2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

The comparison of early healing 1-month after PCI among CoCr-everolimus-eluting stent (EES), biodegradable polymer (BP)-EES and BP-sirolimus-eluting stent: Insights from OFDI and coronary angioscopy

Background

Third-generation stents with abluminal biodegradable polymer (BP) might facilitate early healing. Therefore, we compared early healing between second-generation and third-generation stents using coronary angioscopy (CAS) and optical frequency domain imaging [OFDI].

Methods

We prospectively enrolled 30 consecutive patients with stent implantation for acute coronary syndrome (cobalt‑chromium [CoCr] everolimus-eluting stent [EES] [n = 10], BP-EES [n = 10], and BP-sirolimus eluting stent [SES] [n = 10]). All patients underwent CAS and OFDI 1 month after initial percutaneous coronary intervention. On OFDI, the stent coverage (SC), thrombus, and peri-strut low intensity area (PLIA) were assessed. CAS findings were recorded for the grade of SC, grade of yellow color (YC), and grade of the thrombus (TG).

Results

On OFDI, the incidences of any thrombus at the 1-month follow-up were 70%, 80%, and 80% in the CoCr-EES, BP-EES, and BP-SES groups, respectively. The percentage of coverage was comparable among the groups (CoCr-EES 79.8 vs. BP-EES 79.9 vs. BP-SES 80.1%, P = 0.96). However, the number of struts with PLIA was numerically higher in the BP-SES group than in the CoCr-EES and BP-EES groups (46.4 ± 25.1 vs. 21.6 ± 13.2 vs. 22.0 ± 7.2%, P = 0.08). In the CoCr-EES, BP-EES, and BP-SES groups, mean grades of SC were 1.25 ± 0.5, 1.25 ± 0.5, and 0.85 ± 0.70 (P = 0.60); mean grades of YC were 0.75 ± 0.5, 0.80 ± 0.45, and 0.88 ± 0.37 (P = 0.65), and mean grades of TG were 1.00 ± 1.00, 1.20 ± 0.83, and 0.88 ± 0.64 (P = 0.75), respectively.

Conclusion

Third-generation stents are not inferior to second-generation stents regarding stent coverage. However, PLIA on OFDI was often observed with BP-SESs, indicating involvement of the fibrin component.

Aspirin Plus Clopidogrel vs Aspirin Alone for Preventing Cardiovascular Events Among Patients at High Risk for Cardiovascular Events

CLINICAL QUESTION

Among patients at high risk for or with established cardiovascular disease (ie, history of peripheral artery disease, stroke, or coronary artery disease without a coronary stent), is the addition of clopidogrel to aspirin associated with lower risk of mortality and cardiovascular events compared with aspirin alone?

BOTTOM LINE

Clopidogrel plus aspirin is associated with a reduced risk for myocardial infarction and ischemic stroke and an increased risk for major bleeding compared with aspirin alone among patients at high risk for or with an established cardiovascular disease but without a coronary stent. However, combined therapy is not associated with lower mortality.

Dual versus triple therapy in patients on oral anticoagulants and undergoing coronary stent implantation: A systematic review and meta-analysis

BACKGROUND AND AIMS

There is contrasting evidence regarding the optimal antithrombotic regimen after percutaneous coronary stent implantation in patients on oral anticoagulants. A systematic review and meta-analysis was performed to explore the comparative efficacy and safety of dual (an antiplatelet plus an oral anticoagulant) versus triple therapy (dual antiplatelet therapy plus an oral anticoagulant).

METHODS

We searched the literature for randomized controlled trials (RCTs) or observational studies (OSs) addressing this issue. The efficacy outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction and stent thrombosis. The safety outcomes were major bleeding events and all bleeding events. The analyses were stratified by type of anticoagulant and of antiplatelet used in dual therapy.

RESULTS

Four RCTs and ten OSs met our inclusion criteria including a total of 10,126 patients. 5671 patients received triple therapy whereas 4455 received dual therapy. Median follow up was 12 months. There was no difference between dual therapy and triple therapy regarding efficacy outcomes. Dual therapy significantly reduced the risk of major bleeding (RR 0.66; CI 95% 0.52-0.83; P = 0.0005) and of all bleeding events (RR 0.67, CI 95% 0.55-0.80; P < 0.0001). The effect was consistent regardless of the type of antiplatelet and anticoagulant used in dual therapy.

CONCLUSION

Dual antithrombotic therapy after coronary stenting in anticoagulated patients significantly reduces bleeding events compared with triple therapy. Dual therapy might be considered in this setting especially when bleeding risk outweighs ischemic risk, although our study was not sufficiently powered to detect a difference in ischemic endpoints.

Clopidogrel utilization in patients with coronary artery disease and diabetes mellitus: should we determine CYP2C19*2 genotype?

PURPOSE

Clopidogrel non-responsiveness is multifactorial; several genetic and non-genetic factors may contribute to impaired platelet inhibition. The goal of this study is to determine the effect of the cytochrome P450 CYP2C19*2 polymorphism on the platelet response to clopidogrel in patients with and without diabetes mellitus (DM).

METHODS

We conducted an observational study in patients with coronary artery disease and consequent exposure to clopidogrel therapy (75 mg/day for at least 7 consecutive days). We have analyzed two groups of patients: group I (DM patients) and group II (non-diabetes mellitus patients). Platelet reactivity was assessed by the VerifyNow P2Y12 assay and high on clopidogrel platelet reactivity (HPR) was defined as P2Y12 reaction units (PRU) ≥ 208. Genotyping for CYP2C19*2 polymorphism was performed by PCR-RFLP.

RESULTS

We have included 150 subjects (76 DM and 74 non-diabetes mellitus patients). The carriage of CYP2C19*2 allele, in DM patients, was significantly associated to HPR (odds ratio (OR) 4.437, 95% confidence interval (CI) 1.134 to 17.359; p = 0.032). Furthermore, 8.4% of the variability in percent inhibition by clopidogrel could be attributed to CYP2C19*2 carrier status. However, in non-diabetes mellitus patients, there was no significant difference in platelet response to clopidogrel according to the presence or absence of CYP2C19*2 allele carriage (OR 1.260, 95% CI 0.288 to 5.522; p = 0.759).

CONCLUSIONS

Our study suggests that the carriage of CYP2C19*2 polymorphism, in DM patients, might be a potential predictor of persisting HPR in these high-risk individuals.

TRIAL REGISTRATION

Clinical Trials.gov NCT03373552 (Registered 13 December 2017).

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2017

Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature.

Reduction in postpercutaneous coronary intervention angina in addition to gastrointestinal events in patients on combined proton pump inhibitors and dual antiplatelet therapy: a systematic review and meta-analysis

BACKGROUND

Primary percutaneous coronary intervention (PCI) is a standard treatment in patients with acute coronary syndrome. Studies have shown that proton pump inhibitors (PPIs) can potentially attenuate the antiplatelet effects of P2Y12 inhibitors with associated adverse cardiovascular outcomes.

MATERIALS AND METHODS

Medline was searched using Pubmed from inception to 8 November 2017 for randomized control trials studying the effect of PPIs on coronary artery disease with concomitant use of dual antiplatelet therapy (DAPT). Overall, 692 studies were identified of which five randomized control trials were included. Statistical analysis was done using RevMan, version 5.3.

RESULTS

Five studies with 6239 patients (3113 on PPI with DAPT and 3126 with only DAPT) were included. Our analysis showed that PPI significantly reduced the incidence of gastrointestinal (GI) bleed [22 vs. 66, odds ratio (OR)=0.37, confidence interval (CI)=0.23-0.61, P≤0.0001, I=0%], GI ulcers and GI erosions (7 vs. 18, OR=0.39, CI=0.16-0.94, P=0.04, I=0%), and the incidence of post-PCI unstable angina in patients treated with PPI and P2Y12 agents (46 vs. 67, OR=0.67, CI=0.45-0.99, P=0.05, I=0%). There was an insignificant difference in myocardial infarction, stroke, and cardiovascular cause of mortality. A trend toward decreased all-cause mortality with PPIs was noted. Heterogeneity was calculated using I.

