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Onuk T, Polat F, Yaylak B, Akyüz Ş, Kolak Z, Durak F. Comparison of ticagrelor and clopidogrel in anemic patients with acute coronary syndrome: efficacy and safety outcomes over one year. Eur J Clin Pharmacol 2024; 80:759-770. [PMID: 38360988 DOI: 10.1007/s00228-024-03653-1] [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: 11/11/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE This retrospective study aimed to investigate the potential impact of ticagrelor and clopidogrel treatment on cardiovascular outcomes in patients with anemia and acute coronary syndrome (ACS) and to provide insights into the optimal therapeutic approach for this vulnerable patient population. METHODS A retrospective research design was employed, involving patients diagnosed with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) between 2014 and 2021. Inclusion criteria required a hemoglobin level below 12 mg/dL and a minimum 12-month P2Y12 inhibitor treatment. Comprehensive clinical, biochemical, and echocardiographic data were collected from the hospital's electronic repository. The primary efficacy endpoint was major adverse cardiovascular events (MACE), encompassing total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke. Major hemorrhage was the primary safety endpoint. Secondary outcomes included total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke, individually. RESULTS Patients treated with ticagrelor (n = 118) and clopidogrel (n = 538) were compared. No significant difference was observed in major adverse cardiovascular events (MACE) and major bleeding between ticagrelor and clopidogrel treatment groups (MACE: clopidogrel 10.0% vs. ticagrelor 11.0%, p = 0.75; major bleeding: clopidogrel 2.8%, ticagrelor 2.5%, p = 0.88). Patients with hemoglobin levels ≤ 8 mg/dL demonstrated significantly higher MACE and major bleeding rates in the ticagrelor group (p = 0.008 and p = 0.002, respectively). Among patients aged ≥ 75 years, ticagrelor treatment was associated with a higher risk of major bleeding (p = 0.04). CONCLUSIONS Ticagrelor and clopidogrel exhibited comparable efficacy and safety outcomes in anemic ACS patients over a one-year period. Although ticagrelor demonstrated superiority in reducing ischemic events, it is crucial to recognize the limitations of retrospective studies in informing clinical practice. This study offers valuable insights into tailoring antiplatelet therapy for anemic ACS patients and provides guidance for personalized treatment strategies, acknowledging the hypothesis-generating nature of retrospective analyses.
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Affiliation(s)
- Tolga Onuk
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye.
| | - Fuat Polat
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Barış Yaylak
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Şükrü Akyüz
- Department of Cardiology, Okan University Faculty of Health Sciences, Istanbul, Türkiye
| | - Zeynep Kolak
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Furkan Durak
- Department of Cardiology, Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Istanbul, Türkiye
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Lu Y, Matuska K, Nadimpalli G, Ma Y, Duma N, Zhang HT, Chiang Y, Lyu H, Chillarige Y, Kelman JA, Forshee RA, Anderson SA. Stroke Risk After COVID-19 Bivalent Vaccination Among US Older Adults. JAMA 2024; 331:938-950. [PMID: 38502075 PMCID: PMC10951737 DOI: 10.1001/jama.2024.1059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/24/2024] [Indexed: 03/20/2024]
Abstract
Importance In January 2023, the US Centers for Disease Control and Prevention and the US Food and Drug Administration noted a safety concern for ischemic stroke among adults aged 65 years or older who received the Pfizer-BioNTech BNT162b2; WT/OMI BA.4/BA.5 COVID-19 bivalent vaccine. Objective To evaluate stroke risk after administration of (1) either brand of the COVID-19 bivalent vaccine, (2) either brand of the COVID-19 bivalent plus a high-dose or adjuvanted influenza vaccine on the same day (concomitant administration), and (3) a high-dose or adjuvanted influenza vaccine. Design, Setting, and Participants Self-controlled case series including 11 001 Medicare beneficiaries aged 65 years or older who experienced stroke after receiving either brand of the COVID-19 bivalent vaccine (among 5 397 278 vaccinated individuals). The study period was August 31, 2022, through February 4, 2023. Exposures Receipt of (1) either brand of the COVID-19 bivalent vaccine (primary) or (2) a high-dose or adjuvanted influenza vaccine (secondary). Main Outcomes and Measures Stroke risk (nonhemorrhagic stroke, transient ischemic attack, combined outcome of nonhemorrhagic stroke or transient ischemic attack, or hemorrhagic stroke) during the 1- to 21-day or 22- to 42-day risk window after vaccination vs the 43- to 90-day control window. Results There were 5 397 278 Medicare beneficiaries who received either brand of the COVID-19 bivalent vaccine (median age, 74 years [IQR, 70-80 years]; 56% were women). Among the 11 001 beneficiaries who experienced stroke after receiving either brand of the COVID-19 bivalent vaccine, there were no statistically significant associations between either brand of the COVID-19 bivalent vaccine and the outcomes of nonhemorrhagic stroke, transient ischemic attack, nonhemorrhagic stroke or transient ischemic attack, or hemorrhagic stroke during the 1- to 21-day or 22- to 42-day risk window vs the 43- to 90-day control window (incidence rate ratio [IRR] range, 0.72-1.12). Among the 4596 beneficiaries who experienced stroke after concomitant administration of either brand of the COVID-19 bivalent vaccine plus a high-dose or adjuvanted influenza vaccine, there was a statistically significant association between vaccination and nonhemorrhagic stroke during the 22- to 42-day risk window for the Pfizer-BioNTech BNT162b2; WT/OMI BA.4/BA.5 COVID-19 bivalent vaccine (IRR, 1.20 [95% CI, 1.01-1.42]; risk difference/100 000 doses, 3.13 [95% CI, 0.05-6.22]) and a statistically significant association between vaccination and transient ischemic attack during the 1- to 21-day risk window for the Moderna mRNA-1273.222 COVID-19 bivalent vaccine (IRR, 1.35 [95% CI, 1.06-1.74]; risk difference/100 000 doses, 3.33 [95% CI, 0.46-6.20]). Among the 21 345 beneficiaries who experienced stroke after administration of a high-dose or adjuvanted influenza vaccine, there was a statistically significant association between vaccination and nonhemorrhagic stroke during the 22- to 42-day risk window (IRR, 1.09 [95% CI, 1.02-1.17]; risk difference/100 000 doses, 1.65 [95% CI, 0.43-2.87]). Conclusions and Relevance Among Medicare beneficiaries aged 65 years or older who experienced stroke after receiving either brand of the COVID-19 bivalent vaccine, there was no evidence of a significantly elevated risk for stroke during the days immediately after vaccination.
