncardiac death was considered a competing risk. RESULTS Within a 5-year follow-up, the incidence rates (per 1,000 person-year (95% confidence interval (CI)) of composite ischemic events and any bleeding events in males were respectively 44.09 (40.25-48.30) and 42.55 (38.79-46.68), while those in females were respectively 40.18 (36.51-44.23) and 42.35 (38.57-46.51). After adjustment for clinical variables, male patients had a marginally increased risk in the composite ischemic events (adjusted subdistribution hazard ratio (SHR) = 1.15 (1.00-1.31), p = 0.045) and a similar risk of any bleeding events (adjusted SHR = 1.00 (0.88-1.15), p = 0.946) compared with female patients. CONCLUSIONS Of the HBR population, males had an increased risk of ischemic outcomes but a similar risk of bleeding compared with females following DES implantation.
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Affiliation(s)
- Chao-Feng Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chia-Ling Tsai
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ya-Hui Chang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Department of Pharmacy, MacKay Memorial Hospital, Taipei, Taiwan
| | - Dai-Yi Lin
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Shimono H, Tokushige A, Kanda D, Ohno A, Arikawa R, Chaen H, Okui H, Oketani N, Ohishi M. Comparison of Discriminative Ability of Bleeding Risk Criteria and Scores for Predicting Short- and Mid-Term Major Bleeding Events in Patients Undergoing Percutaneous Coronary Intervention. Circ Rep 2024; 6:4-15. [PMID: 38196402 PMCID: PMC10774022 DOI: 10.1253/circrep.cr-23-0087] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/18/2023] [Accepted: 11/23/2023] [Indexed: 01/11/2024] Open
Abstract
Background: This study aimed to compare the discriminative ability of the Japanese Version of High Bleeding Risk (J-HBR), Academic Research Consortium for High Bleeding Risk (ARC-HBR), and Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) scores for predicting major bleeding events. Methods and Results: Between January 2017 and December 2020, 646 consecutive patients who underwent successful percutaneous coronary intervention (PCI) were enrolled. We scored the ARC-HBR and J-HBR criteria by assigning 1 point to each major criterion and 0.5 point to each minor criterion. The primary outcome was major bleeding events, defined as Bleeding Academic Research Consortium type 3 or 5 bleeding events. According to the J-HBR, ARC-HBR, and PRECISE-DAPT scores, 428 (66.3%), 319 (49.4%), and 282 (43.7%) patients respectively had a high bleeding risk. During the follow-up period (median, 974 days), 44 patients experienced major bleeding events. The area under the curve (AUC) using the time-dependent receiver operating characteristic curve for major bleeding events was 0.84, 0.82, and 0.83 within 30 days and 0.86, 0.83, and 0.80 within 2 years for the J-HBR, ARC-HBR, and PRECISE-DAPT scores, respectively. The AUC values did not differ significantly among the 3 bleeding risk scores. Conclusions: The J-HBR score had a discriminative ability similar to the ARC-HBR and PRECISE-DAPT scores for predicting short- and mid-term major bleeding events.
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Affiliation(s)
- Hirokazu Shimono
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Akihiro Tokushige
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus School of Medicine Okinawa Japan
| | - Daisuke Kanda
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
| | - Ayaka Ohno
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
| | - Ryo Arikawa
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
| | - Hideto Chaen
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
| | - Hideki Okui
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
| | - Naoya Oketani
- Department of Cardiovascular Medicine, Kagoshima City Hospital Kagoshima Japan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
- Department of Prevention and Analysis of Cardiovascular Diseases, Graduate School of Medical and Dental Sciences, Kagoshima University Kagoshima Japan
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10
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Toth GG, Kandzari DE, Kirtane AJ, Windecker S, Latib A, Kedhi E, Mehran R, Price MJ, Choi JW, Caputo R, Troquay R, Diderholm E, Singh S, Brar SS, Loussararian A, Chetcuti S, Tulli M, Stone GW, Lung TH, Mylotte D. Two-year results from Onyx ONE clear in patients with high bleeding risk on one-month DAPT with and without intracoronary imaging. Cardiovasc Revasc Med 2024; 58:60-67. [PMID: 37550123 DOI: 10.1016/j.carrev.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Patients with high bleeding risk (HBR) are often treated with abbreviated dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) to reduce bleeding risk, however this strategy is associated with an increase in ischemic events, especially if the acute PCI result is suboptimal. We compared clinical outcomes among patients with HBR treated with 1-month DAPT who underwent intravascular ultrasound (IVUS)- or optical coherence tomography (OCT)-guided PCI versus those who underwent angiography-guided PCI without intravascular imaging. METHODS The Onyx ONE Clear study includes patients with HBR from the Onyx ONE US/Japan and Onyx ONE randomized studies who were treated with the Resolute Onyx zotarolimus-eluting stent. The primary endpoint was the composite of cardiac death (CD) or myocardial infarction (MI) between 1 month and 2 years after PCI. Propensity-score adjustments and matching were performed for differences in baseline and procedural characteristics between groups. RESULTS Among the 1507 patients in Onyx ONE Clear, 271 (18.0 %) had IVUS or OCT used during PCI (Imaging-guided group) and 1236 (82.0 %) underwent Angiography-guided PCI (Angio-guided group). Imaging-guided patients were less likely to present with atrial fibrillation, acute coronary syndrome, and left ventricle ejection fraction ≤35 %. Conversely, Imaging-guided patients were more likely to have complex (ACC/AHA type B2/C), longer, and heavily calcified lesions. Between 1 month and 2 years, the composite rate of CD or MI was similar between Imaging-guided and Angio-guided patients (9.9 % vs. 12.4 %, P = 0.33). There was also no difference between groups after adjustment; (P = 0.56). However, CD was significantly lower among Imaging-guided patients (2.7 % vs. 6.1 %, P = 0.048). There were no between-group differences in MI or stent thrombosis. Propensity score matching results were similar. CONCLUSION Despite higher lesion complexity, using intravascular imaging guidance for PCI between 1-month and 2-years follow-up had comparable outcomes with angiographic guidance alone in patients with HBR treated with 1-month DAPT. (ClinicalTrials.gov: Identifier: NCT03647475 and NCT03344653). NON-STANDARD ABBREVIATIONS AND ACRONYMS BARC: Bleeding Academic Research Consortium; DAPT: dual antiplatelet therapy; DES: drug-eluting stent; HBR: high bleeding risk; IVUS: intravascular ultrasound; OCT: optical coherence tomography; SAPT: single antiplatelet therapy.
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Affiliation(s)
- Gabor G Toth
- University Heart Center Graz, Medical University Graz, Graz, Austria
| | | | - Ajay J Kirtane
- Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, NY, United States of America; The Cardiovascular Research Foundation, New York, NY, United States of America
| | | | - Azeem Latib
- Montefiore Medical Center, New York, NY, United States of America
| | - Elvin Kedhi
- Free University of Brussels, Brussels, Belgium
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | | | - James W Choi
- Baylor Heart & Vascular Hospital, Dallas, TX, United States of America
| | - Ronald Caputo
- Saint Joseph's Hospital Heart Center, Syracuse, NY, United States of America
| | | | | | - Sunil Singh
- Memorial Hospital of Jacksonville, Jacksonville, FL, United States of America
| | - Somjot S Brar
- Kaiser Permanente Los Angeles, Los Angeles, CA, United States of America
| | - Arthur Loussararian
- Providence Mission Hospital Regional Medical Center, Mission Viejo, CA, United States of America
| | - Stanley Chetcuti
- University of Michigan Health Center, University Hospital, Ann Arbor, MI, United States of America
| | - Mark Tulli
- North Florida Regional Medical Center, Gainesville, FL, United States of America
| | - Gregg W Stone
- The Cardiovascular Research Foundation, New York, NY, United States of America; The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, United States of America
| | - Te-Hsin Lung
- Medtronic, Santa Rosa, CA, United States of America
| | - Darren Mylotte
- University Hospital and National University of Ireland Galway, Galway, Ireland.
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11
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Matsumoto T, Saito Y, Sato T, Yamashita D, Suzuki S, Saito K, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Diagnostic ability of Japanese version of high bleeding risk criteria for ischemic outcomes in patients with acute myocardial infarction. Heart Vessels 2024; 39:1-9. [PMID: 37598361 DOI: 10.1007/s00380-023-02303-3] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
The Japanese version of high bleeding risk (J-HBR) criteria was domestically proposed to identify patients at HBR after percutaneous coronary intervention (PCI). The applicability of J-HBR on bleeding events has been validated, while whether J-HBR predicts ischemic events is uncertain. This bi-center registry included 904 patients with acute myocardial infarction (MI) undergoing primary PCI. Patients were stratified by the J-HBR major (1 point) and minor (0.5 point) criteria. Patients with J-HBR ≥ 1 point were diagnosed as having HBR. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiovascular death, recurrent MI, and ischemic stroke, after discharge. Of the 904 patients, 451 (49.9%) had the J-HBR. The primary endpoint more frequently occurred in patients with J-HBR than in those without (10.9% vs. 4.9%, p < 0.001) during the median follow-up period of 522 days. Probability of MACE was progressively increased with the increase in the number of J-HBR major and minor criteria, in which severe anemia, severe chronic kidney disease, prior heart failure, peripheral artery disease, and prior ischemic stroke were identified as significant factors associated with MACE. In patients with acute MI undergoing PCI, the J-HBR criteria were predictive for ischemic outcomes after discharge, suggesting that the J-HBR criteria may be useful to identify patients at high bleeding and ischemic risks.
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Affiliation(s)
- Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan.
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Sakuramaru Suzuki
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Shinichi Wakabayashi
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Togane, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8677, Japan
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12
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Tokuda T, Yoshioka N, Koyama A, Yamada T, Shimamura K, Nishikawa R. Chronic Limb-Threatening Ischemia is a Residual Bleeding Risk Factor among Patients with Lower Extremity Artery Disease. J Atheroscler Thromb 2024; 31:100-108. [PMID: 37532569 PMCID: PMC10776334 DOI: 10.5551/jat.64242] [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: 03/11/2023] [Accepted: 06/22/2023] [Indexed: 08/04/2023] Open
Abstract
AIM Lower-extremity artery disease (LEAD) is a high-risk factor for bleeding. However, the specific risk factors for bleeding in patients with LEAD remain unclear. We aimed to identify risk factors for bleeding in patients with LEAD after endovascular treatment (EVT). METHODS This multicenter, retrospective, observational study included 732 consecutive patients with LEAD who underwent EVT between January 2018 and December 2019. Patient characteristics, laboratory data, target lesions, and medications were compared between patients with and without chronic limb-threatening ischemia (CLTI). Predictive bleeding risk factors were explored using Cox regression analysis with differential models. RESULTS In model 1, a body mass index (BMI) <18.5 kg/m2, prior heart failure, high bleeding risk, use of single antiplatelet therapy (SAPT) plus warfarin, and CLTI were predictive bleeding risk factors (hazard ratio [HR] 2.05; 95% confidence interval [CI] 1.13-3.52; p<0.01; HR 2.15; 95% CI 1.28-3.55; p<0.01; HR 3.40; 95% CI 1.28-3.55; p<0.01; HR 2.05; 95% CI 1.33-5.84; p<0.01; respectively). In model 2, a BMI <18.5 kg/m2, prior heart failure, anemia (<11 g/dL), low platelet count (<10*104/µL), chronic kidney disease, use of single antiplatelet therapy (SAPT) plus warfarin, and CLTI were independent risk factors for bleeding (model 2: HR 2.05; 95% CI 1.12-3.56; p=0.02; HR 2.35; 95% CI 1.39-3.90; p<0.01; HR 2.71; 95% CI 1.64-4.50; p<0.01; HR 2.66; 95% CI 1.00-5.89; p=0.05; HR 2.47; 95% CI 1.25-5.45; p<0.01; HR 2.79; 95% CI 1.24-5.63; p=0.01; respectively) Conclusions: CLTI is a residual and predictive risk factor for bleeding in patients with LEAD. We have to pay attention to the bleeding events of patients with CLTI after EVT during follow-up.