CONCLUSION

Concomitantly administered PPIs with P2Y12 inhibitors have a protective effect on the GI events. It also decreases the post-PCI angina without increased adverse cardiovascular outcomes.

Impact of right coronary dominance on triple-vessel coronary artery disease: A cross-sectional study

This study was conducted to investigate the relationship between right coronary dominance and coronary angiographic characteristics in patients with or without significant coronary artery disease (CAD).A total of 2225 patients undergoing coronary angiography (CAG) between January 2011 and November 2014 were recruited in our study. Based on the CAG results, patients were divided into the left dominance (LD) group, right dominance (RD) group, and co-dominance (CD) group. Multinomial logistic regression was applied to analyze the relationships between coronary dominance and triple-vessel CAD.We found that patients with RD had a higher prevalence of triple-vessel CAD (36.6% vs 27.3%, P = .008) and significant stenosis in the right coronary artery (40.5% vs 29.2%, P = .001). In addition, results of multinomial logistic regression analysis showed that RD was significantly associated with the triple-vessel disease (odds ratio 1.768, 95% confidence interval 1.057-2.956, P = .030).In conclusion, RD positively correlated with triple-vessel CAD rather than LD or CD in patients. This result suggested that RD may serve as a risk factor for triple-vessel CAD and more effective measures should be taken in RD patients to prevent fatal cardiovascular events.

Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention

The optimal antithrombotic treatment regimen for patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation represents a challenge in clinical practice. In 2016, an updated opinion of selected experts from the United States and Canada on the treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention was reported. After the 2016 North American consensus statement on the management of antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention, results of pivotal clinical trials assessing the type of oral anticoagulant agent and the duration of antiplatelet treatment have been published. On the basis of these results, this focused update on the antithrombotic management of patients with atrial fibrillation undergoing percutaneous coronary intervention recommends that a non–vitamin K antagonist oral anticoagulant be preferred over a vitamin K antagonist as the oral anticoagulant of choice. Moreover, a double-therapy regimen (oral anticoagulant plus single antiplatelet therapy with a P2Y 12 inhibitor) by the time of hospital discharge should be considered for most patients, whereas extending the use of aspirin beyond hospital discharge (ie, triple therapy) should be considered only for selected patients at high ischemic/thrombotic and low bleeding risks and for a limited period of time. The present document provides a focused updated on the rationale for the new expert consensus–derived recommendations on the antithrombotic management of patients with atrial fibrillation treated with oral anticoagulation undergoing percutaneous coronary intervention.

Comparison of 6-Month Costs Between Oral Antiplatelet Agents Following Acute Coronary Syndrome

BACKGROUND

In patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), newer antiplatelet agents prasugrel and ticagrelor have lower rates of cardiovascular events when compared with clopidogrel. However, it is unclear whether there are differences in economic outcomes when comparing these agents in ACS-PCI patients.

OBJECTIVE

To assess aggregated costs and medical resource utilization among ACS-PCI patients prescribed prasugrel, ticagrelor, or generic clopidogrel, using a large commercial insurance claims database.

METHODS

Costs attributable to any medical and pharmacy service and resource utilization including number of admissions, length of hospital stay, emergency room visits, and office visits over the 180-day postdischarge period were compared. All-cause and cardiovascular health care costs and resource utilization were separately analyzed for patients enrolled in the data over the continuous follow-up (CFU) period, and for patients continuously taking their initial treatment for 6 months (CTX). Potential confounders collected over a 6-month baseline assessment period were controlled for, using a generalized linear model.

RESULTS

Over the 180-day follow-up, prasugrel and ticagrelor patients underwent fewer admissions (rate ratio [RR] = 0.87, 95% CI = 0.80-0.95) from CFU and RR = 0.81, 95% CI = 0.71-0.89 from CTX) compared with clopidogrel patients. The newer agent cohort incurred more overall health care costs than the generic clopidogrel group, with added costs of $957 (95% CI = $236-$1,725) in the CFU group and $1,122 (95% CI = $455-$1,865) in the CTX group, which were smaller than the increase in all-cause outpatient pharmacy costs associated with the newer agents versus clopidogrel (CFU: $1,175, 95% CI = $1,079-$1,278 and CTX: $1,360, 95% CI = $1,256-$1,487). Overall, there was no statistically significant difference in the economic outcomes associated with prasugrel and ticagrelor. There were, however, significant correlations between all-cause and cardiovascular-related outcomes.

CONCLUSIONS

The higher price of prasugrel and ticagrelor was partially offset by a decrease in hospital admission compared with generic clopidogrel over a 6-month postdischarge period. Aggregated medical costs and resource utilization were not significantly different between prasugrel and ticagrelor patients.

DISCLOSURES

No funding was received for this study. DiDomenico has received an honorarium from Amgen for preparation of a heart failure drug monograph for Pharmacy Practice News and serves as an advisory board member for a heart failure program at Otsuka America Pharmaceuticals and for Novartis Pharmaceuticals. Touchette has received unrestricted grant funding from Cardinal Health, Sunovion Pharmaceuticals, and Takeda and has served as a consultant to and director of the American College of Clinical Pharmacy Practice-Based Research Network on a study funded by Pfizer. Walton has served as a paid consultant for Bristol-Myers Squibb, Baxter, Merck, Genentech, Primus, Takeda, and Abbott. The other authors have nothing to disclose.

Barriers and enablers to walking in individuals with intermittent claudication: A systematic review to conceptualize a relevant and patient-centered program

BACKGROUND

Walking limitation in patients with peripheral arterial disease (PAD) and intermittent claudication (IC) contributes to poorer disease outcomes. Identifying and examining barriers to walking may be an important step in developing a comprehensive patient-centered self-management intervention to promote walking in this population.

AIM

To systematically review the literature regarding barriers and enablers to walking exercise in individuals with IC.

METHODS

A systematic review was conducted utilizing integrative review methodology. Five electronic databases and the reference lists of relevant studies were searched. Findings were categorized into personal, walking activity related, and environmental barriers and enablers using a social cognitive framework.

RESULTS

Eighteen studies including quantitative (n = 12), qualitative (n = 5), and mixed method (n = 1) designs, and reporting data from a total of 4376 patients with IC, were included in the review. The most frequently reported barriers to engaging in walking were comorbid health concerns, walking induced pain, lack of knowledge (e.g. about the disease pathology and walking recommendations), and poor walking capacity. The most frequently reported enablers were cognitive coping strategies, good support systems, and receiving specific instructions to walk. Findings suggest additionally that wider behavioral and environmental obstacles should be addressed in a patient-centered self-management intervention.

CONCLUSIONS

This review has identified multidimensional factors influencing walking in patients with IC. Within the social cognitive framework, these factors fall within patient level factors (e.g. comorbid health concerns), walking related factors (e.g. claudication pain), and environmental factors (e.g. support systems). These factors are worth considering when developing self-management interventions to increase walking in patients with IC. Systematic review registration CRD42018070418.

Challenges adhering to a medication regimen following first-time percutaneous coronary intervention: A patient perspective

BACKGROUND

Percutaneous coronary intervention is the most common therapeutic intervention for patients with narrowed coronary arteries due to coronary artery disease. Although it is known that patients with coronary artery disease often do not adhere to their medication regimen, little is known about what patients undergoing percutaneous coronary interventions find challenging in adhering to their medication regimen after hospital discharge.