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MESH Headings
- Aged
- Female
- Humans
- Male
- 2019-nCoV Vaccine mRNA-1273/adverse effects
- 2019-nCoV Vaccine mRNA-1273/therapeutic use
- Adjuvants, Immunologic/adverse effects
- Adjuvants, Immunologic/therapeutic use
- BNT162 Vaccine/adverse effects
- BNT162 Vaccine/therapeutic use
- COVID-19/prevention & control
- COVID-19 Vaccines/adverse effects
- COVID-19 Vaccines/therapeutic use
- Hemorrhagic Stroke/chemically induced
- Hemorrhagic Stroke/epidemiology
- Hemorrhagic Stroke/etiology
- Influenza Vaccines/adverse effects
- Influenza Vaccines/therapeutic use
- Ischemic Attack, Transient/chemically induced
- Ischemic Attack, Transient/epidemiology
- Ischemic Attack, Transient/etiology
- Medicare
- Stroke/epidemiology
- Stroke/etiology
- Stroke/prevention & control
- United States/epidemiology
- Vaccination/adverse effects
- Vaccination/methods
- Vaccines, Combined/adverse effects
- Vaccines, Combined/therapeutic use
- Centers for Disease Control and Prevention, U.S./statistics & numerical data
- United States Food and Drug Administration/statistics & numerical data
- Ischemic Stroke/chemically induced
- Ischemic Stroke/epidemiology
- Ischemic Stroke/etiology
- Influenza, Human/prevention & control
- Aged, 80 and over
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Affiliation(s)
- Yun Lu
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Yuxin Ma
- Acumen LLC, Burlingame, California
| | | | - Henry T Zhang
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | | | - Hai Lyu
- Acumen LLC, Burlingame, California
| | | | | | - Richard A Forshee
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Steven A Anderson
- Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Bétrisey S, Haller ML, Efthimiou O, Speierer A, Del Giovane C, Moutzouri E, Blum MR, Aujesky D, Rodondi N, Gencer B. Lipid-Lowering Therapy and Risk of Hemorrhagic Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2024; 13:e030714. [PMID: 38323514 PMCID: PMC11010101 DOI: 10.1161/jaha.123.030714] [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: 04/23/2023] [Accepted: 12/12/2023] [Indexed: 02/08/2024]
Abstract
BACKGROUND There is debate over whether statins increase risk of hemorrhagic stroke, so we assessed current evidence, including data from new statin trials and trials of nonstatin low-density lipoprotein-cholesterol (LDL-C)- and triglyceride-lowering therapies. METHODS AND RESULTS We performed a systematic review of large randomized clinical trials (≥1000 patients with ≥2 years follow-up) of LDL-C-lowering therapy (statin, ezetimibe, and PCSK-9 [proprotein convertase subtilisin/kexin type 9] inhibitor) and triglyceride-lowering therapy (omega-3 supplements and fibrate) that reported hemorrhagic stroke as an outcome. We searched MEDLINE, Embase, and Cochrane Library up to July 2, 2021 and updated a meta-analysis of cardiovascular statin trials published in 2012. Among our several subgroup analyses, we looked at difference depending on stroke status and also depending on age. We identified 37 trials for LDL-C lowering (284 301 participants) and 11 for triglyceride lowering (120 984 participants). Overall, we found a higher risk of hemorrhagic stroke for LDL-C lowering, risk ratio (RR) 1.16 (95% CI, 1.01-1.32, P=0.03). For statins (33 trials, 216 258 participants), RR=1.17 (95% CI, 1.01-1.36); for PCSK-9 inhibitors (2 trials, 46 488 participants), RR=0.86 (95% CI, 0.43-1.74); and for ezetimibe (2 trials, 21 555 participants), RR=1.14 (95% CI, 0.64-2.03). In statin trials of patients with previous stroke/transient ischemic attack, RR was 1.46 (95% CI, 1.05-2.04), and in trials with mean age ≥65 years old, RR=1.34 (95% CI, 1.04-1.73) (Pint=0.14 and Pint=0.23 respectively); for triglyceride lowering (11 trials, 120 984 participants), RR=1.05 (95% CI, 0.86-1.30). CONCLUSIONS We found evidence for a small increased risk of hemorrhagic stroke events with LDL-C-lowering therapies but no clear evidence for triglyceride-lowering therapies. REGISTRATION URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42021275363.
