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

Antithrombotic Strategies in Patients with Atrial Fibrillation and Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Patients with atrial fibrillation (AF) are at increased risk for coronary artery disease (CAD). After percutaneous coronary intervention (PCI), the antithrombotic therapy consists of a combination of anticoagulant and antiplatelet agents to reduce the ischemic and thromboembolic risk, at the cost of increased bleeding events. In the past few years, several randomized clinical trials involving over 12,000 patients have been conducted to compare the safety of vitamin K antagonist (VKA) and direct-acting oral anticoagulants (DOACs) in association with a single- or double-antiplatelet agent, in the so-called dual- (DAT) or triple-antithrombotic therapy (TAT). These studies and several meta-analyses showed a consistent benefit for reducing bleeding events of DAT over TAT and of DOAC over VKA, without concerns about ischemic endpoints, except for a trend for increased stent thrombosis risk. The present paper examines current international guidelines’ recommendations and reviews clinical trials, meta-analyses, and observational studies conducted on AF patients treated with DAT or TAT after PCI for acute coronary syndromes.

Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update

Purpose of Review

Multiple guidelines and recommendations have been written to address the perioperative management of antiplatelet and anticoagulant drugs. In this review, we evaluated the recent guidelines in non-cardiac, cardiac, and regional anesthesia. Furthermore, we focused on unresolved problems and novel approaches for optimized perioperative management.

Recent Findings

Vitamin K antagonists should be stopped 3 to 5 days before surgery. Preoperative laboratory testing is recommended. Bridging therapy does not decrease the perioperative thromboembolic risk and might increase perioperative bleeding risk. In patients on direct-acting oral anticoagulants (DOAC), a discontinuation interval of 24 and 48 h in those scheduled for surgery with low and high bleeding risk, respectively, has been shown to be saved. Several guidelines for regional anesthesia recommend a conservative interruption interval of 72 h for DOACs before neuraxial anesthesia. Finally, aspirin is commonly continued in the perioperative period, whereas potent P2Y12 receptor inhibitors should be stopped, drug-specifically, 3 to 7 days before surgery.

Summary

Many guidelines have been published from various societies. Their applicability is limited in emergent or urgent surgery, where novel approaches might be helpful. However, their evidence is commonly based on small series, case reports, or expert opinions.

Ticagrelor versus clopidogrel in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention

OBJECTIVES

To evaluate the effectiveness and safety of ticagrelor versus clopidogrel in patients with acute coronary syndromes (ACS) undergoing complex percutaneous coronary intervention (PCI).

BACKGROUND

It remains inconclusive whether ticagrelor is superior to clopidogrel in ACS patients undergoing complex PCI in real-world practice.

METHODS

Based on an all-comers PCI registry, we compared the long-term effectiveness and safety between ticagrelor and clopidogrel in ACS patients undergoing complex PCI, defined as PCI procedures for complex lesions including bifurcation, chronic total occlusion, ostial, tortuous, calcific, diffused, thrombus-containing, and restenotic lesions. The primary ischemic outcome was a composite of cardiac death, myocardial infarction, or stroke. The safety outcome comprised Bleeding Academic Research Consortium (BARC) types 2, 3, and 5 bleeding. Propensity score matching (PSM) was performed to reduce bias.

RESULTS

Among ACS patients who underwent complex PCI, 4373 (35.2%) and 8065 (64.8%) received dual antiplatelet therapy based on ticagrelor and clopidogrel, respectively. The incidences of composite ischemic events (before PSM: 1.74% vs. 2.84%; after PSM: 1.50% vs. 2.65%; p < 0.01 for both) and all-cause death (before PSM: 1.23% vs. 2.12%, p < 0.01; after PSM: 1.09% vs. 1.81%, p = 0.02) were significantly lower in the ticagrelor-treated than in the clopidogrel-treated group. There was no significant difference in BARC types 2, 3, and 5 bleeding between groups.

CONCLUSIONS

Whilst the risk of major bleeding was comparable between the two drugs, ticagrelor was associated with a significantly lower risk of ischemic events than clopidogrel in ACS patients undergoing complex PCI.

Helicopter emergency medical service for patients with acute coronary syndrome: selection validity and impact on clinical outcomes

Helicopter emergency medical service (HEMS) has the potential to improve prognosis for acute coronary syndrome (ACS). However, adequacy and effectiveness of HEMS have not been fully evaluated. A total of 862 ACS patients transferred by emergency medical services were divided into two groups: patients transferred by HEMS (n = 171) or by ground ambulance (GA; n = 691). Among them, angiography images for 718 patients (149 in HEMS and 569 in GA group) and optical coherence tomography (OCT) images for 374 patients (75 in HEMS and 299 in GA groups) were analyzed. Additional analysis to compare 2-year cardiac mortality between groups was conducted following propensity score matching to adjust for inter-group differences. ST-segment elevation myocardial infarction (81% vs. 66%, p < 0.001) and cardiogenic shock (Killip IV; 20% vs. 10%, p < 0.001) at admission were more prevalent in HEMS than GA group. Time from admission to balloon angioplasty was shorter in HEMS group (median 54 min vs. 69 min, p < 0.001). Antegrade coronary flow was worse in HEMS group (TIMI flow grade 0 or 1; 68% vs. 51%, p < 0.001). Plaque rupture was more frequently detected by OCT in HEMS group (68% vs. 49%, p = 0.029). Following propensity score matching, the incidence of cardiac death was significantly lower in HEMS group (6.3% vs. 14.9%, p = 0.019). In conclusion, severe ACS patients requiring early reperfusion were appropriately triaged and transferred more rapidly by HEMS. Lower mortality in HEMS group after propensity score matching suggests that HEMS may improve cardiac mortality in ACS patients.

IDENTIFYING THE EFFECTS OF SUPPLEMENTAL OXYGEN ADMINISTRATION ON THE HEALTH OUTCOMES OF PATIENTS PRESENTING WITH ACUTE CORONARY SYNDROME AND OXYGEN SATURATION >93% - A SYSTEMATIC REVIEW

OBJECTIVES

Oxygen was commonly used in the early management of patients presenting with Acute Coronary Syndrome (ACS) regardless of their oxygen saturation. Inappropriate administration of supplemental oxygen could potentially result in adverse patient health outcomes.

AIM

To identify the effects of supplemental oxygen administration on the health outcomes of patients presenting with ACS and oxygen saturations >93%.

METHOD

Systematic review. The CINAHL, PubMed, Cochrane and Medline databases were searched for relevant literature. Inclusion criteria included articles published from 2008-2019, adult participants, primary studies, and participants with uncomplicated ACS and have oxygen saturation >93%. Eligible studies were assessed for rigour using a critical appraisal tool.

RESULTS

Seven randomised controlled studies were included for analysis. Themes were also used to group the assessed endpoints. The three main outcomes analysed were: infarct size and cardiac function; adverse cardiac events; and mortality. Two of the seven studies found a statistically significant relationship between oxygen administration, infarct size, and adverse cardiac events. Conversely, five of the seven studies reported that supplemental oxygen did not have statistically significant benefit over room air.

CONCLUSION

This review identified that oxygen should not be administered to patients who present with ACS and have oxygen saturations >93%. This is due to the potential risk of adverse outcomes: increased infarct size, mortality, and adverse events.

IMPACT STATEMENT

Recent update of guidelines despite evidence opposing oxygen delivery in ACS means the education of nurses is imperative for safe practice.

Healthcare resource utilisation for chronic kidney disease and other major non-communicable chronic diseases in China: a cross-sectional study

OBJECTIVE

To evaluate the healthcare resource utilisation for chronic kidney disease (CKD) and other major non-communicable chronic diseases (NCDs) in China.

DESIGN

A cross-sectional study.

SETTING

A national inpatient database of tertiary hospitals in China.