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Affiliation(s)
- Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
| | - Akio Koyama
- Department of Vascular Surgery, Ichinomiya Municipal Hospital, Aichi, Japan
| | - Takehiro Yamada
- Department of Cardiology, Central Japan International Medical Center, Gifu, Japan
| | | | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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13
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Jacobsen MR, Jabbari R, Engstrøm T, Grove EL, Glinge C, Pedersen F, Holmvang L, Køber L, Torp-Pedersen C, Maeng M, Veien K, Freeman P, Charlot MG, Kelbæk H, Sørensen R. Bleeding risk and P2Y12 inhibitors in all-comer patients with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: a single-centre cohort study. Eur Heart J Cardiovasc Pharmacother 2023; 9:617-626. [PMID: 37403404 DOI: 10.1093/ehjcvp/pvad048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/26/2023] [Accepted: 07/03/2023] [Indexed: 07/06/2023]
Abstract
AIMS To characterize and follow patients with ST-segment elevation myocardial infarction (STEMI) at high bleeding risk (HBR) according to the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score, and to examine the use of P2Y12 inhibitors and the subsequent risk of major adverse cardiovascular events (MACE) and bleeding. METHODS AND RESULTS This single-centre cohort study included 6179 consecutive STEMI patients who underwent percutaneous coronary intervention (PCI) at Copenhagen University Hospital, Rigshospitalet, between 2009 and 2016. Individual linkage to nationwide registries was conducted to obtain information on diagnoses, claimed drugs, and vital status. Of the 5532 (89.5%) patients with available PRECISE-DAPT scores, 33.0% were at HBR and more often elderly and female with more comorbidities than non-HBR patients. One-year cumulative incidence rates per 100 person-years were 8.7 and 2.1 for major bleeding and 36.8 and 8.3 for MACE in HBR and non-HBR patients, respectively. Among the 4749 (85.8%) patients who survived and collected a P2Y12 inhibitor ≤7 days from discharge, 68.2% of HBR patients were treated with ticagrelor or prasugrel and 31.8% with clopidogrel, while 18.2% non-HBR patients were treated with clopidogrel. Adherence was high for all (>75% days coverage). The risk of MACE was lower in ticagrelor- and prasugrel-treated patients than in clopidogrel-treated patients without differences in major bleeding. CONCLUSION One-third of PCI-treated all-comer patients with STEMI were at HBR according to the PRECISE-DAPT score and were more often treated with potent P2Y12 inhibitors instead of clopidogrel. Thus, ischaemic risk may be weighted over bleeding risk in STEMI patients at HBR.
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Affiliation(s)
- Mia Ravn Jacobsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Charlotte Glinge
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
| | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Karsten Veien
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Phillip Freeman
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Gitz Charlot
- Department of Cardiology, Herlev-Gentofte University Hospital, Hellerup, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark
| | - Rikke Sørensen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Inge Lehmanns Vej 7 2100 Copenhagen, Denmark
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14
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Yoshioka N, Tokuda T, Koyama A, Yamada T, Shimamura K, Nishikawa R, Morita Y, Morishima I. Association between High Bleeding Risk and 2-Year Mortality in Patients with Chronic Limb-Threatening Ischemia. J Atheroscler Thromb 2023; 30:1674-1686. [PMID: 36948637 PMCID: PMC10627769 DOI: 10.5551/jat.64157] [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: 01/06/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023] Open
Abstract
AIM Patients with chronic limb-threatening ischemia (CLTI) have a high bleeding risk (HBR) and mortality rate. The 2-year life expectancy is an important factor in deciding the appropriate treatment strategy. This study aimed to assess the influence of HBR on the prognosis of patients with CLTI. METHODS A total of 259 patients with CLTI who underwent endovascular therapy (EVT) (mean age, 76.2 years; male, 62.9%) between January 2018 and December 2019 were evaluated. The Academic Research Consortium for HBR (ARC-HBR) criteria were applied to each patient, and the ARC-HBR scores were calculated. The cut-off score for predicting all-cause mortality within two years was derived using a survival classification and regression tree (CART) model. Causes of death and the association between ARC-HBR scores and major bleeding events within two years were also investigated. RESULTS Based on the CART model, patients were divided into three groups (low HBR score 0-1.0, 48 patients; moderate HBR score 1.5-3.0, 176 patients; and high HBR score ≥ 3.5, 35 patients). During the study period, 82 patients (39.6%) died due to cardiac (n=23) and non-cardiac causes (n=59). All-cause mortality increased significantly with increasing ARC-HBR scores. Cox multivariate analysis revealed a significant association between high ARC-HBR scores and the risk of all-cause mortality within two years. Major bleeding events increased significantly with increasing ARC-HBR scores. CONCLUSIONS The ARC-HBR score could predict 2-year mortality in patients with CLTI who underwent EVT. Thus, this score can help determine the best revascularization strategy for patients with CLTI.
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Affiliation(s)
- Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
| | - Takahiro Tokuda
- Department of Cardiology, Nagoya Heart Center, Nagoya, Japan
| | - Akio Koyama
- Department of Vascular Surgery, Ichinomiya Municipal Hospital, Aichi, Japan
| | - Takehiro Yamada
- Department of Cardiology, Central Japan International Medical Center, Gifu, Japan
| | | | - Ryusuke Nishikawa
- Department of Cardiovascular of Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, Gifu, Japan
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15
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Landi A, Wlodarczak A, Tölg R, Kelbæk H, Legutko J, Galli S, Godin M, Toth GG, Lhermusier T, Honton B, Dietrich PL, Stammen F, Ferdinande B, Silvain J, Capodanno D, Cayla G, Valgimigli M. Design and Rationale of the BIOFLOW-DAPT Trial: a Prospective, Randomized, Multicenter Study to Assess the Safety of the Orsiro Mission Stent Compared to the Resolute Onyx Stent in Subjects at High Risk for Bleeding in Combination with 1-Month Dual Antiplatelet Therapy. J Cardiovasc Transl Res 2023; 16:1135-1143. [PMID: 37264295 DOI: 10.1007/s12265-023-10400-x] [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: 12/05/2022] [Accepted: 05/17/2023] [Indexed: 06/03/2023]
Abstract
The optimal duration of dual antiplatelet therapy (DAPT) in high bleeding risk (HBR) patients undergoing percutaneous coronary intervention (PCI) with implantation of the Orsiro Mission stent remains unclear. The BIOFLOW-DAPT (clinicaltrials.gov, NCT04137510) trial is a prospective, multi-center, randomized controlled study designed to assess the safety of the Orsiro Mission versus the Resolute Onyx stent in HBR patients. Patients are treated with DAPT (aspirin and a P2Y12 inhibitor) for 1 month, followed by a single antiplatelet therapy (SAPT). The primary endpoint is the composite of cardiac death, myocardial infarction, and definite or probable stent thrombosis at 1 year. With a final sample size of 1948 HBR patients, this study is powered to assess the noninferiority of the Orsiro Mission stent with respect to the primary study endpoint. The BIOFLOW-DAPT is the first randomized clinical trial investigating 1-month DAPT duration in HBR patients after implantation of the Orsiro Mission stent.Trial Registration: ClinicalTrials.gov number, NCT04137510 Study design and key features. Patient selection starts before the index PCI, when consented patients will be randomized to the Orsiro Mission or the Resolute Onyx stent with mandated 1-month DAPT. At 1 month, eligibility is reassessed and if met, patients will discontinue DAPT and continue with P2Y12 inhibitor or aspirin monotherapy. PCI, percutaneous coronary intervention; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; HBR, high bleeding risk; P2Y12i, P2Y12 inhibitor; ST, stent thrombosis.
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Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università Della Svizzera Italiana, CH-6900, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | | | - Ralph Tölg
- The Herzzentrum der Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | - Henning Kelbæk
- The Department of Cardiology, Zealand University Hospital, Sygehusvej 10, 4000, Roskilde, Denmark
| | - Jacek Legutko
- The Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Stefano Galli
- The Department of Interventional Cardiology, Centro Cardiologico Monzino, Istituto Di Ricovero E Cura a Carattere Scientifico, Milan, Italy
| | - Matthieu Godin
- The Department of Cardiology, Clinique Saint Hilaire, 2 Place Saint Hilaire, 76000, Rouen, France
| | - Gabor G Toth
- Department of Cardiology, The University Heart Center Graz, Medical University Graz, Graz, Austria
| | - Thibault Lhermusier
- Fédération de Cardiologie, The Hôpital de Rangueil, Pôle Cardio-Vasculaire Et Métabolique, Toulouse, France
| | - Benjamin Honton
- The Department of Interventional Cardiology, Clinique Pasteur, Toulouse, France
| | | | | | - Bert Ferdinande
- The Department of Cardiology, Hospital Oost-Limburg, Genk, Belgium
| | - Johanne Silvain
- ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Sorbonne Université, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco, " University of Catania, Via Santa Sofia, 78, 95123, Catania, Italy
| | - Guillaume Cayla
- The Cardiology Department, Nîmes University Hospital, Montpellier University, Nîmes, France
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), Università Della Svizzera Italiana, CH-6900, Lugano, Switzerland.
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland.
- University of Bern, Bern, Switzerland.
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16
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Kasai Y, Kitai T, Morita J, Okada T, Kasai J, Fujita T. Successful, urgent, single-stage endo-epicardial catheter ablation with a surgically subxiphoid pericardial window for a drug-resistant ventricular tachycardia storm in an extremely old hemodialysis patient with ischemic cardiomyopathy. HeartRhythm Case Rep 2023; 9:736-740. [PMID: 38047188 PMCID: PMC10691947 DOI: 10.1016/j.hrcr.2023.07.018] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Yuhei Kasai
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Takayuki Kitai
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Junji Morita
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Takuya Okada
- Department of Clinical Engineering, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Jungo Kasai
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, Washington
| | - Tsutomu Fujita
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
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17
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Mankerious N, Megaly M, Hemetsberger R, Allali A, Samy M, Toelg R, Garcia S, Richardt G. Short Versus Long-Term Dual Antiplatelet Therapy in Patients at High Bleeding Risk Undergoing PCI in Contemporary Practice: A Systemic Review and Meta-analysis. Cardiol Ther 2023; 12:489-498. [PMID: 37261649 PMCID: PMC10423172 DOI: 10.1007/s40119-023-00318-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Patients at high bleeding risk (HBR patients) represent an important subset of patients undergoing percutaneous coronary intervention (PCI). It remains unclear whether a shortened duration of dual antiplatelet therapy (DAPT) confers benefits compared with prolonged duration of DAPT in this patient population. The aim of this study was to investigate and compare bleeding and ischemic outcomes among HBR patients receiving short- versus long-term DAPT after PCI. METHODS A meta-analysis of studies comparing short-term (1-3 months) and long-term (6-12 months) DAPT after PCI with second-generation drug-eluting stents in HBR patients was performed. RESULTS Six studies [1 randomized controlled trial (RCT), 2 RCT subanalyses, and 3 prospective propensity-matched studies] involving 15,908 patients were included in the meta-analysis. During a follow-up of 12 months, short-term DAPT was associated with a reduction in major bleeding events [odds ratio (OR) 0.63, 95% confidence interval (CI) 0.42-0.95; p = 0.03, I2 = 71] and comparable definite/probable stent thrombosis, all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and ischemic stroke, compared with long-DAPT. Single antiplatelet therapy (SAPT) with aspirin was comparable to SAPT with P2Y12 inhibitor, with no treatment-by-subgroup interaction for major bleeding events (p-interaction = 0.27). In studies including patients presenting with MI, a trend of more frequent MI was noted in the short-DAPT arm (OR 1.25, 95% CI 0.98-1.59; p = 0.07; I2 = 0). In a sensitivity analysis comparing 3- and 12-month DAPT, the 3-month DAPT strategy was associated with a higher risk of ischemic stroke (OR 2.37, 95% CI 1.15-4.87; p = 0.02, I2 = 0%). CONCLUSION Short-term DAPT after PCI in HBR patients was associated a reduction in major bleeding events and similar ischemic outcomes. However, a higher risk of ischemic stroke and MI at 1 year of follow-up was seen in some subsets.