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Affiliation(s)
- Sylvain Bétrisey
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Moa Lina Haller
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Orestis Efthimiou
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Institute of Social and Preventive Medicine (ISPM)University of BernSwitzerland
| | - Alexandre Speierer
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of Medical and Surgical Sciences for Children and AdultsUniversity Hospital of Modena and Reggio EmiliaModenaMOItaly
| | - Elisavet Moutzouri
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of General Internal Medicine, Spital EmmentalBurgdorfSwitzerland
| | - Manuel R. Blum
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, InselspitalBern University Hospital, University of BernSwitzerland
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM)University of BernSwitzerland
- Department of CardiologyGeneva University Hospital (HUG), University of GenevaGenevaSwitzerland
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Turagam MK, Kawamura I, Neuzil P, Nair D, Doshi S, Valderrabano M, Hala P, Della Rocca D, Gibson D, Funasako M, Ha G, Lee B, Musikantow D, Yoo D, Flautt T, Dukkipati S, Natale A, Gurol ME, Halperin J, Mansour M, Reddy VY. Severity of Ischemic Stroke After Left Atrial Appendage Closure vs Nonwarfarin Oral Anticoagulants. JACC Clin Electrophysiol 2024; 10:270-283. [PMID: 37999669 DOI: 10.1016/j.jacep.2023.10.012] [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] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/29/2023] [Accepted: 10/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Strokes after left atrial appendage closure (LAAC) prophylaxis are generally less severe than those after warfarin prophylaxis-thought to be secondary to more hemorrhagic strokes with warfarin. Hemorrhagic strokes are similarly infrequent with direct oral anticoagulant (DOAC) prophylaxis, so the primary subtype after either LAAC or DOAC prophylaxis is ischemic stroke (IS). OBJECTIVES The purpose of this study was to compare the severity of IS using the modified Rankin Scale in atrial fibrillation patients receiving prophylaxis with DOACs vs LAAC. METHODS A retrospective analysis was performed of consecutive patients undergoing LAAC at 8 centers who developed an IS (ISLAAC) compared with contemporaneous consecutive patients who developed IS during treatment with DOACs (ISDOAC). The primary outcome was disabling/fatal stroke (modified Rankin Scale 3-5) at discharge and 3 months later. RESULTS Compared with ISDOAC patients (n = 322), ISLAAC patients (n = 125) were older (age 77.2 ± 13.4 years vs 73.1 ± 11.9 years; P = 0.002), with higher HAS-BLED scores (3.0 vs 2.0; P = 0.004) and more frequent prior bleeding events (54.4% vs 23.6%; P < 0.001), but similar CHA2DS2-VASc scores (5.0 vs 5.0; P = 0.28). Strokes were less frequently disabling/fatal with ISLAAC than ISDOAC at both hospital discharge (38.3% vs 70.3%; P < 0.001) and 3 months later (33.3% vs 56.2%; P < 0.001). Differences in stroke severity persisted after propensity score matching. By multivariate regression analysis, ISLAAC was independently associated with fewer disabling/fatal strokes at discharge (OR: 0.22; 95% CI: 0.13-0.39; P < 0.001) and 3 months (OR: 0.25; 95% CI: 0.12-0.50; P < 0.001), and fewer deaths at 3 months (OR: 0.28; 95% CI: 0.12-0.64; P < 0.001). CONCLUSIONS Ischemic strokes in patients with atrial fibrillation are less often disabling or fatal with LAAC than DOAC prophylaxis.
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Affiliation(s)
- Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Iwanari Kawamura
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Devi Nair
- St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | - Shephal Doshi
- Pacific Heart Institute, Santa Monica, California, USA
| | | | - Pavel Hala
- Homolka Hospital, Prague, Czech Republic
| | | | | | | | - Grace Ha
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Bridget Lee
- St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | | | - David Yoo
- Scripps Health, San Diego, California, USA
| | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Houston, Texas, USA
| | - Mahmut E Gurol
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Moussa Mansour
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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5
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Lin Y, Chao TF, Tsai ML, Tseng CJ, Wang TH, Chang CH, Lin YS, Yang NI, Chu PH, Hung MJ, Wu VCC, Chen TH. Cardiovascular and renal outcomes in patients with atrial fibrillation and stage 4-5 chronic kidney disease receiving direct oral anticoagulants: a multicenter retrospective cohort study. J Thromb Thrombolysis 2024; 57:89-100. [PMID: 37605063 DOI: 10.1007/s11239-023-02885-9] [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] [Accepted: 08/05/2023] [Indexed: 08/23/2023]
Abstract
The role of direct oral anticoagulants (DOAC) in patients with atrial fibrillation (AF) and stage 4-5 chronic kidney disease (CKD) is controversial. Electronic medical records from 2012 to 2021 were retrieved for patients with AF and stage 4-5 CKD receiving oral anticoagulants. Patients were separated into those receiving DOACs (dabigatran, rivaroxaban, apixaban, or edoxaban) or vitamin K antagonists (VKA). Primary outcomes included ischemic stroke (IS), systemic thrombosis (SE), major bleeding, gastrointestinal bleeding, hemorrhagic stroke, acute myocardial infarction, cardiovascular death, and all-cause death. Renal outcomes included eGFR declines, creatinine doubling, progression to dialysis, and major adverse kidney events (MAKE). The primary analysis was until the end of follow up and the results at 1-year and 2-year of follow ups were also assessed. 2,382 patients (DOAC = 1,047, VKA = 1,335) between 2012 and 2021 with AF and stage 4-5 CKD were identified. The mean follow-up period was 2.3 ± 2.1 years in DOCAs and 2.6 ± 2.3 years in VKA respectively. At the end of follow up, the DOAC patients had significantly decreased SE (subdistribution hazard ratio [SHR] = 0.50, 95% confidence interval [CI] = 0.34-0.73), composite of IS/SE (SHR = 0.78, 95% CI = 0.62-0.98), major bleeding (HR = 0.77, 95% CI = 0.66-0.90), hemorrhagic stroke (HR = 0.52, 95% CI = 0.36-0.76), and composite of bleeding events (SHR = 0.80, 95% CI = 0.69-0.92) compared with VKA patients. The IS efficacy outcome revealed neutral between DOAC and VKA patients (HR = 1.05, 95% CI = 0.79-1.39). In addition, DOAC patients had significantly decreased rates of eGFR decline > 50% (SHR = 0.75, 95% CI = 0.64-0.87), creatinine doubling (SHR = 0.80, 95% CI = 0.67-0.95), and MAKE (SHR = 0.81, 95% CI = 0.71-0.93). In patients with AF and stage 4-5 CKD, use of DOAC was associated with decreased rates of a composite of ischemic stroke/systemic embolism, a composite of bleeding events, and renal events compared to VKA. Efficacy and safety benefits associated with apixaban at standard doses were consistent throughout follow-up.