PARTICIPANTS

The study included a total of 19.5 million hospitalisations of adult patients from July 2013 to June 2014. Information on CKD and other major NCDs, including coronary heart disease (CHD), stroke, hypertension, diabetes, chronic obstructive pulmonary disease (COPD) and cancer, was extracted from the unified discharge summary form.

OUTCOME MEASURES

Cost, length of hospital stay and in-hospital mortality.

RESULTS

The percentages of hospitalisations with CKD, CHD, stroke, hypertension, diabetes, COPD and cancer were 4.5%, 9.2%, 8.2%, 18.8%, 7.9%, 2.3% and 19.4%, respectively. For each major NCD, the presence of CKD was independently associated with longer hospital stay, with increased percentages ranging from 7.69% (95% CI 7.11% to 8.28%) for stroke to 21.60% (95% CI 21.09% to 22.10%) for CHD. Hospital mortality for other NCDs was also higher in the presence of CKD, with fully adjusted relative risk ranging from 1.91 (95% CI 1.82 to 1.99) for stroke to 2.65 (95% CI 2.55 to 2.75) for cancer. Compared with other NCDs, CKD was associated with the longest hospital stay (22.1% increase) and resulted in the second highest in-hospital mortality, only lower than that of cancer (relative risk, 2.23 vs 2.87, respectively).

CONCLUSIONS

The presence of diagnosed CKD alongside each major NCD was associated with an additional burden on the healthcare system. Healthcare resource utilisation and prognosis of CKD were comparable with those of other major NCDs, which highlights the importance of CKD as a major public health burden.

Comparison of biodegradable and newer generation durable polymer drug-eluting stents with short-term dual antiplatelet therapy: a systematic review and Bayesian network meta-analysis of randomized trials comprising of 43,875 patients

Newer generation durable polymer drug-eluting stents (DP-DES) and biodegradable polymer DES (BP-DES) have similar efficacy with dual-antiplatelet therapy (DAPT) duration of > 6 months. However, this difference in outcomes have not been well studied in shorter DAPT regime. This study compares the safety and efficacy profiles of DP-DES and BP-DES based on short-term (1-3 months), intermediate-term (4-6 months) and standard DAPT (6-12 months) durations. A search was conducted on Embase and Medline for Randomized Controlled Trials (RCTs) comparing stent types, and DAPT durations. Primary endpoints include cardiac death, myocardial infarction (MI), definite stent thrombosis, stroke, target vessel revascularization (TVR) and major bleeding. Network analysis was conducted to summarize the evidence. A total of 15 RCTs involving 43,875 patients were included. DP-DES was associated with significantly lower major bleeding rates compared to BP-DES (RR 0.44, Crl 0.22-0.83) in short-term DAPT. Among DP-DES patients, short-term DAPT was associated with lower major bleeding risk compared to standard DAPT (RR 0.47, CrI 0.32-0.69). This favorable bleeding profile with short DAPT was not found in BP-DES patients. Cardiac death, MI, definite stent thrombosis, stroke and TVR rates were similar across the various DAPT durations and stent types. Our preliminary findings demonstrated comparable efficacy and safety outcomes between BP-DES and newer generation BP-DES across various DAPT durations. In patients requiring short DAPT, DP-DES had more favourable major bleeding profile compared to BP-DES, without compromising anti-thrombotic efficacy.

Safety Comparison of Monotherapy Aspirin to Dual Antiplatelet Therapy Following Coronary Artery Bypass Surgery

BACKGROUND

Dual antiplatelet therapy (DAPT) is recommended over single antiplatelet therapy (SAPT) in patients following coronary artery bypass grafting (CABG). The compilation of evidence has focused on the efficacy of DAPT to limit risk of graft occlusion, however the safety, especially in the on-pump CABG population, is less well described. The aim of this study was to assess the safety of DAPT versus SAPT after on-pump CABG.

METHODS

This was a single-center, retrospective cohort analysis of adult patients following isolated on-pump CABG between January 2012 and December 2019 not on oral anticoagulation at discharge. The primary endpoint was occurrence of a composite bleeding event identified by pre-specified ICD codes. Secondary endpoints consisted of 30-day and 1-year mortalities along with individual bleeding components.

RESULTS

Of the 2341 patients included 1250 patients were in the SAPT arm and 1091 patients in the DAPT arm. The study populations differed by age, prior MI, PAD, and CHF status/stage. Bleeding events occurred in a total of 70 patients (3.0%), with 36 patients (2.9%) in the SAPT arm and 34 patients (3.1%) in the DAPT arm (P = .74). 30-day (SAPT 0.7% vs DAPT 0.4%) and 1-year (SAPT 3.3% vs DAPT 2.3%) mortality were not significantly different between groups. The most frequent bleed event was in the gastrointestinal tract.

CONCLUSION

In this study, DAPT was not associated with an increase in composite bleeding compared to SAPT. This study could reduce the barrier to prescribing of DAPT given previous efficacy data.

P2Y12-dependent activation of hematopoietic stem and progenitor cells promotes emergency hematopoiesis after myocardial infarction

Emergency hematopoiesis is the driving force of the inflammatory response to myocardial infarction (MI). Increased proliferation of hematopoietic stem and progenitor cells (LSK) after MI enhances cell production in the bone marrow (BM) and replenishes leukocyte supply for local cell recruitment to the infarct. Decoding the regulation of the inflammatory cascade after MI may provide new avenues to improve post-MI remodeling. In this study, we describe the influence of adenosine diphosphate (ADP)-dependent P2Y₁₂-mediated signaling on emergency hematopoiesis and cardiac remodeling after MI. Permanent coronary ligation was performed to induce MI in a murine model. BM activation, inflammatory cell composition and cardiac function were assessed using global and platelet-specific gene knockout and pharmacological inhibition models for P2Y₁₂. Complementary in vitro studies allowed for investigation of ADP-dependent effects on LSK cells. We found that ADP acts as a danger signal for the hematopoietic BM and fosters emergency hematopoiesis by promoting Akt phosphorylation and cell cycle progression. We were able to detect P2Y₁₂ in LSK, implicating a direct effect of ADP on LSK via P2Y₁₂ signaling. P2Y₁₂ knockout and P2Y₁₂ inhibitor treatment with prasugrel reduced emergency hematopoiesis and the excessive inflammatory response to MI, translating to lower numbers of downstream progeny and inflammatory cells in the blood and infarct. Ultimately, P2Y₁₂ inhibition preserved cardiac function and reduced chronic adverse cardiac remodeling after MI. P2Y₁₂-dependent signaling is involved in emergency hematopoiesis after MI and fuels post-ischemic inflammation, proposing a novel, non-canonical value for P2Y₁₂ antagonists beyond inhibition of platelet-mediated atherothrombosis.

Combination of TyG Index and GRACE Risk Score as Long-Term Prognostic Marker in Patients with ACS Complicated with T2DM Undergoing PCI

OBJECTIVE

We aimed to investigate the prognostic value of the triglyceride-glucose (TyG) index combined the with Global Registry of Acute Coronary Events (GRACE) score in adult acute coronary syndrome (ACS) patients with type 2 diabetes mellitus (T2DM) who underwent percutaneous coronary intervention (PCI).

METHODS

The study enrolled total 899 ACS patients with T2DM who underwent PCI. TyG index and the GRACE risk score were calculated and assessed by median. The correlation was analyzed by Spearman's rank correlation coefficient. The cumulative major adverse cardiovascular event (MACE) curve was generated using the Kaplan-Meier method. Multivariate Cox regression was used to identify predictors of MACEs. Additionally, the receiver operating characteristic curve (ROC), net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) were applied to analyze the performance of each single factor index and combined multivariate index in predicting MACE.

