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Leiva O, Yang EH, Rosovsky RP, Alviar C, Bangalore S. In-hospital and readmission outcomes of patients with cancer admitted for pulmonary embolism treated with or without catheter-based therapy. Int J Cardiol 2024; 408:132165. [PMID: 38750964 DOI: 10.1016/j.ijcard.2024.132165] [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: 04/15/2024] [Accepted: 05/11/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Cancer patients are at risk of pulmonary embolism (PE). Catheter-based therapies (CBT) are novel reperfusion options for PE though data in patients with cancer is lacking. STUDY DESIGN AND METHODS Patients with intermediate- or high-risk PE were identified using the National Readmission Database (NRD) from 2017 to 2020. Primary outcome were in-hospital death and 90-day readmission. Secondary outcomes were in-hospital bleeding, 90-day readmission for venous thromboembolism (VTE)-related or right heart failure-related reasons and bleeding. Propensity scores were estimated using logistic regression and inverse-probability treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT as well as CBT versus systemic thrombolysis. RESULTS A total of 7785 patients were included (2511 with high-risk PE) of whom 1045 (13.4%) were managed with CBT. After IPTW, CBT was associated with lower rates of index hospitalization death (OR 0.89, 95% CI 0.83-0.96) and 90-day readmission (HR 0.75, 95% CI 0.69-0.81) but higher rates of in-hospital bleeding (OR 1.11, 95% CI 1.03-1.20) which was predominantly post-procedural bleeding. CBT was associated with lower risk of major bleeding (20.8% vs 24.8%; OR 0.80, 95% CI 0.68-0.94) compared with systemic thrombolysis. INTERPRETATION Among patients with cancer with intermediate or high-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. CBT was also associated with decreased risk of index hospitalization major bleeding compared with systemic thrombolysis. Prospective, randomized trials with inclusion of patients with cancer are needed to confirm these findings.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States of America.
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Bikdeli B, Krishnathasan D, Khairani CD, Bejjani A, Davies J, Porio N, Tristani A, Armero A, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Ortiz-Rios MD, Zuluaga-Sánchez V, Achanta A, Jesudasen SJ, Tiu B, Merli GJ, Leiva O, Fanikos J, Grandone E, Sharma A, Rizzo S, Pfeferman MB, Morrison RB, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll B, Goldhaber SZ, Lan Z, Piazza G. Low absolute risk of thrombotic and cardiovascular events in outpatient pregnant women with COVID-19. Thromb Res 2024; 237:209-215. [PMID: 38677791 DOI: 10.1016/j.thromres.2024.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/17/2024] [Accepted: 02/20/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Pregnancy may contribute to an excess risk of thrombotic or cardiovascular events. COVID-19 increases the risk of these events, although the risk is relatively limited among outpatients. We sought to determine whether outpatient pregnant women with COVID-19 are at a high risk for cardiovascular or thrombotic events. MATERIALS & METHODS We analyzed pregnant outpatients with COVID-19 from the multicenter CORONA-VTE-Network registry. The main study outcomes were a composite of adjudicated venous or arterial thrombotic events, and a composite of adjudicated cardiovascular events. Events were assessed 90 days after the COVID-19 diagnosis and reported for non-pregnant women ≤45 years, and for men ≤45 years, as points of reference. RESULTS Among 6585 outpatients, 169 were pregnant at diagnosis. By 90-day follow-up, two pregnant women during the third trimester had lower extremity venous thrombosis, one deep and one superficial vein thrombosis. The cumulative incidence of thrombotic events was 1.20 % (95 % confidence interval [CI]: 0.0 to 2.84 %). Respective rates were 0.47 % (95 % CI: 0.14 % to 0.79 %) among non-pregnant women, and 0.49 % (95 % CI: 0.06 % to 0.91 %) among men ≤45 years. No non-thrombotic cardiovascular events occurred in pregnant women. The rates of cardiovascular events were 0.53 % (95 % CI: 0.18 to 0.87) among non-pregnant women, and 0.68 % (95 % CI: 0.18 to 1.18) in men aged ≤45 years. CONCLUSIONS Thrombotic and cardiovascular events are rare among outpatients with COVID-19. Although a higher event rate among outpatient pregnant women cannot be excluded, the absolute event rates are low and do not warrant population-wide cardiovascular interventions to optimize outcomes.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; YNHH/ Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ali A Assi
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Marcos D Ortiz-Rios
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", S. Giovanni Rotondo (Foggia), Italy; Department of Obstetrics and Gynecology, First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Samantha Rizzo
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Mariana B Pfeferman
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Ruth B Morrison
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett Carroll
- Smith Center for Cardiovascular Outcomes Research, Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, USA.
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Leiva O, Alviar C, Khandhar S, Parikh SA, Toma C, Postelnicu R, Horowitz J, Mukherjee V, Greco A, Bangalore S. Catheter-based therapy for high-risk or intermediate-risk pulmonary embolism: death and re-hospitalization. Eur Heart J 2024:ehae184. [PMID: 38573048 DOI: 10.1093/eurheartj/ehae184] [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: 08/23/2023] [Revised: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND AND AIMS Catheter-based therapies (CBTs) have been developed as a treatment option in patients with pulmonary embolism (PE). There remains a paucity of data to inform decision-making in patients with intermediate-risk or high-risk PE. The aim of this study was to characterize in-hospital and readmission outcomes in patients with intermediate-risk or high-risk PE treated with vs. without CBT in a large retrospective registry. METHODS Patients hospitalized with intermediate-risk or high-risk PE were identified using the 2017-20 National Readmission Database. In-hospital outcomes included death and bleeding and 30- and 90-day readmission outcomes including all-cause, venous thromboembolism (VTE)-related and bleeding-related readmissions. Inverse probability of treatment weighting (IPTW) was utilized to compare outcomes between CBT and no CBT. RESULTS A total of 14 903 [2076 (13.9%) with CBT] and 42 829 [8824 (20.6%) with CBT] patients with high-risk and intermediate-risk PE were included, respectively. Prior to IPTW, patients with CBT were younger and less likely to have cancer and cardiac arrest, receive systemic thrombolysis, or be on mechanical ventilation. In the IPTW logistic regression model, CBT was associated with lower odds of in-hospital death in high-risk [odds ratio (OR) 0.83, 95% confidence interval (CI) 0.80-0.87] and intermediate-risk PE (OR 0.76, 95% CI 0.70-0.83). Patients with high-risk PE treated with CBT were associated with lower risk of 90-day all-cause [hazard ratio (HR) 0.77, 95% CI 0.71-0.83] and VTE (HR 0.46, 95% CI 0.34-0.63) readmission. Patients with intermediate-risk PE treated with CBT were associated with lower risk of 90-day all-cause (HR 0.75, 95% CI 0.72-0.79) and VTE (HR 0.66, 95% CI 0.57-0.76) readmission. CONCLUSIONS Among patients with high-risk or intermediate-risk PE, CBT was associated with lower in-hospital death and 90-day readmission. Prospective, randomized trials are needed to confirm these findings.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Carlos Alviar
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Sameer Khandhar
- Division of Cardiology, Penn Presbyterian Medical Center, Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sahil A Parikh
- Division of Cardiology, Columbia University Irving Medical School, New York-Presbyterian Hospital, New York, NY, USA
| | - Catalin Toma
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Radu Postelnicu
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - James Horowitz
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
| | - Vikramjit Mukherjee
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Allison Greco
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, NY, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, 550 First Ave, New York, NY 10016, USA
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Dai M, Peterson C, Chorin U, Leiva O, Katz M, Sliman H, Aizer A, Barbhaiya C, Bernstein S, Holmes D, Knotts R, Park D, Spinelli M, Chinitz L, Jankelson L. Risk of malignant ventricular arrhythmias in patients with mildly to moderately reduced ejection fraction after permanent pacemaker implantation. Heart Rhythm 2024:S1547-5271(24)00271-6. [PMID: 38490597 DOI: 10.1016/j.hrthm.2024.03.026] [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: 01/08/2024] [Revised: 02/22/2024] [Accepted: 03/10/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Many patients with mildly to moderately reduced left ventricular ejection fraction (LVEF) who require permanent pacemaker (PPM) implantation do not have a concurrent indication for implantable cardioverter-defibrillator (ICD) therapy. However, the risk of ventricular tachycardia/ventricular fibrillation (VT/VF) in this population is unknown. OBJECTIVE The aim of this study was to describe the risk of VT/VF after PPM implantation in patients with mildly to moderately reduced LVEF. METHODS Retrospective analysis was performed of 243 patients with LVEF between 35% and 49% who underwent PPM placement and did not meet indications for an ICD. The primary end point was occurrence of sustained VT/VF. Competing risks regression was performed to calculate subhazard ratios for the primary end point. RESULTS Median follow-up was 27 months; 73% of patients were male, average age was 79 ± 10 years, average LVEF was 42% ± 4%, and 70% were New York Heart Association class II or above. Most PPMs were implanted for sick sinus syndrome (34%) or atrioventricular block (50%). Of 243 total patients, 11 (4.5%) met the primary end point of VT/VF. Multivessel coronary artery disease (CAD) was associated with significantly higher rates of VT/VF, with a subhazard ratio of 5.4 (95% CI, 1.5-20.1; P = .01). Of patients with multivessel CAD, 8 of 82 (9.8%) patients met the primary end point for an annualized risk of 4.3% per year. CONCLUSION Patients with mildly to moderately reduced LVEF and multivessel CAD undergoing PPM implantation are at increased risk for the development of malignant ventricular arrhythmias. Patients in this population may benefit from additional risk stratification for VT/VF and consideration for upfront ICD implantation.
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Affiliation(s)
- Matthew Dai
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Connor Peterson
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Udi Chorin
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Orly Leiva
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Moshe Katz
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Hend Sliman
- Department of Cardiology, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Chirag Barbhaiya
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Scott Bernstein
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Robert Knotts
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - David Park
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Michael Spinelli
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Larry Chinitz
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York
| | - Lior Jankelson
- Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York.