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Affiliation(s)
- Yuan Lin
- Department of Emergency Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Chang Gung University College of Medicine, Tao-Yuan, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ming-Lung Tsai
- Division of Cardiology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chin-Ju Tseng
- Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Te-Hsiung Wang
- Department of Emergency Medicine, Medical Research Institute, Kitano Hospital, Tazuke Kofukai, Osaka, Japan
- Department of Primary Care and Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Sheng Lin
- Chang Gung University College of Medicine, Tao-Yuan, Taiwan
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ning-I Yang
- Department of Cardiology, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan
| | - Ming-Jui Hung
- Department of Cardiology, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan
| | - Victor Chien-Chia Wu
- Division of Cardiology, Linkou Medical Center, Linkou Chang Gung Memorial Hospital, No. 5, Fuxing Street, Guishan District, Taoyuan City, 33305, Taiwan.
| | - Tien-Hsing Chen
- Department of Cardiology, Keelung Chang Gung Memorial Hospital, 222, Maijin Road, Keelung, Taiwan.
- School of Traditional Chinese Medicine, Chang Gung University, Taoyuan, Taiwan.
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Banaś BP, Brzeźniakiewicz-Janus K, Majdanik S, Parafiniuk M, Łużny S, Stachowicz A, Janus T. Hemorrhagic stroke caused by xylometazoline poisoning. J Forensic Sci 2024; 69:359-364. [PMID: 37919943 DOI: 10.1111/1556-4029.15416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
An increase in the use of over-the-counter medications has been observed in recent years. This also concerns xylometazoline, approved for the treatment of allergic rhinitis or upper respiratory tract infections. We present the fatal case of a 40 year-old-woman with a massive hemorrhagic stroke. Initial toxicology tests of biological material collected during autopsy revealed the presence of xylometazoline. No other significant toxicology findings were noted. LC-MS/MS method has been developed to determine xylometazoline concentration, which was 18.6 ng/mL in blood and 498.9 ng/mL in urine. The macroscopically detected hemorrhagic focus was confirmed by histopathological which confirmed hemorrhagic infarcts in the brain tissue, especially in the subarachnoid area. No other pathological changes were found. Based on findings from autopsy and toxicological analyses, the direct cause of death was concluded to be hemorrhagic stroke resulting from xylometazoline intoxication. Although xylometazoline products are regarded as relatively safe and are available over the counter, the risk of adverse effects, in particular stroke leading to death, should be considered. If adverse effects are observed, it is reasonable to measure the concentration of the drug in blood and urine. With such data, it will be possible to assess the actual exposure to this xenobiotic and draw firmer conclusions.
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Affiliation(s)
- Barbara Potocka Banaś
- Department of Clinical and Forensic Toxicology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | | | - Sławomir Majdanik
- Department of Forensic Medicine, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Mirosław Parafiniuk
- Department of Forensic Medicine, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Sylwester Łużny
- Department of Clinical and Forensic Toxicology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Agnieszka Stachowicz
- Department of Clinical and Forensic Toxicology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Tomasz Janus
- Department of Clinical and Forensic Toxicology, Pomeranian Medical University in Szczecin, Szczecin, Poland
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Suryadi T, Kulsum K. Case Report: Case report: Administration of anticoagulant therapy after neuro-anesthesia procedure for hemorrhagic stroke patients with COVID-19 complications and its ethical and medicolegal consideration. F1000Res 2023; 10:1303. [PMID: 38144172 PMCID: PMC10739180 DOI: 10.12688/f1000research.75630.2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 12/26/2023] Open
Abstract
Background Ethical dilemmas can occur in any situation in clinical medicine. In patients undergoing neuro-anesthesia for surgical procedure evacuation of intracerebral hemorrhage with a history of hemorrhagic stroke, anticoagulants should not be given because they can cause recurrent bleeding. Meanwhile, at the same time, the patient could also be infected with coronavirus disease 2019 (COVID-19), one of treatment is the administration of anticoagulants. Methods A case report. A 46-year-old male patient was admitted to hospital with a loss of consciousness and was diagnosed with intracerebral hemorrhage due to a hemorrhagic stroke and was confirmed positive for COVID-19. Giving anticoagulants to patients is considered counterproductive so, an ethical dilemma arises. For this reason, a joint conference was held to obtain the best ethical and medicolegal solutions for the patient. Results By using several methods of resolving ethical dilemmas such as basic ethical principles, supporting ethical principles, and medicolegal considerations, it was decided that the patient was not to be given anticoagulants. Conclusions Giving anticoagulants to hemorrhagic stroke patients is dangerous even though it is beneficial for COVID-19 patients, so here the principle of risk-benefit balance is applied to patients who prioritize risk prevention rather than providing benefits. This is also supported by the prima facie principle by prioritizing the principle of non-maleficence rather than beneficence, the minus malum principle by seeking the lowest risk, and the double effect principle by making the best decision even in a slightly less favorable way as well as the medicolegal aspect by assessing patient safety and risk management.