RESULTS

In the ACS patients with T2DM after PCI, there were significant differences in the TyG index and GRACE risk score between the MACE group and the MACE-free group (P < 0.001). Kaplan-Meier analysis showed that the TyG index combined with the GRACE risk score was positively correlated with the occurrence of MACEs (log rank P < 0.001). Multivariate Cox regression analyses showed that the TyG index, the GRACE risk score, and the TyG index combined with the GRACE risk score were independent predictors of long-term MACEs (adjusted HR: 1.805; 95% CI: 1.479-2.203, P < 0.001; adjusted HR: 1.012; 95% CI: 1.009-1.016, P < 0.001; and adjusted HR: 2.337; 95% CI: 1.805-3.025, P < 0.001, respectively). Correlation analysis indicated that the TyG index was positively correlated with the GRACE risk score (R = 0.140, P < 0.001). The analysis of AUC, NRI and IDI revealed that the combined multivariate index performed better prognostic role than each single factor index in predicting the occurrence of MACE.

CONCLUSION

Both the GRACE risk score and the TyG index could be significant and independent predictors of clinical outcomes in ACS patients with T2DM after PCI. A combination of them could be enhanced predictions of clinical outcomes in these patients.

Short- and long-term outcomes of percutaneous coronary interventions of high-risk vs. low-risk lesions performed at a hospital without an on-site cardiac surgery unit

Aim    Widespread utilization of technology has led to the construction of a growing number of facilities with coronary angiography units and percutaneous coronary intervention (PCI) capability. Some of these centers do not have cardiovascular surgery (CVS) on site. Studies regarding the efficacy and safety of PCIs performed at these hospitals have been conducted. However, to date, high-risk procedures in this context have not been evaluated. The present study compares the outcomes of PCI procedures performed on high- and low-risk lesions groups in a center without CVS back-up.Material and methods    A total of 999 patients treated with PCI with diagnoses other than ST elevation myocardial infarction were included in this study. Patients with SYNTAX scores 22 or higher, bifurcation lesions, chronic total occlusions, left main coronary artery lesions and saphenous graft lesions were classified as a high-risk group. In contrast, patients with SYNTAX scores lower than 22 were included in the low-risk group. Coronary lesions were classified as Type-A, B, and C. The 30‑day major adverse cardiac events (MACE) and 1‑year target vessel revascularization (TVR) rates were compared.Results    There was no significant difference between the groups in terms of the rates of MACE (2 (0.9 %) vs 5 (0.6 %); p=0.64) and TVR (9 (4.2 %) vs 25 (3.2 %); p=0.52). Analysis regarding the lesion type also revealed no significant difference between the MACE and TVR rates (p=0.56 and p=0.43, respectively).Conclusions    The findings in this study demonstrated that, similar to low-risk procedures, complex and high-risk coronary interventions can safely and effectively be conducted in hospitals without a CVS unit.

Appraising the contemporary role of aspirin for primary and secondary prevention of atherosclerotic cardiovascular events

INTRODUCTION

Although the role of aspirin for primary prevention of atherosclerotic cardiovascular disease (ASCVD) has been disputed, its use in secondary ASCVD prevention is well established. Recent trials of primary prevention do not suggest a significant net benefit with aspirin, whereas accruing evidence supports adopting aspirin-free strategies in the context of potent P2Y₁₂ inhibition for the secondary prevention of selected patients undergoing percutaneous coronary intervention.

AREAS COVERED

This updated review aims at summarizing and appraising the pharmacological characteristics and the contemporary role of aspirin for the primary and secondary prevention of ASCVD.

EXPERT OPINION

Recent trials and metanalyses in the context of primary prevention highlighted a modest reduction in ischemic events with aspirin use, counterbalanced by a significant increase in bleeding events. However, ongoing studies on cancer prevention could modify the current paradigm of the unfavorable benefit-risk ratio of aspirin in patients with no overt ASCVD. Conversely, aspirin use is crucial for secondary ASCVD prevention, both in chronic and acute coronary syndromes. Nevertheless, after a brief period of dual antiplatelet therapy, patients at high bleeding risk may benefit from discontinuation of aspirin if a P2Y₁₂ inhibitor is used, hence reducing the bleeding risk with no rebound in thrombotic events.

Integrated Gene Expression Profiling Analysis Reveals Potential Molecular Mechanisms and Candidate Biomarkers for Early Risk Stratification and Prediction of STEMI and Post-STEMI Heart Failure Patients

Objective: To explore the molecular mechanism and search for the candidate differentially expressed genes (DEGs) with the predictive and prognostic potentiality that is detectable in the whole blood of patients with ST-segment elevation (STEMI) and those with post-STEMI HF. Methods: In this study, we downloaded GSE60993, GSE61144, GSE66360, and GSE59867 datasets from the NCBI-GEO database. DEGs of the datasets were investigated using R. Gene ontology (GO) and pathway enrichment were performed via ClueGO, CluePedia, and DAVID database. A protein interaction network was constructed via STRING. Enriched hub genes were analyzed by Cytoscape software. The least absolute shrinkage and selection operator (LASSO) logistic regression algorithm and receiver operating characteristics analyses were performed to build machine learning models for predicting STEMI. Hub genes for further validated in patients with post-STEMI HF from GSE59867. Results: We identified 90 upregulated DEGs and nine downregulated DEGs convergence in the three datasets (|log₂FC| ≥ 0.8 and adjusted p < 0.05). They were mainly enriched in GO terms relating to cytokine secretion, pattern recognition receptors signaling pathway, and immune cells activation. A cluster of eight genes including ITGAM, CLEC4D, SLC2A3, BST1, MCEMP1, PLAUR, GPR97, and MMP25 was found to be significant. A machine learning model built by SLC2A3, CLEC4D, GPR97, PLAUR, and BST1 exerted great value for STEMI prediction. Besides, ITGAM and BST1 might be candidate prognostic DEGs for post-STEMI HF. Conclusions: We reanalyzed the integrated transcriptomic signature of patients with STEMI showing predictive potentiality and revealed new insights and specific prospective DEGs for STEMI risk stratification and HF development.

Atrial Fibrillation and Coronary Artery Disease: A Long-Term Perspective on the Need for Combined Antithrombotic Therapy

BACKGROUND

Older adults with atrial fibrillation (AF) are often treated with the shortest possible duration of antiplatelet/anticoagulant therapy after myocardial infarction (MI) or percutaneous coronary intervention (PCI) due to concern for bleeding. However, the risk of recurrent MI or PCI prompting antiplatelet therapy extension is unknown in this population.

METHODS

Using the National Cardiovascular Data Registry linked to Medicare claims, we described the cumulative incidence of recurrent MI or PCI over a median of 7-year follow-up for patients ≥65 years old with AF discharged alive after acute MI between 2008 and 2017. We used pharmacy fill data to describe the proportion of patients filling prescriptions for both oral anticoagulants and P2Y₁₂ inhibitors for ≥50% of the indicated duration after MI or PCI.

RESULTS

Of 187 622 older patients discharged alive after MI, 50 539 (26.9%) had AF. Over a median of 7-year follow-up in patients with AF, the cumulative incidence was 14.5% for recurrent MI, 12.1% for PCI, 7.9% for stroke, and 9.5% for bleeding hospitalization. Among 7998 patients with AF and recurrent MI or PCI, 1668 (20.9%) had >1 MI or PCI during follow-up. Assuming each MI or PCI should be followed by 6 months of P2Y₁₂ inhibitor therapy, patients with AF who had a recurrent MI/PCI had a median estimated indication for antiplatelet/anticoagulant treatment of 287 days (194, 358), but filled both P2Y₁₂ inhibitor and oral anticoagulant for a median of 0 days (0, 21). In this cohort, 12.2% of patients filled prescriptions for both a P2Y₁₂ inhibitor and oral anticoagulant for ≥50% of the indicated duration.