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Affiliation(s)
- Nader Mankerious
- Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany.
- Cardiology Department, Zagazig University, Sharkia, Egypt.
| | - Michael Megaly
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
- Division of Cardiology, Hennepin Healthcare, Minneapolis, MN, USA
| | - Rayyan Hemetsberger
- Department of Cardiology and Angiology, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bochum, Germany
| | - Abdelhakim Allali
- Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany
| | - Mohamed Samy
- Cardiology Department, Zagazig University, Sharkia, Egypt
| | - Ralph Toelg
- Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany
| | - Santiago Garcia
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Gert Richardt
- Heart Center, Segeberger Kliniken GmbH, Am Kurpark 1, 23795, Bad Segeberg, Germany
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18
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Zhang J, He S, Chen Z, Li Y, Guo Y, He Y. The Management and Antithrombotic Strategies of Patients with Coronary Artery Disease and High Bleeding Risk. Curr Cardiol Rep 2023:10.1007/s11886-023-01893-8. [PMID: 37285104 DOI: 10.1007/s11886-023-01893-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE OF REVIEW In this review, we aim to summarize the current understanding of high bleeding risk (HBR) patients in coronary artery disease (CAD) and provide a comprehensive evaluation of the available antithrombotic strategies for both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) procedures. RECENT FINDINGS CAD is a major cause of mortality among cardiovascular diseases, resulting from insufficient blood flow in the coronary artery due to atherosclerosis. Antithrombotic therapy is a crucial component of drug therapy for CAD and multiple studies had been focusing on the optimal antithrombotic strategies of different CAD populations. However, there is no fully harmonized definition of the model of bleeding, and the optimal antithrombotic strategy for such patients at HBR is inconclusive. In this review, we summarize bleeding risk stratification models for CAD patients and discuss the de-escalation of antithrombotic strategies among HBR patients. Furthermore, we realize that for certain subgroups of CAD-HBR patients, more individualized and precise antithrombotic strategy development is needed. So, we highlight special populations, such as CAD patients combined with valvular diseases, with both high ischemia and bleeding risks, and those proceeding surgical treatment, which requires greater research attention. We note that de-escalating therapy for CAD-HBR patients is an emerging trend in managing this population, but the optimal antithrombotic strategies should be re-considered according to the patient's baseline characteristics.
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Affiliation(s)
- Junyan Zhang
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Siyu He
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yuanxi Li
- School of Medicine), West China Hospital, Sichuan University, Chengdu, West China, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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Jiménez-Rodríguez GM, Jackson-Pedroza C, Hurtado-Belizario KS, Carmona-Levario P, Encarnación-Martínez U, Carrillo-Vega J, Rojas-Velasco G, Eid-Lidt G. Left circumflex artery injury occurring during mitral valve surgery treated successfully with percutaneous intervention in a high surgical and bleeding risk patient. J Cardiol Cases 2023; 27:245-247. [PMID: 37283911 PMCID: PMC10240417 DOI: 10.1016/j.jccase.2023.02.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/17/2022] [Accepted: 01/24/2023] [Indexed: 06/08/2023] Open
Abstract
Perioperative myocardial infarction is a complication of cardiac surgery, and the cause can be multifactorial. Injury of the left circumflex coronary artery has been described, particularly after mitral valve replacement. We present the case of a 72-year-old woman who underwent mitral valve replacement but developed a lesion in the proximal circumflex coronary artery related to partial mechanical kinking caused by a suture. The therapeutic options are surgical or percutaneous. In this patient, the percutaneous strategy was successful. Learning objective • Percutaneous coronary intervention is an option in cases involving kinking of the left circumflex coronary artery after mitral valve replacement.• If unable to cross the lesion with a workhorse guide wire, one alternative is to use wires with good support properties and avoid very high tip loads to reduce the risk of perforation.In patients at high risk of bleeding, use of a drug-eluting stent and short-duration dual antiplatelet therapy is recommended.
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Affiliation(s)
| | - Cynthia Jackson-Pedroza
- Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Patricia Carmona-Levario
- Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Jorge Carrillo-Vega
- Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Gustavo Rojas-Velasco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Guering Eid-Lidt
- Interventional Cardiology Department, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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20
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Landi A. Duration more than type of dual antiplatelet therapy matters in ACS patients with high bleeding risk. Int J Cardiol 2023; 378:10. [PMID: 36812988 DOI: 10.1016/j.ijcard.2023.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023]
Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale (EOC), CH-6900 Lugano, Switzerland; Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland.
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21
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Costa F, Montalto C, Branca M, Hong SJ, Watanabe H, Franzone A, Vranckx P, Hahn JY, Gwon HC, Feres F, Jang Y, De Luca G, Kedhi E, Cao D, Steg PG, Bhatt DL, Stone GW, Micari A, Windecker S, Kimura T, Hong MK, Mehran R, Valgimigli M. Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials. Eur Heart J 2023; 44:954-968. [PMID: 36477292 DOI: 10.1093/eurheartj/ehac706] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [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: 11/29/2021] [Revised: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. The current study, using the totality of existing evidence, evaluated the impact of an abbreviated DAPT regimen in HBR patients. METHODS AND RESULTS A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated [i.e. very-short (1 month) or short (3 months)] with standard (≥6 months) DAPT in HBR patients without indication for oral anticoagulation. A total of 11 trials, including 9006 HBR patients, were included. Abbreviated DAPT reduced major or clinically relevant non-major bleeding [risk ratio (RR): 0.76, 95% confidence interval (CI): 0.61-0.94; I2 = 28%], major bleeding (RR: 0.80, 95% CI: 0.64-0.99, I2 = 0%), and cardiovascular mortality (RR: 0.79, 95% CI: 0.65-0.95, I2 = 0%) compared with standard DAPT. No difference in all-cause mortality, major adverse cardiovascular events, myocardial infarction, or stent thrombosis was observed. Results were consistent, irrespective of HBR definition and clinical presentation. CONCLUSION In HBR patients undergoing PCI, a 1- or 3-month abbreviated DAPT regimen was associated with lower bleeding and cardiovascular mortality, without increasing ischaemic events, compared with a ≥6-month DAPT regimen. STUDY REGISTRATION PROSPERO registration number CRD42021284004.
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Affiliation(s)
- Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Claudio Montalto
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy
| | | | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Korea
| | | | - Elvin Kedhi
- Clinique Hopitaliere Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Davide Cao
- Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera Italiana (USI), Lugano, Switzerland
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22
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Matsumoto T, Saito Y, Sato T, Yamashita D, Suzuki S, Saito K, Wakabayashi S, Kitahara H, Sano K, Kobayashi Y. Validation of the Domestic High Bleeding Risk Criteria for Japanese Patients with Acute Myocardial Infarction. J Atheroscler Thromb 2023; 30:299-309. [PMID: 35613875 PMCID: PMC9981348 DOI: 10.5551/jat.63576] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Indexed: 11/11/2022] Open
Abstract
AIMS The Academic Research Consortium (ARC) has proposed international criteria to standardize the definition of high bleeding risk (HBR) in patients undergoing percutaneous coronary intervention (PCI). In this context, Japan has also established its own guidelines, that is, the Japanese version of HBR (J-HBR) criteria. However, the J-HBR criteria have not been fully validated, especially in patients with acute myocardial infarction (MI). METHODS This bi-center registry included 1079 patients with acute MI undergoing primary PCI in a contemporary setting. Patient bleeding risks were evaluated using the ARC-HBR and J-HBR criteria. The primary endpoint was rates of major bleeding events (Bleeding Academic Research Consortium type 3 or 5) at 1 year. RESULTS Of the 1079 patients, 505 (46.8%) and 563 (52.2%) met the ARC-HBR and J-HBR criteria, respectively. Patients who met the J-HBR criteria were found to have a higher rate of major bleeding events at 1 year than those who did not (12.8% vs. 3.3%, p<0.001). When patients were scored and stratified using the J-HBR major and minor criteria, risks of major bleedings were progressively increased with the increase in the number of J-HBR criteria. In the receiver operating characteristic curve analysis, the ARC-HBR and J-HBR significantly predicted subsequent major bleedings after PCI, with ARC-HBR having greater predictive ability than J-HBR. CONCLUSIONS More than half of the patients with acute MI undergoing primary PCI in Japan met the J-HBR criteria. Although the J-HBR criteria successfully identified patients who were likely to develop major bleeding events after primary PCI, the superiority of J-HBR to ARC-HBR in predicting bleeding outcomes warrants further investigation.
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Affiliation(s)
- Tadahiro Matsumoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takanori Sato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Daichi Yamashita
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sakuramaru Suzuki
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Chiba, Japan
| | - Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shinichi Wakabayashi
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Koichi Sano
- Department of Cardiovascular Medicine, Eastern Chiba Medical Center, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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23
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Sawayama Y, Tomita Y, Kohyama S, Higo Y, Kodama K, Asada K, Yagi N, Fukuyama M, Hayashi A, Shioyama W, Sakai H, Ozawa T, Isono T, Hira D, Yamamoto T, Morita SY, Nakagawa Y. Clopidogrel Use in CYP2C19 Loss-of-Function Carriers With High Bleeding Risk After Percutaneous Coronary Intervention. Circ J 2023; 87:755-763. [PMID: 36792180 DOI: 10.1253/circj.cj-22-0826] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND It is not known whether clopidogrel use in cytochrome P450 (CYP) 2C19 loss-of-function (LOF) carriers with high bleeding risk (HBR) contributes to adverse outcomes after percutaneous coronary intervention (PCI).Methods and Results: This retrospective observational study included 618 consecutive patients with available CYP2C19 polymorphism information who underwent PCI between September 2014 and August 2021. Patients with HBR (319 [52%] met the Academic Research Consortium definition) were divided into 2 groups according to P2Y12inhibitor action, namely decreased (i.e., clopidogrel in CYP2C19 LOF carriers) and retained (i.e., clopidogrel in CYP2C19 LOF non-carriers or prasugrel regardless of CYP2C19 polymorphisms), and clinical outcomes at 1 year were compared using inverse probability-weighted Cox proportional hazard regression. The primary ischemic outcome (a composite of cardiovascular death, myocardial infarction, or ischemic stroke) was significantly higher in the decreased than retained group (10.2% vs. 3.0%; adjusted hazard ratio [aHR] 2.78; 95% confidence interval [CI] 1.40-5.52; P=0.004). The primary bleeding outcome (Bleeding Academic Research Consortium 3 or 5) did not differ significantly between the decreased and retained groups (3.4% vs. 6.9%, respectively; aHR 0.48; 95% CI 0.22-1.01; P=0.054). There were no interactions between the treatment groups and HBR status in primary ischemic and bleeding outcomes. CONCLUSIONS Among patients with HBR, clopidogrel use in CYP2C19 LOF carriers was significantly associated with increased ischemic events after PCI.
