Optimal duration of dual antiplatelet therapy for coronary artery disease

Inter-relationships between cardiovascular, renal and metabolic diseases: Underlying evidence and implications for integrated interdisciplinary care and management

Cardiovascular, renal and metabolic (CaReMe) diseases are individually among the leading global causes of death, and each is associated with substantial morbidity and mortality. However, as these conditions commonly coexist in the same patient, the individual risk of mortality and morbidity is further compounded, leading to a considerable healthcare burden. A number of pathophysiological pathways are common to diseases of the CaReMe spectrum, including neurohormonal dysfunction, visceral adiposity and insulin resistance, oxidative stress and systemic inflammation. Because of the shared pathology and common co-occurrence of the CaReMe diseases, the value of managing these conditions holistically is increasingly being realized. A number of pharmacological and non-pharmacological approaches have been shown to offer simultaneous metabolic, cardioprotective and renoprotective benefits, leading to improved patient outcomes across the CaReMe spectrum. In addition, increasing value is being placed on interdisciplinary team-based and coordinated care models built on greater integration between specialties to increase the rate of early diagnosis and adherence to practice guidelines, and improve clinical outcomes. This interdisciplinary approach also facilitates integration between primary and specialty care, improving the patient experience, optimizing resources, and leading to efficiencies and cost savings. As the burden of CaReMe diseases continues to increase, implementation of innovative and integrated care delivery models will be essential to achieve effective and efficient chronic disease management and to ensure that patients benefit from the best care available across all three disciplines.

Non-vitamin-K-antagonist oral anticoagulants (NOACs) after acute myocardial infarction: a network meta-analysis

BACKGROUND

Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited.

OBJECTIVES

To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials.

SELECTION CRITERIA

We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI.

DATA COLLECTION AND ANALYSIS

Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale.

MAIN RESULTS

We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation.

AUTHORS' CONCLUSIONS

Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.

Factors associated with early, late, and very late stent thrombosis among patients with acute coronary syndrome undergoing coronary stent placement: analysis from the ATLAS ACS 2-TIMI 51 trial

Background

Stent thrombosis (ST) is an uncommon but serious complication of stent implantation. This study aimed to explore factors associated with early, late, and very late ST to help guide risk assessment and clinical decision-making on ST.

Methods

The analysis included patients who received stent placement for the index acute coronary syndrome (ACS). Cumulative incidence of ST was assessed at 30 days (early ST), 31-360 days (late ST), 361-720 days (very late ST), and up to 720 days. Cox proportional hazards models were used to assess associations between ST and various factors, including patient characteristics [i.e., age, sex, ACS presentation, history of hypertension, smoking, diabetes, prior myocardial infarction (MI), heart failure, prior ischemic stroke, and cancer], laboratory tests [i.e., positive cardiac biomarker, hemoglobin, platelet count, white blood cell (WBC) count], and treatment [i.e., drug-eluting stent (DES) vs. bare-metal stent (BMS) and anticoagulant with rivaroxaban vs. placebo].

Results

Among the 8,741 stented patients, 155 ST events (2.25%) occurred by Day 720. The cumulative incidences of early, late, and very late ST were 0.80%, 0.81%, and 0.77%, respectively. After multivariable adjustment, age ≥ 75 [hazard ratio (HR) = 2.13 (95% confidence interval, CI: 1.26-3.60)], a history of prior MI [HR = 1.81 (95% CI: 1.22-2.68)], low hemoglobin level [HR = 2.34 (95% CI: 1.59-3.44)], and high WBC count [HR = 1.58 (95% CI: 1.02-2.46)] were associated with a greater risk of overall ST, whereas DES [HR = 0.56 (95% CI: 0.38-0.83)] and rivaroxaban therapy [HR = 0.63 (95% CI: 0.44-0.88)] were associated with a lower risk of overall ST up to 720 days. Low hemoglobin level and high WBC count were associated with early ST (low hemoglobin: HR = 2.35 [95% CI: 1.34-4.12]; high WBC count: HR = 2.11 [95% CI: 1.17-3.81]). Low hemoglobin level and prior MI were associated with a greater risk of late ST (low hemoglobin: HR = 2.32 [95% CI: 1.26-4.27]; prior MI: HR = 2.98 [95% CI: 1.67-5.31]), whereas DES was associated with a lower risk of late ST [HR = 0.33 (95% CI: 0.16-0.67)]. Age ≥75 years was associated with very late ST.