CONCLUSIONS

Older adults with AF and MI have high incidences of downstream recurrent MI or PCI requiring extended antiplatelet/anticoagulant therapy durations, yet many appear to be under-treated. These results highlight the need for better thrombosis prevention strategies in this group of patients.

Rotational Thromboelastometry in High-Risk Patients on Dual Antithrombotic Therapy After Percutaneous Coronary Intervention

Aims: Patients using antithrombotic drugs after percutaneous coronary intervention (PCI) are at risk for bleeding and recurrent ischemia. We aimed to explore routine and tissue plasminogen activated (tPA) ROTEM results in a post-PCI population on dual antithrombotic treatment.

Methods and Results: In this prospective cohort, 440 patients treated with double antithrombotic therapy after recent PCI and with ≥3 risk factors for either ischemic or bleeding complications were included and compared with a control group (n = 95) consisting of perioperative patients not using antithrombotic medication. Laboratory assessment, including (tPA) ROTEM, was performed one month post-PCI and bleeding/ischemic complications were collected over a five-month follow-up. Patients were stratified by antithrombotic regimen consisting of a P2Y12 inhibitor with either aspirin (dual antiplatelet therapy; DAPT, n = 323), a vitamin K antagonist (VKA, n = 69) or a direct oral anticoagulant (DOAC, n = 48). All post-PCI patients had elevated ROTEM clot stiffness values, but only the DAPT group additionally presented with a decreased fibrinolytic potential as measured with tPA ROTEM. Patients receiving anticoagulants had prolonged clotting times (CT) when compared to the control and DAPT group; EXTEM and FIBTEM CT could best discriminate between patients (not) using anticoagulants (AUC > 0.97). Furthermore, EXTEM CT was significantly prolonged in DAPT patients with bleeding complications during follow-up (68 [62–70] vs. 62 [57–68], p = 0.030).

Conclusion: ROTEM CT has high potential for identifying anticoagulants and tPA ROTEM could detect a diminished fibrinolytic potential in patients using DAPT. Furthermore, the ability of EXTEM CT to identify patients at risk for bleeding may be promising and warrants further research.

Duration of Dual Antiplatelet Therapy After Implantation of Drug-Coated Balloon

The drug-coated balloon (DCB) is an emerging percutaneous coronary intervention (PCI) device with theoretical advantages and promising results. Recent clinical observations have demonstrated that DCB tends to have both good efficacy and a good safety profile in the treatment of in-stent restenosis (ISR) for both bare-metal and drug-eluting stents (DES), de novo coronary artery disease (CAD), and other situation, such as high bleeding risk, chronic total occlusion, and acute coronary syndrome (ACS). Dual antiplatelet therapy (DAPT) has become an essential medication in daily clinical practice, but the optimal duration of DAPT after the implantation of a DCB remains unknown. At the time of the first in vivo implantation of paclitaxel-DCB for the treatment of ISR in 2006, the protocol-defined DAPT duration was only 1 month. Subsequently, DAPT duration ranging from 1 to 12 months has been recommended by various trials. However, there have been no randomized controlled trials (RCTs) on the optimal duration of DAPT after DCB angioplasty. Current clinical guidelines normally recommend the duration of DAPT after DCB-only angioplasty based on data from RCTs on the optimal duration of DAPT after stenting. In this review, we summarized current clinical trials on DCB-only angioplasty for different types of CADs and their stipulated durations of DAPT, and compared their clinical results such as restenosis, target lesion revascularization (TLR) and stent thrombosis event. We hope this review can assist clinicians in making reasonable decisions about the duration of DAPT after DCB implantation.

Efficacy and safety of tirofiban bridge as an alternative to suspension of dual antiplatelet therapy in patients undergoing surgery: a systematic review

Use of a tirofiban bridge is an alternative to simply withdrawing dual antiplatelet therapy prior to operating on patients at high risk of stent thrombosis and bleeding. We aimed to evaluate the efficacy and safety of this protocol in patients undergoing surgery within 12 months of a percutaneous coronary intervention involving stenting. We performed a systematic review based on searches of the PubMed, Web of Science, Cochrane, Embase, Lilacs, and Scielo databases and of the references of relevant articles on the topic. Five of the 107 studies identified were included after application of eligibility criteria and analysis of methodological quality, totaling 422 patients, 227 in control groups. Notwithstanding the limitations reported, four of the five studies included indicate that the tirofiban bridge technique is effective for reducing adverse cardiac events and is safe in terms of not interfering with the risk of hemorrhagic events or bleeding. However, randomized clinical trials are needed to provide robust evidence.

Stroke and Myocardial Infarction: A Bidirectional Mendelian Randomization Study

Background

Stroke and myocardial infarction (MI) are associated with each other, as demonstrated in observational studies. However, it is unclear whether this relationship is causal, and the purpose of this study was to explore the bidirectional causality between stroke and MI.

Methods

Causality between stroke and MI was assessed using two-sample Mendelian randomization (MR). All genetic instruments related to stroke (40,585 cases; 406,111 controls) and MI (43,676 cases; 128,199 controls) were derived from large published genome-wide association study. The MR analysis was calculated with inverse-variance weighting, MR-Egger, weighted mode, weighted median, and simple mode methods, and sensitivity analyses are used to detect the heterogeneity or pleiotropy.

Results

Genetically predicted large-artery stroke (LAS) was causally related to higher odds of MI (odds ratio [OR] = 1.13, 95% confidence interval [CI]: 1.06–1.20, p = 1.0×10⁻⁴), and the causal effect of LAS on MI was significantly weakened (OR = 1.09, 95% CI: 1.02–1.17, p = 0.017) after excluding the multipotent single-nucleotide polymorphisms (SNPs). MI phenotypes were genetically correlated with all ischemic strokes (OR = 1.15, 95% CI: 1.03–1.28, p = 0.013) and LAS (OR = 1.39, 95% CI: 1.14–1.71, p = 0.001); but a causal effect of MI on all ischemic strokes (OR = 1.00, 95% CI: 0.95–1.28, p = 0.219) and LAS (OR = 1.26, 95% CI: 0.93–1.69, p = 0.130) was not observed after excluding the multipotent SNPs.

Conclusion

This MR analysis provides evidence to support the causal effect of LAS subtype on MI, and some factors act as confiding factors whereas others may act as mediators.

Post-traumatic Stress Disorder and Risk Factors in Patients With Acute Myocardial Infarction After Emergency Percutaneous Coronary Intervention: A Longitudinal Study

This study aimed to investigate the status and risk factors of post-traumatic stress disorder (PTSD) in patients with acute myocardial infarction (AMI) after emergency percutaneous coronary intervention (PCI) in acute and convalescence phases. A longitudinal study design was used. Two questionnaire surveys were conducted in the acute stage of hospitalization, and 3 months after onset in patients. Logistic regression was used to analyze the risk factors for PTSD in AMI patients. The incidence of PTSD was 33.1 and 20.4% in acute and convalescent patients, respectively. The risk factors related to PTSD were door-to-balloon time (DTB) (≥92.6 min), left ventricular ejection fraction (LVEF) (<50%), smoking, anxiety, and depression. AMI patients after PCI had PTSD in the acute and convalescent stage. The findings indicate that tailored measures should be developed and carried out to prevent PTSD and improve the mental health of patients with AMI after undergoing PCI.

Addressing disparities of care in non-ST-segment elevation myocardial infarction patients without standard modifiable risk factors: insights from a nationwide cohort study

AIMS

The importance of standard modifiable cardiovascular risk factors (SMuRFs) in preventing non-ST-segment elevation myocardial infarction (NSTEMI) is established. However, NSTEMI may present in the absence of SMuRFs, and little is known about their outcomes.