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Affiliation(s)
- Yuichi Sawayama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | | | - Soji Kohyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Yosuke Higo
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Kenji Kodama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Kohei Asada
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Noriaki Yagi
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Megumi Fukuyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Atsushi Hayashi
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Wataru Shioyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Hiroshi Sakai
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Tomoya Ozawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Tetsuichiro Isono
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Daiki Hira
- Department of Pharmacy, Shiga University of Medical Science Hospital.,Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital
| | | | - Shin-Ya Morita
- Department of Pharmacy, Shiga University of Medical Science Hospital
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
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24
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Shimono H, Tokushige A, Kanda D, Ohno A, Hayashi M, Fukuyado M, Akao M, Kawasoe M, Arikawa R, Otsuji H, Chaen H, Okui H, Oketani N, Ohishi M. Association between the number of Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria and clinical outcomes in patients with acute coronary syndrome. J Cardiol 2023:S0914-5087(23)00003-5. [PMID: 36682715 DOI: 10.1016/j.jjcc.2023.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have been used to identify high-risk patients undergoing percutaneous coronary intervention (PCI) in current clinical practice. This study aimed to evaluate the association between the number of ARC-HBR criteria and clinical outcomes in patients with acute coronary syndrome (ACS) after an emergent PCI. METHODS We assessed 338 consecutive patients with ACS who underwent successful emergent PCI between January 2017 and December 2020. The ARC-HBR score was calculated by assigning 1 point to each major criterion and 0.5 points to each minor criterion. The patients were classified into low (ARC-HBR score<1), intermediate (1≤ARC-HBR score<2), and high (ARC-HBR score≥2) bleeding risk groups. We investigated the association between the ARC-HBR score and major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke. We also compared the diagnostic ability of the ARC-HBR score and Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) risk score. RESULTS The mean age of the patients was 67.6±12.4years, and 78.4% were men. During the median follow-up of 864 (557-1309) days, 70 patients developed MACEs. Kaplan-Meier curves showed that the cumulative incidence of MACE was significantly higher as the ARC-HBR score increased in a stepwise manner (log-rank p<0.001). There were no significant differences in the area under the receiver operating characteristic curve (AUC) for predicting MACE within two years after an emergent PCI between the ARC-HBR and CADILLAC risk scores (AUC: 0.763 vs. 0.777). CONCLUSIONS ARC-HBR score was independently associated with an increased risk of MACE in patients with ACS after an emergent PCI. Moreover, it had a similar diagnostic ability for predicting MACE within two years compared to the CADILLAC risk score.
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25
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Koiwaya H, Nishihira K, Kadooka K, Kuriyama N, Shibata Y. Vascular healing in high-bleeding-risk patients at 3-month after everolimus-eluting stent versus biolimus A9-coated stent implantation: insights from analysis of optical coherence tomography and coronary angioscopy. Cardiovasc Interv Ther 2023; 38:64-74. [PMID: 35918588 DOI: 10.1007/s12928-022-00877-9] [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: 02/04/2022] [Accepted: 07/11/2022] [Indexed: 01/06/2023]
Abstract
The prevalence of high-bleeding-risk (HBR) patients who undergo coronary stenting has been reported as 20-40%. This study sought to assess vascular healing in HBR patients by coronary angioscopy (CAS) and optical coherence tomography (OCT). We prospectively analyzed 38 HBR patients with coronary artery disease who successfully underwent everolimus-eluting stent (EES) implantation (20 patients, 23 lesions) or drug-coated stent (DCS) implantation (18 patients, 18 lesions). Follow-up coronary angiography, CAS, and OCT were planned at 3 months after the procedure. The clinical characteristics and inclusion criteria of HBR were comparable between groups. CAS analysis showed that mean yellow color grade was significantly higher with EES than with DCS (1.33 [1.0, 1.67] vs. 1.0 [0.67, 1.5]; P = 0.04). In contrast, OCT analysis demonstrated that most struts in both groups were well-apposed struts with neointimal coverage (93.9% each; P = 1.00), and percentages of the mean neointimal area were comparable between EES and DCS (4.4 ± 3.5 mm2 vs. 4.5 ± 4.1 mm2; P = 0.91). The frequency of uncovered struts was significantly lower with EES than with DCS (2.4% vs. 5.3%; P < 0.001), whereas the frequency of malapposed struts was significantly higher with EES than with DCS (3.5% vs. 0.8%; P < 0.001). During follow-up, no stent thrombosis or major bleeding complications were encountered in either group. Among HBR patients, both EES and DCS demonstrated good vascular healing at 3-month follow-up with some different features in CAS and OCT assessments.
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Affiliation(s)
- Hiroshi Koiwaya
- Cardiovascular Center, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki, 880-2102, Japan.
| | - Kensaku Nishihira
- Cardiovascular Center, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki, 880-2102, Japan.
| | - Kosuke Kadooka
- Cardiovascular Center, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki, 880-2102, Japan
| | - Nehiro Kuriyama
- Cardiovascular Center, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki, 880-2102, Japan
| | - Yoshisato Shibata
- Cardiovascular Center, Miyazaki Medical Association Hospital, 1173 Arita, Miyazaki, 880-2102, Japan
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26
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Kobari Y, Inohara T, Hayashida K; OCEAN-TAVI Registry. Antithrombotic therapy after transcatheter aortic valve replacement. Cardiovasc Interv Ther 2023; 38:9-17. [PMID: 36115004 DOI: 10.1007/s12928-022-00893-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 01/06/2023]
Abstract
Aortic stenosis is a major valvular disease, which affects prognosis, and its prevalence is increasing due to an aging population. Transcatheter aortic valve replacement (TAVR) is a well-established therapy for symptomatic severe aortic stenosis across the entire risk spectrum, and the number of patients who undergo TAVR is increasing worldwide. Generally, ischemic and bleeding events after TAVR are not rare and can be devastating. Thus, antithrombotic therapy is recommended to prevent thromboembolic events after TAVR. Recently, a lot of randomized control trials have been published on antithrombotic therapy following TAVR, and the situation regarding the optimal antithrombotic regiment following TAVR is dramatically changing. This report reviews the current status and remaining issues in the field of optimal antithrombotic therapy following TAVR and leaflet thrombosis.
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27
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van Hemert ND, Stella PR, Rozemeijer R, Stein M, Frambach P, Kraaijeveld AO, Rittersma SZ, Meijs TA, Leenders GE, van der Harst P, Agostoni P, Voskuil M. High bleeding risk in patients undergoing percutaneous coronary intervention with drug-eluting stent implantation: ReCre8 subanalysis. Am Heart J Plus 2022; 24:100227. [PMID: 38560639 PMCID: PMC10978429 DOI: 10.1016/j.ahjo.2022.100227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/11/2022] [Accepted: 11/04/2022] [Indexed: 04/04/2024]
Abstract
Objectives In an all-comers cohort undergoing percutaneous coronary intervention (PCI), we aimed to assess prevalence of high bleeding risk (HBR) patients and impact of HBR and dual antiplatelet therapy (DAPT) on clinical events. Background HBR represents a complex subgroup of patients undergoing PCI. Methods In the ReCre8 trial, patients undergoing PCI were stratified for troponin status and diabetes and randomized to a permanent polymer zotarolimus-eluting- or polymer-free amphilimus-eluting stent. Patients were treated with 12 months (troponin-positive) or one month (troponin-negative) of DAPT. We evaluated clinical outcomes in patients with and without HBR according to the Academic Research Consortium for High Bleeding Risk criteria. Results From a total of 1488 patients included in this subanalysis, 406 patients (27.3 %) were identified as being at HBR. Among HBR patients, target-lesion failure (TLF) was similar after one year yet was higher after three years (13.3 % vs. 9.1 %; p = 0.013), compared to non-HBR patients. There was no difference in Bleeding Academic Research Consortium (BARC) 3 to 5 bleeding, however BARC 2 to 5 bleeding was higher after three years with 4.9 % vs. 3.0 % (p = 0.037). There were no differences between troponin-positive (12-months DAPT) and -negative (1-month DAPT) HBR patients with respect to ischemic and bleeding outcomes. Conclusions In this all-comers population of PCI patients, a higher TLF rate among HBR patients at long-term follow-up was found, underlining the complexities involving treatment of HBR patients. We did not observe statistically significant differences in BARC 3 to 5 bleeding between HBR and non-HBR patients regardless of DAPT duration. Clinical trial registration URL: http://www.clinicaltrials.gov, unique identifier: NCT02328898.
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Affiliation(s)
- Nicole D. van Hemert
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pieter R. Stella
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Rik Rozemeijer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mèra Stein
- Department of Cardiology, Zuyderland Medical Center, Heerlen, the Netherlands
| | - Peter Frambach
- National Institute of Cardiac Surgery and Interventional Cardiology, Luxembourg, Luxembourg
| | | | - Saskia Z. Rittersma
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Timion A. Meijs
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Geert E.H. Leenders
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - The ReCre8 Study Investigators
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Cardiology, Zuyderland Medical Center, Heerlen, the Netherlands
- National Institute of Cardiac Surgery and Interventional Cardiology, Luxembourg, Luxembourg
- Department of Cardiology, Hospital Network Antwerp Middelheim, Antwerp, Belgium
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28
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Sato Y, Yoshihisa A, Takeishi R, Ohara H, Sugawara Y, Ichijo Y, Hotsuki Y, Watanabe K, Abe S, Misaka T, Sato T, Oikawa M, Kobayashi A, Nakazato K, Takeishi Y. B-type natriuretic peptide is associated with the occurrence of bleeding events in heart failure patients with a history of coronary artery disease. J Cardiol 2022:S0914-5087(22)00026-0. [PMID: 35216888 DOI: 10.1016/j.jjcc.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/30/2021] [Accepted: 01/27/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Bleeding risk in heart failure (HF) patients with coronary artery disease (CAD) has not yet been fully investigated. METHODS We analyzed the data of 677 patients with a previous history of CAD who were hospitalized for HF. The patients were divided into three groups based on the tertiles of B-type natriuretic peptide (BNP) levels: Low, Middle, and High BNP groups (n = 225, 226, and 226, respectively). The primary endpoint was post-discharge bleeding events, which was defined as hemorrhagic stroke and gastrointestinal bleeding. RESULTS The High BNP group was the oldest (Low, Middle, High, 67.0, 74.0, and 75.0 years, respectively; p < 0.001), showed the lowest left ventricular ejection fraction (56.0%, 50.7%, and 40.3%, respectively; p < 0.001), and contained more patients at high bleeding risk (HBR) defined by the simplified version of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition (65.3%, 85.4%, and 93.8%, respectively, p < 0.001). Kaplan-Meier analysis demonstrated that post-discharge bleeding events occurred most frequently in the High BNP group (log-rank p = 0.008). In the Cox proportional hazard analysis, compared to the Low BNP group as a reference, the High BNP group was independently associated with bleeding events after adjustment for age, sex, simplified ARC-HBR definition, and left ventricular ejection fraction (hazard ratio 3.208, 95% confidence interval 1.078-9.544, p = 0.036). CONCLUSIONS High BNP is associated with bleeding events in HF patients with a history of CAD.
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29
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Iijima R, Kadota K, Nakao K, Nakagawa Y, Shite J, Yokoi H, Kozuma K, Tanabe K, Akasaka T, Shinke T, Ueno T, Hirayama A, Uemura S, Harada A, Kuroda T, Takita A, Murakami Y, Saito S, Nakamura M. Ischemic and Bleeding Events in PENDULUM Patients With High Bleeding Risk and High Platelet Reactivity. Circ J 2021; 86:763-771. [PMID: 34880154 DOI: 10.1253/circj.cj-21-0717] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The balance between thrombotic and bleeding risk is of great concern in high bleeding risk (HBR) patients. This study evaluated the relationship between perioperative antiplatelet reactivity and thrombotic and bleeding events in patients at HBR undergoing percutaneous coronary intervention (PCI).Methods and Results:In this post hoc analysis of the PENDULUM (Platelet rEactivity in patieNts with DrUg eLUting stent and balancing risk of bleeding and ischeMic event) registry, patients undergoing PCI were categorized as HBR or non-HBR, and stratified as having high platelet reactivity (HPR; P2Y12reaction unit [PRU] >208) or non-HPR (PRU ≤208). Cumulative incidences of cardiovascular and cerebrovascular events (Journal of the American College of Cardiologyexpert definitions) and bleeding events (Bleeding Academic Research Consortium criteria) were assessed 12 months after index PCI. The incidence of ischemic and bleeding events was ~3-fold higher in HBR vs. non-HBR patients. Thrombotic/ischemic events were significantly more common in the HPR subgroup in HBR patients (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.11-2.28; P=0.012), but there was no difference in non-HBR patients. After adjustment for covariates, HPR in HBR patients remained an independent factor for thrombotic and ischemic events (HR: 1.69; 95% CI: 1.13-2.54; P=0.011), but not for bleeding events (HR: 1.56; 95% CI: 0.78-3.11; P=0.210). CONCLUSIONS Maintaining adequate PRU levels during PCI is an important factor in improving clinical outcomes, especially for HBR patients.