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Affiliation(s)
- Taufik Suryadi
- Ethics and Medicolegal Consultant, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
- Department of Forensic Medicine and Medicolegal, Faculty of Medicine, Universitas Syiah Kuala, Aceh, 23111, Indonesia
- Department of Forensic Medicine and Medicolegal, Dr.Zainoel Abidin Hospital, Banda Aceh, Aceh, 23126, Indonesia
| | - Kulsum Kulsum
- Neuro-anesthesia and Critical Care Consultant, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
- Department of Anesthesiology and Intensive Therapy, Dr.Zainoel Abidin Hospital, Banda Aceh, Aceh, 23126, Indonesia
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
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Duan C, Wang S, Xiong Y, Gu HQ, Yang K, Zhao XQ, Meng X, Wang Y. Short- and long-term outcomes of patients with minor stroke and nonvalvular atrial fibrillation. BMC Neurol 2023; 23:410. [PMID: 37986056 PMCID: PMC10658860 DOI: 10.1186/s12883-023-03457-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND PURPOSE Nonvalvular atrial fibrillation (NVAF) is a risk factor for stroke. This study was undertaken to determine the influence of NVAF on the mortality and recurrent stroke after a minor stroke event. METHODS Data were derived from the Third China National Stroke Registry (CNSR-III) which enrolled 15,166 subjects during August 2015 through March 2018 in China. Patients with minor stroke (NIHSS ≤ 5) within 24 h after onset were included. Clinical outcomes including all-cause mortality, cardiovascular death, recurrent ischemic stroke, and recurrent hemorrhagic stroke were collected. The Cox proportional hazards models were used to determine the association between NVAF and clinical outcomes. RESULTS A total of 4,753 patients were included in our study. Of them, 222 patients had NVAF (4.7%) (mean age, 71.1 years) and 4,531 patients were without AF (95.3%) (mean age, 61.4 years). NVAF was associated with 12-month cardiovascular mortality in both univariate (hazards ratio [HR], 4.13; 95% confidence interval [CI], 1.84 to 9.31; P < 0.001) and multivariate analyses (HR, 4.66; 95% CI, 1.79 to 12.15; P = 0.001). There was no difference in the in-hospital ischemic stroke recurrence rate between the two groups (HR, 0.45 [95% CI, 0.19 to 1.05] P = 0.07 at discharge). However, patients with NVAF had a lower rate of recurrent ischemic stroke at medium- (3 months and 6 months) and long-term (12 months) follow-up (HR, 0.33 [95% CI, 0.16 to 0.68] P = 0.003 at 3 months; 0.49 [95% CI, 0.27 to 0.89] P = 0.02 at 6 months; 0.55 [95% CI, 0.32 to 0.94] P = 0.03 at 12 months, respectively) compared with those without. There was no difference in all-cause mortality and hemorrhagic stroke between the two groups during follow-up. CONCLUSIONS Minor stroke patients with NVAF were at higher risk of cardiovascular death but had a lower rate of recurrent ischemic stroke compared to those without during the subsequent year after stroke event. A more accurate stroke risk prediction model for NVAF is warranted for optimal patient care strategies.
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Affiliation(s)
- Chunmiao Duan
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Department of Neurology, Beijing Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Shang Wang
- Neurocardiology Center, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunyun Xiong
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Chinese Institute for Brain Research, Beijing, China
| | - Hong Qiu Gu
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Kaixuan Yang
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China
| | - Xing-Quan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yongjun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- National Center for Healthcare Quality Management in Neurological Diseases, Beijing, China.
- Center for Stroke, Beijing Institute for Brain Disorders, Beijing, China.
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Wu CK, Lin CH, Yar N, Kao ZK, Yang YB, Chen YY. Long-Term Effectiveness of Cilostazol in Patients with Hemodialysis with Peripheral Artery Disease. J Atheroscler Thromb 2023; 30:943-955. [PMID: 36216573 PMCID: PMC10406651 DOI: 10.5551/jat.63404] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 08/25/2022] [Indexed: 08/04/2023] Open
Abstract
AIM The aim of this study was to investigate the effects of continuous cilostazol use on emergency department (ED) visits, hospitalizations, and vascular outcomes in patients with hemodialysis (HD) with peripheral artery disease (PAD). METHODS This retrospective cohort study recruited 558 adult patients, who had received chronic HD for at least 90 days between January 1, 2008 and December 31, 2012, from the National Health Insurance Research Database. Eligible patients were divided into two groups based on continuing or discontinuing cilostazol treatment. Outcome measures were ED visits, hospitalizations, mortality, and vascular outcomes such as percutaneous transluminal angioplasty, surgical bypass, lower leg amputation, ischemic stroke, hemorrhagic stroke, and cardiovascular events. RESULTS Patients with continuous cilostazol use had significantly higher prevalence of stroke, cancer, vintage, and the use of angiotensin receptor blocker and β-blocker, but significantly lower incidence of ischemic stroke and cardiovascular events, as well as lower mortality, than those without continuous cilostazol use (all p<.05). Continuous cilostazol use was independently associated with lower risk of ED visits, hemorrhagic stroke, and cardiovascular events (adjusted hazard ratios: 0.79, 0.29, and 0.67; 95% confidence intervals: 0.62-0.98, 0.10-0.84, and 0.48-0.96, respectively; all p<.05). Continuous cilostazol use was significantly associated with higher ED visit-free and cardiovascular event-free rates (log-rank test; p<.05). CONCLUSION Continuous treatment of cilostazol in patients with HD with PAD significantly decreases the risk of ED visits, hemorrhagic stroke, and cardiovascular events and improves ED visit-free and cardiovascular event-free rates during long-term follow-up.