METHODS AND RESULTS

We analysed 176 083 adult (≥18 years) hospitalizations with NSTEMI using data from the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP). Clinical characteristics and all-cause in-hospital mortality were analysed according to SMuRF status, with 135 223 patients presenting with at least one of diabetes, hypertension, hypercholesterolaemia, or current smoking status and 40 860 patients without any SMuRFs. Those with a history of coronary artery disease were excluded. Patients without SMuRFs were more frequently older (median age 72 year vs. 71 years, P < 0.001), male (62% vs. 61%, P < 0.001), and Caucasian (95% vs. 92%, P < 0.001). Those without SMuRFs less frequently received statins (71% vs. 81%, P < 0.001), had their left ventricular (LV) function recorded (62% vs. 65%, P < 0.001) or for those with moderate or severe LV systolic dysfunction were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (80% vs. 85%, P < 0.001). Following propensity score matching the odds of all-cause mortality [odds ratio (OR): 0.85, 95% confidence interval (CI): 0.77-0.93], cardiac mortality (OR: 0.85, 95% CI: 0.76-0.94), and major adverse cardiovascular events (MACE) (OR: 0.85, 95% CI: 0.77-0.93) were lower in patients without SMuRFs.

CONCLUSION

More than one in five patients presenting with NSTEMI had no SMuRFs, who were less frequently received guideline-recommended management and had lower in-hospital (all-cause and cardiac) mortality and MACE than patients with SMuRFs.

Interventional cardiologists' attitudes towards pharmacogenetic testing and impact on antiplatelet prescribing decisions

Aim: To determine if interventional cardiologists' knowledge and attitudes toward pharmacogenetic (PGx) testing influenced their antiplatelet prescribing decisions in response to CYP2C19 results. Materials & methods: Surveys were administered prior to participating in a randomized trial of CYP2C19 testing. Associations between baseline knowledge/attitudes and agreement with the genotype-guided antiplatelet recommendations were determined using multivariable logistic regression. Results: 50% believed that PGx testing would be valuable to predict medication toxicity or efficacy. 64% felt well informed about PGx testing and its therapeutic application. However, PGx experience, knowledge, nor attitudes were significantly associated with agreement to genotype-guided antiplatelet recommendations. Conclusion: Cardiologists' knowledge and attitudes were not associated with CYP2C19-guided antiplatelet prescribing, but larger studies should be done to confirm this finding.

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.

Clopidogrel versus ticagrelor in the treatment of Chinese patients undergoing percutaneous coronary intervention: effects on platelet function assessed by platelet function tests and mean platelet volume

Background

Knowledge on the pharmacodynamic effects of antiplatelet drugs including clopidogrel and ticagrelor on Asian patients is scarce. We aim to evaluate the effects of the two drugs on platelet reactivity in the treatment of Chinese patients who underwent percutaneous coronary intervention (PCI), using two platelet function tests (PFT). Meanwhile, the relationship between mean platelet volume (MPV), a routine index of platelet size, and high on-treatment platelet reactivity (HPR) is also investigated.

Methods

Patients receiving dual antiplatelet therapy (DAPT) were scheduled for the assessment of platelet reactivity at 2–3 days after PCI. Two PFTs, light transmission aggregometry (LTA) and vasodilator-stimulated phosphoprotein (VASP)-FCM assay, were applied in the evaluation of platelet reactivity. The MPV was measured simultaneously with EDTA plasma using a Sysmex XN 2000 automated hematology analyzer.

Results

The final study population included the aspirin + clopidogrel group (n = 46) and the aspirin + ticagrelor group (n = 66). In the aspirin + ticagrelor group, the maximal light transmittance (LT) changes in response to 5 μM ADP assessed by LTA was obviously lower than that in the aspirin + clopidogrel group (P <  0.001). The platelet reactivity index (PRI) level in the VASP test was also markedly lower in the group given aspirin and ticagrelor (P <  0.001). There was a significant difference in HPR between the two groups. MPV showed a potent ability to predict the presence of HPR at VASP assay (AUC = 0.788, 95% CI: 0.701–0.875, P <  0.001) in receiver-operating characteristic curve analysis.

Conclusions

Compared with clopidogrel, ticagrelor has dramatically greater antiplatelet effect, with a superiority in suppressing platelet function and a lower HPR rate. In addition, there existed a significant independent association between MPV and high prevalence of HPR in the VASP assay.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-021-00350-2.

Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis

BACKGROUND

Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF).

OBJECTIVE

To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF.

DESIGN

Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019.

PARTICIPANTS

New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis.

MEASUREMENTS

Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time.

RESULTS

After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72).

LIMITATIONS

Residual confounding.

CONCLUSIONS

In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.

The Impact of American College of Cardiology Chest Pain Center Accreditation on Guideline Recommended Acute Myocardial Infarction Management

BACKGROUND

Whether American College of Cardiology (ACC) Chest Pain Center (CPC) accreditation alters guidelines adherence rates is unclear.

METHODS

We analyzed patient-level, hospital-reported, quality metrics for myocardial infarction (MI) patients from 644 hospitals collected in the ACC's Chest Pain-MI Registry from January 1, 2019, to December 31, 2020, stratified by CPC accreditation for >1 year.

RESULTS

Of 192,374 MI patients, 67,462 (35.1%) received care at an accredited hospital. In general, differences in guideline adherence rates between accredited and nonaccredited hospitals were numerically small, although frequently significant. Patients at accredited hospitals were more likely to undergo coronary angiography (98.6% vs. 97.9%, P < 0.0001), percutaneous coronary intervention for NSTEMI (55.4% vs. 52.3%, P < 0.0001), have overall revascularization for NSTEMI (63.5% vs. 61.0%, P < 0.0001), and receive P2Y12 inhibitor on arrival (63.5% vs. 60.2%, P < 0.0001). Nonaccredited hospitals more ECG within 10 minutes (62.3% vs. 60.4%, P < 0.0001) and first medical contact to device activation ≤90 minutes (66.8% vs. 64.8%, P < 0.0001). Accredited hospitals had uniformly higher discharge medication guideline adherence, with patients more likely receiving aspirin (97.8% vs. 97.4%, P < 0.0001), angiotensin-converting enzyme inhibitor (46.7% vs. 45.3%, P < 0.0001), beta blocker (96.6% vs. 96.2%, P < 0.0001), P2Y12 inhibitor (90.3% vs. 89.2%, P < 0.0001), and statin (97.8% vs. 97.5%, P < 0.0001). Interaction by accredited status was significant only for length of stay, which was slightly shorter at accredited facilities for specific subgroups.

CONCLUSIONS

ACC CPC accreditation was associated with small consistent improvement in adherence to guideline-based treatment recommendations of catheter-based care (catheterization and PCI) for NSTEMI and discharge medications, and shorter hospital stays.

How to Handle Arterial Conduits in Liver Transplantation? Evidence From the First Multicenter Risk Analysis

OBJECTIVE

The aims of the present study were to identify independent risk factors for conduit occlusion, compare outcomes of different AC placement sites, and investigate whether postoperative platelet antiaggregation is protective.

BACKGROUND

Arterial conduits (AC) in liver transplantation (LT) offer an effective rescue option when regular arterial graft revascularization is not feasible. However, the role of the conduit placement site and postoperative antiaggregation is insufficiently answered in the literature.

STUDY DESIGN

This is an international, multicenter cohort study of adult deceased donor LT requiring AC. The study included 14 LT centers and covered the period from January 2007 to December 2016. Primary endpoint was arterial occlusion/patency. Secondary endpoints included intra- and perioperative outcomes and graft and patient survival.

RESULTS

The cohort was composed of 565 LT. Infrarenal aortic placement was performed in 77% of ACs whereas supraceliac placement in 20%. Early occlusion (≤30 days) occurred in 8% of cases. Primary patency was equivalent for supraceliac, infrarenal, and iliac conduits. Multivariate analysis identified donor age >40 years, coronary artery bypass, and no aspirin after LT as independent risk factors for early occlusion. Postoperative antiaggregation regimen differed among centers and was given in 49% of cases. Graft survival was significantly superior for patients receiving aggregation inhibitors after LT.