OBJECTIVES

To explore patients' experiences in adhering to medications following early post-discharge after first-time percutaneous coronary intervention.

DESIGN

An abductive qualitative approach was used to conduct in-depth interviews of patients undergoing first-time percutaneous coronary intervention.

SETTINGS

Participants were recruited from a single tertiary university hospital, which services a large geographical area in western Norway. Patients fulfilling the inclusion criteria were identified through the Norwegian Registry for Invasive Cardiology.

PARTICIPANTS

Participants were patients aged 18 years or older who had their first percutaneous coronary intervention six to nine months earlier, were living at home at the time of study inclusion, and were prescribed dual antiplatelet therapy. Patients who were cognitively impaired, had previously undergone cardiac surgery, and/or were prescribed anticoagulation therapy with warfarin or novel oral anticoagulants were excluded. Purposeful sampling was used to include patients of different gender, age, and geographic settings. Twenty-two patients (12 men) were interviewed between December 2016 and April 2017.

METHODS

Face-to-face semi-structured interviews were conducted, guided by a set of predetermined open-ended questions to gather patient experiences on factors relating to medication adherence or non-adherence. Transcribed interviews were analysed by qualitative content analysis.

FINDINGS

Patients failed to adhere to their medication regimen for several reasons; intentional and unintentional reasons, multifaceted side effects from heart medications, scepticism towards generic drugs, lack of information regarding seriousness of disease after percutaneous coronary intervention, psychological impact of living with coronary artery disease, and these interacted. There were patients who felt that the medication information they received from physicians and nurses was uninformative and inadequate. Side effects from heart medications were common, ranging from minor ones to more disabling side effects, such as severe muscle and joint pain and fatigue. Patients found well established medication taking routines and aids to be necessary, and these improved adherence.

CONCLUSION

Patients undergoing first-time percutaneous coronary intervention face multiple, interacting challenges in trying to adhere to prescribed medications following discharge. This study highlights the need for a more structured follow-up care in order to improve medication adherence and to maximise their self-care abilities.

Fractional Flow Reserve or Coronary Flow Reserve for the Assessment of Myocardial Perfusion : Implications of FFR as an Imperfect Reference Standard for Myocardial Ischemia

Purpose of Review

Accumulating evidence exists for the value of coronary physiology for clinical decision-making in ischemic heart disease (IHD). The most frequently used pressure-derived index to assess stenosis severity, the fractional flow reserve (FFR), has long been considered the gold standard for this purpose, despite the fact that the FFR assesses solely epicardial stenosis severity and aims to estimate coronary flow impairment in the coronary circulation. The coronary flow reserve (CFR) directly assesses coronary blood flow in the coronary circulation, including both the epicardial coronary artery and the coronary microvasculature, but is nowadays less established than FFR. It is now recognized that both tools may provide insight into the pathophysiological substrate of ischemic heart disease, and that particularly combined FFR and CFR measurements provide a comprehensive insight into the multilevel involvement of IHD. This review discusses the diagnostic and prognostic characteristics, as well as future implications of combined assessment of FFR and CFR pressure and flow measurements as parameters for inducible ischemia.

Recent Findings

FFR and CFR disagree in up to 40% of all cases, giving rise to fundamental questions regarding the role of FFR in contemporary ischemic heart disease management, and implying a renewed approach in clinical management of these patients using combined coronary pressure and flow measurement to allow appropriate identification of patients at risk for cardiovascular events.

Summary

This review emphasizes the value of comprehensive coronary physiology measurements in assessing the pathophysiological substrate of IHD, and the importance of acknowledging the broad spectrum of epicardial and microcirculatory involvement in IHD. Increasing interest and large clinical trials are expected to further strengthen the potential of advanced coronary physiology in interventional cardiology, consequently inducing reconsideration of current clinical guidelines.

Elevated preoperative heart rate associated with increased risk of cardiopulmonary complications after resection for lung cancer

BACKGROUND

The study aimed to assess whether preoperative resting heart rate could be a risk factor for cardiopulmonary complications (CPCs) after lung cancer resection.

METHODS

Eligible consecutive patients who underwent resection surgery for non-small cell lung cancer (NSCLC) at Ningbo NO.2 Hospital between May, 2010 and July, 2015 were included. The demographic, clinical characteristics and laboratory parameters were compared in patients with or without CPCs within postoperative 30 days. The multivariate logistic regression analysis was used to analyze the association between CPCs and risk factors. Receiver operating characteristic (ROC) curve analysis was utilized for the predictive role of preoperative resting heart rate for CPCs.

RESULTS

One hundred eighty participants were enrolled into the final analysis and 42 of them had an established diagnosis of CPCs within postoperative 30 days. Elevated preoperative resting heart rate was an independent risk factor for postoperative CPCs (OR: 4.48, 95% CI: 1.17-18.42, P = 0.021) by the multivariate logistic regression analysis. ROC curve analysis indicated elevated resting heart rate as a predictor for CPCs with a cut-off value of 86 beats/min (AUC: 0.813, specificity: 80.95%, sensitivity: 72.46%, P < 0.001).

CONCLUSIONS

Elevated preoperative resting heart rate was associated with an increased risk of postoperative CPCs in patients after resection for lung cancer.

Serial Assessment of Strut Coverage of Biodegradable Polymer Drug-Eluting Stent at 1, 2, and 3 Months After Stent Implantation by Optical Frequency Domain Imaging: The DISCOVERY 1TO3 Study (Evaluation With OFDI of Strut Coverage of Terumo New Drug Eluting Stent With Biodegradable Polymer at 1, 2, and 3 Months)

BACKGROUND

To assess the vessel-healing pattern of Ultimaster drug-eluting stent using optical frequency domain imaging. Our hypothesis is that biodegradable polymer-based drug-eluting technology allows complete very early strut coverage.

METHODS AND RESULTS

The DISCOVERY 1TO3 study (Evaluation With OFDI of Strut Coverage of Terumo New Drug Eluting Stent With Biodegradable Polymer at 1, 2, and 3 Months) is a prospective, single-arm, multicenter study. A total of 60 patients with multivessel disease requiring staged procedure at 1 month were treated with Ultimaster. Optical frequency domain imaging was acquired at baseline, 1, 2, and 3 months. The primary end point is optical frequency domain imaging-assessed strut coverage at 3 months. Mean age of patients was 67.2±9.9 years, and 73.3% were male, and 36.7% presented with acute coronary syndrome. A total of 132 lesions were treated, with average 1.4 lesions per patient treated at baseline and 1.1 lesions treated at 1 month. Strut coverage at 3 months of single implanted stents (n=71, primary end point) was 95.2±5.2% and of combined single and overlapped stents was 95.4±4.9%. Strut coverage of combined single and overlapped stents at 1 (n=49) and 2 months (n=38) was 85.1±12.7% and 87.9±10.8%, respectively. The median neointimal hyperplasia thickness was 0.04, 0.05, and 0.06 mm, whereas mean neointimal hyperplasia obstruction was 4.5±2.4%, 5.2±3.4%, and 6.6±3.3% at 1, 2, and 3 months, respectively.

CONCLUSIONS

Nearly complete strut coverage was observed in this complex population very early after implantation of Ultimaster drug-eluting stent.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01844843.

Challenges in Implementation of Institutional Protocols for Patients With Acute Coronary Syndrome

The diagnosis of acute coronary syndrome (ACS) encompasses ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (non-STEMI and unstable angina). In recent years, there have been improvements in the rates of death, cardiogenic shock, and recurrent myocardial infarction in patients with ACS, primarily due to the introduction of new pharmacological and interventional therapies, as well as the introduction of and adherence to new treatment guidelines. However, ACS still represents a considerable public health burden. Treatment recommendations for STEMI and non-ST-segment elevation differ and there is wide variation in practice patterns and adherence among and within hospitals especially for the latter diagnosis. Adoption of institutional protocols may help decrease variability and improve quality of care, efficiency, and, ultimately, patient outcomes. This report discusses the process of developing and implementing institutional protocols for patients with ACS, from initial medical contact to discharge and beyond.