Conclusion

The study identified positive and negative associations with early, late, and very late ST. These variables may be useful in constructing risk assessment models for ST.

Clinical Trial Registration

http://www.clinicaltrials.gov, identifier NCT00809965.

Individualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based Review

Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is the cornerstone of post-percutaneous coronary intervention treatment to prevent stent thrombosis and reduce the risk of adverse cardiovascular events. The selection of an optimal DAPT regimen, considering the interplay of various antiplatelet agents, patient profiles, and procedural characteristics, remains an evolving challenge. Traditionally, a standard duration of 12 months has been recommended for DAPT in most patients. While contemporary guidelines provide general frameworks, DAPT modulation with longer or shorter treatment courses followed by aspirin or P2Y12 inhibitor monotherapy are evolving towards an individualized strategy to optimize the balance between efficacy and safety. This review comprehensively examines the current landscape of DAPT strategies after coronary stenting, with a focus on emerging evidence for treatment individualization.

Duration and kind of dual antiplatelet therapy for acute coronary syndrome patients: a network meta-analysis

INTRODUCTION

For acute coronary syndrome (ACS) patients treated with percutaneous coronary intervention (PCI), the choice of the duration and kind of dual antiplatelet therapy (DAPT) offering the most accurate balance between ischemic and bleeding risk remains unknown.

EVIDENCE ACQUISITION

A network meta-analysis was performed including all Randomized Controlled Trials (RCTs) comparing different DAPT regimens and duration in ACS patients undergoing PCI. Trial-defined MACE and major bleedings were the primary endpoints. Stroke, stent thrombosis (ST), all-cause and cardiovascular death, myocardial infarction (MI) represented secondary endpoints.

EVIDENCE SYNTHESIS

13 RCTs encompassing 46145 patients were included. Mean age was 62 (61-64) years old, 42% being admitted with STEMI, 33% with NSTEMI and 25% with UA. The competitive arms were: clopidogrel and aspirin for 12 months (6 arms/18183 patients), clopidogrel and aspirin for 6 months (4/3329), clopidogrel and aspirin >12 months (3/2238), ticagrelor and aspirin for 12 months (6/12942) and prasugrel and aspirin for 12 months (3/9453). Trial-defined MACE and major bleedings, stroke and death were similar among the different arms. DAPT with prasugrel and aspirin for 12 months reduced MI compared to aspirin and clopidogrel for 12 months (OR 0.71, 95% CI: 0.54.0.94) and reduced the risk of ST compared to ticagrelor (OR 0.66, 95% CI: 0.49-0.90). Both prasugrel and ticagrelor reduced ST as compared to clopidogrel and aspirin for 12 months.

CONCLUSIONS

Different DAPT strategies yield similar risk of MACE, major bleeding, death and stroke in ACS patients. Prasugrel and aspirin for 12 months proved to be the most effective strategy regarding ST and MI.

Real-world experience of clinical management with antiplatelet and lipid-lowering therapy in post acute coronary syndrome patients in Indian setting

Objective:

The objective is to evaluate the pattern for use of triple-drug therapy (dual antiplatelet therapy [DAPT] and statin) in the management of patients with postacute coronary syndrome (ACS) and associated risk factors in Indian settings.

Materials and Methods:

This was a retrospective multi-centric (n = 63), real-world, cross-sectional study which included patients (aged ≥18 years) diagnosed with an ACS, post-ACS patients from 3 months to 3 years, and receiving DAPT and lipid-lowering agents for ACS. Demographics, baseline characteristics, risk factors, medical history, and therapy details were retrieved from medical charts. Descriptive and comparative analysis for qualitative and quantitative variable was performed.

Results:

A total of 1548 patients with a mean age of 57.4 years were included. Male preponderance was observed across all the age groups. A total of 973 patients were on triple-drug therapy, and the most common triple fixed-dose combination prescribed was rosuvastatin, clopidogrel, and aspirin, among all the groups (age-wise: 76.1%–88.6%; sex-wise: 78.5% and 79.2%; clinical status-wise: 75.7%–81.4%). The majority of patients with non-ST-segment elevation myocardial infarction (43.0%), ST-segment elevation myocardial infarction (42.7%), and unstable angina (40.8%) received triple-drug therapy for >6 to ≤12 months duration. Adverse effect observed in patients receiving triple-drug therapy were skin rash (n = 5), bleeding (n = 2), facial puffing (n = 2), and hematuria (n = 2). A total of 357 patients were undergone switch in DAPT therapy (prasugrel to clopidogrel or ticagrelor to clopidogrel).