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Leiva O, Yuriditsky E, Postelnicu R, Yang EH, Mukherjee V, Greco A, Horowitz J, Alviar C, Bangalore S. Catheter-based therapy for intermediate or high-risk pulmonary embolism is associated with lower in-hospital mortality in patients with cancer: Insights from the National Inpatient Sample. Catheter Cardiovasc Interv 2024; 103:348-358. [PMID: 37997287 DOI: 10.1002/ccd.30917] [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: 01/26/2023] [Revised: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common complication among patients with cancer and is a significant contributor to morbidity and mortality. Catheter-based therapies (CBT), including catheter-directed thrombolysis (CDT) and mechanical thrombectomy, have been developed and are used in patients with intermediate or high-risk PE. However, there is a paucity of data on outcomes in patients with cancer as most clinical studies exclude this group of patients. AIMS To characterize outcomes of patients with cancer admitted with intermediate or high-risk PE treated with CBT compared with no CBT. METHODS Patients with an admission diagnosis of intermediate or high-risk PE and a history of cancer from October 2015 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest were in-hospital death or cardiac arrest (CA) and major bleeding. Inverse probability treatment weighting (IPTW) was utilized to compare outcomes between patients treated with and without CBT. Variables that remained unbalanced after IPTW were adjusted using multivariable logistic regression. RESULTS A total of 2084 unweighted admissions (10,420 weighted) for intermediate or high-risk PE and cancer were included, of which 136 (6.5%) were treated with CBT. After IPTW, CBT was associated with lower death or CA (aOR 0.54, 95% CI 0.46-0.64) but higher major bleeding (aOR 1.41, 95% CI 1.21-1.65). After stratifying by PE risk type, patients treated with CBT had lower risk of death or CA in both intermediate (aOR 0.52, 95% CI 0.36-0.75) and high-risk PE (aOR 0.48, 95% CI 0.33-0.53). However, patients with CBT were associated with increased risk of major bleeding in intermediate-risk PE (aOR 2.12, 95% CI 1.67-2.69) but not in those with high-risk PE (aOR 0.84, 95% CI 0.66-1.07). CONCLUSIONS Among patients with cancer hospitalized with intermediate or high-risk PE, treatment with CBT was associated with lower risk of in-hospital death or CA but higher risk of bleeding. Prospective studies and inclusion of patients with cancer in randomized trials are warranted to confirm our findings.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Radu Postelnicu
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, New York, USA
| | - Eric H Yang
- Department of Medicine, Division of Cardiology, UCLA Cardio-Oncology Program, University of California Los Angeles, Los Angeles, California, USA
| | - Vikramjit Mukherjee
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, New York, USA
| | - Allison Greco
- Department of Medicine, Division of Pulmonology and Critical Care, New York University Grossman School of Medicine, New York, New York, USA
| | - James Horowitz
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Carlos Alviar
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
| | - Sripal Bangalore
- Department of Medicine, Division of Cardiology, New York University Grossman School of Medicine, New York, New York, USA
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Leiva O, How J, Grevet J, Brunner A, Hobbs G. In-Hospital and readmission outcomes of patients with myeloproliferative neoplasms and atrial fibrillation: insights from the National Readmissions Database. J Thromb Thrombolysis 2024; 57:186-193. [PMID: 37839025 DOI: 10.1007/s11239-023-02900-z] [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] [Accepted: 09/20/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Patients with myeloproliferative neoplasms (MPNs) and atrial fibrillation (AF) are at increased risk of thrombosis and bleeding. However, the risk of thrombosis and bleeding in patients with AF and MPN compared with the general population with AF is unclear. Additionally, traditional risk scores (CHA2DS2-VASC and HAS-BLED) for risk/benefit estimation of thromboprophylaxis in AF do not account for MPN status. Therefore, we aimed to investigate bleeding and thrombosis risk in patients with MPN hospitalized for AF. METHODS We utilized the National Readmission Database (NRD) to identify patients with AF with and without MPN. Primary bleeding and thrombosis outcomes were in-hospital or 30-day readmission for bleeding or thrombosis, respectively. We propensity score (PS) matched patients with and without MPN. Risk of primary outcomes in MPN was assessed in PS matched cohort using logistic regression. Receiver operating characteristic (ROC) curve used to evaluate predictive ability of CHA2DS2-VASC and HAS-BLED of primary thrombosis and bleeding outcomes, respectively. RESULTS 24,185 patients without MPN were matched with 1,617 patients with MPN and variables were balanced between groups. Patients with MPN were at increased risk of meeting the thrombosis (OR 1.98, 95% CI 1.23-3.21) but not bleeding (OR 0.87, 95% CI 0.63-1.19) primary outcomes. In MPN, CHA2DS2-VASC predicted thrombosis (C-statistic 0.66, 95% CI 0.54-0.78) but HAS-BLED was a poor predictor of bleeding (C-statistic 0.55, 95% CI 0.46-0.64). CONCLUSION In patients with AF, MPN was associated with increased risk of bleeding and thrombosis. HAS-BLED scores did not accurately predict bleeding in MPN. Further investigation is needed to refine risk scores in MPN.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Joan How
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Jeremy Grevet
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Brunner
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, USA.
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Leiva O, Alvarez-Cardona J, How J, Brunner A, Hobbs G. In-Hospital and readmission outcomes of patients with myeloproliferative neoplasms and heart failure: Insights from the National Readmissions Database. Int J Cardiol Heart Vasc 2023; 49:101304. [PMID: 38173785 PMCID: PMC10761308 DOI: 10.1016/j.ijcha.2023.101304] [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: 09/05/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
Background Myeloproliferative neoplasms (MPNs) are chronic leukemias associated with increased risk of cardiovascular (CV) events. Prior studies suggest patients with MPN are at increased risk of HF. Additionally, pre-clinical murine models harboring the JAK2 mutation, the most common driver mutation in MPNs, have shown accelerated adverse cardiac remodeling in myocardial infarction and pressure overload HF models. However, clinical outcomes, including in-hospital and readmission outcomes, of patients with MPN admitted for HF have not been well characterized. Methods Patients hospitalized for HF with and without MPN were identified using the 2017 and 2018 National Readmission Database. Propensity score matching (PSM) was performed to match 1 MPN with 10 non-MPN controls. Outcomes were in-hospital death, 90-day CV-related, HF-related, and all-cause readmissions. Logistic regression and Cox proportional hazards regression models were used to estimate risk of in-hospital death and 90-day readmission outcomes, respectively. Results After PSM, 4,626 patients with MPN were matched with 46,260 without. Patients with MPN were associated with increased risk of in-hospital death (OR 1.17, 95% CI 1.00 - 1.35), 90-day CV-related (HR 1.10, 95% CI 1.02 - 1.18) and all-cause (HR 1.24, 95% CI 1.17 - 1.31) but not HF-related (HR 1.05, 95% CI 0.97 - 1.14) readmissions. Conclusion Among patients hospitalized for HF, MPN was associated with increased risk of in-hospital death, and 90-day CV-related readmissions (driven primarily by thrombotic readmissions). Further investigation is needed in order to improve outcomes in patients with MPN and HF.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Jose Alvarez-Cardona
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - Joan How
- Division of Hematology, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, United States
| | - Andrew Brunner
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Gabriela Hobbs
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Leiva O, Hobbs G, Bangalore S. Reply: Prognosis of MPN Patients Experiencing Acute Thrombotic Events and the Potential Role of Cytoreduction. JACC CardioOncol 2023; 5:843-844. [PMID: 38205013 PMCID: PMC10774770 DOI: 10.1016/j.jaccao.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
| | | | - Sripal Bangalore
- New York University Grossman School of Medicine, 550 First Avenue, New York City, NY 10016, USA
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9
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Leiva O, Connors JM, Connell NT, Berger JS. Acute myocardial infarction in von Willebrand disease: characteristics and outcomes. Res Pract Thromb Haemost 2023; 7:102198. [PMID: 37808952 PMCID: PMC10558305 DOI: 10.1016/j.rpth.2023.102198] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 10/10/2023] Open
Abstract
Background Von Willebrand disease (VWD) is the most common inherited bleeding disorder. As treatments have improved prognosis of VWD, age-related diseases, including acute myocardial infarction (AMI), have become more prevalent. The treatment of AMI includes antithrombotic therapies, which increase the risk of bleeding. Current guidelines suggest weighing risks/benefits of antithrombotic therapy in patients with VWD. However, data to inform these discussions are lacking. Objective To characterize outcomes of patients with VWD after AMI. Methods We conducted a retrospective cohort study utilizing the National Readmissions Database of patients with and without VWD admitted with AMI in 2017 and 2018. Primary outcomes were 90-day any-cause, bleeding-related, and arterial thrombosis-related readmissions. Case-control matching was performed for age, sex (male or female), ST-elevation myocardial infarction, percutaneous coronary intervention, diabetes, and chronic kidney disease. Time-to-event analysis was performed after matching using Cox proportional hazards regression. Results A total of 136 patients with VWD were matched with 3400 controls without VWD. At 90 days, there were no differences in all-cause (10.7% vs 11.5%; P = 1.00), arterial thrombosis (1.9% vs 3.1%; P = .77), and bleeding (1.9% vs 0.4%; P = .083) readmission in patients with VWD. VWD was associated with increased risk of 90-day bleeding (hazard ratio [HR], 4.75; 95% CI, 1.05-21.66) but not all-cause (HR, 0.91; 95% CI, 0.50-1.67) or arterial thrombosis (HR, 0.54; 95% CI, 0.39-2.19) readmission. Conclusion Among patients admitted with AMI, VWD was associated with higher risk of 90-day readmission for bleeding but not any-cause and arterial thrombosis-related readmissions. Further studies are needed to balance bleeding and thrombotic risks post-AMI in patients with VWD.