BOLD cardiac MRI for differentiating reversible and irreversible myocardial damage in ST segment elevation myocardial infarction

OBJECTIVES

BOLD imaging is a quantitative MRI technique allowing the evaluation of the balance between supply/demand in myocardial oxygenation and myocardial haemorrhage. We sought to investigate the ability of BOLD imaging to differentiate reversible from irreversible myocardial injury as well as the chronological progression of myocardial oxygenation after reperfusion in patients with ST segment elevation myocardial infarction (STEMI).

METHODS

Twenty-two patients (age, 60 ± 11 years; 77.3% male) with STEMI underwent cardiac MRIs on four occasions: on days 1, 3, 7 and 30 after reperfusion. BOLD MRI was obtained with a multi-echo turbo field echo (TFE) sequence on a 3-T scanner to assess myocardial oxygenation in MI.

RESULTS

T2* value in MI with intramyocardial haemorrhage (IMH) was the lowest (9.77 ± 3.29 ms), while that of the salvaged zone was the highest (33.97 ± 3.42 ms). T2* values in salvaged myocardium demonstrated a unimodal temporal pattern from days 1 (37.91 ± 2.23 ms) to 30 (30.68 ± 1.59 ms). T2* values in the MI regions were significantly lower than those in remote myocardium, although the trends in both were constant overall. There was a slightly positive correlation between T2* in MI regions and EF (Rho = 0.27, p < 0.05) or SV (Rho = 0.22, p = 0.04) and a slightly negative correlation between T2* in salvaged myocardium and LVEDV (Rho = - 0.23, p < 0.05).

CONCLUSIONS

BOLD MRI performed in post-STEMI patients allows accurate evaluation of myocardial damage severity and could differentiate reversible from irreversible myocardial injury. The increased T2* values may imply the pathophysiological mechanism of salvaged myocardium. BOLD MRI could represent a more accurate alternative to the other currently available options.

KEY POINTS

• Myocardial oxygenation and haemorrhage after myocardial infarction affect BOLD MRI values • BOLD MRI could be used to differentiate irreversible from reversible myocardial damage • Changed oxygenation implies the pathophysiological mechanism of salvaged myocardium.

Primary and secondary prevention of stroke and systemic embolism with rivaroxaban in patients with non-valvular atrial fibrillation : Sub-analysis of the EXPAND Study

The EXPAND Study examined the real-world efficacy and safety of rivaroxaban for the prevention of stroke and systemic embolism (SE) in Japanese patients with non-valvular atrial fibrillation (NVAF). In this sub-analysis, we compared the differences in efficacy and safety between patients with and those without history of stroke or transient ischemic attack (TIA). This multicenter, prospective, non-interventional, observational, cohort study was conducted at 684 medical centers in Japan. A total of 7141 NVAF patients aged ≥ 20 years [mean age 71.6 ± 9.4 (SD) years] who were being or planned to be treated with rivaroxaban (10 mg/day, 43.5%; 15 mg/day, 56.5%) were followed for a mean period of 897.1 ± 206.8 days with a high follow-up rate (99.7%). The primary prevention group comprised patients without history of ischemic stroke or TIA (n = 5546, 77.7%), and the secondary prevention group comprised those with history of ischemic stroke or TIA (n = 1595, 22.3%). In the primary and secondary prevention groups, the incidence rate of stroke or SE (primary efficacy endpoint) was 0.7 and 2.2%/year, respectively (P < 0.001), and the incidence rate of major bleeding (primary safety endpoint) was 1.2 and 1.5%/year, respectively (P = 0.132). For major bleeding events, the incidence rate of intracranial bleeding was 0.4 and 0.8%/year (P = 0.002) in the primary and secondary prevention groups, respectively. This sub-analysis of the EXPAND Study showed that the Japan-specific dosages of rivaroxaban were effective and safe in Japanese NVAF patients with and those without ischemic stroke or TIA in routine clinical practice.

THE POSSIBILITIES OF USING A NEW FIXED-DOSE COMBINATION OF ROSUVASTATIN AND ACETYLSALICYLIC ACID: FOCUS GROUPS OF PATIENTS

The review focuses on the impairment of the carotid, coronary arteries and lower-extremity arterial disease. Systemic involvement of various vascular beds in atherogenesis is emphasized. Epidemiological characteristics of morbidity and mortality from the main clinical manifestations of atherosclerosis - ischemic stroke, ischemic heart disease and lower-extremity arterial disease are given. The current principles of drug therapy are considered from the point of view of improving the prognosis and eliminating ischemia. The basic positions of International and Russian clinical recommendations on the management of patients with the presence of certain clinical manifestations of atherosclerosis are discussed. Detailed administration schemes and the preferred doses of statins and antiplatelet agents depending on the localization of atherosclerotic lesion and the severity of stenosis are described. The target blood lipids levels in the treatment with statins are given. The advantages of statins as drugs that reduce the risk of cardiovascular complications are presented. Current data on the pattern of antiplatelet use, including acetylsalicylic acid, in individuals with clinical manifestations of atherosclerosis are given. The principal tactic of dual antiplatelet therapy and schemes of its use in patients undergoing percutaneous coronary intervention, coronary artery bypass surgery and in individuals with a history of acute coronary disorders are considered.

Favorable early vessel healing after everolimus-eluting stent implantation: 3-, 6-, and 12-month follow-up of optical coherence tomography

BACKGROUND

Although a prospective randomized control study revealed that 3-month dual anti-platelet therapy (DAPT) is safe and does not compromise the efficacy of everolimus-eluting stent (EES) in selected patients, detailed vessel healing at early phase after EES implantation has yet to be investigated in Japanese patients.

METHODS AND RESULTS

A total of 27 lesions in 19 patients treated with EES were serially evaluated by using optical coherence tomography (OCT) at 3, 6, and 12 months after stent implantation. In addition to standard quantitative OCT parameters, the percentage of stents with peri-strut low-intensity area (PLIA, a region around stent struts homogenously showing lesser intensity than the surrounding tissue, suggesting fibrin deposition or impaired neointima maturation) and that with in-stent thrombi were evaluated. There was a significant, but small increase in neointimal thickness (63±17μm; 83±30μm; and 111±44μm, respectively; p=0.006) and small decrease in average lumen area (6.80±2.57mm², 6.62±2.58mm², 6.33±2.58mm², p=0.038) from the 3- to the 12-month follow-up. The incidences of uncovered and malapposed struts were low at 3 months and did not significantly change at 6 months and 12 months (3.01±4.43; 2.45±3.75; and 1.47±3.16, p=0.143, and 0.75±0.65; 0.63±0.73; and 0.58±1.42, p=0.162, respectively). Also, frequency of struts with PLIA was already low at three months and significantly decreased during the follow-up (6.4±6.5; 4.6±5.4; and 2.3±3.3, respectively; p=0.001).

CONCLUSION

Favorable vessel healing was achieved at 3 months after EES implantation without neointimal hyperplasia which was persistently suppressed up to 12 months.