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Affiliation(s)
- Raisuke Iijima
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Junya Shite
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | - Ken Kozuma
- Division of Cardiology, Department of Internal Medicine, Teikyo University
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Takafumi Ueno
- Department of Cardiovascular Medicine, Fukuoka Kinen Hospital
| | | | - Shiro Uemura
- Department of Cardiology, Kawasaki Medical School
| | | | - Takeshi Kuroda
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Shigeru Saito
- Division of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
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30
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Escaned J, Cao D, Baber U, Nicolas J, Sartori S, Zhang Z, Dangas G, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Mehta S, Moliterno DJ, Ohman EM, Oldroyd KG, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Ticagrelor monotherapy in patients at high bleeding risk undergoing percutaneous coronary intervention: TWILIGHT-HBR. Eur Heart J 2021; 42:4624-4634. [PMID: 34662382 DOI: 10.1093/eurheartj/ehab702] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/08/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Patients at high bleeding risk (HBR) represent a prevalent subgroup among those undergoing percutaneous coronary intervention (PCI). Early aspirin discontinuation after a short course of dual antiplatelet therapy (DAPT) has emerged as a bleeding avoidance strategy. The aim of this study was to assess the effects of ticagrelor monotherapy after 3-month DAPT in a contemporary HBR population. METHODS AND RESULTS This prespecified analysis of the TWILIGHT trial evaluated the treatment effects of early aspirin withdrawal followed by ticagrelor monotherapy in HBR patients undergoing PCI with drug-eluting stents. After 3 months of ticagrelor plus aspirin, event-free patients were randomized to 12 months of aspirin or placebo in addition to ticagrelor. A total of 1064 (17.2%) met the Academic Research Consortium definition for HBR. Ticagrelor monotherapy reduced the incidence of the primary endpoint of Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in HBR (6.3% vs. 11.4%; hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.35-0.82) and non-HBR patients (3.5% vs. 5.9%; HR 0.59, 95% CI 0.46-0.77) with similar relative (Pinteraction = 0.67) but a trend towards greater absolute risk reduction in the former [-5.1% vs. -2.3%; difference in absolute risk differences (ARDs) -2.8%, 95% CI -6.4% to 0.8%, P = 0.130]. A similar pattern was observed for more severe BARC 3 or 5 bleeding with a larger absolute risk reduction in HBR patients (-3.5% vs. -0.5%; difference in ARDs -3.0%, 95% CI -5.2% to -0.8%, P = 0.008). There was no significant difference in the key secondary endpoint of death, myocardial infarction, or stroke between treatment arms, irrespective of HBR status. CONCLUSIONS Among HBR patients undergoing PCI who completed 3-month DAPT without experiencing major adverse events, aspirin discontinuation followed by ticagrelor monotherapy significantly reduced bleeding without increasing ischaemic events, compared with ticagrelor plus aspirin. The absolute risk reduction in major bleeding was larger in HBR than non-HBR patients.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid 28040, Spain
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw 02-507, Poland
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Sigmund Freud University, Medical Faculty, Vienna 1160, Austria
| | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith G Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Richard Shlofmitz
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Giora Weisz
- NewYork Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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31
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Sato Y, Yoshihisa A, Takeishi R, Ohara H, Sugawara Y, Ichijo Y, Hotsuki Y, Watanabe K, Abe S, Misaka T, Sato T, Oikawa M, Kobayashi A, Nakazato K, Takeishi Y. Simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) Definition Predicts Bleeding Events in Patients With Heart Failure. Circ J 2021; 86:147-155. [PMID: 34707066 DOI: 10.1253/circj.cj-21-0686] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND It has recently been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition, which excludes 6 rare criteria, is comparable to the original ARC-HBR definition in predicting major bleeding in patients with coronary artery disease (CAD) who undergo percutaneous coronary intervention. In this study, we investigated whether the simplified ARC-HBR definition could be applied to patients with heart failure (HF) to identify those at high bleeding risk (HBR).Methods and Results:In all, 2,437 patients hospitalized for HF were enrolled in this study. Patients were divided into 2 groups based on the simplified ARC-HBR definition: those at HBR (n=2,026; 83.1%) and those not (non-HBR group; n=411; 16.9%). The HBR group was older (72.0 vs. 61.0 years; P<0.001) and had a lower prevalence of CAD (31.1% vs. 36.5%; P=0.034) than the non-HBR group. Kaplan-Meier analysis showed that post-discharge bleeding events defined as hemorrhagic stroke or gastrointestinal bleeding were more frequent in the HBR than non-HBR group (log-rank P<0.001). The simplified ARC-HBR definition accurately predicted bleeding events (Fine-Gray model; hazard ratio 2.777, 95% confidence interval 1.464-5.270, P=0.001). CONCLUSIONS The simplified ARC-HBR definition predicts a high risk of bleeding events in patients with HF.
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Affiliation(s)
- Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University.,Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science
| | - Ryohei Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Himika Ohara
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yukiko Sugawara
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yasuhiro Ichijo
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yu Hotsuki
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Satoshi Abe
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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32
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Natsuaki M, Morimoto T, Shiomi H, Yamamoto K, Yamaji K, Watanabe H, Uegaito T, Matsuda M, Tamura T, Taniguchi R, Inoko M, Mabuchi H, Takeda T, Domei T, Shirotani M, Ehara N, Eizawa H, Ishii K, Tanaka M, Inada T, Onodera T, Nawada R, Shinoda E, Yamada M, Yamamoto T, Sakai H, Toyofuku M, Tamura T, Takahashi M, Tada T, Sakamoto H, Tada T, Kaneda K, Miki S, Aoyama T, Suwa S, Sato Y, Ando K, Furukawa Y, Nakagawa Y, Kadota K, Kimura T. Bleeding Outcomes After Percutaneous Coronary Intervention in the Past Two Decades in Japan - From the CREDO-Kyoto Registry Cohort-2 and Cohort-3. Circ J 2021; 86:748-759. [PMID: 34526432 DOI: 10.1253/circj.cj-21-0526] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND Optimal intensity is unclear for P2Y12receptor blocker therapy after percutaneous coronary intervention (PCI) in real-world clinical practice.Methods and Results:From the CREDO-Kyoto Registry, the current study population consisted of 25,419 patients (Cohort-2: n=12,161 and Cohort-3: n=13,258) who underwent their first PCI. P2Y12receptor blocker therapies were reduced dose of ticlopidine (200 mg/day), and global dose of clopidogrel (75 mg/day) in 87.7% and 94.8% of patients in Cohort-2 and Cohort-3, respectively. Cumulative 3-year incidence of GUSTO moderate/severe bleeding was significantly higher in Cohort-3 than in Cohort-2 (12.1% and 9.0%, P<0.0001). After adjusting 17 demographic factors and 9 management factors potentially related to the bleeding events other than the type of P2Y12receptor blocker, the higher bleeding risk in Cohort-3 relative to Cohort-2 remained significant (hazard ratio (HR): 1.52 95% confidence interval (CI) 1.37-1.68, P<0.0001). Cohort-3 compared with Cohort-2 was not associated with lower adjusted risk for myocardial infarction/ischemic stroke (HR: 0.96, 95% CI: 0.87-1.06, P=0.44). CONCLUSIONS In this historical comparative study, Cohort-3 compared with Cohort-2 was associated with excess bleeding risk, which might be at least partly explained by the difference in P2Y12receptor blockers.
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Affiliation(s)
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | | | | | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | | | | | | | | | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Hiroshi Eizawa
- Department of Cardiovascular Medicine, Kobe City Nishi-Kobe Medical Center
| | | | | | | | - Tomoya Onodera
- Department of Cardiology, Shizuoka City Shizuoka Hospital
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital
| | - Eiji Shinoda
- Department of Cardiology, Hamamatsu Rosai Hospital
| | - Miho Yamada
- Department of Cardiology, Hamamatsu Rosai Hospital
| | - Takashi Yamamoto
- Department of Cardiology, Shiga University of Medical Science Hospital
| | - Hiroshi Sakai
- Department of Cardiology, Shiga University of Medical Science Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Takashi Tamura
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | | | | | | | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Shinji Miki
- Department of Cardiology, Mitsubishi Kyoto Hospital
| | | | - Satoru Suwa
- and Department of Cardiology, Juntendo University Shizuoka Hospital
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Sotomi Y, Hikoso S, Nakatani D, Dohi T, Mizuno H, Okada K, Kida H, Oeun B, Sunaga A, Sato T, Kitamura T, Sakata Y, Sato H, Hori M, Komuro I, Sakata Y. Practical Assessment of the Tradeoff between Fatal Bleeding and Coronary Thrombotic Risks using the Academic Research Consortium for High Bleeding Risk Criteria. J Atheroscler Thromb 2021; 29:1236-1248. [PMID: 34526434 PMCID: PMC9371753 DOI: 10.5551/jat.62999] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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] [Indexed: 11/29/2022] Open
Abstract
Aims: We aimed to establish a practical method for the assessment of tradeoff between thrombotic and bleeding risks.
Methods: We aimed to investigate the balance between bleeding risk and coronary thrombotic risk according to the number of the Academic Research Consortium for high bleeding risk (ARC-HBR) criteria in the multicenter prospective ST/non-ST elevation myocardial infarction (STEMI/NSTEMI) registry (N=12,093). Patients were divided as follows by the number of ARC-HBR criteria fulfilled: group 0, 0 major with ≤ 1 minor (N=6,792); group 1, 1 major with 0 minor (N=1,705); group 2, 0 major with ≥ 2 minors (N=790); group 3, 1 major with ≥ 1 minor (N=1,709); group 4, 2 majors with ≥ 0 minors (N=861); and group 5, ≥ 3 majors with ≥ 0 minor (N=236). We assessed the acute-phase absolute risk differences between bleeding and coronary thrombotic events in each group.
Results: At 7-day follow-up, all patients (groups 0–5) had a higher risk of major bleeding than that of any myocardial infarction (MI). Patients at ARC-HBR (groups 1–5) had a balanced risk between fatal MI and fatal bleeding, whereas patients at non-ARC-HBR (group 0) had a higher risk of fatal MI than that of fatal bleeding.
Conclusions: All STEMI/NSTEMI patients have a relatively high risk of major bleeding as compared with the risk of any MI in the acute phase. The ARC-HBR criteria would be a practical tool for assessing the tradeoff between fatal bleeding and fatal MI risks. This practical assessment would be helpful for the optimal decision-making of appropriate treatment strategy considering the balance between bleeding and coronary thrombotic risks.
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Affiliation(s)
- Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine.,Department of Transformative System for Medical Information, Osaka University Graduate School of Medicine.,Division of Fostering Required Medical Human Resources, Center for Infectious Disease Education and Research (CiDER), Osaka University
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Taiki Sato
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Graduate School of Medicine, Osaka University
| | - Yasuhiko Sakata
- Department of Clinical Medicine and Development and Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiroshi Sato
- School of Human Welfare Studies Health Care Center and Clinic, Kwansei Gakuin University
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, University of Tokyo Graduate School of Medicine
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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34
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Dannenberg L, M'Pembele R, Metzen D, Petzold T, Zeus T, Kelm M, Polzin A. European NSTEMI guidelines-return of clopidogrel? Eur J Clin Pharmacol 2021; 78:151-153. [PMID: 34528121 PMCID: PMC8724138 DOI: 10.1007/s00228-021-03200-2] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/09/2021] [Indexed: 11/14/2022]
Affiliation(s)
- Lisa Dannenberg
- Medical Faculty, Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), University Duesseldorf, Duesseldorf, Germany
| | - René M'Pembele
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Daniel Metzen
- Medical Faculty, Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), University Duesseldorf, Duesseldorf, Germany
| | - Tobias Petzold
- Medizinische Klinik Und Poliklinik I, Klinikum Der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Tobias Zeus
- Medical Faculty, Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), University Duesseldorf, Duesseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), University Duesseldorf, Duesseldorf, Germany
| | - Amin Polzin
- Medical Faculty, Division of Cardiology, Pulmonology, and Vascular Medicine, Cardiovascular Research Institute Düsseldorf (CARID), University Duesseldorf, Duesseldorf, Germany.
