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Shahid I, Nizam MA, Motiani V, Menezes RG, Naeem U, Siddiqi TJ, Rizwan T, Makhdom F, Ram P, Usman MS. Efficacy and Safety of Oral P2Y12 Inhibitors in Older Patients with Acute Coronary Syndrome: A Frequentist Network Meta-Analysis. Drugs Aging 2021; 38:1003-1016. [PMID: 34664214 DOI: 10.1007/s40266-021-00896-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Previous studies and meta-analyses have assessed optimal P2Y12 inhibitors following acute coronary syndrome in overall trial cohorts. However, there are insufficient data for the elderly cohort who are prone to high bleeding and ischemic events. We aimed to assess the optimal P2Y12 inhibitor therapy for older patients. METHODS PubMed, CENTRAL, and ClinicalTrials.gov databases were searched from inception through July 2020 to identify randomized controlled trials and propensity-matched observational studies including older patients (aged ≥ 65 years) that reported study-defined major adverse cardiovascular events (MACE) or major bleeding events. Outcomes at the mid-term follow-up were pooled to conduct a frequentist network meta-analysis. RESULTS Fourteen studies involving 12,953 older patients were included in our analysis. No significant difference was observed with MACE when all three P2Y12 inhibitors were compared with each other. Compared with clopidogrel, ticagrelor significantly increased the risk of major bleeding (risk ratio 1.35, 95% confidence interval 1.10-1.67) while prasugrel did not (risk ratio 1.02, 95% confidence interval 0.67-1.57). A sensitivity analysis of only randomized controlled trials yielded similar results for both MACE and major bleeding. The P score displayed prasugrel (0.5871) as the best treatment for MACE, while clopidogrel (0.7701) was the best P2Y12 inhibitor to decrease the risk of major bleeding. Ticagrelor (0.0634) was ranked the lowest because of an increased bleeding risk. CONCLUSIONS No significant difference is observed between the three P2Y12 inhibitors in study-defined MACE. Ranking by p-score suggests prasugrel as the best P2Y12 inhibitor to reduce the risk of MACE while clopidogrel is a better alternative than ticagrelor in older patients with acute coronary syndrome to decrease the risk of major bleeding. Because of a lack of individual-patient data analysis and heterogeneity amongst studies, future studies representing older patients with acute coronary syndrome are required to strengthen evidence regarding optimal antithrombotic therapy in this cohort.
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Affiliation(s)
- Izza Shahid
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | | | - Vanita Motiani
- Department of Medicine, Ziauddin Medical University, Karachi, Pakistan
| | - Ritesh G Menezes
- Department of Pathology, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Unaiza Naeem
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tehlil Rizwan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Fahd Makhdom
- Department of Surgery, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Pradhum Ram
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
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Kupó P, Tornyos D, Bálint A, Lukács R, Jánosi A, Komócsi A. Use of drug-eluting stents in elderly patients with acute myocardial infarction: An analysis of the Hungarian Myocardial Infarction Registry. Int J Clin Pract 2021; 75:e13652. [PMID: 32851755 DOI: 10.1111/ijcp.13652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 08/04/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Bare-metal stents (BMS) are frequently implanted in elderly patients instead of drug-eluting stents (DES). We aimed to compare the prognosis of patients treated for myocardial infarction with the two types of stents over the age of 75. METHODS Data of patients registered in the Hungarian Myocardial Infarction Registry, a mandatory nationwide programme for hospitals treating patients with myocardial infarction were processed. From patients included between January 2014 and December 2017 we created two groups according to DES and BMS implantation. The outcome measures included all-cause mortality, the composite of cardiac events (MACE), repeated revascularisation and transfusion. Propensity score matching was used to balance the groups and Cox proportional hazards' models to estimate the risk during the 1st year after the index event. RESULTS From 7383 patients (age: 81.08 ± 4.38 years) 3266 (44.2%) patients received DES. The PS-matched cohort included 5780 cases with balanced characteristics. In the DES group, the mortality (HR 0.66 [0.60-0.72]), MACE (HR 0.66 [0.60-0.72]) and the rate of transfusion (HR 0.84 [0.73-0.97]) were significantly lower. The PS-matched cohort showed a similar trend but with a lower rate of benefits with a 21% reduction of mortality and 23% of MACE. Difference in transfusion did not reach the level of significance. In multivariate models, stent type prevailed as an independent predictor of mortality and but not of transfusion. CONCLUSIONS Based on our analysis of a real-life, high-risk population, implantation of DES seems to be an advantageous strategy for elderly patients.