Vasodilator-stimulated phosphoprotein (VASP) is not a major mediator of platelet aggregation, thrombogenesis, haemostasis, and antiplatelet effect of prasugrel in rats

Vasodilator-stimulated phosphoprotein (VASP) is a member of actin regulatory proteins implicated in platelet adhesion. In addition, phosphorylation of VASP is utilised for the assessment of platelet reactivity in patients treated with P2Y₁₂ receptor antagonists, a class of antiplatelet agents. However, the role of VASP in platelet aggregation, thrombogenesis, haemostasis, and the antiplatelet effect of P2Y₁₂ receptor antagonists remains unclear. We investigated these effects using heterozygous and homozygous VASP knockout rats generated with a CRISPR/Cas9 system. Baseline characteristics, such as haematology and other biochemical parameters, were comparable among the genotypes. In vitro platelet aggregation stimulated by adenosine diphosphate (ADP) or collagen, P-selectin expression of rat platelets treated with ADP, and in vivo thrombocytopenia induced by collagen were also comparable among the genotypes. In addition, in vivo thrombogenesis in a ferric chloride-induced arterial thrombosis model and bleeding time were also comparable among the genotypes. Furthermore, the in vitro antiplatelet effect of prasugrel, a third-generation P2Y₁₂ receptor antagonist, was unaffected by VASP knockout. Although phosphorylated VASP is still an important surrogate marker specific for P2Y₁₂ antagonists, our findings demonstrate that VASP is not a major mediator of platelet aggregation, thrombogenesis, haemostasis, and the antiplatelet effect of prasugrel in rats.

Trends in Platelet Adenosine Diphosphate P2Y12 Receptor Inhibitor Use and Adherence Among Antiplatelet-Naive Patients After Percutaneous Coronary Intervention, 2008-2016

IMPORTANCE

Current guidelines recommend prasugrel hydrochloride and ticagrelor hydrochloride as preferred therapies for patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). However, it is not well known how frequently these newer agents are being used in clinical practice or how adherence varies among the platelet adenosine diphosphate P2Y12 receptor (P2Y12) inhibitors.

OBJECTIVES

To determine trends in use of the different P2Y12 inhibitors in patients who underwent PCI from 2008 to 2016 in a large cohort of commercially insured patients and differences in patient adherence and costs among the P2Y12 inhibitors.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study used administrative claims from a large US national insurer (ie, UnitedHealthcare) from January 1, 2008, to December 1, 2016, comprising patients aged 18 to 64 years hospitalized for PCI who had not received a P2Y12 inhibitor for 90 days preceding PCI. The P2Y12 inhibitor filled within 30 days of discharge was identified from pharmacy claims.

MAIN OUTCOMES AND MEASURES

Proportion of patients filling prescriptions for P2Y12 inhibitors within 30 days of discharge by year, as well as medication possession ratios (MPRs) and total P2Y12 inhibitor copayments at 6 and 12 months for patients who received drug-eluting stents.

RESULTS

A total of 55 340 patients (12 754 [23.0%] women; mean [SD] age, 54.4 [7.1] years) who underwent PCI were included in this study. In 2008, 7667 (93.6%) patients filled a prescription for clopidogrel bisulfate and 521 (6.4%) filled no P2Y12 inhibitor prescription within 30 days of hospitalization. In 2016, 2406 (44.0%) patients filled clopidogrel prescriptions, 2015 (36.9%) filled either prasugrel or ticagrelor prescriptions, and 1045 (19.1%) patients filled no P2Y12 inhibitor prescription within 30 days of hospitalization. At 6 months, mean MPRs for patients who received a drug-eluting stent filling clopidogrel, prasugrel, and ticagrelor prescriptions were 0.85 (interquartile range [IQR], 0.82-1.00), 0.79 (IQR, 0.66-1.00), and 0.76 (IQR, 0.66-0.98) (P < .001), respectively; mean copayments for a 6 months' supply were $132 (IQR, $47-$203), $287 (IQR, $152-$389), and $265 (IQR, $53-$387) (P < .001), respectively. At 12 months, mean MPRs for clopidogrel, prasugrel, and ticagrelor were 0.76 (IQR, 0.58-0.99), 0.71 (IQR, 0.49-0.98), and 0.68 (IQR, 0.41-0.94) (P < .001), respectively; mean total copayments were $251 (IQR, $100-$371), $556 (IQR, $348-$730), and $557 (IQR, $233-$744) (P < .001), respectively.

CONCLUSIONS AND RELEVANCE

Between 2008 and 2016, increased use of prasugrel and ticagrelor was accompanied by increased nonfilling of prescriptions for P2Y12 inhibitors within 30 days of discharge. Prasugrel and ticagrelor had higher patient costs and lower adherence in the year following PCI compared with clopidogrel. The introduction of newer, more expensive P2Y12 inhibitors was associated with lower adherence to these therapies.

Algorithmic Approach for Optical Coherence Tomography-Guided Stent Implantation During Percutaneous Coronary Intervention

Intravascular imaging plays a key role in optimizing outcomes for percutaneous coronary intervention (PCI). Optical coherence tomography (OCT) utilizes a user-friendly interface and provides high-resolution images. OCT can be used as part of daily practice in all stages of a coronary intervention: baseline lesion assessment, stent selection, and stent optimization. Incorporating a standardized, algorithmic approach when using OCT allows for precision PCI.

A qualitative study of nuisance bleeding and medication-related beliefs with dual antiplatelet drug therapy

OBJECTIVES

The purpose of this qualitative study was to explore perceptions of nuisance bleeding and medication-related beliefs among adults taking dual antiplatelet drug therapy.

METHODS

We conducted qualitative telephone interviews with 34 community-dwelling adults with cardiovascular disease.

RESULTS

Using qualitative content analysis, we identified 4 dominant themes: nuisance bruising, nuisance bleeding, importance of medication adherence, and duration of therapy. Participants' bruising was frequently more severe than expected given the force of the bump that caused it. Concerns focused on whether increased bleeding tendencies would lead to hemorrhage in the event of a major traumatic injury, confusion about the duration of therapy, and the rationale for when and why therapy should be discontinued.

CONCLUSION

Excessive bruising and medication-related concerns about hemorrhage and duration of treatment were salient issues for participants. Effective clinician-patient communication should be used to assist individuals in managing concerns to help assure positive health outcomes with antiplatelet drugs.

Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry

BACKGROUND

Ticagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high-dose aspirin.

METHODS AND RESULTS

Patients in the acute coronary treatment and intervention outcomes network (ACTION) Registry-Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high-dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%-13.9% and 54.2%-51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in-hospital re-infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in-hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High-dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high-dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST-segment-elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01).

CONCLUSIONS

Our contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low-dose aspirin at discharge.

Perioperative and Periprocedural Management of Antithrombotic Therapy: Consensus Document of SEC, SEDAR, SEACV, SECTCV, AEC, SECPRE, SEPD, SEGO, SEHH, SETH, SEMERGEN, SEMFYC, SEMG, SEMICYUC, SEMI, SEMES, SEPAR, SENEC, SEO, SEPA, SERVEI, SECOT and AEU

During the last few years, the number of patients receiving anticoagulant and antiplatelet therapy has increased worldwide. Since this is a chronic treatment, patients receiving it can be expected to need some kind of surgery or intervention during their lifetime that may require treatment discontinuation. The decision to withdraw antithrombotic therapy depends on the patient's thrombotic risk versus hemorrhagic risk. Assessment of both factors will show the precise management of anticoagulant and antiplatelet therapy in these scenarios. The aim of this consensus document, coordinated by the Cardiovascular Thrombosis Working Group of the Spanish Society of Cardiology, and endorsed by most of the Spanish scientific societies of clinical specialities that may play a role in the patient-health care process during the perioperative or periprocedural period, is to recommend some simple and practical guidelines with a view to homogenizing daily clinical practice.

Effects of Coronary Artery Revascularization with a Polymer-Free Biolimus A9-Coated BioFreedom Stent Versus Bypass Surgery before Noncardiac Surgery

PURPOSE

The present study aimed to evaluate the efficacy and safety of polymer-free drug-coated BioFreedom stent implantation in comparison to coronary artery bypass graft (CABG) before major noncardiac surgery.