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35
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Tsukizawa T, Fujihara M. Relationship between in-hospital event rates and high bleeding risk score in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction. Cardiovasc Interv Ther 2021. [PMID: 34406605 DOI: 10.1007/s12928-021-00805-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
Academic Research Consortium for High Bleeding Risk (ARC-HBR) was defined as a criterion for predicting the risk of bleeding in patients who undergo percutaneous coronary intervention (PCI). Major bleeding is related to in-hospital mortality. However, few studies examining the HBR criteria in patients with acute myocardial infarction (AMI) have been reported. We analyzed the relationship between HBR criteria in AMI patients and in-hospital events. This study was a single-center retrospective study that included 781 patients who underwent PCI for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) from January 2010 to December 2018. Patients were classified into the HBR group (n = 309, 39.6%) and non-HBR group (n = 472, 60.4%) and investigated. The primary endpoint was the incidence of in-hospital mortality, major bleeding, recurrent MI, and stroke. As a secondary endpoint, a multivariate analysis of cases of in-hospital death was performed to identify predictors of in-hospital mortality. As the primary outcome, the rate of all events in the HBR group was significantly higher than that in the non-HBR group (29.1% vs. 11.2%, p < 0.001). Among the individual events, the rates of major bleeding (11.3% vs. 3.8%, p < 0.001) and in-hospital mortality (16.2% vs. 4.2%, p < 0.001) were significantly higher in the HBR group. Regarding the secondary outcome, the overall in-hospital mortality rate was 9.0%. The multivariate analysis revealed that ejection fraction < 40%, HBR, Killip 4, and left main trunk lesion were significant predictors of in-hospital mortality. In conclusion, the HBR criteria were associated with in-hospital events in AMI patients who underwent primary PCI.
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36
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Nicolas J, Beerkens F, Cao D, Sartori S, Pivato CA, Qiu H, Giustino G, Chiarito M, Claessen BE, Zhang Z, Nardin M, Razuk V, Jones D, Camaj A, Power D, Banashefski B, Sweeny J, Baber U, Dangas G, Sharma SK, Kini A, Mehran R. Performance of the academic research consortium high-bleeding risk criteria in patients undergoing PCI for acute myocardial infarction. J Thromb Thrombolysis 2021. [PMID: 34347202 DOI: 10.1007/s11239-021-02534-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
Patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) are at increased risk for thrombotic and bleeding complications compared to patients with chronic coronary syndrome (CCS). The academic research consortium (ARC) recently suggested a set of criteria to identify patients at high bleeding risk (HBR). We sought to evaluate the performance of the ARC-HBR criteria among patients undergoing PCI according to clinical presentation. We included all consecutive patients undergoing PCI at a tertiary-care center. Patients were deemed at HBR if they fulfilled ≥ 1 major or ≥ 2 minor ARC-HBR criteria. The primary bleeding endpoint was a composite of in-hospital or post-discharge bleeding at 1-year follow-up. Secondary outcomes included all-cause death and myocardial infarction. Out of 6068 patients, 1391 (22.9 %) presented with AMI and were more often at HBR than those with CCS (46.9 % vs. 43.0 %, p = 0.01). HBR patients had a higher risk for the primary bleeding endpoint than non-HBR, irrespective of the clinical indication for PCI (AMI: 19.5 % vs. 5.5 %; HR 3.86, 95 % CI 2.63-5.69; CCS: 6.8 % vs. 2.6 %; HR 2.65, 95 % CI 1.92-3.68; p-interaction = 0.11). Secondary outcomes followed a similar trend. After multivariable adjustment, AMI presentation remained significantly associated with increased risk for bleeding at 1 year (HR 1.64, 95 % CI 1.13-2.38, p = 0.01). The ARC-HBR criterion associated with the highest bleeding risk was severe/end-stage chronic kidney disease in AMI and moderate/severe anemia in CCS. The ARC-HBR framework successfully identified AMI and CCS patients with increased risk for bleeding complications at 1 year post-PCI. Figure prepared with BioRender.
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37
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Affiliation(s)
- Johny Nicolas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Davide Cao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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Miura K, Shima Y, Okabe K, Taguchi Y, Ikuta A, Takahashi K, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Academic Research Consortium for High Bleeding Risk Definitions for Early, Late, and Very Late Bleeding Events. Circ J 2021; 85:797-805. [PMID: 33853992 DOI: 10.1253/circj.cj-21-0120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND The validity of the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definitions of early (<1 year), late (1-4 years), and very late (>4 years) bleeding events is unknown.Methods and Results:This study was performed on patients (n=3,453) implanted with second-generation drug-eluting stents (DES) between 2010 and 2013. Data on all criteria of the ARC-HBR definition were collected retrospectively. The primary endpoint was Bleeding Academic Research Consortium Type 3 or 5 bleeding events; the ischemic endpoint was a composite of cardiac death, myocardial infarction, and ischemic stroke. The mean follow-up period was 7.5 years. Compared with non-high bleeding risk (HBR) patients, HBR patients (n=1,840; 53.3%) had an increased risk of the primary endpoint (early events, 3.6% vs. 0.5% [P<0.0001]; late events, 5.3% vs. 2.5% [P<0.0001]; very late events, 5.5% vs. 2.1% [P<0.0001]) and of ischemic events during follow-up. The discrimination ability of the ARC-HBR definition for late and very late bleeding events was comparable to that of early bleeding events (C statistics 0.679, 0.621, and 0.620, respectively) with high negative predictive value (96.6%, 95.1%, and 93.1%, respectively). Multivariate analysis revealed the different effects of individual criteria on bleeding events in each follow-up period. CONCLUSIONS The ARC-HBR definition consistently identified patients at risk of long-term bleeding and ischemic events after second-generation DES implantation.
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Affiliation(s)
- Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital
| | - Koya Okabe
- Department of Cardiology, Kurashiki Central Hospital
| | - Yuya Taguchi
- Department of Cardiology, Kurashiki Central Hospital
| | - Akihiro Ikuta
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital
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Bhatt DL, Kaski JC, Delaney S, Alasnag M, Andreotti F, Angiolillo DJ, Ferro A, Gorog DA, Lorenzatti AJ, Mamas M, McNeil J, Nicolau JC, Steg PG, Tamargo J, Tan D, Valgimigli M. Results of an international crowdsourcing survey on the treatment of non-ST segment elevation ACS patients at high-bleeding risk undergoing percutaneous intervention. Int J Cardiol 2021; 337:1-8. [PMID: 34000356 DOI: 10.1016/j.ijcard.2021.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/11/2022]
Abstract
AIMS Choosing an antiplatelet strategy in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) at high bleeding risk (HBR), undergoing post-percutaneous coronary intervention (PCI), is complex. We used a unique open-source approach (crowdsourcing) to document if practices varied across a small, global cross-section of antiplatelet prescribers in the post-PCI setting. METHODS AND RESULTS Five-hundred and fifty-nine professionals from 70 countries (the 'crowd') completed questionnaires containing single- or multi-option and free form questions regarding antiplatelet clinical practice in post-PCI NSTE-ACS patients at HBR. A threshold of 75% defined 'agreement'. There was strong agreement favouring monotherapy with either aspirin or a P2Y12 inhibitor following initial DAPT, within the first year (94%). No agreement was reached on the optimal duration of DAPT or choice of monotherapy: responses were in equipoise for shorter (≤3 months, 51%) or longer (≥6 months, 46%) duration, and monotherapy choice (45% aspirin; 53% P2Y12 inhibitor). Most respondents stated use of guideline-directed tools to assess risk, although clinical judgement was preferred by 32% for assessing bleeding risk and by 46% for thrombotic risk. CONCLUSION The crowdsourcing methodology showed potential as a tool to assess current practice and variation on a global scale and to achieve a broad demographic representation. These preliminary results indicate a high degree of variation with respect to duration of DAPT, monotherapy drug of choice following DAPT and how thrombotic and bleeding risk are assessed. Further investigations should concentrate on interrogating practice variation between key demographic groups.
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Affiliation(s)
- Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, London, UK.
| | - Sean Delaney
- Radcliffe Cardiology Bourne End Business Park, Cores End Rd, Wooburn Green, Bourne End SL8 5AS, UK.
| | - Mirvat Alasnag
- King Fahd Armed Forces Hospital, Jeddah-KSA, Al Kurnaysh Rd, Al Andalus, Jeddah 23311, Saudi Arabia.
| | - Felicita Andreotti
- Scientific Directorate, FPUG IRCCS, Rome, Italy; Cardiovascular Dept, Catholic University, Rome, Italy.
| | - Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, Division of Cardiology, ACC Building 5th floor 655 West 8th Street, Jacksonville, FL 32209, USA.
| | - Albert Ferro
- King's College London, School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, Franklin-Wilkins Building, 150 Stamford Street, London SE1 9NH, UK.
| | - Diana A Gorog
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, UK; School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK.
| | - Alberto J Lorenzatti
- Instituto Medico DAMIC, Av. Colon 2057, Cordoba, Argentina; Departamento de Cardiologia, Hospital Córdoba, Av. Patria 656, Córdoba, Argentina
| | - Mamas Mamas
- University Hospitals of North Midlands NHS Trust, Keel University, Staffordshire ST5 5BG, UK
| | - John McNeil
- School of Public Health and Preventive Medicine, Monash University, Wellington Rd, Clayton VIC, Melbourne 3800, Australia.
| | - José C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455 - Cerqueira César, São Paulo, Brazil.
| | - Philippe Gabriel Steg
- Université de Paris, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Paris, France.
| | - Juan Tamargo
- Faculty of Medicine of the Complutense University of Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
| | - Doreen Tan
- Dept of Pharmacy, National University of Singapore, 8 Science Drive 4, 117543, Singapore.
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40
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Bagga S, Dani SS, Hook BG, Nohria A, Ganatra S. Strategies to balance stroke and bleeding risk in patients with atrial fibrillation and cancer. Heart Rhythm 2021; 18:1533-8. [PMID: 33930550 DOI: 10.1016/j.hrthm.2021.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/04/2021] [Accepted: 04/22/2021] [Indexed: 11/23/2022]
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41
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Natsuaki M, Morimoto T, Shiomi H, Kadota K, Tada T, Takeji Y, Matsumura-Nakano Y, Yoshikawa Y, Watanabe H, Yamamoto K, Imada K, Domei T, Yamaji K, Kaneda K, Taniguchi R, Ehara N, Nawada R, Toyofuku M, Shinoda E, Suwa S, Tamura T, Inada T, Matsuda M, Aoyama T, Sato Y, Furukawa Y, Ando K, Nakagawa Y, Kimura T. Effects of Acute Coronary Syndrome and Stable Coronary Artery Disease on Bleeding and Ischemic Risk After Percutaneous Coronary Intervention. Circ J 2021; 85:1928-1941. [PMID: 33907052 DOI: 10.1253/circj.cj-21-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Data evaluating the effects of acute coronary syndrome (ACS) relative to stable coronary artery disease (CAD) on bleeding risk after percutaneous coronary intervention (PCI) are scarce.Methods and Results:From the CREDO-Kyoto Registry Cohort-3, 13,258 patients undergoing first PCI (5,521 ACS; 7,737 stable CAD) were identified. Patients were further stratified according to ACS presentation and Academic Research Consortium High Bleeding Risk (HBR): ACS/HBR: n=2,502; ACS/no-HBR: n=3,019; stable CAD/HBR: n=3,905; and stable CAD/no-HBR: n=3,832. The primary bleeding endpoint was Bleeding Academic Research Consortium 3/5 bleeding, whereas the primary ischemic endpoint was myocardial infarction (MI)/ischemic stroke. Compared with stable CAD, ACS was associated with a significantly higher adjusted risk for bleeding (hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.68-2.03; P<0.0001), with a markedly higher risk within 30 days (HR 4.24; 95% CI 3.56-5.06; P<0.0001). Compared with the stable CAD/no-HBR group, the ACS/HBR, no-ACS/HBR, and ACS/no-HBR groups were associated with significantly higher adjusted risks for bleeding, with HRs of 3.05 (95% CI 2.64-3.54; P<0.0001), 1.89 (95% CI 1.66-2.15; P<0.0001), and 1.69 (95% CI 1.45-1.98; P<0.0001), respectively. There was no excess adjusted risk of the ACS relative to stable CAD group for MI/ischemic stroke (HR 1.07; 95% CI 0.94-1.22; P=0.33). CONCLUSIONS Bleeding risk after PCI depended on both ACS presentation and HBR, with a significant effect of ACS within 30 days.