Conclusion:

DAPT and statin were the standard of care in majority of ACS patients. Triple fixed-dose combination therapy of aspirin, clopidogrel, and rosuvastatin was the most preferred choice of physicians, for optimal management post-ACS patient in Indian setting.

Incidence, mortality, and complications of acute myocardial infarction with and without percutaneous coronary intervention in hip fracture patients

INTRODUCTION

Acute myocardial infarction (AMI) is a common cause of death following hip fracture surgery. This study aimed to determine the incidence and timing of perioperative AMI treated with percutaneous coronary intervention (PCI) in hip fracture patients, and to compare in-hospital mortality and complications between hip fracture patients who did not have an AMI, those who sustained a perioperative AMI and did not undergo PCI, and those who sustained an AMI and underwent PCI.

METHODS

The National Inpatient Sample (NIS) was queried from 2010 through the third quarter of 2015 to identify all patients undergoing hip fracture surgery. Patients were stratified into three cohorts: perioperative AMI but no PCI (no PCI cohort), perioperative AMI with PCI (PCI cohort), and no perioperative AMI or PCI (no AMI cohort). Patient demographics, comorbidities, in-hospital mortality, and complications were compared between cohorts. Multivariable logistic regression adjusting for age, sex, procedure, and Elixhauser score was used to assess the relative odds of in-hospital mortality for each cohort.

RESULTS

A total of 1,535,917 hip fracture cases were identified, with 1.9% in the no PCI cohort, 0.01% in the PCI cohort, and 98.0% in the no AMI cohort. In-hospital mortality was lower in the PCI cohort than in the no PCI cohort (8.8% vs. 14%), and was greater for both than in the no AMI cohort (1.6%, p < 0.001 for all). Both the no PCI cohort (OR, 6.1; 95% CI, 5.6-6.6) and PCI cohort (OR, 4.1; 95% CI, 2.8-6.0) had increased adjusted odds of in-hospital mortality compared to the no AMI cohort. The PCI cohort had a higher rate of bleeding complications than both other cohorts, and the no PCI cohort had a higher rate of transfusion than both other cohorts.

CONCLUSIONS

Perioperative AMI both with and without PCI independently increases the risk of mortality in hip fracture patients, with the highest risk of mortality in those with AMI without PCI. Providers should understand the increased morbidity and mortality associated with AMI in hip fracture patients, as well as the risks and benefits of perioperative PCI, in order to better counsel and manage these patients.

LEVEL OF EVIDENCE

III.

Flavonoids as potential anti-platelet aggregation agents: from biochemistry to health promoting abilities

Cardiovascular ailments are the number one cause of mortalities throughout the globe with 17.9 million deaths per year. Platelet activation and aggregation play a crucial role in the pathogenesis of arterial diseases, including acute coronary syndrome, acute myocardial infarction, cerebrovascular transient ischemia, unstable angina, among others. Flavonoids-rich plant extracts are gaining interest for treating the heart-related problems due to safe nature of these herbal extracts. Consumption of plant-food-derived bioactives, particularly flavonoids, has shown antithrombotic, and cardiovascular protective effects due to its anti-platelet activity. Preclinical and clinical trials have proven that flavonoid-rich plant extracts are protective against the cardiac ailments through anti-platelet aggregation activity. This review aims to highlight the anti-platelet aggregation potential of flavonoids with a key emphasis on the therapeutic efficacy in humans. The mechanism of flavonoids in preventing and treating cardiovascular diseases is also highlighted based on preclinical and clinical experimental trials. Further studies are the need of time for exploring the exact molecular mechanism of flavonoids as anti-platelet aggregation agents for treating heart-related problems.