CONCLUSION

When AC is required for rescue graft revascularization, the conduit placement site seems to be negligible and should follow the surgeon's preference. In this high-risk group, the study supports the concept of postoperative antiaggregation in LT requiring AC.

Preoperative Care for Cataract Surgery: The Society for Ambulatory Anesthesia Position Statement

Cataract surgeries are among the most common procedures requiring anesthesia care. Cataracts are a common cause of blindness. Surgery remains the only effective treatment of cataracts. Patients are often elderly with comorbidities. Most cataracts can be treated using topical or regional anesthesia with minimum or no sedation. There is minimal risk of adverse outcomes. There is general consensus that cataract surgery is extremely low risk, and the benefits of sight restoration and preservation are enormous. We present the Society for Ambulatory Anesthesia (SAMBA) position statement for preoperative care for cataract surgery.

Coronary Intravascular Lithotripsy Versus Rotational Atherectomy in an Asian Population: Clinical Outcomes in Real-World Patients

Intravascular lithotripsy (IVL) is a newer calcium modification therapy with limited clinical experience compared to other established techniques. Single-armed studies have shown IVL is safe and effective for heavily calcified coronary lesions. This study compares our initial IVL experience with rotational atherectomy in real-world high-risk patients. We found that in-hospital adverse outcomes were not statistically significant, although 30-day major adverse cardiovascular events was higher with IVL. Differences in baseline characteristics and the small cohort numbers preclude definitive conclusions. With better experience and case selection, these outcomes are likely to improve, allowing IVL to effectively treat complex calcified coronary lesions.

Background and Objectives

We compared real-world clinical outcomes of patients receiving intravascular lithotripsy (IVL) versus rotational atherectomy (RA) for heavily calcified coronary lesions.

Methods

Fifty-three patients who received IVL from January 2017 to July 2020 were retrospectively compared to 271 patients who received RA from January 2017 to December 2018. Primary endpoints were in-hospital and 30-day major adverse cardiovascular events (MACE).

Results

IVL patients had a higher prevalence of acute coronary syndrome (56.6% vs 24.4, p<0.001), multivessel disease (96.2% vs 73.3%, p<0.001) and emergency procedures (17.0% vs 2.2%, p<0.001) compared to RA. In-hospital MACE (11.3% vs 5.9%, p=0.152), MI (7.5% vs 3.3%, p=0.152), and mortality (5.7% vs 3.0%, p=0.319) were not statistically significant. 30-day MACE was higher in the IVL cohort vs RA (17.0% vs 7.4%, p=0.035). Propensity score adjusted regression using IVL was also performed on in-hospital MACE (odds ratio [OR], 1.677; 95% confidence interval [CI], 0.588–4.779) and 30-day MACE (OR, 1.910; 95% CI, 0.774–4.718).

Conclusions

These findings represent our initial IVL experience in a high-risk, real-world cohort. Although the event rate in the IVL arm was numerically higher compared to RA, the small numbers and retrospective nature of this study preclude definitive conclusions. These clinical outcomes are likely to improve with greater experience and better case selection, allowing IVL to effectively treat complex calcified coronary lesions.

Aspirin in the Modern Era of Cardiovascular Disease Prevention

Aspirin’s antithrombotic effects have a long-established place in the prevention of cardiovascular disease (CVD), and its traditional use as a core therapy for secondary prevention of CVD is well recognized. However, with the advent of newer antiplatelet agents and an increasing understanding of aspirin’s bleeding risks, its role across the full spectrum of modern CVD prevention has become less certain. As a consequence, recent trials have begun investigating aspirin-free strategies in secondary prevention. For example, a contemporary metanalysis of trials that assessed P2Y₁₂ inhibitor monotherapy versus prolonged (≥ 12 months) dual antiplatelet therapy (which includes aspirin) after percutaneous coronary intervention reported a lower risk of major bleeding and no increase in stent thrombosis, all-cause mortality, myocardial infarction (MI), or stroke in the P2Y₁₂ monotherapy group.

In contrast to secondary prevention, aspirin’s role in primary prevention has always been more controversial. While historical trials reported a reduction in MI and stroke, more contemporary trials have suggested diminishing benefit for aspirin in this setting, with no reduction in hard outcomes, and some primary prevention trials have even indicated a potential for harm. In this review, we discuss how changing population demographics, enhanced control of lipids and blood pressure, changes in the definition of outcomes like MI, evolution of aspirin formulations, and updated clinical practice guidelines have all impacted the use of aspirin for primary and secondary CVD prevention.

2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y12 Receptor Antagonists in the Asia-Pacific Region: Special Populations

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y₁₂ inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y₁₂ inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.

Research Progress of Electrical Stimulation in Ischemic Heart Disease

Ischemic heart disease (IHD) is a considerable health burden worldwide with high mortality and morbidity. Treatments for IHD are mainly focused on decreasing oxygen demand or increasing myocardial oxygen supply, including pharmacological, interventional, and surgical treatment, but there are also some limitations. Therefore, it is important to find a simple, effective, and economical treatment. As non-invasive and safe physiotherapy, electrical stimulation (ES) has a promising application in the treatment of IHD. Current studies suggest that ES can affect the occurrence and development of IHD by promoting angiogenesis, regulating autophagy and apoptosis, inhibiting the inflammatory response and oxidative stress. In this review, we focus predominantly on the mechanism of ES and the current progress of ES therapy in IHD, furthermore, give a brief introduction to the forms of ES in clinical application.

From Coronaries to Cirrhosis: The Role of Percutaneous Coronary Intervention and Dual Antiplatelet Therapy in End-Stage Liver Disease

Drug-eluting stents (DES) have superior efficacy compared with bare metal stents (BMS) for treatment of coronary artery lesions. However, BMS continue to play an important role in percutaneous coronary intervention for patients who are at a high bleeding risk, because they require a shorter duration of dual antiplatelet therapy. However, new developments in DES and understanding of the optimal time required for dual antiplatelet therapy after percutaneous coronary intervention may further limit the use of BMS. Furthermore, the use of dual antiplatelet therapy is complicated in patients with cirrhosis, who may have coagulopathy. In this article, we present the case of a patient with cirrhosis and end-stage chronic liver disease with coronary artery disease and a proximal left anterior descending stenosis who received a DES and had multiple episodes of gastrointestinal bleeding. We review the literature addressing DES and BMS in patients at high risk of bleeding. We also review the optimal duration of dual antiplatelet therapy.

Incidence of ischaemic stroke and mortality in patients with acute coronary syndrome and first-time detected atrial fibrillation: a nationwide study

AIMS

The aim of this study was to examine contemporary data on the 1-year prognosis of patients surviving acute coronary syndrome (ACS) and concomitant first-time detected atrial fibrillation (AF).

METHODS AND RESULTS

Using Danish nationwide registries, we identified all patients surviving a first-time admission with ACS from 2000 to 2018 and grouped them into (i) those without AF prior to or during ACS; (ii) those with a history of AF; and (iii) those with first-time detected AF during admission with ACS. With 1 year of follow-up, rates of ischaemic stroke, death, and bleeding were compared between study groups using multivariable adjusted Cox proportional hazards analysis. We included 161 266 ACS survivors: 135 878 (84.2%) without AF, 18 961 (11.8%) with history of AF, and 6427 (4.0%) with first-time detected AF at admission with ACS. Compared to those without AF, the adjusted 1-year rates of outcomes were as follows: ischaemic stroke [hazard ratio (HR) 1.38 (95% CI 1.22-1.56) for patients with history of AF and HR 1.67 (95% CI 1.38-2.01) for patients with first-time detected AF]; mortality [HR 1.25 (95% CI 1.21-1.31) for patients with history of AF and HR 1.52 (95% CI 1.43-1.62) for patients with first-time detected AF]; and bleeding [HR 1.22 (95% CI 1.14-1.30) for patients with history of AF and HR 1.28 (95% CI 1.15-1.43) for patients with first-time detected AF].