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Affiliation(s)
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | | | - Yasuaki Takeji
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | | | | | | | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | - Eiji Shinoda
- Department of Cardiology, Hamamatsu Rosai Hospital
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | | | | | | | | | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Hioki H, Kozuma K, Kinoshita Y, Nanasato M, Ito Y, Yamaguchi J, Shiode N, Hibi K, Tanabe K, Ako J, Morino Y, Hirohata A, Sonoda S, Nakagawa Y, Okada H, Nakagami T, Takamisawa I, Ando K, Abe M, Ikari Y. Ischemic/bleeding event after short dual-antiplatelet therapy in patients with high bleeding risk: Sub-analysis of the MODEL U-SES study. J Cardiol 2021; 78:107-113. [PMID: 33875313 DOI: 10.1016/j.jjcc.2021.03.015] [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: 12/16/2020] [Revised: 02/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI). METHODS We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated. RESULTS Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y12 inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR. CONCLUSION In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y12 inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events.
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Affiliation(s)
- Hirofumi Hioki
- Division of Cardiology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan
| | - Ken Kozuma
- Division of Cardiology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan.
| | | | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Yoshiaki Ito
- Department of Cardiology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Nobuo Shiode
- Department of Cardiology, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Junya Ako
- Department of Cardiology, Kitazato University Hospital, Sagamihara, Japan
| | - Yoshihiro Morino
- Department of Cardiology, Iwate Medical University Hospital, Morioka, Japan
| | - Atsushi Hirohata
- Department of Cardiology, Sakakibara Heart Institute of Okayama, Okayama, Japan
| | - Shinjo Sonoda
- Department of Cardiology, Hospital of the University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiology, Shiga University of Medical Science Hospital, Otsu, Japan
| | - Hisayuki Okada
- Department of Cardiology, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Takuo Nakagami
- Department of Cardiology, Omihachiman Community Medical Center, Omihachiman, Japan
| | - Itaru Takamisawa
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University Hospital, Isehara, Japan
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Wang HY, Yin D, Zhao YY, Zhang R, Yang YJ, Xu B, Dou KF. Prognostic and Practical Validation of ESC/EACTS High Ischemic Risk Definition on Long-Term Thrombotic and Bleeding Events in Contemporary PCI Patients. J Atheroscler Thromb 2021; 29:502-526. [PMID: 33746144 PMCID: PMC9090477 DOI: 10.5551/jat.60129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims:
The ESC/EACTS myocardial revascularization guidelines recently standardized the definition of patients at high ischemic risk (HIR). However, the ability of ESC/EACTS–HIR criteria to stratify ischemic and bleeding risk in a contemporary real-world East Asian cohort remains unexplored.
Methods:
A total of 10,167 consecutive patients undergoing PCI from prospective Fuwai PCI Registry (January 2013 to December 2013) were reviewed. ESC/EACTS–HIR features was defined as having at least one of the eight clinical and angiographic characteristics. The primary ischemic endpoint was target vessel failure (cardiac death, target vessel myocardial infarction [MI], or target vessel revascularization [TVR]); bleeding outcome was assessed using the BARC type 2, 3, or 5 bleeding. Median follow-up was 29 months.
Results:
Compared with non-HIR patients, HIR patients (
n
=5,149, 50.6%) were associated with increased risk for target vessel failure (adjusted hazard ratio [HR
adjust
]: 1.48 [1.25–1.74]) and patient-oriented composite outcome (HR
adjust
: 1.44 [1.28–1.63]), as well as cardiac death, MI, and TVR. By contrast, the risk of clinically relevant bleeding was not significantly different between the two groups. (HR
adjust
: 0.84 [0.66–1.06]). Greater than or equal to three implanted stents and diabetic patients with diffuse multivessel coronary disease emerged as independent predictors for long-term adverse outcomes. There was no significant interaction between high bleeding risk (HBR) status and clinical outcomes associated with ESC/EACTS–HIR criteria (all P
interaction
>0.05).
Conclusion:
The ESC/EACTS–HIR features identified patients at increased risk of thrombotic events, including cardiac death, but not for clinically relevant bleeding. Importantly, HBR did not modify cardiovascular risk subsequent to patients with ESC/EACTS–HIR features, suggesting its potential clinical applicability in tailoring antithrombotic therapy.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.,State Key Laboratory of Cardiovascular Disease.,National Clinical Research Center for Cardiovascular Diseases
| | - Dong Yin
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.,State Key Laboratory of Cardiovascular Disease.,National Clinical Research Center for Cardiovascular Diseases
| | - Yan-Yan Zhao
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases
| | - Rui Zhang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.,State Key Laboratory of Cardiovascular Disease.,National Clinical Research Center for Cardiovascular Diseases
| | - Yue-Jin Yang
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.,State Key Laboratory of Cardiovascular Disease.,National Clinical Research Center for Cardiovascular Diseases
| | - Bo Xu
- National Clinical Research Center for Cardiovascular Diseases.,Catheterization Laboratories, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College
| | - Ke-Fei Dou
- Department of Cardiology, Coronary Heart Disease Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.,State Key Laboratory of Cardiovascular Disease.,National Clinical Research Center for Cardiovascular Diseases
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Sotomi Y, Hikoso S, Nakatani D, Suna S, Dohi T, Mizuno H, Okada K, Kida H, Oeun B, Sunaga A, Sato T, Kitamura T, Sakata Y, Sato H, Hori M, Komuro I, Sakata Y; Osaka Acute Coronary Insufficiency Study (OACIS) Group. Prevalence of the Japanese high bleeding risk criteria and its prognostic significance for fatal bleeding in patients with acute myocardial infarction. Heart Vessels 2021; 36:1484-95. [PMID: 33743047 DOI: 10.1007/s00380-021-01836-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Japanese high-bleeding-risk criteria (Japanese-HBR), modified criteria of the Academic Research Consortium (ARC) HBR, has been recently proposed. We aimed to investigate the prevalence of the ARC-HBR and the Japanese-HBR, and to assess their prognostic significance in patients with acute myocardial infarction (AMI). METHODS AND RESULTS We applied the ARC-HBR and the Japanese-HBR criteria to the OACIS prospective multicenter acute myocardial infarction registry (12,093 patients, 66 ± 12 years, 9,096 males). The primary endpoint was fatal bleeding (BARC-5). Median follow-up duration was 4.84 [inter-quartile range 1.35, 5.01] years. Prevalence of the ARC-HBR was 43.8%, while that of the Japanese-HBR was 61.8%. Cumulative incidence of fatal bleeding was higher in the ARC-HBR group than in the no ARC-HBR group at 1 year (1.3 vs. 0.6%) and at 5 years (2.0 vs. 0.7%). The Kaplan-Meier curves stratified by the Japanese-HBR criteria more prominently diverged (1.3 vs. 0.2% at 1 year; and 1.9 vs. 0.3% at 5 years). The Japanese-HBR criteria showed superior discriminative performance over the ARC-HBR criteria (C-statistics: 0.677 vs. 0.598, P < 0.001). CONCLUSIONS In the real-world Japanese AMI registry, nearly half of the patients fulfilled the criteria of ARC-HBR, and two-thirds met the Japanese-HBR. Our findings support the validity of both ARC- and Japanese-HBR criteria in AMI patients but encourage the future application of the Japanese-HBR criteria to the Japanese AMI cohort. TRIAL REGISTRATION NUMBER UMIN000004575.
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Kuno T, Claessen B, Cao D, Chandiramani R, Guedeney P, Sorrentino S, Krucoff M, Kozuma K, Ge J, Seth A, Makkar R, Bangalore S, Bhatt DL, Angiolillo DJ, Saito S, Neumann FJ, Hermiller J, Rau V, Ruster K, Wang J, Valgimigli M, Mehran R. Impact of renal function in high bleeding risk patients undergoing percutaneous coronary intervention: a patient-level stratified analysis from four post-approval studies. J Thromb Thrombolysis 2021. [PMID: 33709255 DOI: 10.1007/s11239-020-02321-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/21/2022]
Abstract
Data on ischemic and bleeding outcomes after percutaneous coronary intervention (PCI) in high bleeding risk (HBR) patients with chronic kidney disease (CKD) are scarce. We aimed to evaluate the association between CKD and ischemic and bleeding outcomes in HBR patients who underwent PCI. Among 10,502 patients in the four post-approval registries evaluating patients undergoing PCI, 2,300 patients presented with at least one major or two minor ARC-HBR criteria. CKD was defined as eGFR < 60 mL/min/1.73 m2. These HBR patients were divided into 3 groups: eGFR < 30 mL/min/1.73 m2 defined as severe CKD (N = 221), eGFR 30- < 60 mL/min/1.73 m2 defined as moderate CKD (N = 970), eGFR ≥ 60 mL/min/1.73 m2 defined as no CKD (N = 1,109). The primary endpoint was the composite of cardiac death, myocardial infarction, or stent thrombosis, and the safety endpoint was major bleeding up to 4-year follow-up. HBR patients with CKD were more often female and had higher rates of comorbidities compared to those without CKD. Reduced renal function was associated with higher rates of the primary endpoint (severe CKD vs. moderate CKD vs. no CKD: 30.2% vs. 12.5% vs. 9.1%, P < 0.01) as well as major bleeding (10.3% vs. 8.9% vs. 6.4%, P = 0.03). After adjustment, severe CKD and moderate CKD in HBR patients remained independent predictors for the primary endpoint (HR [95%CI] 2.84 [1.94-4.16], P < 0.01, 1.48 [1.10-2.00], P < 0.01) compared to those with no CKD. However, decreased renal function was no longer significantly associated with major bleeding after adjustment. In conclusions, in HBR patients undergoing PCI, CKD has an important impact on major ischemic events after PCI.