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Affiliation(s)
- Chung-Kuan Wu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
- School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
| | - Chia-Hsun Lin
- School of Medicine, Fu-Jen Catholic University, New Taipei, Taiwan
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Noi Yar
- College of Management, School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| | - Zih-Kai Kao
- Institute of Biophotonics, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Bei Yang
- Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Yun-Yi Chen
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Research, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, Taipei, Taiwan
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10
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Uchida K, Ueda S, Sakakibara F, Kinjo N, Nezu M, Arai H, Morimoto T. Statins Reduce Bleeding Risk in Patients Taking Oral Anticoagulants for Nonvalvular Atrial Fibrillation: A Retrospective Registry Study. Am J Cardiovasc Drugs 2023; 23:89-99. [PMID: 36380115 DOI: 10.1007/s40256-022-00555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The effects of statins in patients with non-valvular atrial fibrillation (NVAF) taking oral anticoagulants (OACs) are not well-studied. This study was a historical multicenter registry of patients with NVAF taking OACs in Japan. METHODS We excluded those patients with mechanical heart valves or a history of pulmonary or deep vein thrombosis. Overall, 7826 patients were registered on 26 February 2013 and followed until 25 February 2017. We compared those with versus without statin treatment (statin vs. no-statin groups) for the primary outcome of major bleeding and secondary outcomes of all-cause mortality, ischemic events, hemorrhagic stroke, and ischemic stroke. RESULTS Statins were administered in 2599 (33%) patients. The statin group was more likely to have paroxysmal AF (37% vs. 33%; p = 0.0003), hypertension (84% vs. 76%; p < 0.0001), diabetes mellitus (41% vs. 27%; p < 0.0001), and dyslipidemia (91% vs. 30%; p < 0.0001) than the no-statin group. The cumulative incidence of major bleeding was 6.9% and 8.1% (p = 0.06). The adjusted hazard ratio [HR] (95% confidence interval [CI]) of the statin group for major bleeding was 0.77 (0.63-0.94) compared with the no-statin group. The adjusted HR (95% CI) for all-cause mortality, ischemic events, hemorrhagic stroke, and ischemic stroke were 0.58 (0.47-0.71), 0.77 (0.59-0.999), 0.85 (0.48-1.50), and 0.79 (0.60-1.05), respectively. CONCLUSIONS Statins significantly reduced the risk of major bleeding, all-cause mortality, and ischemic events in patients with NVAF taking OACs. Their additive benefits should be considered in routine practice and thus be further researched.
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Affiliation(s)
- Kazutaka Uchida
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichiro Ueda
- Department of Clinical Pharmacology and Therapeutics, University of the Ryukyus, Okinawa, Japan
| | - Fumihiro Sakakibara
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Norito Kinjo
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Mari Nezu
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Hideki Arai
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, 1-1 Mukogawa, Nishinomiya, Hyogo, 663-8501, Japan.
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Wei J, Yang B, Wang R, Ye H, Wang Y, Wang L, Zhang X. Risk of stroke and retinopathy during GLP-1 receptor agonist cardiovascular outcome trials: An eight RCTs meta-analysis. Front Endocrinol (Lausanne) 2022; 13:1007980. [PMID: 36545339 PMCID: PMC9760859 DOI: 10.3389/fendo.2022.1007980] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To explore the risk of stroke (including ischemic and hemorrhagic stroke) in type 2 diabetes mellitus treated with glucagon-like peptide 1 receptor agonist (GLP-1RA) medication according to data from the Cardiovascular Outcome Trials(CVOT). METHODS Randomized controlled trials (RCT) on GLP-1RA therapy and cardiovascular outcomes in type 2 diabetics published in full-text journal databases such as Medline (via PubMed), Embase, Clinical Trials.gov, and the Cochrane Library from establishment to May 1, 2022 were searched. We assess the quality of individual studies by using the Cochrane risk of bias algorithm. RevMan 5.4.1 software was use for calculating meta- analysis. RESULTS A total of 60,081 randomized participants were included in the data of these 8 GLP-1RA cardiovascular outcomes trials. Pooled analysis reported statistically significant effect on total stroke risk[RR=0.83, 95%CI(0.73, 0.95), p=0.005], and its subtypes such as ischemic Stroke [RR=0.83, 95%CI(0.73, 0.95), p=0.008] from treatment with GLP-1RA versus placebo, and have no significant effect on the risk of hemorrhagic stroke[RR=0.83, 95%CI(0.57, 1.20), p=0.31] and retinopathy [RR=1.54, 95%CI(0.74, 3.23), p=0.25]. CONCLUSION GLP-1RA significantly reduces the risk of ischemic stroke in type 2 diabetics with cardiovascular risk factors.