A Systematic Review on Bleeding Risk Scores' Accuracy after Percutaneous Coronary Interventions in Acute and Elective Settings

Dual antiplatelet therapy (DAT) is recommended for all patients undergoing percutaneous coronary intervention (PCI), as it significantly reduces the ischemic risk at the cost of increasing the incidence of bleeding events. Several clinical predictive models were developed to better stratify the bleeding risk associated with DAT. This systematic review aims to perform a literature survey of both standard and emerging bleeding risk scores and report their performance on predicting hemorrhagic events, especially in the era of second-generation drug-eluting stents and more potent P2Y12 inhibitors. We searched PubMed, ScienceDirect, and Cochrane databases for full-text studies that developed or validated bleeding risk scores in adult patients undergoing PCI with subsequent DAT. The risk of bias for each study was assessed using the prediction model risk of bias assessment tool (PROBAST). Eighteen studies were included in the present systematic review. Bleeding risk scores showed a modest to good discriminatory power with c-statistic ranging from 0.49 (95% CI, 0.45-0.53) to 0.82 (95% CI, 0.80-0.85). Clinical models that predict in-hospital bleeding events had a relatively good predictive performance, with c-statistic ranging from 0.70 (95% CI, 0.67-0.72) to 0.80 (95% CI, 0.73-0.87), depending on the risk scores and major hemorrhagic event definition used. The knowledge and utilization of the current bleeding risk scores in appropriate clinical contexts could improve the prediction of bleeding events.

Economic Evaluations of CYP2C19 Genotype-Guided Antiplatelet Therapy Compared to the Universal Use of Antiplatelets in Patients With Acute Coronary Syndrome: A Systematic Review

Background and Objectives:

Clopidogrel is widely used after the percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and requires activation by cytochrome P450 (CYP), primarily CYP2C19. Patients with CYP2C19 loss-of-function alleles are at increased risk of major adverse cardiovascular events, while more expensive novel antiplatelet agents (ticagrelor and prasugrel) are unaffected by the CYP2C19 mutations. This systematic review aims to answer the question about whether overall evidence supports the genotype-guided selection of antiplatelet therapy as a cost-effective strategy in post-PCI ACS.

Methods:

A systematic literature search of PubMed, EMBASE, EconLit, and PharmGKB was done to identify all the economic evaluations related to genotype-guided therapy compared to the universal use of antiplatelets in ACS patients. Quality of Health Economic Studies tool was used for quality assessment.

Results:

The search identified 13 articles, where genotype-guided treatment was compared to universal clopidogrel, ticagrelor, and/or prasugrel. Six studies showed that genotype-guided therapy was cost-effective compared to universal clopidogrel, while 5 studies showed that it was dominant. One study specified that genotype-guided with ticagrelor is cost-effective only in both CYP2C19 intermediate and poor metabolizers. Genotype-guided therapy was dominant when compared to universal prasugrel, ticagrelor, or both in 5, 1, and 3 studies, respectively. Only 2 studies reported that universal ticagrelor was cost-effective compared to genotype-guided treatment. All the included articles had good quality.

Conclusion:

Based on current economic evaluations in the literature, implementing CYP2C19 genotype-guided therapy is a cost-effective approach in guiding the selection of medication in patients with ACS undergoing PCI.

Drug-eluting versus bare-metal stents for first myocardial infarction in patients with atrial fibrillation: A nationwide population-based cohort study

BACKGROUND

Acute myocardial infarction (AMI) complicates the clinical management of atrial fibrillation (AF) because coronary stenting may influence subsequent antithrombotic therapy. We investigated the use of a bare-metal stent (BMS) or a drug-eluting stent (DES) and associated outcomes in patients with pre-existing AF and first AMI undergoing percutaneous coronary intervention.

METHODS AND RESULTS

Patient records in this population-based study were retrospectively collected from the Taiwan National Health Insurance Research Database. Using propensity score matching (PSM), we used 1:2 ratio stratification into a DES group of 436 and a BMS group of 785 patients from 2007 to 2011. The mean follow-up of matched cohorts was 1.7 years. After PSM, DESs were associated with lower rates of cardiovascular death (7.8%, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.39-0.86 and 10.1%, HR 0.64, 95% CI 0.45-0.90) and primary composite outcome (35.1%, HR 0.76, 95% CI 0.63-0.92 and 48.2%, HR 0.81, 95% CI 0.69-0.96) than BMSs within the first year and at the end of follow-up. Although the greatest benefit from DESs, irrespective of the first- and second- generation DESs, implantation was observed within the first year only, this benefit was not observed in patients with diabetes, chronic kidney disease, or dialysis.

CONCLUSIONS

Use of DESs in AMI patients with pre-existing AF is associated with significantly lower rates of cardiovascular death and primary composite outcome within the first year follow-up. However, the effect is not apparent in patients with diabetes, chronic kidney disease or dialysis.