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Affiliation(s)
- Orly Leiva
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Jean M. Connors
- Division of Hematology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathan T. Connell
- Division of Hematology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey S. Berger
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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10
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Leiva O, Garcia BD, Hobbs G. Pulmonary Hypertension in Myeloproliferative Neoplasms: New Insights and Unexplored Horizons. Am J Respir Crit Care Med 2023; 208:518-521. [PMID: 37429036 PMCID: PMC10492239 DOI: 10.1164/rccm.202306-1001ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/10/2023] [Indexed: 07/12/2023] Open
Affiliation(s)
- Orly Leiva
- Department of Medicine New York University Grossman School of Medicine New York, New York
| | - Brenda D Garcia
- Department of Medicine Northwell Health-Lenox Hill Hospital and Zucker School of Medicine at Hofstra/Northwell New York, New York
| | - Gabriela Hobbs
- Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
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Bikdeli B, Khairani CD, Krishnathasan D, Bejjani A, Armero A, Tristani A, Davies J, Porio N, Assi AA, Nauffal V, Campia U, Almarzooq Z, Wei E, Achanta A, Jesudasen SJ, Tiu BC, Merli GJ, Leiva O, Fanikos J, Sharma A, Vishnevsky A, Hsia J, Nehler MR, Welker J, Bonaca MP, Carroll BJ, Lan Z, Goldhaber SZ, Piazza G. Major cardiovascular events after COVID-19, event rates post-vaccination, antiviral or anti-inflammatory therapy, and temporal trends: Rationale and methodology of the CORONA-VTE-Network study. Thromb Res 2023; 228:94-104. [PMID: 37302267 PMCID: PMC10226776 DOI: 10.1016/j.thromres.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/19/2023] [Accepted: 05/24/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with excess risk of cardiovascular and thrombotic events in the early post-infection period and during convalescence. Despite the progress in our understanding of cardiovascular complications, uncertainty persists with respect to more recent event rates, temporal trends, association between vaccination status and outcomes, and findings within vulnerable subgroups such as older adults (aged 65 years or older), or those undergoing hemodialysis. Sex-informed findings, including results among pregnant and breastfeeding women, as well as adjusted comparisons between male and female adults are similarly understudied. METHODS Adult patients, aged ≥18 years, with polymerase chain reaction-confirmed COVID-19 who received inpatient or outpatient care at the participating centers of the registry are eligible for inclusion. A total of 10,000 patients have been included in this multicenter study, with Brigham and Women's Hospital (Boston, MA) serving as the coordinating center. Other sites include Beth Israel Deaconess Medical Center, Anne Arundel Medical Center, University of Virginia Medical Center, University of Colorado Health System, and Thomas Jefferson University Health System. Data elements will be ascertained manually for accuracy. The two main outcomes are 1) a composite of venous or arterial thrombotic events, and 2) a composite of major cardiovascular events, defined as venous or arterial thrombosis, myocarditis or heart failure with inpatient treatment, new atrial fibrillation/flutter, or cardiovascular death. Clinical outcomes are adjudicated by independent physicians. Vaccination status and time of inclusion in the study will be ascertained for subgroup-specific analyses. Outcomes are pre-specified to be reported separately for hospitalized patients versus those who were initially receiving outpatient care. Outcomes will be reported at 30-day and 90-day follow-up. Data cleaning at the sites and the data coordinating center and outcomes adjudication process are in-progress. CONCLUSIONS The CORONA-VTE-Network study will share contemporary information related to rates of cardiovascular and thrombotic events in patients with COVID-19 overall, as well as within key subgroups, including by time of inclusion, vaccination status, patients undergoing hemodialysis, the elderly, and sex-informed analyses such as comparison of women and men, or among pregnant and breastfeeding women.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, CT, USA; Cardiovascular Research Foundation (CRF), New York, NY, USA
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darsiya Krishnathasan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andre Armero
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anthony Tristani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Julia Davies
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Porio
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali A Assi
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Victor Nauffal
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Umberto Campia
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zaid Almarzooq
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric Wei
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Achanta
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Sirus J Jesudasen
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce C Tiu
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Geno J Merli
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aditya Sharma
- Department of Medicine, Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
| | - Alec Vishnevsky
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Judith Hsia
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | | | - James Welker
- Anne Arundel Research Institute, Annapolis, MD, USA
| | - Marc P Bonaca
- CPC Clinical Research, Aurora, CO, USA; Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Brett J Carroll
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Zhou Lan
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Center for Clinical Investigation, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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12
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Leiva O, Xia Y, Siddiqui E, Hobbs G, Bangalore S. Outcomes of Patients With Myeloproliferative Neoplasms Admitted With Myocardial Infarction: Insights From National Inpatient Sample. JACC CardioOncol 2023; 5:457-468. [PMID: 37614585 PMCID: PMC10443106 DOI: 10.1016/j.jaccao.2023.03.014] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 08/25/2023] Open
Abstract
Background Myeloproliferative neoplasms (MPNs) are hematopoietic stem cell neoplasms with a high risk of thrombosis, including acute myocardial infarction (AMI). However, outcomes after AMI have not been thoroughly characterized. Objectives The purpose of this study was to characterize outcomes after AMI in patients with MPNs compared with patients without MPNs. Methods Patients with a primary admission of AMI from January 2006 to December 2018 were identified using the National Inpatient Sample. Outcomes of interest included in-hospital death or cardiac arrest (CA) and major bleeding. Propensity score weighting was used to compare outcomes between MPN and non-MPN groups. Results A total of 1,644,304 unweighted admissions for AMI were included; of these admissions, 5,374 (0.3%) were patients with MPNs. After propensity score weighting, patients with MPNs had a lower risk of in-hospital death or CA (OR: 0.83; 95% CI: 0.82-0.84) but a higher risk of major bleeding (OR: 1.29; 95% CI: 1.28-1.30) compared with non-MPN patients. There was a decreasing temporal rate of in-hospital death or CA and bleeding in patients without MPNs (Ptrend < 0.001 for both). However, there was an increasing temporal rate of in-hospital death or CA (Ptrend < 0.001) and a stable rate of major bleeding (Ptrend = 0.48) in patients with MPNs. Conclusions Among patients hospitalized with AMI, patients with MPNs have a lower risk of in-hospital death or CA compared with patients without MPNs, although they have a higher risk of bleeding. More investigation is needed in order to improve post-AMI bleeding outcomes in patients with MPN.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Yuhe Xia
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Emaad Siddiqui
- Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sripal Bangalore
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
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13
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Leiva O, Alam U, Bohart I, Yang EH. Interventional Cardio-Oncology: Unique Challenges and Considerations in a High-Risk Population. Curr Treat Options Oncol 2023:10.1007/s11864-023-01110-2. [PMID: 37296366 PMCID: PMC10356652 DOI: 10.1007/s11864-023-01110-2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/12/2023]
Abstract
OPINION STATEMENT Patients with cancer are at risk of developing cardiovascular disease (CVD) including atherosclerotic heart disease (AHD), valvular heart disease (VHD), and atrial fibrillation (AF). Advances in percutaneous catheter-based treatments, including percutaneous coronary intervention (PCI) for AHD, percutaneous valve replacement or repair for VHD, and ablation and left atrial appendage occlusion devices (LAAODs) for AF, have provided patients with CVD significant benefit in the recent decades. However, trials and registries investigating outcomes of these procedures often exclude patients with cancer. As a result, patients with cancer are less likely to undergo these therapies despite their benefits. Despite the inclusion of cancer patients in randomized clinical trial data, studies suggest that cancer patients derive similar benefits of percutaneous therapies for CVD compared with patients without cancer. Therefore, percutaneous interventions for CVD should not be withheld in patients with cancer, as they may still benefit from these procedures.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Usman Alam
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Isaac Bohart
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, UCLA Cardio-Oncology Program, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA.
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14
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Leiva O, Jenkins A, Rosovsky RP, Leaf RK, Goodarzi K, Hobbs G. Risk Factors for Death or Cardiovascular Events after Acute Coronary Syndrome in Patients with Myeloproliferative Neoplasms. Hematol Rep 2023; 15:398-404. [PMID: 37367089 DOI: 10.3390/hematolrep15020040] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/21/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023] Open
Abstract
Patients with myeloproliferative neoplasms (MPNs) are at increased risk of cardiovascular disease (CVD), including acute coronary syndrome (ACS). However, data on long-term outcomes of patients with MPN who have had ACS and risk factors for all-cause death or CV events post-ACS hospitalization are lacking. We conducted a single-center study of 41 consecutive patients with MPN with ACS hospitalization after MPN diagnosis. After a median follow-up of 80 months after ACS hospitalization, 31 (76%) experienced death or a CV event (myocardial infarction, ischemic stroke, or heart failure hospitalization). After multivariable Cox proportional hazards regression, index ACS within 12 months of MPN diagnosis (HR 3.84, 95% CI 1.44-10.19), WBC ≥ 20 K/µL (HR 9.10, 95% CI 2.71-30.52), JAK2 mutation (HR 3.71, 95% CI 1.22-11.22), and prior CVD (HR 2.60, 95% CI 1.12-6.08) were associated with increased death or CV events. Further studies are warranted to improve cardiovascular outcomes in this patient population.
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Affiliation(s)
- Orly Leiva
- Division of Cardiovascular Medicine, Department of Medicine, New York University Langone Health, New York, NY 10016, USA
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Andrew Jenkins
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Rachel P Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Rebecca K Leaf
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Katayoon Goodarzi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02115, USA
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15
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Leiva O, Hobbs G. Author's reply. J Cardiol 2023; 81:587-588. [PMID: 36681318 DOI: 10.1016/j.jjcc.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 12/19/2022] [Indexed: 01/20/2023]
Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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16
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Leiva O. Atrial fibrillation and cancer: Two peas in a pod. Res Pract Thromb Haemost 2023; 7:100073. [PMID: 36876283 PMCID: PMC9974423 DOI: 10.1016/j.rpth.2023.100073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 12/28/2022] [Indexed: 02/17/2023] Open
Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
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17
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Leiva O, Bohart I, Ahuja T, Park D. Off-Target Effects of Cancer Therapy on Development of Therapy-Induced Arrhythmia: A Review. Cardiology 2023; 148:324-334. [PMID: 36702116 PMCID: PMC10614257 DOI: 10.1159/000529260] [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: 12/02/2022] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Advances in cancer therapeutics have improved overall survival and prognosis in this patient population; however, this has come at the expense of cardiotoxicity including arrhythmia. SUMMARY Cancer and its therapies are associated with cardiotoxicity via several mechanisms including inflammation, cardiomyopathy, and off-target effects. Among cancer therapies, anthracyclines and tyrosine kinase inhibitors (TKIs) are particularly known for their pro-arrhythmia effects. In addition to cardiomyopathy, anthracyclines may be pro-arrhythmogenic via reactive oxygen species (ROS) generation and altered calcium handling. TKIs may mediate their cardiotoxicity via inhibition of off-target tyrosine kinases. Ibrutinib-mediated inhibition of CSK may be responsible for the increased prevalence of atrial fibrillation. Further investigation is warranted to further elucidate the mechanisms behind arrhythmias in cancer therapies. KEY MESSAGES Arrhythmias are a common cardiotoxicity of cancer therapies. Cancer therapies may induce arrhythmias via off-target effects. Understanding the mechanisms underlying arrhythmogenesis associated with cancer therapies may help design cancer therapies that can avoid these toxicities.
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Isaac Bohart
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - Tania Ahuja
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
| | - David Park
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York City, New York, USA
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18
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Leiva O, Ren S, Neuberg D, Bhatt A, Jenkins A, Rosovsky R, Karp Leaf R, Goodarzi K, Hobbs G. Pulmonary hypertension is associated with poor cardiovascular and hematologic outcomes in patients with myeloproliferative neoplasms and cardiovascular disease. Int J Hematol 2023; 117:90-99. [PMID: 36183283 DOI: 10.1007/s12185-022-03454-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 09/07/2022] [Indexed: 01/07/2023]
Abstract
Cardiovascular events and hematologic progression to myelofibrosis or leukemia are leading causes of morbidity and mortality among patients with myeloproliferative neoplasms (MPN). Pulmonary hypertension (PH) is also associated with MPN and cardiovascular disease (CVD), though its prognostic significance in MPN is not well characterized. Our primary objective was to investigate the effect of PH, defined as right-ventricular systolic pressure (RVSP) ≥ 50 mmHg on echocardiogram or mean pulmonary artery pressure (mPAP) ≥ 20 on right heart catheterization, on cardiovascular and all-cause mortality and hematologic progression in patients with MPN and CVD (atrial fibrillation, heart failure hospitalization, and myocardial infarction after MPN diagnosis). Of the 197 patients included (86 ET, 80 PV, 31 PMF), 92 (47%) had PH and 98 (50%) were male. All-cause mortality (58 vs 37%, p = 0.004), cardiovascular death (35 vs 9%, p < 0.0001), and hematologic progression (23 vs 11%, p = 0.037) occurred more frequently in patients with PH. Multivariable competing-risk and proportional hazards regression showed that PH was associated with increased risk of all-cause death (adjusted hazard ratio [HR], 1.80, 95% CI 1.10-2.93), CV death (adjusted subdistribution HR 3.71, 95% CI 1.58-8.73), and hematologic progression (adjusted subdistribution HR 1.99, 95% CI 1.21-3.27).
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Division of Cardiovascular Medicine, Department of Medicine, New York University Langone Health, New York, NY, USA
| | - Siyang Ren
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ankeet Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Jenkins
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rachel Rosovsky
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Rebecca Karp Leaf
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Katayoon Goodarzi
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA, USA.