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Hashimoto R, Numasawa Y, Yokokura S, Daigo K, Sakata S, Imaeda S, Hitomi Y, Sato K, Taruoka A, Haginiwa S, Kojima H, Tanaka M, Kuno T, Kodaira M. Prevalence of the Academic Research Consortium high bleeding risk criteria in patients undergoing endovascular therapy for peripheral artery disease in lower extremities. Heart Vessels 2021; 36:1350-1358. [PMID: 33651134 DOI: 10.1007/s00380-021-01813-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
The Academic Research Consortium (ARC) recently published a definition of patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. However, the prevalence of the ARC-HBR criteria in patients undergoing endovascular therapy (EVT) for peripheral artery disease in lower extremities has not been thoroughly investigated. This study sought to investigate the prevalence and impact of the ARC-HBR criteria in patients undergoing EVT. We analyzed 277 consecutive patients who underwent their first EVT from July 2011 to September 2019. We applied the full ARC-HBR criteria to the study population. The primary end point was a composite outcome of all-cause mortality, Bleeding Academic Research Consortium 3 or 5 bleeding, and lower limb amputation within 12 months of EVT. Among the 277 patients, 193 (69.7%) met the ARC-HBR criteria. HBR patients had worse clinical outcomes compared with non-HBR patients at 12 months after EVT, including a higher incidence of the composite primary outcome (19.2% vs. 3.6%, p < 0.001) and all-cause death (7.8% vs. 0%, p = 0.007). In a multivariate Cox proportional hazards regression analysis, presence of the ARC-HBR criteria [hazard ratio (HR) 4.15, 95% confidence interval (CI) 1.25-13.80, p = 0.020], body mass index (HR 1.13, 95% CI 1.01-1.27, p = 0.042), diabetes mellitus (HR 2.70, 95% CI 1.28-5.69, p = 0.009), hyperlipidemia (HR 0.41, 95% CI 0.21-0.80, p = 0.009), and infrapopliteal lesions (HR 3.51, 95% CI 1.63-7.56, p = 0.001) were independent predictors of the primary composite outcome. Approximately 70% of Japanese patients undergoing EVT met the ARC-HBR criteria, and its presence was strongly associated with adverse outcomes within 12 months of EVT.
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Affiliation(s)
- Ryota Hashimoto
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Cardiovascular Medicine, Dokkyo Medical University Hospital, Mibu, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.
| | - Souichi Yokokura
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Kyohei Daigo
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Shingo Sakata
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Shohei Imaeda
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Yasuhiro Hitomi
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Kazuki Sato
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Akira Taruoka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Sho Haginiwa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Hidenori Kojima
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Makoto Tanaka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan
| | - Toshiki Kuno
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Masaki Kodaira
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan.,Department of Cardiology, McGill University, Montreal, Canada
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47
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Yoshioka N, Takagi K, Morita Y, Kanzaki Y, Nagai H, Watanabe N, Morishima I. Bleeding events and mid-term mortality in the patients undergoing endovascular interventions for peripheral artery disease of the lower limbs based on the academic research consortium high bleeding risk criteria. Heart Vessels 2021; 36:1336-1349. [PMID: 33616719 DOI: 10.1007/s00380-021-01804-3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/05/2021] [Indexed: 11/28/2022]
Abstract
This study applied the Academic Research Consortium for HBR (ARC-HBR) criteria to peripheral artery disease (PAD) patients after Endovascular therapy (EVT) and assessed the prevalence of HBR, as well as the association between HBR and clinical outcomes. This is a single-center, non-randomized, controlled, and retrospective study. EVTs for symptomatic PAD are minimally invasive and efficient. Although bleeding can be a serious adverse event, the criteria for HBR and assessment of bleeding events in patients who underwent EVT have been limited. A total of 156 patients with PAD who underwent EVT were divided into two groups according to ARC-HBR criteria. The associations between HBR and bleeding events, which was defined as Bleeding Academic Research Consortium Type 3 or Type 5 bleeding within 1 year and all-cause mortality within 1 year, were analyzed. The percentage of patients who were categorized as having HBR was 75.0%. Bleeding events occurred in 12.6% of the patients. All bleeding events occurred in the HBR group, while no bleeding events occurred in the no-HBR group. (16.9% vs. 0.0%, respectively; p = 0.008). During the follow-up period, 11.1% of the patients had died. All-cause mortality was significantly higher in the HBR group than in the no-HBR group (14.7% vs. 0.0%, respectively; p = 0.019). Most patients with PAD were classified as having HBR as assessed by ARC-HBR criteria, and patients with HBR were at a higher risk of not only bleeding events but also mid-term mortality compared to those without HBR. ARC-HBR criteria can be a helpful parameter when treating PAD patients after EVT.
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Affiliation(s)
- Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Yasunori Kanzaki
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Hiroaki Nagai
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Naoki Watanabe
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan
| | - Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Gifu, Japan.
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Colleran R, Joner M, Cutlip D, Urban P, Maeng M, Jauhar R, Barakat M, Michel JM, Mehran R, Kirtane AJ, Maillard L, Kastrati A, Byrne RA. Design and rationale of a randomized trial of COBRA PzF stenting to REDUCE duration of triple therapy (COBRA-REDUCE). Cardiovasc Revasc Med 2021; 34:17-24. [PMID: 33608239 DOI: 10.1016/j.carrev.2021.01.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/19/2021] [Accepted: 01/19/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND/PURPOSE A coronary stent with thromboresistant and pro-healing properties such as the polymer polyzene F-coated (COBRA PzF) stent might safely allow for a very short duration of triple therapy in patients taking oral anticoagulation (OAC) who undergo coronary stenting. METHODS The COBRA-REDUCE trial is a prospective, multinational, randomized, open-label, assessor-blinded trial. A total of 996 patients at high bleeding risk because of requirement for OAC (with a vitamin K antagonist or non-vitamin K antagonist for any indication) will be randomized at sites in the United States and Europe to treatment with the COBRA-PzF stent followed by very short duration (14 days) DAPT or a Food and Drug Administration (FDA)-approved new generation drug-eluting stent followed by guideline-recommended DAPT duration (3 or 6 months). Two co-primary endpoints will be tested at 6 months: a bleeding co-primary endpoint (bleeding academic research consortium [BARC] ≥2 bleeding beyond 14 days or after hospital discharge, whichever is later [superiority hypothesis]) and a thrombo-embolic co-primary endpoint (the composite of all-cause death, myocardial infarction, definite/probable stent thrombosis or ischaemic stroke [non-inferiority hypothesis]). The trial is registered at clinicaltrials.gov (NCT02594501). CONCLUSION The COBRA-REDUCE trial will determine whether coronary stenting with the COBRA PzF stent followed by 14 days of clopidogrel will reduce bleeding without increasing thrombo-embolic events compared with FDA-approved DES followed by 3-6 months clopidogrel in patients taking OAC and aspirin.
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Affiliation(s)
- Róisín Colleran
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michael Joner
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
| | - Donald Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States of America
| | - Philip Urban
- La Tour Hospital, Geneva, Switzerland; CERC (Cardiovascular European Research Center), Massy, France
| | | | - Rajiv Jauhar
- North Shore University Hospital, Manhasset New York, NY, USA
| | | | - Jonathan M Michel
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Ajay J Kirtane
- Department of Medicine, Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, NY, United States of America; Cardiovascular Research Foundation, New York, NY, United States of America
| | - Luc Maillard
- GCS-ES Axium-Rambot, Clinique Axium, Aix en Provence, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany.
| | - Robert A Byrne
- Cardiovascular Research Institute Dublin, Mater Private Hospital, Dublin, Ireland; School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons University of Medicine and Health Sciences, Dublin, Ireland.
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Nakamura M, Iijima R. Implications and characteristics of high bleeding risk in East Asian patients undergoing percutaneous coronary intervention: Start with what is right rather than what is acceptable. J Cardiol 2020; 78:91-98. [PMID: 33358236 DOI: 10.1016/j.jjcc.2020.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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] [Accepted: 11/24/2020] [Indexed: 11/25/2022]
Abstract
Recent advances in percutaneous coronary intervention (PCI) technology and medication have changed the main focus of PCI from preventing ischemic to preventing bleeding events. Bleeding risk assessment is essential for preventing bleeding. Several types of assessment tools have been established, but they are heterogeneous, making interpretation, generalization, and comparison between trials difficult. In 2019, the Academic Research Consortium (ARC) introduced a new consensus document with 20 criteria to define high bleeding risk (HBR). The applicability of the ARCHBR criteria were subsequently investigated, and 4 studies have already demonstrated wide applicability worldwide, including in Japan. Nevertheless, it hase been suggested that bleeding risk is higher in people from East Asian countries than in people from Western countries. Patients with HBR have a 3-fold higher risk of major bleeding, and in Japan approximately 50% of patients undergoing PCI have HBR. In addition, patients with overlapping factors, such as older age, renal disease, and anemia, are at increased risk of bleeding, and each additional factor further increases the risk. In Japanese patients undergoing PCI, in addition to the ARC-HBR criteria, low body weight, heart failure, and peripheral arterial disease are high-risk subsets for bleeding. The addition of these factors to the ARCHBR criteria increases the prevalence of HBR in Japanese patients to 58% and improves the sensitivity of diagnostic evaluations. The additional factors are clinically important because they are often encountered in everyday practice, and Japan's newly updated guideline has adopted them as criteria for HBR. Studies found a temporal trend over the past 20 years of a gradual and consistent increase of bleeding risk. This finding contrasts with improved outcomes in people at risk of ischemic and thrombotic events. Therefore, further research is needed to eliminate the risk of bleeding while maintaining the efficacy of antithrombotic therapy after PCI.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan.
| | - Raisuke Iijima
- Division of Cardiovascular Medicine, Ohashi Medical Center, Toho University, 2-22-36 Ohashi, Meguro-ku, Tokyo 153-8515, Japan
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50
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Natsuaki M, Morimoto T, Shiomi H, Ehara N, Taniguchi R, Tamura T, Tada T, Suwa S, Kaneda K, Watanabe H, Tazaki J, Watanabe S, Yamamoto E, Saito N, Fuki M, Takeda T, Eizawa H, Shinoda E, Mabuchi H, Shirotani M, Uegaito T, Matsuda M, Takahashi M, Inoko M, Tamura T, Ishii K, Onodera T, Sakamoto H, Aoyama T, Sato Y, Ando K, Furukawa Y, Nakagawa Y, Kadota K, Kimura T. Application of the Modified High Bleeding Risk Criteria for Japanese Patients in an All-Comers Registry of Percutaneous Coronary Intervention - From the CREDO-Kyoto Registry Cohort-3. Circ J 2020; 85:769-781. [PMID: 33298644 DOI: 10.1253/circj.cj-20-0836] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [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] [Indexed: 11/09/2022]
Abstract
BACKGROUND The prevalence of and expected bleeding event rate in patients with the Japanese version of high bleeding risk (J-HBR) criteria are currently unknown in real-world percutaneous coronary intervention (PCI) practice.Methods and Results:We applied the J-HBR criteria in the multicenter CREDO-Kyoto registry cohort-3 that enrolled 13,258 consecutive patients who underwent first PCI. The J-HBR criteria included Japanese-specific major criteria such as heart failure, low body weight, peripheral artery disease and frailty in addition to the Academic Research Consortium (ARC)-HBR criteria. There were 8,496 patients with J-HBR, and 4,762 patients without J-HBR. The J-HBR criteria identified a greater proportion of patients with HBR than did ARC-HBR (64% and 48%, respectively). Cumulative incidence of the Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding was significantly higher in the J-HBR group than in the no-HBR group (14.0% vs. 4.1% at 1 year; 23.1% vs. 8.4% at 5 years, P<0.0001). Cumulative 5-year incidence of BARC 3/5 bleeding was 25.1% in patients with ARC-HBR, and 23.1% in patients with J-HBR. Cumulative incidence of myocardial infarction or ischemic stroke was also significantly higher in the J-HBR group than in the no-HBR group (6.9% vs. 3.6% at 1 year; 13.2% vs. 7.1% at 5 years, P<0.0001). CONCLUSIONS The J-HBR criteria successfully identified those patients with very high bleeding risk after PCI, who represented 64% of patients in this all-comers registry.
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Affiliation(s)
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Natsuhiko Ehara
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | | | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital
| | | | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Shin Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Erika Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masayuki Fuki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Hiroshi Eizawa
- Department of Cardiology, Kobe City Nishi-Kobe Medical Center
| | - Eiji Shinoda
- Department of Cardiology, Hamamatsu Rosai Hospital
| | | | | | | | | | | | - Moriaki Inoko
- Department of Cardiology, Tazuke Kofukai Medical Research Institute, Kitano Hospital
| | - Takashi Tamura
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center
| | | | - Tomoya Onodera
- Department of Cardiology, Shizuoka City Shizuoka Hospital
| | | | | | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | | | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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