MATERIALS AND METHODS

In a multicenter registry, 55 patients required revascularization before major noncardiac surgery that should not be delayed >6 months. Of them, 27 underwent BioFreedom stent implantation and 28 underwent CABG. Primary outcomes included rate of noncardiac surgery, time from revascularization to noncardiac surgery, and occurrence of composite outcomes (all-cause death, myocardial infarction, stent thrombosis, stroke, repeat revascularization, or major bleeding).

RESULTS

The rate of major noncardiac surgery was significantly higher in the BioFreedom group (92.6%) than in the CABG group (64.3%; p=0.027). Time from revascularization to noncardiac surgery was significantly shorter in the BioFreedom group (38.0 days) than in the CABG group (73.0 days; p=0.042). During the hospitalization for revascularization period, the occurrence of primary outcomes did not differ between the groups. However, the BioFreedom group showed a shorter hospitalization period and lower total treatment cost than the CABG group. During the hospital stay for noncardiac surgery, the occurrence of composite outcome was not significantly different between groups (4% vs. 0%; p>0.999): stroke occurred in only 1 case, and there were no cases of death or stent thrombosis in the BioFreedom group.

CONCLUSION

This study demonstrated that BioFreedom stenting as a revascularization strategy before major noncardiac surgery might be feasible and safe in selected patients with less severe coronary artery diseases.

Dual Antithrombotic Therapy with Clopidogrel and Novel Oral Anticoagulants in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Real-world Study

INTRODUCTION

For patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), proper antithrombotic therapy is equivocal. Current guidelines recommend triple therapy, which carries a high risk of bleeding. Recent large trials suggest that dual therapy (DT) with novel oral anticoagulant (NOAC) plus P2Y12 inhibitor can be an appropriate alternative, but real-world data for this alternative are scarce and the optimal duration of DT has not yet been established.

METHODS

This analysis was performed in a single-center prospective cohort. We investigated 216 PCI patients with indication for anticoagulation due to AF. After PCI patients received DT with reduced doses NOAC plus P2Y12 inhibitor for 6 months, which was followed by standard dose NOAC monotherapy. Efficacy endpoints were defined as cardiac death, myocardial infarction (MI), stent thrombosis (ST), and stroke. Safety endpoints were bleeding events as defined by Bleeding Academic Consortium (BARC).

RESULTS

Baseline characteristics of our study population were described by a CHA2DS2-VASc score of greater than 4 and a HAS-BLED score of greater than 3. After a mean follow-up of 18.7 months, efficacy events occurred in 12 patients (5.6%). We observed three (1.4%) cardiac deaths, two (0.9%) MIs, six (2.8%) strokes, and one (0.5%) definite ST. After switching from DT to NOAC monotherapy after 6.3 ± 1.7 months, there was no rebound of ischemic events. Bleeding events occurred in 34 patients (15.7%) mainly under DT, while bleeding was less during NOAC monotherapy.

CONCLUSIONS

In this long-term study of high-risk and real-world AF-patients with PCI, DT with NOAC and P2Y12 inhibitor (6 months) followed by NOAC monotherapy was safe and effective.

Impact of Baseline Thrombocytopenia on Bleeding and Mortality After Percutaneous Coronary Intervention

It is still controversial whether baseline thrombocytopenia is independently associated with adverse events after percutaneous coronary intervention. We evaluated the influence of baseline thrombocytopenia against ischemic, bleeding and mortality among the 19,353 patients whose baseline platelet counts were available in the pooled database from the 3 studies in Japan. Baseline thrombocytopenia was classified as follows: mild, ≥100 and <150 × 10⁹/L; moderate, ≥50 and <100 × 10⁹/L; and severe, <50 × 10⁹/L. Primary ischemic outcome measure was defined as composite of myocardial infarction and ischemic stroke, and primary bleeding outcome measure was defined by the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded arteries trial as moderate or severe bleeding. There were 2,590 patients (13.4%) with baseline thrombocytopenia comprising 292 patients (1.5%) with moderate/severe (moderate: 277 and severe: 15) thrombocytopenia and 2,298 patients (11.9%) with mild thrombocytopenia, whereas 16,763 patients (86.6%) had no thrombocytopenia. During 3-year follow-up, the adjusted risks of moderate/severe and mild thrombocytopenia relative to none were neutral for primary ischemic outcome (hazard ratio [HR] 1.07 [95% confidence interval [CI] 0.72 to 1.60], p = 0.74, and HR 0.93 [0.79 to 1.09], p = 0.37, respectively) but were significantly higher for primary bleeding outcome (HR 2.35 [1.80 to 3.08], p <0.001, and HR 1.20 [1.03 to 1.40], p = 0.02), and for mortality (HR 2.34 [1.87 to 2.93], p <0.001, and HR 1.26 [1.11 to 1.43], p <0.001). In conclusion, patients with baseline thrombocytopenia, even a mild one, had a higher risk of bleeding events and all-cause death, but not for ischemic events after percutaneous coronary intervention.

Acute stent thrombosis: Should preventative measures start in the emergency department?

Stent thrombosis is a potentially life threatening condition caused by several factors or a combination factors, such as resistance to platelet agents and type of anticoagulation used as well as stent types. We report a case of acute thrombosis and discuss potential areas of intervention with literature review.

Interventional Cardio-Oncology: Adding a New Dimension to the Cardio-Oncology Field

The management of cardiovascular disease in patients with active cancer presents a unique challenge in interventional cardiology. Cancer patients often suffer from significant comorbidities such as thrombocytopenia and coagulopathic and/or hypercoagulable states, which complicates invasive evaluation and can specifically be associated with an increased risk for vascular access complications. Furthermore, anticancer therapies cause injury to the vascular endothelium as well as the myocardium. Meanwhile, improvements in diagnosis and treatment of various cancers have contributed to an increase in overall survival rates in cancer patients. Proper management of this patient population is unclear, as cancer patients are largely excluded from randomized clinical trials on percutaneous coronary intervention (PCI) and national PCI registries. In this review, we will discuss the role of different safety measures that can be applied prior to and during these invasive cardiovascular procedures as well as the role of intravascular imaging techniques in managing these high risk patients.

Relevance of Antiplatelet Therapy Duration After Stent-Assisted Coil Embolization for Unruptured Intracranial Aneurysms

BACKGROUND

The optimal duration of dual-antiplatelet therapy (DAPT) for preventing delayed thromboembolic events (DTEs) remains unclear. We aimed to determine whether longer DAPT provides improved protection against delayed DTEs.

METHODS

This retrospective cohort study included 507 stent-assisted coil embolization procedures using a single stent for unruptured intracranial aneurysms. We performed coarsened exact matching according to the duration of maintenance DAPT. DTEs were defined as any neurologic symptoms concerning the stented vascular territory and occurring at 1 month or later after the procedure. After stratification according to DAPT duration (short-term, <9 months; long-term, ≥9 months), the log-rank test and Z-analysis were performed to evaluate the efficacy of long-term DAPT for preventing DTEs.

RESULTS

Of 507 treated patients (median follow-up, 44 months), 25 (4.9%) experienced DTEs at 1 month after the procedure. Among all DTEs, 9 (1.8%) were infarctions confirmed on magnetic resonance imaging. Permanent neurologic deficit (modified Rankin Scale score ≥2) occurred in 2 (0.4%) patients. On procedure-to-event analysis, long-term DAPT was not superior for preventing DTEs. Most events occurred within 1 month of switching from DAPT to single-antiplatelet therapy, regardless of DAPT duration. The longest time from the procedure to DTE occurrence was 22 months. Age older than 54.5 years was identified as independent risk factor for DTE-stroke.