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Affiliation(s)
- Jinjing Wei
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Bing Yang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ruxin Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haowen Ye
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Ying Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lihong Wang
- Department of Endocrinology and Metabolism, First Affiliated Hospital of Jinan University, Guangzhou, China
- The Guangzhou Key Laboratory of Basic and Translational Research on Chronic Diseases, The First Affiliated Hospital, Jinan University, Guangzhou, China
- *Correspondence: Xiaofang Zhang, ; Lihong Wang,
| | - Xiaofang Zhang
- Department Clinical Experimental Center, First Affiliated Hospital of Jinan University, Guangzhou, China
- *Correspondence: Xiaofang Zhang, ; Lihong Wang,
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12
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Qin J, Liu L, Su XD, Wang BB, Fu BS, Cui JZ, Liu XY. The effect of PCSK9 inhibitors on brain stroke prevention: A systematic review and meta-analysis. Nutr Metab Cardiovasc Dis 2021; 31:2234-2243. [PMID: 34052073 DOI: 10.1016/j.numecd.2021.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 08/14/2020] [Revised: 03/18/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Although proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to improve cardiovascular outcomes, their effects on brain stroke risk are unclear. The present meta-analysis aimed to evaluate the effects of PCSK9 inhibitors on brain stroke prevention. METHODS AND RESULTS We searched PubMed, Embase, Cochrane Library, Web of Science, and ClinicalTrials.gov for research published until December 30, 2020, to find randomized controlled trials (RCTs) of PCSK9 inhibitors for brain stroke prevention. Relative risk (RR) and 95% confidence intervals (CIs) were used to represent the outcomes. Seven RCTs with 57,440 participants, including 29,850 patients treated with PCSK9 inhibitors and 27,590 control participants, were included. PCSK9 inhibitors were associated with significant reductions in total brain stroke risk (RR, 0.77; 95% CI, 0.67-0.88; P < 0.001) and ischemic brain stroke risk (RR, 0.76; 95% CI, 0.66, 0.89; P < 0.001) in comparison with the control group. There was no significant difference in cardiovascular mortality (RR, 0.95; 95% CI, 0.84-1.07; P = 0.382) and the risk of hemorrhagic brain stroke (RR, 1.00; 95% CI, 0.66-1.51; P = 0.999) between patients treated with PCSK9 inhibitors and controls. PCSK9 inhibitors did not significantly increase the incidence of neurocognitive adverse events (RR, 1.02; 95% CI, 0.81-1.29; P = 0.85). Moreover, subgroup analysis showed no difference in cognitive function disorder risks among different PCSK9 inhibitors and treatment times. CONCLUSIONS PCSK9 inhibitors significantly reduced the risk of total brain stroke and ischemic brain stroke without increasing the risk of brain hemorrhage and neurocognitive impairment.
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Affiliation(s)
- Jin Qin
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Lin Liu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Xu D Su
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Bin B Wang
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Bao S Fu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Jun Z Cui
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China
| | - Xiao Y Liu
- Neurology Department, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, 05000, China.
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13
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Gaffey AE, Rosman L, Burg MM, Haskell SG, Brandt CA, Skanderson M, Dziura J, Sico JJ. Posttraumatic Stress Disorder, Antidepressant Use, and Hemorrhagic Stroke in Young Men and Women: A 13-Year Cohort Study. Stroke 2021; 52:121-129. [PMID: 33297868 PMCID: PMC7770089 DOI: 10.1161/strokeaha.120.030379] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Antidepressants are commonly prescribed for posttraumatic stress disorder (PTSD) and may increase the risk of bleeding, including hemorrhagic stroke. METHODS We prospectively examined independent effects of PTSD, selective serotonin and norepinephrine reuptake inhibitors (SSRI and SNRI) on the risk of incident hemorrhagic stroke in a nationwide sample of 1.1 million young and middle-aged veterans. Time-varying multivariate Cox models were used to examine hemorrhagic stroke risk by PTSD status and use of SSRI or SNRI while adjusting for demographics, lifestyle factors, stroke, and psychiatric comorbidities. Sensitivity analyses controlled for health care utilization. RESULTS During 13 years of follow-up (2.14 years on average), 507 patients (12% women) suffered a hemorrhagic stroke. The overall incidence rate was 1.70 events per 10 000-person years. In unadjusted models, PTSD was associated with an 82% greater risk of new-onset hemorrhagic stroke (hazard ratio [HR], 1.82 [95% CI, 1.48-2.24]), SSRI use was associated with a >2-fold risk (HR, 2.02 [95% CI, 1.66-2.57]), and SNRI use was associated with a 52% greater risk (HR, 1.52 [95% CI, 1.08-2.16]). In fully adjusted models, effects of PTSD and SNRI were attenuated (adjusted HR, 1.03 [95% CI, 0.81-1.34]; adjusted HR, 1.19 [95% CI, 0.83-1.71]), but SSRI use remained associated with a 45% greater risk of hemorrhagic stroke (adjusted HR, 1.45 [95% CI, 1.13-1.85]). Hypertension, drug abuse, and alcohol abuse were also associated with increased stroke risk. Nonobesity and being non-Hispanic were protective factors. In sensitivity analyses, health care utilization was a small but significant predictor of stroke. CONCLUSIONS In the largest known investigation of PTSD and antidepressant-associated risk for hemorrhagic stroke in young adults, use of SSRIs, but neither PTSD nor SNRIs were independently associated with incident stroke. SNRIs may be preferable for treating PTSD and comorbid conditions, although pursuing other modifiable risk factors and non-pharmacological treatments for PTSD also remains essential.