CONCLUSION

In patients with ACS, first-time detected AF appeared to be at least as strongly associated with the 1-year rates of ischaemic stroke, mortality, and bleeding as compared with patients with a history of AF.

Patient characteristics and safety outcomes in new users of ticagrelor and clopidogrel-An observational cohort study in Sweden

PURPOSE

We aimed to describe characteristics of new users of ticagrelor or clopidogrel following a recent coronary event, and to compare incidences of selected safety outcomes.

METHODS

This observational cohort study used data from national Swedish registers. Patients first dispensed ticagrelor or clopidogrel (June 2011-December 2013) were identified from the Prescribed Drug Register and followed until censoring or 31 December 2014. Cohorts were restricted to patients with a recent coronary event-related hospital contact identified in the Patient Register.

RESULTS

The study included 45 987 unique, naïve users of ticagrelor (73% men; mean age 66 years) or clopidogrel (69% men; mean age 69 years). Corresponding to indication, diagnoses before initiation were acute coronary syndrome (93%), myocardial infarction (76%), and percutaneous coronary intervention (69%). The most common medications used in the year before initiation of study therapy were antithrombotic agents (clopidogrel 62%, ticagrelor 43%), mainly low-dose acetylsalicylic acid. Ticagrelor users had a higher incidence (per 1000 person-years) of respiratory bleeding (24.6 [95% confidence interval (CI): 22.1-27.3]; vs clopidogrel users: 14.4 [13.1-15.8]) and dyspnea (25.9 [23.3-28.7]; vs clopidogrel users: 16.8 [15.4-18.4]). Epistaxis accounted for 83-93% of respiratory bleeds. Adjusted analyses found increased risks of gout and acute renal failure with ticagrelor.

CONCLUSIONS

Clopidogrel users were older with a higher prevalence of concomitant medications than ticagrelor users. Our study showed increased incidences of dyspnea and respiratory bleeding (mainly epistaxis) among current ticagrelor users compared with clopidogrel users, and increased risks of gout and acute renal failure after adjustment.

The P2Y12 Receptor Antagonist Selatogrel Dissolves Preformed Platelet Thrombi In Vivo

Selatogrel, a potent and reversible antagonist of the P2Y12 receptor, inhibited FeCl₃-induced thrombosis in rats. Here, we report the anti-thrombotic effect of selatogrel after subcutaneous applications in guinea pigs and mice. Selatogrel inhibited platelet function only 10 min after subcutaneous application in mice. In addition, in a modified Folts thrombosis model in guinea pigs, selatogrel prevented a decrease in blood-flow, indicative of the inhibition of ongoing thrombosis, approximately 10 min after subcutaneous injection. Selatogrel fully normalised blood flow; therefore, we speculate that it may not only prevent, but also dissolve, platelet thrombi. Thrombus dissolution was investigated using real-time intravital microscopy in mice. The infusion of selatogrel during ongoing platelet thrombus formation stopped growth and induced the dissolution of the preformed platelet thrombus. In addition, platelet-rich thrombi were given 30 min to consolidate in vivo. The infusion of selatogrel dissolved the preformed and consolidated platelet thrombi. Dissolution was limited to the disintegration of the occluding part of the platelet thrombi, leaving small mural platelet aggregates to seal the blood vessel. Therefore, our experiments uncovered a novel advantage of selatogrel: the dissolution of pre-formed thrombi without the disintegration of haemostatic seals, suggesting a bipartite benefit of the early application of selatogrel in patients with acute thrombosis.

MIKB: A manually curated and comprehensive knowledge base for myocardial infarction

Myocardial infarction knowledge base (MIKB; http://www.sysbio.org.cn/mikb/; latest update: December 31, 2020) is an open-access and manually curated database dedicated to integrating knowledge about MI to improve the efficiency of translational MI research. MIKB is an updated and expanded version of our previous MI Risk Knowledge Base (MIRKB), which integrated MI-related risk factors and risk models for providing help in risk assessment or diagnostic prediction of MI. The updated MIRKB includes 9701 records with 2054 single factors, 209 combined factors, 243 risk models, 37 MI subtypes and 3406 interactions between single factors and MIs collected from 4817 research articles. The expanded functional module, i.e. MIGD, is a database including not only MI associated genetic variants, but also the other multi-omics factors and the annotations for their functional alterations. The goal of MIGD is to provide a multi-omics level understanding of the molecular pathogenesis of MI. MIGD includes 1782 omics factors, 28 MI subtypes and 2347 omics factor-MI interactions as well as 1253 genes and 6 chromosomal alterations collected from 2647 research articles. The functions of MI associated genes and their interaction with drugs were analyzed. MIKB will be continuously updated and optimized to provide precision and comprehensive knowledge for the study of heterogeneous and personalized MI.

Real-World Use and Outcomes of Oral Antiplatelets Among Patients with Acute Coronary Syndrome: A Retrospective Cohort Study

BACKGROUND

Acute coronary syndrome (ACS)-related readmission is an important hospital quality measure. Medication management therapy, especially adherence to antiplatelet agents post discharge, could play an important role in reducing readmission rates. Newer agents such as ticagrelor and prasugrel have been shown, in randomized control trials, to have superior effectiveness to cardiovascular outcomes compared to clopidogrel, but they are more expensive and have more common adverse events such as bleeding and dyspnea.

OBJECTIVE

We compared real-world readmission rates and adherence to antiplatelet agents among patients who initiated these agents post discharge.

METHODS

This was a retrospective cohortstudy of patients with an index ACS-related hospitalization between 1 July 2017 and 31 December 2018. Using integrated pharmacy and medical claims data from a large national pharmacy benefits manager for commercially insured adults aged ≥ 18 years, we compared ACS-related readmission and medication adherence (as medication possession ratio (MPR)) among the three agents. ANOVA and logistic regression, controlling for demographics such as age, gender, and Charlson Comorbidity Index, were used to estimate any association between the agents and 365-day readmission rates.

RESULTS

Of the 948 eligible patients, 86, 342, and 520 were initiated on prasugrel, ticagrelor, and clopidogrel (PTC), respectively. There were 4.7%, 5.3%, and 8.5% readmissions rates in the PTC cohorts, respectively, but these were not statistically significant in either the ANOVA or the logistic regression analyses. MPR was highest in the ticagrelor (88.1%) cohort, followed by the prasugrel (79.1%) and clopidogrel (76.4%) cohorts.

CONCLUSION

Ticagrelor cohort had the highest medication adherence. Clopidogrel cohort had the highest readmission rate but the difference with the other cohorts was statistically insignificant.

Pharmacogenetics to Avoid Adverse Reactions in Cardiology: Ready for Implementation?

Cardiovascular Diseases (CVs) are one of the main causes of mortality and disability around the world. Advances in drug treatment have greatly improved survival and quality of life in the past decades, but associated adverse events remain a relevant problem. Pharmacogenetics can help individualize cardiovascular treatment, reducing associated toxicities and improving outcomes. Several scientific societies and working groups periodically review available studies and provide consensus recommendations for those gene-drug pairs with a sufficient level of evidence. However, these recommendations are rarely mandatory, and the indications on how to adjust treatment can vary between different guidelines, which limits their clinical applicability. The aim of this review is to compile, compare and discuss available guidelines and recommendations by the main Pharmacogenetics Consortiums (Clinical Pharmacogenetics Implementation Consortium (CPIC); Dutch Pharmacogenetics Working Group (DPWG); the French Network of Pharmacogenetics (Réseau national de pharmacogénétique (RNPGx) and The Canadian Pharmacogenomics Network for Drug Safety (CPNDS) regarding how to apply pharmacogenetic results to optimize pharmacotherapy in cardiology. Pharmacogenetic recommendations included in European or American drug labels, as well as those included in the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) and the American Heart Association (AHA) treatment guidelines are also discussed.