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19
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Leiva O, Campia U, Snyder J, Barns BM, Rizzo S, Khairani CD, Brunner A, Al-Samkari H, Leaf RK, Rosovsky R, Goodarzi K, Bornikova L, Fathi A, Goldhaber SZ, Hobbs G, Piazza G. Patients with myeloproliferative neoplasms and COVID-19 have increased rates of arterial thrombosis. Res Pract Thromb Haemost 2022; 6:e12752. [PMID: 35979196 PMCID: PMC9372283 DOI: 10.1002/rth2.12752] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 12/15/2022] Open
Abstract
Background Both coronavirus disease‐2019 (COVID‐19) and myeloproliferative neoplasms (MPNs) are associated with systemic inflammation and risk of thrombosis. Risk of thrombosis in patients with COVID with and without MPNs has not been extensively studied. Methods Retrospective cohort study of 44 patients with MPNs and 1114 patients without MPNs positive for SARS‐COV‐2. Outcomes were arterial thrombosis (AT), venous thromboembolism (VTE), bleeding, and death. Time‐to‐event analysis was performed using competing risk regression model and Cox proportional hazards. Results AT occurred more frequently in patients with MPN (7% vs. 1%, p = 0.03). Rates of VTE (7% vs. 5%, p = 0.73), bleeding (7% vs. 2%, p = 0.06), and death (9% vs. 6%, p = 0.32) were similar. MPN patients were older and had more cardiovascular comorbidities. After time‐to‐event competing‐risk regression adjusting for age, MPN patients had higher risk of AT (subdivision hazards ratio 3.95, 95% CI 1.09–14.39) but not VTE, bleeding, or death. Conclusions Among patients with COVID‐19, MPN patients had higher risk of arterial thrombosis but not VTE, bleeding, and death compared with non‐MPN patients. Larger studies are needed to confirm our findings given the limited sample size.
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Affiliation(s)
- Orly Leiva
- Division of Cardiovascular Medicine, Department of Medicine New York University Langone Health New York City New York USA.,Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Julia Snyder
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Briana M Barns
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Samantha Rizzo
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Candrika D Khairani
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Andrew Brunner
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Hanny Al-Samkari
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Rebecca Karp Leaf
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Rachel Rosovsky
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Katayoon Goodarzi
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Larissa Bornikova
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Amir Fathi
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
| | - Gabriela Hobbs
- Division of Hematology and Oncology, Department of Medicine Massachusetts General Hospital and Harvard Medical School Boston Massachusetts USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine Brigham and Women's Hospital and Harvard Medical School Boston Massachusetts USA
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Leiva O, Hobbs G, Ravid K, Libby P. Cardiovascular Disease in Myeloproliferative Neoplasms: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:166-182. [PMID: 35818539 PMCID: PMC9270630 DOI: 10.1016/j.jaccao.2022.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 11/24/2022] Open
Abstract
Myeloproliferative neoplasms are associated with increased risk for thrombotic complications. These conditions most commonly involve somatic mutations in genes that lead to constitutive activation of the Janus-associated kinase signaling pathway (eg, Janus kinase 2, calreticulin, myeloproliferative leukemia protein). Acquired gain-of-function mutations in these genes, particularly Janus kinase 2, can cause a spectrum of disorders, ranging from clonal hematopoiesis of indeterminate potential, a recently recognized age-related promoter of cardiovascular disease, to frank hematologic malignancy. Beyond thrombosis, patients with myeloproliferative neoplasms can develop other cardiovascular conditions, including heart failure and pulmonary hypertension. The authors review the pathophysiologic mechanisms of cardiovascular complications of myeloproliferative neoplasms, which involve inflammation, prothrombotic and profibrotic factors (including transforming growth factor-beta and lysyl oxidase), and abnormal function of circulating clones of mutated leukocytes and platelets from affected individuals. Anti-inflammatory therapies may provide cardiovascular benefit in patients with myeloproliferative neoplasms, a hypothesis that requires rigorous evaluation in clinical trials.
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Key Words
- ASXL1, additional sex Combs-like 1
- CHIP, clonal hematopoiesis of indeterminate potential
- DNMT3a, DNA methyltransferase 3 alpha
- IL, interleukin
- JAK, Janus-associated kinase
- JAK2, Janus kinase 2
- LOX, lysyl oxidase
- MPL, myeloproliferative leukemia protein
- MPN, myeloproliferative neoplasm
- STAT, signal transducer and activator of transcription
- TET2, tet methylcytosine dioxygenase 2
- TGF, transforming growth factor
- atherosclerosis
- cardiovascular complications
- clonal hematopoiesis
- myeloproliferative neoplasms
- thrombosis
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Affiliation(s)
- Orly Leiva
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York, USA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriela Hobbs
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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21
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Leiva O, AbdelHameid D, Connors JM, Cannon CP, Bhatt DL. Common Pathophysiology in Cancer, Atrial Fibrillation, Atherosclerosis, and Thrombosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:619-634. [PMID: 34988471 PMCID: PMC8702799 DOI: 10.1016/j.jaccao.2021.08.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [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: 06/04/2021] [Accepted: 08/06/2021] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease and cancer are the 2 leading causes of death worldwide. Emerging evidence suggests common mechanisms between cancer and cardiovascular disease, including atrial fibrillation and atherosclerosis. With advances in cancer therapies, screening, and diagnostics, cancer-specific survival and outcomes have improved. This increase in survival has led to the coincidence of cardiovascular disease, including atrial fibrillation and atherosclerosis, as patients with cancer live longer. Additionally, cancer and cardiovascular disease share several risk factors and underlying pathophysiologic mechanisms, including inflammation, cancer-related factors including treatment effects, and alterations in platelet function. Patients with cancer are at increased risk for bleeding and thrombosis compared with the general population. Although optimal antithrombotic therapy, including agent choice and duration, has been extensively studied in the general population, this area remains understudied in patients with cancer despite their altered thrombotic and bleeding risk. Future investigation, including incorporation of cancer-specific characteristics to traditional thrombotic and bleeding risk scores, clinical trials in the cancer population, and the development of novel antithrombotic and anti-inflammatory strategies on the basis of shared pathophysiologic mechanisms, is warranted to improve outcomes in this patient population.
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Key Words
- AF, atrial fibrillation
- CAD, coronary artery disease
- CHIP, clonal hematopoiesis of indeterminate potential
- CI, confidence interval
- CLEC-2, C-type lectin-like receptor 2
- HR, hazard ratio
- IL, interleukin
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- ROS, reactive oxygen species
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- arrhythmia
- risk factor
- thrombosis
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Duaa AbdelHameid
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P. Cannon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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22
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Zeymer U, Leiva O, Hohnloser S, Steg PG, Oldgren J, Nickenig G, Gabor Kiss R, Ongen Z, Navarro Estrada J, Oude Ophuis T, Lip GY, Nordaby M, Miede C, ten Berg JM, Bhatt DL, Cannon CP. Dual antithrombotic therapy with dabigatran in patients with atrial fibrillation after percutaneous coronary intervention for ST-segment elevation myocardial infarction: a post hoc analysis of the randomised RE-DUAL PCI trial. EUROINTERVENTION 2021; 17:474-480. [PMID: 33164896 PMCID: PMC9724936 DOI: 10.4244/eij-d-20-00799] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Little is known about the optimal antithrombotic therapy in patients with atrial fibrillation undergoing PCI for ST-elevation myocardial infarction (STEMI). AIMS The aim of this study was to investigate the safety and efficacy of dabigatran dual therapy (110 or 150 mg twice daily, plus clopidogrel or ticagrelor) versus warfarin triple therapy in patients with atrial fibrillation and STEMI. METHODS In the RE-DUAL PCI trial, 305 patients with STEMI were randomised to dabigatran 110 mg (n=113 versus 106 warfarin) or 150 mg (n=86 versus 84 warfarin). The primary endpoint was the time to first major/clinically relevant non-major bleeding event (MBE/CRNMBE). The thrombotic endpoint was a composite of death, thromboembolic events, or unplanned revascularisation. RESULTS In STEMI patients, dabigatran 110 mg (HR 0.39, 95% CI: 0.20-0.74) and 150 mg (0.43, 0.21-0.89) dual therapy reduced the risk of MBE/CRNMBE versus warfarin triple therapy (p for interaction vs all other patients=0.31 and 0.16). The risk of thrombotic events for dabigatran 110 mg (HR 1.61, 95% CI: 0.85-3.08) and 150 mg (0.56, 0.20-1.51) had p interactions of 0.20 and 0.33, respectively. For net clinical benefit, the HRs were 0.74 (95% CI: 0.46-1.17) and 0.49 (0.27-0.91) for dabigatran 110 and 150 mg (p for interaction=0.80 and 0.12), respectively. CONCLUSIONS After PCI for STEMI, patients on dabigatran dual therapy had lower risks of bleeding events versus warfarin triple therapy with similar risks of thromboembolic events, supporting dabigatran dual therapy even in patients with high thrombotic risk.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Bremserstrasse 79, 67063 Ludwigshafen, Germany
| | - Orly Leiva
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
| | | | - Philippe Gabriel Steg
- Université Paris Diderot, Paris, France,INSERM U_1148, Paris, France,Hôpital Bichat Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences Uppsala University, Uppsala, Sweden
| | | | | | - Zeki Ongen
- Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom,Aalborg Thrombosis Research Unit Department of Clinical Medicine, Aalborg University Aalborg, Denmark
| | | | | | | | - Deepak L. Bhatt
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
| | - Christopher P. Cannon
- Brigham and Women’s Hospital and Heart and Vascular Center, and Harvard Medical School Boston, MA, USA
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23
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Berman AN, Biery DW, Ginder C, Hulme OL, Marcusa D, Leiva O, Wu WY, Cardin N, Hainer J, Bhatt DL, Di Carli MF, Turchin A, Blankstein R. Natural language processing for the assessment of cardiovascular disease comorbidities: The cardio-Canary comorbidity project. Clin Cardiol 2021; 44:1296-1304. [PMID: 34347314 PMCID: PMC8428009 DOI: 10.1002/clc.23687] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/24/2021] [Indexed: 12/02/2022] Open
Abstract
Objective: Accurate ascertainment of comorbidities is paramount in clinical research. While manual adjudication is labor‐intensive and expensive, the adoption of electronic health records enables computational analysis of free‐text documentation using natural language processing (NLP) tools. Hypothesis: We sought to develop highly accurate NLP modules to assess for the presence of five key cardiovascular comorbidities in a large electronic health record system. Methods: One‐thousand clinical notes were randomly selected from a cardiovascular registry at Mass General Brigham. Trained physicians manually adjudicated these notes for the following five diagnostic comorbidities: hypertension, dyslipidemia, diabetes, coronary artery disease, and stroke/transient ischemic attack. Using the open‐source Canary NLP system, five separate NLP modules were designed based on 800 “training‐set” notes and validated on 200 “test‐set” notes. Results: Across the five NLP modules, the sentence‐level and note‐level sensitivity, specificity, and positive predictive value was always greater than 85% and was most often greater than 90%. Accuracy tended to be highest for conditions with greater diagnostic clarity (e.g. diabetes and hypertension) and slightly lower for conditions whose greater diagnostic challenges (e.g. myocardial infarction and embolic stroke) may lead to less definitive documentation. Conclusion: We designed five open‐source and highly accurate NLP modules that can be used to assess for the presence of important cardiovascular comorbidities in free‐text health records. These modules have been placed in the public domain and can be used for clinical research, trial recruitment and population management at any institution as well as serve as the basis for further development of cardiovascular NLP tools.