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Affiliation(s)
- Allison E. Gaffey
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine),
Yale School of Medicine, New Haven, CT
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, University
of North Carolina, Chapel Hill, Chapel Hill, NC
| | - Matthew M. Burg
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (Cardiovascular Medicine),
Yale School of Medicine, New Haven, CT
- Department of Anesthesiology, Yale School of Medicine
| | - Sally G. Haskell
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale
School of Medicine
| | - Cynthia A. Brandt
- VA Connecticut Healthcare System, West Haven, CT
- Department of Emergency Medicine, Yale School of
Medicine
- Yale Center for Medical Informatics, Yale School of
Medicine
| | | | - James Dziura
- VA Connecticut Healthcare System, West Haven, CT
- Department of Emergency Medicine, Yale School of
Medicine
| | - Jason J. Sico
- VA Connecticut Healthcare System, West Haven, CT
- Department of Internal Medicine (General Medicine), Yale
School of Medicine
- Department of Neurology and Center for NeuroEpidemiological
and Clinical Neurological Research, Yale School of Medicine
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Huang T, Fu G, Gao J, Zhang Y, Cai W, Wu S, Jia S, Xia S, Bachmann T, Bekker A, Tao YX. Fgr contributes to hemorrhage-induced thalamic pain by activating NF-κB/ERK1/2 pathways. JCI Insight 2020; 5:139987. [PMID: 33055425 PMCID: PMC7605540 DOI: 10.1172/jci.insight.139987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 09/09/2020] [Indexed: 12/22/2022] Open
Abstract
Thalamic pain, a type of central poststroke pain, frequently occurs following ischemia/hemorrhage in the thalamus. Current treatment of this disorder is often ineffective, at least in part due to largely unknown mechanisms that underlie thalamic pain genesis. Here, we report that hemorrhage caused by microinjection of type IV collagenase or autologous whole blood into unilateral ventral posterior lateral nucleus and ventral posterior medial nucleus of the thalamus increased the expression of Fgr, a member of the Src family nonreceptor tyrosine kinases, at both mRNA and protein levels in thalamic microglia. Pharmacological inhibition or genetic knockdown of thalamic Fgr attenuated the hemorrhage-induced thalamic injury on the ipsilateral side and the development and maintenance of mechanical, heat, and cold pain hypersensitivities on the contralateral side. Mechanistically, the increased Fgr participated in hemorrhage-induced microglial activation and subsequent production of TNF-α likely through activation of both NF-κB and ERK1/2 pathways in thalamic microglia. Our findings suggest that Fgr is a key player in thalamic pain and a potential target for the therapeutic management of this disorder.
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Affiliation(s)
| | | | - Ju Gao
- Department of Anesthesiology
| | | | | | | | | | | | | | | | - Yuan-Xiang Tao
- Department of Anesthesiology
- Department of Pharmacology, Physiology & Neuroscience; and
- Department of Cell Biology & Molecular Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey, USA
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15
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François E, Mineur L, Deplanque G, Laplaige P, Smith D, Gourgou S, Tanang A, Ionescu-Goga M, Veerabudun K, Lelarge Y, Kim S, Rollot F. Efficacy and Safety of Bevacizumab Combined With First-Line Chemotherapy in Elderly (≥75 Years) Patients With Metastatic Colorectal Cancer: A Real-World Study. Clin Colorectal Cancer 2020; 19:e100-e109. [PMID: 32299778 DOI: 10.1016/j.clcc.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 06/26/2019] [Revised: 01/12/2020] [Accepted: 02/04/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although elderly patients are the first concerned by colorectal cancer (CRC), they are underrepresented in clinical trials. The real-world CASSIOPEE study was thus conducted in elderly patients treated for metastatic CRC (mCRC). METHODS This French prospective, multicenter, noninterventional study aimed to estimate 1-year progression-free survival (PFS) and overall survival (OS), and describe treatments, patient autonomy (Instrumental Activities of Daily Living; Balducci scale), and safety over 24 months, in patients older than 75 with mCRC, starting first-line bevacizumab plus chemotherapy (NCT01555762). RESULTS From 2012 to 2014, 402 patients were included (safety population: n = 383, efficacy population: n = 358). Patient characteristics were as follows: mean age, 81 ± 4 years (<80 years, 46%; 80-85 years, 44%; >85 years, 10%); men, 52%; colon primary tumor, 80%; main metastatic site, liver 66%; Eastern Cooperative Oncology Group performance 0-1, 81%. Median PFS was 9.1 months (95% confidence interval [CI]: 8.3-10.2). It was superior for patients ≤85 years (<80 years: 9.3 months; 80-85 years: 9.5 months) compared with patients >85 years (8.3 months). Median OS was 19.0 months (95% CI, 16.5-21.5) and decreased in the 2 oldest groups (20.6, 17.8, and 13.0 months). Autonomy assessments decreased over time leading to nonconclusive results. Twenty-six percent of patients experienced serious adverse events (SAEs): 7% bevacizumab-related SAEs, and 6% bevacizumab-targeted SAEs. Two fatal bevacizumab-related adverse events were reported (hemorrhagic stroke and intestinal ischemia). CONCLUSIONS This large French real-world study showed that medically fit older patients with mCRC could have a benefit/risk balance similar to that of younger patients when treated with first-line bevacizumab plus chemotherapy. Improvements in geriatric assessments are needed to better define this population.
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Affiliation(s)
- Eric François
- Oncologie médicale, Centre Antoine Lacassagne, Nice, France.
| | - Laurent Mineur
- Radiation Oncology, Gastro-Intestinal and Liver Cancer Unit, Institut Sainte-Catherine, Avignon, France
| | - Gaël Deplanque
- Oncologie médicale, Groupe hospitalier Paris Saint Joseph, Paris, France
| | - Philippe Laplaige
- Oncologie et chimiothérapie ambulatoire, Polyclinique de Blois, La Chaussée St Victor, France
| | - Denis Smith
- Hépato-gastro-entérologie, Hôpital Saint André, Bordeaux, France
| | - Sophie Gourgou
- Unité de Biométrie, Institut du Cancer de Montpellier, Montpellier, France
| | - Alexandre Tanang
- Medical Department, Oncology, Roche SAS, Boulogne Billancourt, France
| | | | | | - Yoann Lelarge
- Medical Department, Oncology, Roche SAS, Boulogne Billancourt, France
| | - Stefano Kim
- Oncologie médicale, Centre Hospitalier Régional Universitaire de Besançon, Besançon, France
| | - Florence Rollot
- Soins de support en oncologie/onco-gériatrie, Institut Curie, Paris, France
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