CONCLUSIONS

Compared with short-term DAPT, long-term DAPT delays the occurrence of DTEs but does not lower their incidence. Longer-term DAPT (>9 months) should be considered after stent-assisted coil embolization for unruptured intracranial aneurysms, although its efficacy remains to be clarified.

Impact of mean platelet aggregation degree on long-term clinical outcomes among patients undergoing a complex percutaneous coronary intervention

OBJECTIVE

The aim of this study was to evaluate the association between the mean platelet aggregation degree and long-term clinical outcomes in patients receiving a complex percutaneous coronary intervention (CPCI).

PATIENTS AND METHODS

We screened 2141 patients after a percutaneous coronary intervention (PCI) treated with aspirin and clopidogrel. CPCI was defined as a procedure targeted to at least one of the following: left main disease, bifurcation lesion, ostial lesion, chronic total occlusion, and small-vessel stenting. ADP-induced platelet aggregation was serially measured by light transmission aggregometry at least three times after PCI and the mean value was calculated. The population was categorized on the basis of the mean ADP degree and the presence of CPCI. The primary endpoint measured was a major adverse cardiovascular and cerebral event (MACCE).

RESULTS

A total of 1245 patients enrolled in the study were divided into four groups: group A (CPCI and ADP≥40%), group B (CPCI and ADP<40%), group C (non-CPCI and ADP≥40%), and group D (non-CPCI and ADP<40%). The median follow-up was 29.9 months. The Cox multivariate analysis suggested that group A was an independent risk factor for MACCE (hazard ratio: 2.70, 95% confidence interval: 1.25-5.81; P<0.001). Compared with group A, the remaining groups (groups B, C, and D) had a lower rate of MACCE. When group C was set as the reference, groups B and D had similar risks for primary endpoints.

CONCLUSION

Patients undergoing CPCI with a high mean ADP degree are at a high risk for MACCE. Serial platelet function testing is therefore important in patients receiving CPCI.

Are Shorter Durations of Dual Antiplatelet Therapy Acceptable Following Percutaneous Coronary Intervention?

Much debate has centered on whether or not the standard 12-month duration of dual antiplatelet therapy (DAPT) is still necessary postpercutaneous coronary intervention, given recent improvements in stent technology. The benefits of shorter (3-6 months) durations of DAPT include a potential lower risk for bleeding and less patient drug cost and pill burden. Although randomized clinical trials have shown noninferiority for shorter versus longer DAPT regimens in many regards, some endpoints (e.g., myocardial infarction) may still occur less frequently with longer DAPT regimens, particularly in higher risk populations (e.g., acute coronary syndromes). Bleeding risk is either comparable or less with shorter versus longer DAPT regimens. Given the lack of unequivocal data regarding the equality of shorter versus longer DAPT regimens in all patients, there is a growing consensus that an individualized approach is advisable for determining DAPT duration postpercutaneous coronary intervention. Clinical decision aids and updated clinical practice guidelines are available that consider risk:benefit ratios and clinical trial data to assist the clinician in developing a personalized DAPT regimen.

Perioperative Management of the Gynecologic Patient on Long-term Anticoagulation

The perioperative management of patients taking antithrombotic or antiplatelet medications is based on an assessment of the individual patient's risk for thrombosis or bleeding, the specific medication involved, and the nature of the planned procedure. This article describes specific strategies for whether and how these medications should be interrupted before gynecologic procedures, when they can be restarted following the procedure, and whether bridging therapy should be considered.

Aspirin use and long-term rates of sepsis: A population-based cohort study

OBJECTIVE

Sepsis is the syndrome of life-threatening organ dysfunction resulting from dysregulated host response to infection. Aspirin, an anti-inflammatory agent, may play a role in attenuating the inflammatory response during infection. We evaluated the association between aspirin use and long-term rates of sepsis as well as sepsis outcomes.

METHODS

We analyzed data from 30,239 adults ≥45 years old in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The primary exposure was aspirin use, identified via patient interview. The primary outcome was sepsis hospitalization, defined as admission for infection with two or more systemic inflammatory response syndrome criteria. We fit Cox proportional hazards models assessing the association between aspirin use and rates of sepsis, adjusted for participant demographics, health behaviors, chronic medical conditions, medication adherence, and biomarkers. We used a propensity-matched analysis and a series of sensitivity analyses to assess the robustness of our results. We also examined risk of organ dysfunction and hospital mortality during hospitalization for sepsis.

RESULTS

Among 29,690 REGARDS participants with follow-up data available, 43% reported aspirin use (n = 12,869). Aspirin users had higher sepsis rates (hazard ratio 1.35; 95% CI: 1.22-1.49) but this association was attenuated following adjustment for potential confounders (adjusted HR 0.99; 95% CI: 0.88-1.12). We obtained similar results in propensity-matched and sensitivity analyses. Among sepsis hospitalizations, aspirin use was not associated with organ dysfunction or hospital death.

CONCLUSIONS

In the REGARDS cohort, baseline aspirin use was not associated with long-term rates of sepsis.

Differential Prognostic Impact on Mortality of Myocardial Infarction Compared With Bleeding Severity in Contemporary Acute Coronary Syndrome Patients

INTRODUCTION AND OBJECTIVES

The impact on mortality of myocardial infarction (MI) compared with the specific degree of bleeding severity occurring after discharge in acute coronary syndrome is poorly characterized. Defining this relationship may help to achieve a favorable therapeutic risk-benefit balance.

METHODS

Using Cox-based shared frailty models, we assessed the relationship between mortality and postdischarge MI and bleeding severity-graded according to Bleeding Academic Research Consortium (BARC)-in 4229 acute coronary syndrome patients undergoing in-hospital coronary arteriography between January 2012 and December 2015.

RESULTS

Both MI (HR, 5.8; 95%CI, 3.7-9.8) and bleeding (HR, 5.1; 95%CI, 3.6-7.7) were associated with mortality. Myocardial infarction had a stronger impact on mortality than BARC type 2 and 3a bleedings: (RRr, 3.8 and 1.9; P < .05), respectively, but was equivalent to BARC type 3b (RRr, 0.9; P = .88). Mortality risk after MI was significantly lower than after BARC type 3c bleeding (RRr, 0.25; P < .001). Mortality was higher after an MI in patients on dual antiplatelet therapy (DAPT) at the time of the event (HR, 2.9; 95%CI, 1.8-4.5) than in those off-DAPT (HR, 1.5; 95%CI, 0.7-3.4). In contrast, mortality was lower after a bleeding event in patients on-DAPT (HR, 1.6; 95%CI, 1.1-2.6) than in those off-DAPT (HR, 3.2; 95%CI, 1.7-5.8).

CONCLUSIONS

The differential effect on mortality of a postdischarge MI vs bleeding largely depends on bleeding severity. The DAPT status at the time of MI or bleeding is a modifier of subsequent mortality risk.

Incidence, Predictors, and Clinical Impact of Early Prasugrel Cessation in Patients With ST-Elevation Myocardial Infarction

BACKGROUND

Early withdrawal of recommended antiplatelet treatment with clopidogrel adversely affects prognosis following percutaneous coronary interventions. Optimal antiplatelet treatment is essential following ST-segment elevation myocardial infarction (STEMI) given the increased risk of thrombotic complications. This study assessed the frequency, predictors, and clinical impact of early prasugrel cessation in patients with STEMI undergoing primary percutaneous coronary interventions.