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Affiliation(s)
- Adam N Berman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David W Biery
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Curtis Ginder
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olivia L Hulme
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Marcusa
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wanda Y Wu
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas Cardin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jon Hainer
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcelo F Di Carli
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander Turchin
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Blankstein
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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24
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Leiva O, Baker O, Jenkins A, Brunner AM, Al-Samkari H, Leaf RK, Rosovsky RP, Fathi AT, Weitzman J, Bornikova L, Nardi V, Hobbs GS. Association of Thrombosis With Hypereosinophilic Syndrome in Patients With Genetic Alterations. JAMA Netw Open 2021; 4:e2119812. [PMID: 34357393 PMCID: PMC8346937 DOI: 10.1001/jamanetworkopen.2021.19812] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Hypereosinophilic syndromes (HESs) are a rare group of disorders that result in overproduction of eosinophils, leading to tissue damage. Thrombotic complications in HES and associated risk factors in this patient population have not been extensively studied. OBJECTIVE To investigate the rates of and risk factors associated with thrombotic events in patients with HES, including markers of clonal hematopoiesis as evidenced by molecular aberrations on next-generation sequencing. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study evaluated patients seen at Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, from January 1, 2015, to January 1, 2020. Patients who had hypereosinophilia with an absolute eosinophil count of 1500 cells/μL or greater on 2 separate occasions at least 1 month apart and who underwent genetic or molecular testing as part of their work-up were included. Patients with secondary eosinophilia were excluded. MAIN OUTCOMES AND MEASURES Symptomatic and asymptomatic arterial and venous thrombotic events after the diagnosis of HES and all-cause death. RESULTS A total of 71 patients (median age, 58 years [interquartile range (IQR), 43-67 years]; 36 women [51%]; 57 White patients [80%]) were included. Patients had a median follow-up time of 29 months (IQR, 19-49 months). Seventeen patients (24%) had 1 or more thrombotic events, including 11 venous thromboembolic events and 11 arterial thrombotic events (8 patients had ≥1 event and 3 patients had recurrent events). Patients with 1 or more thrombotic events had a higher median Eastern Cooperative Oncology Group performance status (median, 1 [IQR, 1-2] vs 0 [IQR, 0-1]; P = .002), had more frequent cardiac involvement (7 of 17 events [41%] vs 6 of 54 events [11%]; P = .01), more frequently received treatment (17 of 17 events [100%] vs 40 of 54 events [74%]; P = .02), and had more molecular aberrations on next-generation sequencing (12 of 17 [71%] vs 12 of 54 [26%]; P = .003) vs patients without thrombosis. After multivariable analysis, the presence of molecular aberration was associated with increased odds of thrombosis (adjusted odds ratio, 5.4; 95% CI, 1.1-27.7). Death occurred more frequently in patients with thrombotic events compared with those without (6 of 17 [35%] vs 2 of 54 [4%]; P = .002) and in patients with molecular aberrations compared with those without (6 of 24 [25%] vs 1 of 40 [3%]; P = .009), although only thrombotic events were significantly associated with increased odds of death after multivariable analysis. CONCLUSIONS AND RELEVANCE In this cohort study, thrombosis was common in patients with HES and was significantly associated with increased risk of death.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Olesya Baker
- Center for Clinical Investigation, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Andrew Jenkins
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew M. Brunner
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rebecca Karp Leaf
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rachel P. Rosovsky
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Amir T. Fathi
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - James Weitzman
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Larissa Bornikova
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Valentina Nardi
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Gabriela S. Hobbs
- Division of Hematology Oncology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer and portends a poor prognosis. Our understanding of the underlying pathophysiology of VTE in cancer has advanced since Trousseau first described hypercoagulability in patients with malignancy and Virchow described his famous triad of thrombosis formation. Malignancy itself induces a thrombophilic state by increasing the risk of venous stasis, endothelial injury and an imbalance of pro and anti-thrombotic factors leading to a hypercoaguable state. Additional insults to this thrombotic balance are introduced by patient-specific, treatment related and tumor-specific factors. The importance of understanding the factors associated with increased thrombosis in cancer is paramount in order to adequately identify patients who will benefit from thromboprophylaxis.
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Affiliation(s)
- O Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - R Newcomb
- Division of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - J M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - H Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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26
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Abstract
Primary myelofibrosis (PMF) is a type of myeloproliferative neoplasm (MPN) that portends a poor prognosis and has limited options for treatment. PMF is often driven by clonal mutations in one of three genes that regulate the JAK-STAT signaling pathway, leading to hyperactivation of this signaling pathway and over-proliferation of megakaryocytes (MKs) and their precursors. PMF presents with debilitating symptoms such as splenomegaly and weight loss. The few available treatments for PMF include a JAK2 inhibitor, ruxolitinib, which causes side effects and is not always effective. The extracellular matrix (ECM) and bone marrow (BM) microenvironment may play an important role in the pathogenesis of PMF. Lysyl oxidase (LOX), an enzyme that plays a key role in the ECM by facilitating the cross-linking of collagen and elastin fibers, has been shown to be upregulated in MKs of PMF mice and in PMF patients, suggesting its role in the progression of BM fibrosis. Recently, LOX has been identified as a potential novel therapeutic target for PMF and the development of new small molecule LOX inhibitors, PXS-LOX_1 and PXS-LOX_2, has shown some promise in slowing the progression of PMF in pre-clinical studies. Given that these inhibitors displayed an ability to target the dysregulation of the ECM via LOX inhibition, they show promise as therapeutic agents for an underappreciated aspect of PMF.
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Affiliation(s)
- Andrew Piasecki
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston MA 02118, USA
- Department of Biology, Boston University, Boston, MA 02215, USA
| | - Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston MA 02118, USA
- Author for correspondence:
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27
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Piazza G, Campia U, Hurwitz S, Snyder JE, Rizzo SM, Pfeferman MB, Morrison RB, Leiva O, Fanikos J, Nauffal V, Almarzooq Z, Goldhaber SZ. Registry of Arterial and Venous Thromboembolic Complications in Patients With COVID-19. J Am Coll Cardiol 2020; 76:2060-2072. [PMID: 33121712 PMCID: PMC7588178 DOI: 10.1016/j.jacc.2020.08.070] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/26/2020] [Accepted: 08/29/2020] [Indexed: 12/11/2022]
Abstract
Background Cardiovascular complications, including myocardial infarction, ischemic stroke, and pulmonary embolism, represent an important source of adverse outcomes in coronavirus disease-2019 (COVID-19). Objectives To assess the frequency of arterial and venous thromboembolic disease, risk factors, prevention and management patterns, and outcomes in patients with COVID-19, the authors designed a multicenter, observational cohort study. Methods We analyzed a retrospective cohort of 1,114 patients with COVID-19 diagnosed through our Mass General Brigham integrated health network. The total cohort was analyzed by site of care: intensive care (n = 170); hospitalized nonintensive care (n = 229); and outpatient (n = 715). The primary study outcome was a composite of adjudicated major arterial or venous thromboembolism. Results Patients with COVID-19 were 22.3% Hispanic/Latinx and 44.2% non-White. Cardiovascular risk factors of hypertension (35.8%), hyperlipidemia (28.6%), and diabetes (18.0%) were common. Prophylactic anticoagulation was prescribed in 89.4% of patients with COVID-19 in the intensive care cohort and 84.7% of those in the hospitalized nonintensive care setting. Frequencies of major arterial or venous thromboembolism, major cardiovascular adverse events, and symptomatic venous thromboembolism were highest in the intensive care cohort (35.3%, 45.9%, and 27.0 %, respectively) followed by the hospitalized nonintensive care cohort (2.6%, 6.1%, and 2.2%, respectively) and the outpatient cohort (0% for all). Conclusions Major arterial or venous thromboembolism, major adverse cardiovascular events, and symptomatic venous thromboembolism occurred with high frequency in patients with COVID-19, especially in the intensive care setting, despite a high utilization rate of thromboprophylaxis.
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Affiliation(s)
- Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Shelley Hurwitz
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julia E Snyder
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samantha M Rizzo
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mariana B Pfeferman
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ruth B Morrison
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Orly Leiva
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Nauffal
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zaid Almarzooq
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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28
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Berman AN, Biery DW, Ginder C, Hulme OL, Marcusa D, Leiva O, Wu WY, Singh A, Divakaran S, Hainer J, Turchin A, Januzzi JL, Natarajan P, Cannon CP, Di Carli MF, Bhatt DL, Blankstein R. Study of lipoprotein(a) and its impact on atherosclerotic cardiovascular disease: Design and rationale of the Mass General Brigham Lp(a) Registry. Clin Cardiol 2020; 43:1209-1215. [PMID: 32893370 PMCID: PMC7661644 DOI: 10.1002/clc.23456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 12/24/2022] Open
Abstract
Lipoprotein(a) [Lp(a)] is independently associated with atherosclerotic cardiovascular disease and calcific aortic valve stenosis. Elevated Lp(a) affects approximately one in five individuals and meaningfully contributes to the residual cardiovascular risk in individuals with otherwise well-controlled risk factors. With targeted therapies in the therapeutic pipeline, there is a need to further characterize the clinical phenotypes and outcomes of individuals with elevated levels of this unique biomarker. The Mass General Brigham Lp(a) Registry will be built from the longitudinal electronic health record of two large academic medical centers in Boston, Massachusetts, to develop a detailed cohort of patients who have had their Lp(a) measured. In combination with structured data sources, clinical documentation will be analyzed using natural language processing techniques to accurately characterize baseline characteristics. Important outcome measures including all-cause mortality, cardiovascular mortality, and cardiovascular events will be available for analysis. Approximately 30 000 patients who have had their Lp(a) tested within the Mass General Brigham system from January 2000 to July 2019 will be included in the registry. This large Lp(a) cohort will provide meaningful observational data regarding the differential risk associated with Lp(a) values and cardiovascular disease. With a new frontier of targeted Lp(a) therapies on the horizon, the Mass General Brigham Lp(a) Registry will help provide a deeper understanding of Lp(a)'s role in long term cardiovascular outcomes.
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Affiliation(s)
- Adam N. Berman
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - David W. Biery
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Curtis Ginder
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Olivia L. Hulme
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Daniel Marcusa
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Orly Leiva
- Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Wanda Y. Wu
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Avinainder Singh
- Department of MedicineYale University School of MedicineNew HavenConnecticutUSA
| | - Sanjay Divakaran
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Jon Hainer
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Alexander Turchin
- Division of Endocrinology, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - James L. Januzzi
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Pradeep Natarajan
- Cardiology DivisionMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Christopher P. Cannon
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Marcelo F. Di Carli
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Deepak L. Bhatt
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Ron Blankstein
- Cardiovascular Division, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
- Department of RadiologyBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
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Leiva O, Hollingsworth P, Singh V, Qian X, Blankstein R, Vaduganathan M. What Looks Like a Clot But Is Not a Clot?: Cardiac Leiomyosarcoma Mimicking Pulmonary Embolism. JACC Case Rep 2020; 2:1966-1968. [PMID: 34317090 PMCID: PMC8299237 DOI: 10.1016/j.jaccas.2020.08.018] [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: 06/22/2020] [Accepted: 08/21/2020] [Indexed: 11/02/2022]
Abstract
Primary cardiac tumors in the right ventricular outflow tract are often misdiagnosed as pulmonary embolism due to rarity and inadequate imaging characterization. Multimodality imaging offers advantages and facilitates subsequent diagnostics and management. We present a case of a woman with suspected submassive pulmonary embolism who was found to have pleomorphic leiomyosarcoma. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Parker Hollingsworth
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Vasvi Singh
- Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Xiaohua Qian
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ron Blankstein
- Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Department of Medicine, Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
- Address for correspondence: Dr. Muthiah Vaduganathan, Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, 75 Francis Street., Boston, Massachusetts 02115.