Early- and Middle-Phase Angioscopic Assessment of Arterial Healing Following Current Drug-Eluting Stent Implantation in Patients With Acute Coronary Syndrome

Background: Drug-eluting stents (DESs) have been widely used for the treatment of acute coronary syndrome (ACS). However, there are few reports on early- and middle-phase arterial repair after DES implantation in ACS patients. Methods and Results: Coronary angioscopy (CAS) findings covering the early and middle phases (mean [±SD] 4±1 and 10±2 months, respectively) of arterial healing after second- and later-generation DES placement between May 2009 and January 2020 were extracted from the Kansai Rosai Hospital Cardiovascular Center database. Neointimal coverage (NIC), yellow color intensity, and the incidence of thrombus adhesion were compared between ACS and chronic coronary syndrome (CCS) in the early (54 stents of 47 lesions, 38 ACS patients; 86 stents of 70 lesions, 52 CCS patients) and middle (179 stents of 154 lesions from 136 ACS patients; 459 stents of 374 lesions from 287 CCS patients) phases. In the early phase, NIC, the incidence of thrombus adhesion (ACS, 39.1%; CCS, 38.0%), and maximum yellow color grade were similar between the 2 groups. In the middle phase, although the maximum yellow color grade was significantly higher in the ACS group (P=0.013), NIC and the incidence of thrombus adhesion (ACS, 24.6%; CCS, 23.4%) were similar in the 2 groups. Conclusions: Arterial healing assessment with CAS showed that NIC and the incidence of thrombus adhesion after DES implantation were similar between ACS and CCS patients.

Post-ST-Segment Elevation Myocardial Infarction Follow-Up Care During the COVID-19 Pandemic and the Possible Benefit of Telemedicine: An Observational Study

Background: Infectious control measures during the COVID-19 pandemic have led to the propensity toward telemedicine. This study examined the impact of telemedicine during the pandemic on the long-term outcomes of ST-segment elevation myocardial infarction (STEMI) patients.

Methods: This study included 288 patients admitted 1 year before the pandemic (October 2018–December 2018) and during the pandemic (January 2020–March 2020) eras, and survived their index STEMI admission. The follow-up period was 1 year. One-year primary safety endpoint was all-cause mortality. Secondary safety endpoints were cardiac readmissions for unplanned revascularisation, non-fatal myocardial infarction, heart failure, arrythmia, unstable angina. Major adverse cardiovascular events (MACE) was defined as the composite outcome of each individual safety endpoint.

Results: Despite unfavorable in-hospital outcomes among patients admitted during the pandemic compared to pre-pandemic era, both groups had similar 1-year all-cause mortality (11.2 vs. 8.5%, respectively, p = 0.454) but higher cardiac-related (14.1 vs. 5.1%, p < 0.001) and heart failure readmissions in the pandemic vs. pre-pandemic groups (7.1 vs. 1.7%, p = 0.037). Follow-up was more frequently conducted via teleconsultations (1.2 vs. 0.2 per patient/year, p = 0.001), with reduction in physical consultations (2.1 vs. 2.6 per patient/year, p = 0.043), during the pandemic vs. pre-pandemic era. Majority achieved guideline-directed medical therapy (GDMT) during pandemic vs. pre-pandemic era (75.9 vs. 61.6%, p = 0.010). Multivariable Cox regression demonstrated achieving medication target doses (HR 0.387, 95% CI 0.164–0.915, p = 0.031) and GDMT (HR 0.271, 95% CI 0.134–0.548, p < 0.001) were independent predictors of lower 1-year MACE after adjustment.

Conclusion: The pandemic has led to the wider application of teleconsultation, with increased adherence to GDMT, enhanced medication target dosing. Achieving GDMT was associated with favorable long-term prognosis.

NOD2-mediated P2Y12 upregulation increases platelet activation and thrombosis in sepsis

BACKGROUND

Platelets from septic patients exhibit increased reactivity. However, the underlying mechanism of sepsis-induced platelet hyperactivity is still not completely understood.

OBJECTIVE

P2Y₁₂ is a central receptor for platelet activation. In this study, we investigated the role of platelet P2Y₁₂ in platelet hyperactivity during sepsis.

METHODS

We measured platelet P2Y₁₂ expression and aggregation in response to ADP in septic patients and cecal ligation and puncture (CLP)-treated mice. We also detected the downstream signaling of P2Y₁₂ in resting platelets from patients and mice with sepsis. The role of nucleotide-binding oligomerization domain 2 (NOD2)/RIP2/NF-κB/P65 pathway in sepsis-induced platelet P2Y₁₂ high expression was also investigated. Finally, we compared the antiplatelet and antithrombotic effects of clopidogrel, prasugrel, and ticagrelor in experimental sepsis in mice and rats.

RESULTS

Compared to healthy subjects, platelets from septic patients exhibit P2Y₁₂ hyperactivity and higher P2Y₁₂ expression. pAkt is enhanced and pVASP is impaired in resting platelets from the patients, indicating the constitutive activation of platelet P2Y₁₂ receptor. Mouse sepsis model recapitulates the findings in septic patients. NOD2 deficiency attenuates sepsis-induced platelet P2Y₁₂ high expression, hyperactivity, and thrombosis. Prasugrel and ticagrelor are potent P2Y₁₂ inverse agonists, and exhibit superior antiplatelet and antithrombotic efficacy over clopidogrel in mice and rats with sepsis.

CONCLUSIONS

NOD2 activation upregulates platelet P2Y₁₂ expression, which is constitutively activated and contributes to platelet hyperactivity in septic status. Compared to clopidogrel, prasugrel and ticagrelor are potent P2Y₁₂ inverse agonists with superior antiplatelet and antithrombotic efficacy in experimental sepsis.

Risk of bleeding with ticagrelor in elderly patients over 75 years old: A systematic review and meta-analysis

BACKGROUND

Bleeding is an untoward outcome in the management of elderly patients with acute coronary syndrome (ACS). Although the potent oral P2Y12 inhibitor, ticagrelor is clinically beneficial, its association with bleeding events in elderly ACS patients (≥75 years) is poorly understood.

METHODS

We conducted a systematic search of 7 databases up to May 20, 2020 to identify studies which examined the risk of bleeding (defined according to each study) among elderly ACS patients (≥75 years) receiving ticagrelor compared to clopidogrel. Summary risk ratios (RR) were estimated using the random effects model.

RESULTS

Eight studies consisting of 5 observational studies and 3 randomized controlled trials involving 7032 elderly patients met the eligibility criteria. The mean age of the patients was 77.8 years, and the mean follow-up duration was 12 months. Overall, the pooled RRs showed higher risk of a bleeding event with ticagrelor compared to clopidogrel (RR 1.20, 95% confidence interval [95% CI] 1.03-1.40; P = .017). No statistically significant heterogeneity was observed among the studies (Q = 6.93; P = .44; I2 = 0). Also, pooled RRs did not show a higher risk of major bleeding (RR 1.32, 95% CI 0.91-1.92; P = .15) or minor bleeding (RR 1.09, 95% CI 0.76-1.58; P = .64) when comparing the ticagrelor to the clopidogrel group.

CONCLUSIONS

There is a 20% increased risk of a bleeding event in elderly ACS patients treated with ticagrelor compared to clopidogrel; for such patients, clopidogrel may be considered as an alternative agent to ticagrelor due to its lower risk of bleeding.