METHODS AND RESULTS

We pooled patients with STEMI discharged on prasugrel in 2 prospective registries (Bern PCI Registry [NCT02241291] and SPUM-ACS (Inflammation and Acute Coronary Syndromes) [NCT01000701]) and 1 STEMI trial (COMFORTABLE-AMI (Comparison of Biomatrix Versus Gazelle in ST-Elevation Myocardial Infarction) [NCT00962416]). Prasugrel treatment status at 1 year was categorized as no cessation; crossover to another P2Y12-inhibitor; physician-recommended discontinuation; and disruption because of bleeding, side effects, or patient noncompliance. In time-dependent analyses, we assessed the impact of prasugrel cessation on the primary end point, a composite of cardiac death, myocardial infarction, and stroke. Of all 1830 included patients (17% women, mean age 59 years), 83% were treated with new-generation drug-eluting stents. At 1 year, any prasugrel cessation had occurred in 13.8% of patients including crossover (7.2%), discontinuation (3.7%), and disruption (2.9%). Independent predictors of any prasugrel cessation included female sex, age, and history of cerebrovascular event. The primary end point occurred in 5.2% of patients and was more frequent following disruption (hazard ratio 3.04, 95% confidence interval,1.34-6.91; P=0.008), without significant impact of crossover or discontinuation. Consistent findings were observed for all-cause death, myocardial infarction, and stent thrombosis following prasugrel disruption.

CONCLUSIONS

In this contemporary study of patients with STEMI, early prasugrel cessation was not uncommon and primarily involved change to another P2Y12-inhibitor. Disruption was the only type of early prasugrel cessation associated with statistically significant excess in ischemic risk within 1 year following primary percutaneous coronary interventions.

In-stent restenosis assessed with frequency domain optical coherence tomography shows smooth coronary arterial healing process in second-generation drug-eluting stents

INTRODUCTION

The pathophysiology and mechanism of in-stent restenosis (ISR) after implantation of second-generation drug-eluting stents (DESs) are not fully clear. We compared the morphological characteristics of ISR between first- and second-generation DESs using frequency domain optical coherence tomography (OCT).

METHODS

Patients who underwent follow-up coronary angiography (CAG) after first-generation (CYPHER™ and TAXUS™) and second-generation (Nobori®, PROMUS Element™, Resolute Integrity and XIENCE) DES implantations were examined. ISR was defined as lesions of over 50% diameter stenosis at follow-up CAG. Frequency domain OCT was performed at the time of revascularisation of ISR. Tissue morphology was assessed at minimum lumen area. OCT images of DESs at both early (≤ 1 year) and late (> 1 year) phase follow-up were compared.

RESULTS

On qualitative OCT assessment, the ratios of homogeneous, layered, heterogeneous without-attenuation and heterogeneous with-attenuation morphologies were 57.1%, 17.1%, 20.0% and 5.7%, respectively, for second-generation DES ISR (n = 35), and 16.7%, 25.0%, 25.0% and 33.3%, respectively, for first-generation DES ISR (n = 36). At late phase follow-up, homogeneous morphology was significantly more common for second-generation DES ISR compared to first-generation DES ISR (first-generation: 8.0% vs. second-generation: 50.0%; p < 0.01) while heterogeneous with-attenuation morphology was significantly more common for first-generation DES ISR (first-generation: 44.0% vs. second-generation: 5.6%; p < 0.01).

CONCLUSION

Homogeneous tissue morphology was more frequently found for second-generation than first-generation DES ISR, especially in the late phase. This suggested that neointimal hyperplasia was the main mechanism in second-generation DES ISR, and that the neointima was stabilised, much like in bare metal stent implantation.

CAD-RADS - a new clinical decision support tool for coronary computed tomography angiography

Coronary computed tomography angiography (CTA) has been established as an accurate method to non-invasively assess coronary artery disease (CAD). The proposed 'Coronary Artery Disease Reporting and Data System' (CAD-RADS) may enable standardised reporting of the broad spectrum of coronary CTA findings related to the presence, extent and composition of coronary atherosclerosis. The CAD-RADS classification is a comprehensive tool for summarising findings on a per-patient-basis dependent on the highest-grade coronary artery lesion, ranging from CAD-RADS 0 (absence of CAD) to CAD-RADS 5 (total occlusion of a coronary artery). In addition, it provides suggestions for clinical management for each classification, including further testing and therapeutic options. Despite some limitations, CAD-RADS may facilitate improved communication between imagers and patient caregivers. As such, CAD-RADS may enable a more efficient use of coronary CTA leading to more accurate utilisation of invasive coronary angiograms. Furthermore, widespread use of CAD-RADS may facilitate registry-based research of diagnostic and prognostic aspects of CTA.

KEY POINTS

• CAD-RADS is a tool for standardising coronary CTA reports. • CAD-RADS includes clinical treatment recommendations based on CTA findings. • CAD-RADS has the potential to reduce variability of CTA reports.

No Significant Association Between Proton Pump Inhibitor Use and Risk of Stroke After Adjustment for Lifestyle Factors and Indication

BACKGROUND & AIMS

Proton pump inhibitors (PPI) are among the top 10 most prescribed medications worldwide. We investigated the association between PPI use and ischemic stroke.

METHODS

We collected data on 68,514 women (mean age, 65 ± 7 years) enrolled in the Nurses' Health Study since 2000 and 28,989 men (mean age, 69 ± 8 years) in the Health Professionals Follow-up Study since 2004, without a history of stroke. We used Cox proportional hazards models to examine the association between risk of incident stroke and PPI use among participants. The primary end point was first incident stroke.

RESULTS

In the 2 cohorts, we documented 2599 incident strokes (2037 in women and 562 in men) over a 12-year period, encompassing 949,330 person-years. After adjustment for established risk factors for stroke, PPI use was associated with a significant increase in risk of ischemic stroke (hazard ratio, 1.18; 95% confidence interval, 1.02-1.37). The association was reduced after we adjusted for potential indications for PPI use, including history of peptic ulcer disease, gastroesophageal reflux disease, or gastrointestinal bleeding, and prior use of histamine-2 receptor antagonist therapy (hazard ratio, 1.08; 95% confidence interval, 0.91-1.27). Regular PPI use was not associated with increased risk of stroke overall or hemorrhagic stroke.

CONCLUSIONS

In an analysis of data from the Nurses' Health Study and the Health Professionals Follow-up Study, we did not find a significant association between PPI use and ischemic stroke, after accounting for indications for PPI use. Prior reports of an increased risk of stroke may be due to residual confounding related to chronic conditions associated with PPI use.

Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: Where Are We Now?

OBJECTIVE

To synthesize the literature and provide guidance to practitioners regarding double therapy (DT) and triple therapy (TT) in patients with atrial fibrillation (AF) requiring percutaneous coronary intervention (PCI).

DATA SOURCES

PubMed and MEDLINE (January 2000 to February 2018) were searched using the following terms: atrial fibrillation, myocardial infarction, acute coronary syndrome, percutaneous coronary intervention, anticoagulation, dual-antiplatelet therapy, clopidogrel, aspirin, ticagrelor, prasugrel, and triple therapy.

STUDY SELECTION AND DATA EXTRACTION

The results included randomized and nonrandomized clinical trials and meta-analyses. Each study was reported based on study design, population, intervention, comparator, and key cardiovascular (CV) and bleeding outcomes.

DATA SYNTHESIS

A total of 15 studies were included in the review. The majority of studies evaluating DT and TT utilized clopidogrel and warfarin as components of the regimen, although there are emerging data with newer agents. Evidence purporting DT regimens to be equally effective in preventing CV events and improved safety profiles compared with TT regimens included populations with relatively low risk for recurrent CV events, and many of these studies were observational in nature. Overall, current evidence as well as American and European guidelines support the use of TT in patients with AF who require PCI for the least possible amount of time, depending on patient-specific factors involving bleeding and thrombosis.

CONCLUSIONS

In the majority of patients with AF who require PCI, TT should be used for the shortest period of time possible. DT regimens may be used in patients requiring PCI who have low risk for thrombosis and/or high bleeding risk.