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How J, Leiva O, Bogue T, Fell GG, Bustoros MW, Connell NT, Connors JM, Ghobrial IM, Kuter DJ, Mullally A, Neuberg D, Zwicker JI, Fogerty AE, Hobbs GS. Pregnancy outcomes, risk factors, and cell count trends in pregnant women with essential thrombocythemia. Leuk Res 2020; 98:106459. [PMID: 33022566 DOI: 10.1016/j.leukres.2020.106459] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/21/2020] [Accepted: 09/27/2020] [Indexed: 01/26/2023]
Abstract
Pregnancy in essential thrombocythemia (ET) is associated with increased risk of obstetric complications. We retrospectively evaluated risk factors in 121 pregnancies in 52 ET women seen at 3 affiliate hospitals. Univariable and multivariable analyses were performed at the α = 0.10 level. Cell counts were characterized throughout pregnancy and correlated with outcomes using logistic modeling. The overall live birth rate was 69 %. 48.7 % of all women experienced a pregnancy complication, the most common being spontaneous abortion, which occurred in 26 % of all pregnancies. Maternal thrombosis and hemorrhage rates were 2.5 % and 5.8 %. On multivariable analysis, aspirin use (OR 0.29, p = 0.014, 90 % CI 0.118-0.658) and history of prior pregnancy loss (OR 3.86, p = 0.011, CI 1.49-9.15) were associated with decreased and increased pregnancy complications, respectively. A Markov model was used to analyze the probability of a future pregnancy complication based on initial pregnancy outcome. An ET woman who suffers a pregnancy complication has a 0.594 probability of a subsequent pregnancy complication, compared to a 0.367 probability if she didn't suffer a complication. However, despite this elevated risk, overall prognosis is good, with a >50 % probability of a successful pregnancy by the third attempt. Platelet counts decreased by 43 % in ET during pregnancy, with nadir at delivery and prompt recovery in the postpartum period. Women with larger declines in gestational platelet counts were less likely to suffer complications (p = 0.083). Our study provides important guidance to physicians treating ET women during pregnancy, including counseling information regarding risk assessment and expected trajectory of platelet levels.
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Affiliation(s)
- Joan How
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA; Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Orly Leiva
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Thomas Bogue
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA
| | - Geoffrey G Fell
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, 02115, USA
| | - Mark W Bustoros
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA
| | - Nathan T Connell
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Jean M Connors
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Irene M Ghobrial
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Ann Mullally
- Department of Medical Oncology, Dana Farber Cancer Institute, Harvard Medical School Boston, MA, 02115, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Donna Neuberg
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, 02115, USA
| | - Jeffrey I Zwicker
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02115, USA
| | - Annemarie E Fogerty
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Gabriela S Hobbs
- Department of Medical Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA.
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Matsuura S, Thompson CR, Belghasem ME, Bekendam RH, Piasecki A, Leiva O, Ray A, Italiano J, Yang M, Merill-Skoloff G, Chitalia VC, Flaumenhaft R, Ravid K. Platelet Dysfunction and Thrombosis in JAK2 V617F-Mutated Primary Myelofibrotic Mice. Arterioscler Thromb Vasc Biol 2020; 40:e262-e272. [PMID: 32814440 DOI: 10.1161/atvbaha.120.314760] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The risk of thrombosis in myeloproliferative neoplasms, such as primary myelofibrosis varies depending on the type of key driving mutation (JAK2 [janus kinase 2], CALR [calreticulin], and MPL [myeloproliferative leukemia protein or thrombopoietin receptor]) and the accompanying mutations in other genes. In the current study, we sought to examine the propensity for thrombosis, as well as platelet activation properties in a mouse model of primary myelofibrosis induced by JAK2V617F (janus kinase 2 with valine to phenylalanine substitution on codon 617) mutation. Approach and Results: Vav1-hJAK2V617F transgenic mice show hallmarks of primary myelofibrosis, including significant megakaryocytosis and bone marrow fibrosis, with a moderate increase in red blood cells and platelet number. This mouse model was used to study responses to 2 models of vascular injury and to investigate platelet properties. Platelets derived from the mutated mice have reduced aggregation in response to collagen, reduced thrombus formation and thrombus size, as demonstrated using laser-induced or FeCl3-induced vascular injury models, and increased bleeding time. Strikingly, the mutated platelets had a significantly reduced number of dense granules, which could explain impaired ADP secretion upon platelet activation, and a diminished second wave of activation. CONCLUSIONS Together, our study highlights for the first time the influence of a hyperactive JAK2 on platelet activation-induced ADP secretion and dense granule homeostasis, with consequent effects on platelet activation properties.
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Affiliation(s)
- Shinobu Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute (S.M., C.R.T., A.P., O.L., K.R.), Boston University School of Medicine, MA
| | - Cristal R Thompson
- Department of Medicine and Whitaker Cardiovascular Institute (S.M., C.R.T., A.P., O.L., K.R.), Boston University School of Medicine, MA
| | | | - Roelof H Bekendam
- Department of Medicine (R.H.B.), Boston University School of Medicine, MA
| | - Andrew Piasecki
- Department of Medicine and Whitaker Cardiovascular Institute (S.M., C.R.T., A.P., O.L., K.R.), Boston University School of Medicine, MA
| | - Orly Leiva
- Department of Medicine and Whitaker Cardiovascular Institute (S.M., C.R.T., A.P., O.L., K.R.), Boston University School of Medicine, MA
| | - Anjana Ray
- Department of Medicine, Brigham and Women's Hospital, Boston MA (A.R., J.I.)
| | - Joseph Italiano
- Department of Medicine, Brigham and Women's Hospital, Boston MA (A.R., J.I.)
| | - Moua Yang
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.Y., G.M.-S., R.F.)
| | - Glenn Merill-Skoloff
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.Y., G.M.-S., R.F.)
| | - Vipul C Chitalia
- Renal Section, Department of Medicine (V.C.C.), Boston University School of Medicine, MA
| | - Robert Flaumenhaft
- Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.Y., G.M.-S., R.F.)
| | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute (S.M., C.R.T., A.P., O.L., K.R.), Boston University School of Medicine, MA
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Leiva O, Lilly LS, Gaziano TA. A Woman in Her 90s With Dyspnea on Exertion and a Systolic and Diastolic Murmur. JAMA Cardiol 2020; 5:962. [DOI: 10.1001/jamacardio.2020.1453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Thomas A. Gaziano
- Department of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
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Leiva O, Connors JM, Al-Samkari H. Impact of Tumor Genomic Mutations on Thrombotic Risk in Cancer Patients. Cancers (Basel) 2020; 12:cancers12071958. [PMID: 32707653 PMCID: PMC7409200 DOI: 10.3390/cancers12071958] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/19/2022] Open
Abstract
Venous thromboembolism (VTE) is common in patients with cancer and is an important contributor to morbidity and mortality in these patients. Early thromboprophylaxis initiated only in those cancer patients at highest risk for VTE would be optimal. Risk stratification scores incorporating tumor location, laboratory values and patient characteristics have attempted to identify those patients most likely to benefit from thromboprophylaxis but even well-validated scores are not able to reliably distinguish the highest-risk patients. Recognizing that tumor genetics affect the biology and behavior of malignancies, recent studies have explored the impact of specific molecular aberrations on the rate of VTE in cancer patients. The presence of certain molecular aberrations in a variety of different cancers, including lung, colon, brain and hematologic tumors, have been associated with an increased risk of VTE and arterial thrombotic events. This review examines the findings of these studies and discusses the implications of these findings on decisions relating to thromboprophylaxis use in the clinical setting. Ultimately, the integration of tumor molecular genomic information into clinical VTE risk stratification scores in cancer patients may prove to be a major advancement in the prevention of cancer-associated thrombosis.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02215, USA;
- Harvard Medical School, Boston, MA 02215, USA;
| | - Jean M. Connors
- Harvard Medical School, Boston, MA 02215, USA;
- Hematology Division, Brigham and Women’s Hospital, Boston, MA 02215, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA 02215, USA;
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence: ; Tel.: +1-617-643-6214
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Al-Samkari H, Leiva O, Dagogo-Jack I, Shaw A, Lennerz J, Iafrate AJ, Bendapudi PK, Connors JM. Impact of ALK Rearrangement on Venous and Arterial Thrombotic Risk in NSCLC. J Thorac Oncol 2020; 15:1497-1506. [PMID: 32437899 DOI: 10.1016/j.jtho.2020.04.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [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: 02/12/2020] [Revised: 04/24/2020] [Accepted: 04/24/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Clinical venous thromboembolism (VTE) risk prediction scores, such as the Khorana Risk Score, perform poorly in NSCLC, possibly because the tumor molecular subtype is omitted. Previous studies suggest a possible increased VTE risk in ALK-rearranged NSCLC, but data are conflicting. METHODS We performed a retrospective cohort study of patients with advanced-stage NSCLC diagnosed between 2009 and 2019. Multivariable, time-to-event analyses modeling the risk of first venous or arterial thrombosis in ALK and non-ALK NSCLC groups, controlling for covariates known to impact thrombosis risk (15 in VTE model and 17 in arterial thrombosis model), were performed using Cox proportional hazards regression and competing-risks regression. Multivariable negative binomial regression modeled the total VTE rate. RESULTS A total of 422 patients with ALK-rearranged and 385 patients with non-ALK-rearranged NSCLC were included. Patients with an ALK rearrangement were younger, had better performance status, and had lower rates of most thrombotic risk factors but had significantly higher rates of initial VTE (42.7% versus 28.6%, p < 0.0001), recurrent VTE (13.5% versus 3.1%, p < 0.0001), and similar rates of arterial thrombosis (5.0% versus 4.4%, p = 0.71) compared with non-ALK NSCLC. VTE risk attributable to ALK was significant (Cox model: hazard ratio 3.70, [95% confidence interval [CI]: 2.51-5.44, p < 0.001], competing risks: subhazard ratio 3.91 [95% CI: 2.55-5.99, p < 0.001]). Negative binomial modeling revealed higher VTE rates in patients with an ALK rearrangement (incidence rate ratio 2.47 [95% CI: 1.72-3.55, p < 0.001]). The OR for recurrent VTE was 4.85 (95% CI: 2.60-9.52, p < 0.001). Arterial thrombosis risk attributable to ALK was significant (Cox model: hazard ratio 3.15 [95% CI: 1.18-8.37, p = 0.021], competing risks: subhazard ratio 2.80 [95% CI: 1.06-7.43, p = 0.038]). CONCLUSIONS In time-to-event analyses controlling for thrombosis risk factors, the ALK rearrangement conferred a fourfold increase in VTE risk and a threefold increase in arterial thrombosis risk in NSCLC. These patients may benefit from pharmacologic thromboprophylaxis.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Orly Leiva
- Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ibiayi Dagogo-Jack
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alice Shaw
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jochen Lennerz
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Boston, Massachusetts
| | - Anthony J Iafrate
- Harvard Medical School, Boston, Massachusetts; Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital, Boston, Massachusetts
| | - Pavan K Bendapudi
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Jean M Connors
- Harvard Medical School, Boston, Massachusetts; Hematology Division, Brigham and Women's Hospital, Boston, Massachusetts
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Leiva O, Ng SK, Matsuura S, Chitalia V, Lucero H, Findlay A, Turner C, Jarolimek W, Ravid K. Novel lysyl oxidase inhibitors attenuate hallmarks of primary myelofibrosis in mice. Int J Hematol 2019; 110:699-708. [PMID: 31637674 DOI: 10.1007/s12185-019-02751-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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: 04/25/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/22/2022]
Abstract
Primary myelofibrosis (PMF) is a chronic myeloproliferative neoplasm (MPN) that usually portends a poor prognosis with limited therapeutic options available. Currently, only allogeneic stem cell transplantation is curative in those who are candidates, while administration of the JAK1/2 inhibitor ruxolitinib carries a risk of worsening cytopenia. The limited therapeutic options available highlight the need for the development of novel treatments for PMF. Lysyl oxidase (LOX), an enzyme vital for collagen cross-linking and extracellular matrix stiffening, has been found to be upregulated in PMF. Herein, we evaluate two novel LOX inhibitors, PXS-LOX_1 and PXS-LOX_2, in two animal models of PMF (GATA1low and JAK2V617F-mutated mice). Specifically, PXS-LOX_1 or vehicle was given to 15- to 16-week-old GATA1low mice via intraperitoneal injection at a dose of 15 mg/kg four times a week for 9 weeks. PXS-LOX_1 was found to significantly decrease the bone marrow fibrotic burden and megakaryocyte number compared to vehicle in both male and female GATA1low mice. Given these results, PXS-LOX_1 was then tested in 15- to 17-week-old JAK2V617F-mutated mice at a dose of 30 mg/kg four times a week for 8 weeks. Again, we observed a significant decrease in bone marrow fibrotic burden. PXS-LOX_2, a LOX inhibitor with improved oral bioavailability, was next evaluated in 15- to 17-week-old JAK2V617F-mutated mice at a dose of 5 mg/kg p.o. four times a week for 8 weeks. This inhibitor also resulted in a significant decrease in bone marrow fibrosis, albeit with a more pronounced amelioration in female mice. Taking these results together, PXS-LOX_1 and PXS-LOX_2 appear to be promising new candidates for the treatment of fibrosis in PMF.
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Affiliation(s)
- Orly Leiva
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany St., W-6, Boston, MA, 02118, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Seng Kah Ng
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany St., W-6, Boston, MA, 02118, USA
| | - Shinobu Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany St., W-6, Boston, MA, 02118, USA
| | - Vipul Chitalia
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, MA, 02118, USA
| | - Hector Lucero
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany St., W-6, Boston, MA, 02118, USA
| | - Alison Findlay
- Pharmaxis Ltd., 20 Rodborough Road, Frenchs Forest, NSW, Australia
| | - Craig Turner
- Pharmaxis Ltd., 20 Rodborough Road, Frenchs Forest, NSW, Australia
| | | | - Katya Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany St., W-6, Boston, MA, 02118, USA.
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Leiva O, Bekendam RH, Garcia BD, Thompson C, Cantor A, Chitalia V, Ravid K. Emerging Factors Implicated in Fibrotic Organ-Associated Thrombosis: The Case of Two Organs. TH Open 2019; 3:e165-e170. [PMID: 31259299 PMCID: PMC6598088 DOI: 10.1055/s-0039-1692204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/30/2019] [Indexed: 12/19/2022] Open
Abstract
Thrombosis is at the heart of cardiovascular complications observed in specific diseases. A heightened thrombosis risk above that in general population in diseases such as myelofibrosis and chronic kidney disease implicates disease-specific mediators of thrombosis. This relative lack of information regarding the mechanisms of thrombosis in specific organ pathologies hitherto has remained limited. Evolving literature implicates some soluble factors in the blood of patients with discrete disorders, inflicting fundamental changes in the components of thrombosis. In this era of precision medicine, integrating these disease-specific factors in a comprehensive thrombotic risk assessment of patients is imperative in guiding therapeutic decisions. A complex network of mechanisms regulates each organ pathology and resultant thrombotic phenotypes. This review surveys different effectors of thrombogenicity associated with two pathologically fibrotic organs used as model systems, the bone marrow and kidney, as well as focuses attention to a common inducer of fibrosis and thrombosis, lysyl oxidase.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Roelof H Bekendam
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Brenda D Garcia
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Department of Medicine, Mount Auburn Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Cristal Thompson
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Alan Cantor
- Children's Hospital Boston, Boston, Massachusetts, United States
| | - Vipul Chitalia
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States.,VA Boston Healthcare System, Boston, Massachusetts, United States
| | - Katya Ravid
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, United States
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Leiva O, McMahon L, Sloan JM, Lee J, Lerner A. Recognition of hemophagocytic lymphohistiocytosis in sickle cell vaso-occlusive crises is a potentially lifesaving diagnosis. Haematologica 2019; 104:e167-e169. [PMID: 30705096 DOI: 10.3324/haematol.2018.206458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Orly Leiva
- Department of Medicine, Boston University School of Medicine.,Department of Medicine, Brigham and Women's Hospital, Boston
| | - Lillian McMahon
- Department of Medicine, Boston University School of Medicine
| | - J Mark Sloan
- Department of Medicine, Boston University School of Medicine
| | - John Lee
- Department of Pathology & Laboratory Medicine, Boston University School of Medicine, MA, USA
| | - Adam Lerner
- Department of Medicine, Boston University School of Medicine
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Leiva O, Leon C, Kah Ng S, Mangin P, Gachet C, Ravid K. The role of extracellular matrix stiffness in megakaryocyte and platelet development and function. Am J Hematol 2018; 93:430-441. [PMID: 29247535 DOI: 10.1002/ajh.25008] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/11/2017] [Accepted: 12/13/2017] [Indexed: 12/16/2022]
Abstract
The extracellular matrix (ECM) is a key acellular structure in constant remodeling to provide tissue cohesion and rigidity. Deregulation of the balance between matrix deposition, degradation, and crosslinking results in fibrosis. Bone marrow fibrosis (BMF) is associated with several malignant and nonmalignant pathologies severely affecting blood cell production. BMF results from abnormal deposition of collagen fibers and enhanced lysyl oxidase-mediated ECM crosslinking within the marrow, thereby increasing marrow stiffness. Bone marrow stiffness has been recently recognized as an important regulator of blood cell development, notably by modifying the fate and differentiation process of hematopoietic or mesenchymal stem cells. This review surveys the different components of the ECM and their influence on stem cell development, with a focus on the impact of the ECM composition and stiffness on the megakaryocytic lineage in health and disease. Megakaryocyte maturation and the biogenesis of their progeny, the platelets, are thought to respond to environmental mechanical forces through a number of mechanosensors, including integrins and mechanosensitive ion channels, reviewed here.
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Affiliation(s)
- Orly Leiva
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
| | - Catherine Leon
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Seng Kah Ng
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
| | - Pierre Mangin
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Christian Gachet
- Université de Strasbourg, INSERM, EFS Grand-Est, BPPS UMR-S 949, FMTS; Strasbourg F-67000 France
| | - Katya Ravid
- Department of Medicine; Whitaker Cardiovascular Institute, Boston University School of Medicine; Boston Massachusetts
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Leiva O, Ng SK, Chitalia S, Balduini A, Matsuura S, Ravid K. The role of the extracellular matrix in primary myelofibrosis. Blood Cancer J 2017; 7:e525. [PMID: 28157219 PMCID: PMC5386340 DOI: 10.1038/bcj.2017.6] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 12/20/2016] [Indexed: 02/06/2023] Open
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative neoplasm that arises from clonal proliferation of hematopoietic stem cells and leads to progressive bone marrow (BM) fibrosis. While cellular mutations involved in the development of PMF have been heavily investigated, noteworthy is the important role the extracellular matrix (ECM) plays in the progression of BM fibrosis. This review surveys ECM proteins contributors of PMF, and highlights how better understanding of the control of the ECM within the BM niche may lead to combined therapeutic options in PMF.
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Affiliation(s)
- O Leiva
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S K Ng
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S Chitalia
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - A Balduini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.,Laboratory of Biotechnology, IRCCS San Matteo Foundation, Pavia, Italy
| | - S Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - K Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
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Affiliation(s)
- S Matsuura
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - S Patterson
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - H Lucero
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - O Leiva
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - A K Grant
- Department of Radiology, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
| | - V L M Herrera
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - K Ravid
- Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
- Department of Biochemistry, Boston University School of Medicine, Boston, MA, USA
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Grobe N, Leiva O, Morris M, Elased KM. Loss of prolyl carboxypeptidase in two-kidney, one-clip goldblatt hypertensive mice. PLoS One 2015; 10:e0117899. [PMID: 25706121 PMCID: PMC4338234 DOI: 10.1371/journal.pone.0117899] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 01/05/2015] [Indexed: 11/19/2022] Open
Abstract
It is well documented that angiotensin (Ang) II contributes to kidney disease progression. The protease prolyl carboxypeptidase (PRCP) is highly expressed in the kidney and may be renoprotective by degrading Ang II to Ang-(1-7). The aim of the study was to investigate whether renal PRCP protein expression and activity are altered in two-kidney, one-clip (2K1C) Goldblatt hypertensive mice. Left renal artery was constricted by using 0.12 mm silver clips. Blood pressure was measured using telemetry over the eleven weeks of study period and revealed an immediate increase in 2K1C animals during the first week of clip placement which was followed by a gradual decrease to baseline blood pressure. Similarly, urinary albumin excretion was significantly increased one week after 2K1C and returned to baseline levels during the following weeks. At 2 weeks and at the end of the study, renal pathologies were exacerbated in the 2K1C model as revealed by a significant increase in mesangial expansion and renal fibrosis. Renal PRCP expression and activity were significantly reduced in clipped kidneys. Immunofluorescence revealed the loss of renal tubular PRCP but not glomerular PRCP. In contrast, expression of prolyl endopeptidase, another enzyme capable of converting Ang II into Ang-(1-7), was not affected, while angiotensin converting enzyme was elevated in unclipped kidneys and renin was increased in clipped kidneys. Results suggest that PRCP is suppressed in 2K1C and that this downregulation may attenuate renoprotective effects via impaired Ang II degradation by PRCP.
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Affiliation(s)
- Nadja Grobe
- Department of Pharmacology and Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States of America
- * E-mail:
| | - Orly Leiva
- Department of Pharmacology and Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States of America
| | - Mariana Morris
- College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, United States of America
| | - Khalid M. Elased
- Department of Pharmacology and Toxicology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio, United States of America
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Leiva O, Elased KM, Morris M, Grobe N. Abstract 188: Loss of Renal Prolyl Carboxypeptidase in Mice With Chronic Kidney Disease. Hypertension 2013. [DOI: 10.1161/hyp.62.suppl_1.a188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are 26 million adults with chronic kidney disease (CKD) in the U.S. and the incidence continues to increase. It is well documented that the activation of the renin angiotensin system and the elevated formation of angiotensin (Ang) II both contribute to renal pathophysiology in CKD. Emerging evidence suggests that the Ang II degrading protease prolyl carboxypeptidase (PCP) is renoprotective. Thus, we investigated protein expression and activity of renal PCP using immunofluorescence, western blot and mass spectrometry in a mouse model of CKD. Renal injury in male C57Bl6 mice was caused by constriction of the left renal artery using silver clips (2K1C-method). Blood pressure measurements by radiotelemetry revealed a significant increase of 36.1 ± 3.9 mm Hg in 2K1C animals compared with control animals 1 week after clip placement (p<0.0001). Using immunofluorescence and confocal microscopy, PCP was localized in the Bowman’s capsule of the glomerulus and in proximal and distal renal tubules. Western blot analysis showed PCP was significantly reduced in clipped 2K1C kidneys compared to unclipped kidneys of the 2K1C mice or compared to control mice (clipped 0.04 ± 0.02 vs unclipped 0.58 ± 0.16 vs control 0.65 ± 0.18, p < 0.05). In addition, renal PCP enzyme activity was found to be markedly reduced in 2K1C kidneys as assessed by mass spectrometric based enzyme assays (clipped 37.1 ± 4.3 pmol Ang-(1-7)/h/μg vs unclipped 77.3 ± 12.3 pmol Ang-(1-7)/h/μg vs control 120.7 ± 14.7 pmol Ang-(1-7)/h/μg, p < 0.01). In contrast, protein expression of prolyl endopeptidase, another enzyme capable of converting Ang II into Ang-(1-7), was not affected. Notably, renal pathologies were exacerbated in the 2K1C model as revealed by a significant increase in mesangial expansion (clipped 34.6 ± 3.1 vs unclipped 52.1 ± 4.0 vs control 1.2 ± 2.1, p < 0.0001) and renal fibrosis (clipped 57.5 ± 0.9 vs unclipped 33.0 ± 0.7 vs control 3.3 ± 0.2, p < 0.0001). Results suggest that PCP is suppressed in chronic kidney injury and that this downregulation may attenuate renoprotective effects via impaired Ang II degradation by PCP. Therefore, Ang II processing by PCP may have clinical implications in patients with renal pathologies.
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Grobe N, Weir NM, Leiva O, Ong FS, Bernstein KE, Schmaier AH, Morris M, Elased KM. Identification of prolyl carboxypeptidase as an alternative enzyme for processing of renal angiotensin II using mass spectrometry. Am J Physiol Cell Physiol 2013; 304:C945-53. [PMID: 23392115 DOI: 10.1152/ajpcell.00346.2012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Angiotensin-converting enzyme 2 (ACE2) catalyzes conversion of ANG II to ANG-(1-7). The present study uses newly established proteomic approaches and genetic mouse models to examine the contribution of alternative renal peptidases to ACE2-independent formation of ANG-(1-7). In situ and in vitro mass spectrometric characterization showed that substrate concentration and pH control renal ANG II processing. At pH ≥6, ANG-(1-7) formation was significantly reduced in ACE2 knockout (KO) mice. However, at pH <6, formation of ANG-(1-7) in ACE2 KO mice was similar to that in wild-type (WT) mice, suggesting alternative peptidases for renal ANG II processing. Furthermore, the dual prolyl carboxypeptidase (PCP)-prolyl endopeptidase (PEP) inhibitor Z-prolyl-prolinal reduced ANG-(1-7) formation in ACE2 KO mice, while the ACE2 inhibitor MLN-4760 had no effect. Unlike the ACE2 KO mice, ANG-(1-7) formation from ANG II in PEP KO mice was not different from that in WT mice at any tested pH. However, at pH 5, this reaction was significantly reduced in kidneys and urine of PCP-depleted mice. In conclusion, results suggest that ACE2 metabolizes ANG II in the kidney at neutral and basic pH, while PCP catalyzes the same reaction at acidic pH. This is the first report demonstrating that renal ANG-(1-7) formation from ANG II is independent of ACE2. Elucidation of ACE2-independent ANG-(1-7) production pathways may have clinically important implications in patients with metabolic and renal disease.
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Affiliation(s)
- Nadja Grobe
- Department of Pharmacology and Toxicology, Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
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Leiva O, Grobe N, Weir NM, Neff V, Elased KM, Morris M. Abstract 633: Lack of ACE2 Abolishes High Fat Diet-Induced Upregulation of Prolyl Carboxypeptidase. Hypertension 2012. [DOI: 10.1161/hyp.60.suppl_1.a633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Emerging evidence suggests that activation of the proteases, Ang converting enzyme 2 (ACE2) and prolyl carboxypeptidase (PCP), are associated with metabolic pathologies. We hypothesized that global loss of ACE2 affects high fat diet induced renal expression of PCP. ACE2 knockout (ACE2KO) and wild type (WT) male mice were fed a 60% high fat (HF) or normal chow (NC) diet for 12 weeks. Using dual immunofluorescence microscopy and western blotting, we determined the expression pattern and abundance of ACE2 and PCP in kidney. PCP was co-localized with ACE2 in the Bowman’s capsule of the glomerulus. PCP was also localized along the apical membrane of proximal tubules along with ACE2. There was no evidence for protease co-localization in the tubules. ACE2 was absent in kidney from ACE2KO (immunofluorescence or western). PCP localization was unchanged in ACE2KO and the localization of both proteases did not change in response to HF diet. Protein intensity, normalized to ß-actin, showed no difference in PCP between untreated WT and KO (0.76±0.18 vs 0.57±0.07). PCP in HF WT was significantly elevated as compared to HF KO (0.94±0.02 vs 0.57±0.03, p≤0.05) while HF WT ACE2 levels remained unchanged as compared to untreated WT (0.90±0.24 vs 0.94±0.16). Results indicate loss of ACE2 negatively affects HF diet-induced PCP expression. Neither the absence of ACE2 nor HF diet changed the localization of PCP. These results suggest interactions between ACE2 and PCP in metabolic pathologies.
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Affiliation(s)
- Orly Leiva
- Wright State Univ Boonshoft Sch of Medicine, Dayton, OH
| | - Nadja Grobe
- Wright State Univ Boonshoft Sch of Medicine, Dayton, OH
| | - Nathan M Weir
- Wright State Univ Boonshoft Sch of Medicine, Dayton, OH
| | - Valerie Neff
- Wright State Univ Boonshoft Sch of Medicine, Dayton, OH
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Medina Polo J, Morales JM, Blanco M, Aguirre JF, Andrés A, Díaz R, Jiménez C, Leiva O, Meneu JC, Moreno E, Pamplona M, Passas J, Rodríguez A, de la Rosa F. Urological complications after simultaneous pancreas-kidney transplantation. Transplant Proc 2010; 41:2457-9. [PMID: 19715950 DOI: 10.1016/j.transproceed.2009.06.065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE We evaluated the incidence of urological complications after simultaneous renal and pancreatic transplantation. PATIENTS AND METHODS We retrospectively reviewed urological complications following 107 simultaneous kidney-pancreas transplantations performed at our institution between March 1995 and June 2008. The 46 women and 61 men were of mean age 37.8 years (range, 25-66). The mean duration of diabetes mellitus was 23.0 years (range, 9-48) and the mean duration of dialysis was 19.9 months (range, 0-70). The exocrine pancreatic secretions were drained to bladder in 58 cases, or enterically in 49 patients. The mean length of follow-up was 51.7 months. RESULTS The most frequent urological complication was urinary tract infection, reported in 63.8% of patients: 42 bladder-drained and 25 enteric-drained (P = .011). Hematuria occurred in 13 patients (12.5%): 12 bladder-drained and 1 enteric-drained (P = .002). Five bladder-drained patients developed bladder calculi. Among 58 bladder-drained patients, reflux pancreatitis occurred in 28 patients and urine leaks related to the pancreatic graft occurred in 7 patients. Conversion of exocrine secretions from bladder to enteric diversion was required in 6 patients. One- and 3-year patient survival rates were 92.7% and 89.1%, respectively. Moreover, 1 and 3-year kidney graft survival rates were 90.6% and 84.4%, and pancreas graft survival rates were 78.1 and 70.3%, respectively. CONCLUSION Simultaneous kidney-pancreas transplantation with bladder drainage is associated with a high frequency of urological complications. Appropriate treatment can resolve most complications. In our opinion, both enteric and bladder drainage seemed to be safe and effective alternatives to manage pancreatic exocrine secretions.
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Affiliation(s)
- J Medina Polo
- Department of Urology, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Blanco M, Medina J, Pamplona M, Miranda N, Gonzalez E, Aguirre JF, Andres A, Leiva O, Morales JM. Outcome of renal transplantation in adult patients with augmented bladders. Transplant Proc 2010; 41:2382-4. [PMID: 19715926 DOI: 10.1016/j.transproceed.2009.06.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We studied the long-term renal graft functions, survivals, and complications among patients with augmented bladders. PATIENTS AND METHODS Between 1976 and 2008, we performed 6/2600 renal transplantations in patients with augmented bladders. The mean patient age was 52 years. The cause of end-stage renal disease was chronic interstitial kidney disease in all patients, being secondary to lower urinary tract dysfunction. The etiology of bladder dysfunction was tuberculosis in 4 cases, bladder exstrophy in 1, and myelomeningocele in 1. Enterocystoplasty had been performed at a mean of 19 years prior to transplantation. The ureter was implanted into the native ureter in 5 cases and the bowel segment in 1 case. RESULTS With a mean follow-up of 56 months (range, 20-100 months), the overall graft survival was 50%. Three grafts were lost due to venous thrombosis (n = 1), and chronic allograft nephropathy (n = 2) at 37 and 100 months posttransplantation. No patient died during follow-up. Mean serum creatinine was 1.44 mg/dL with Modification of Diet in Renal Disease (MDRD) clearance of 76 mL/min/1.73 m(2). One fistula that caused obstructive uropathy and 2 cases of migration of a double J catheter were among the surgical complications. These patients showed a mean of 7 episodes of uncomplicated urinary infections. Only 1 patient was rehospitalized due to a complicated urinary tract infection. CONCLUSIONS Patients with enterocystoplasty and renal transplantation show a greater risk of urinary tract infections, albeit mostly uncomplicated. Despite this, the long-term results are acceptable.
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Affiliation(s)
- M Blanco
- Department of Urology, Doce de Octubre University Hospital, Madrid, Spain.
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Cabeza M, Antolín A, Romero J, Duarte J, Duque G, Medina-Polo J, Lanzós E, Domínguez M, De La Rosa F, García M, Villacampa F, Leiva O. UP-2.158: First Year Acute Toxicity Analysis of Low Dose Brachytherapy to Treat Low Risk Prostate Cancer: A Uro-Oncologic Radiotherapeutic Multidisciplinar Unit Experience. Urology 2009. [DOI: 10.1016/j.urology.2009.07.377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Andrés A, Polanco N, Cebrian M, Sol Vereda M, Vazquez S, Nuño E, Bello T, Gutierrez E, Gonzalez E, Praga M, Morales E, Morales J, Leiva O, Aguirre F, Diaz R. Kidneys From Elderly Deceased Donors Discarded for Transplantation. Transplant Proc 2009; 41:2379-81. [DOI: 10.1016/j.transproceed.2009.06.156] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Blanco M, Medina J, Gonzalez E, Dominguez M, Rodriguez A, Pamplona M, Andres A, Leiva O, Morales J. Third Kidney Transplantation: A Permanent Medical-Surgical Challenge. Transplant Proc 2009; 41:2366-9. [DOI: 10.1016/j.transproceed.2009.06.105] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Cabrera F, Duque G, Duarte J, Passas J, Villacampa F, Tejido A, Leiva O. UP.51: The Impact of Obesity on Laparoscopic Radical Prostatectomy. Urology 2008. [DOI: 10.1016/j.urology.2008.08.373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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