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Affiliation(s)
- Péter Kupó
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Tornyos
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Alexandra Bálint
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Lukács
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - András Jánosi
- Hungarian Myocardial Infarction Registry, Gyorgy Gottsegen Hungarian Institute of Cardiology, Budapest, Hungary
| | - András Komócsi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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Bae S, Kim Y, Gogas BD, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y, Jeong MH. Efficacy and safety of drug-eluting stents in elderly patients: A meta-analysis of randomized trials. Cardiol J 2019; 28:223-234. [PMID: 31702046 DOI: 10.5603/cj.a2019.0109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/06/2019] [Accepted: 10/29/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Current guidelines recommend newer generation drug-eluting stents (DES) over bare-metal stents (BMS) in patients with ischemic heart disease. However, there is no age-specific recommendation in elderly patients. METHODS Meta-analysis was performed of 6 randomized studies enrolling 5,042 elderly patients who underwent percutaneous coronary intervention (PCI) with stent implantation (DES, n = 2,579; BMS, n = 2,463). RESULTS Combined data indicated a significant reduction in major adverse cardiovascular events (MACEs) with use of DES (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.44-0.71, p < 0.001). Moreover, use of DES was associated with a significantly lower incidence of myocardial infarction (OR 0.54, 95% CI 0.36-0.81, p = 0.003) and repeat revascularization (OR 0.44, 95% CI 0.31-0.62, p < 0.001), was compared to that with the use of BMS. Stent thrombosis and bleeding complication rates were not significantly different between groups. In a subgroup meta-analysis, short duration (1 or 6 months) dual antiplatelet therapy (DAPT) was associated with a significantly lower MACE rate (OR 0.49, 95% CI 0.34-0.80; p = 0.003) in elderly patients who underwent PCI with everolimuseluting stent implantation, compared with that using long duration DAPT. CONCLUSIONS This meta-analysis provides clinically relevant evidence that DES rather than BMS should be selected for elderly patients.
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Affiliation(s)
- SungA Bae
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Yongcheol Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Bill D Gogas
- The Spencer B. King III Catheterization Laboratory, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Min Chul Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Doo Sun Sim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Young Joon Hong
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Ju Han Kim
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Youngkeun Ahn
- Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Myung Ho Jeong
- Chonnam National University Hospital, Gwangju, Republic of Korea.
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Anoke SC, Normand SL, Zigler CM. Approaches to treatment effect heterogeneity in the presence of confounding. Stat Med 2019; 38:2797-2815. [PMID: 30931547 PMCID: PMC6613382 DOI: 10.1002/sim.8143] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 12/26/2022]
Abstract
The literature on causal effect estimation tends to focus on the population mean estimand, which is less informative as medical treatments are becoming more personalized and there is increasing awareness that subpopulations of individuals may experience a group-specific effect that differs from the population average. In fact, it is possible that there is underlying systematic effect heterogeneity that is obscured by focusing on the population mean estimand. In this context, understanding which covariates contribute to this treatment effect heterogeneity (TEH) and how these covariates determine the differential treatment effect (TE) is an important consideration. Towards such an understanding, this paper briefly reviews three approaches used in making causal inferences and conducts a simulation study to compare these approaches according to their performance in an exploratory evaluation of TEH when the heterogeneous subgroups are not known a priori. Performance metrics include the detection of any heterogeneity, the identification and characterization of heterogeneous subgroups, and unconfounded estimation of the TE within subgroups. The methods are then deployed in a comparative effectiveness evaluation of drug-eluting versus bare-metal stents among 54 099 Medicare beneficiaries in the continental United States admitted to a hospital with acute myocardial infarction in 2008.
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Affiliation(s)
- Sarah C. Anoke
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Massachusetts, United States
| | - Sharon-Lise Normand
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Massachusetts, United States
- Department of Health Care Policy, Harvard Medical School, Massachusetts, United States
| | - Corwin M. Zigler
- Department of Statistics & Data Sciences and Department of Womens Health, University of Texas at Austin and Dell Medical School, Texas, United States
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Kheiri B, Osman M, Abdalla A, Haykal T, Chahine A, Gwinn M, Ahmed S, Hassan M, Bachuwa G, Bhatt DL. Drug-Eluting Versus Bare-Metal Stents in Older Patients: A Meta-Analysis of Randomized Controlled Trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:744-751. [PMID: 30446398 DOI: 10.1016/j.carrev.2018.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 10/22/2018] [Accepted: 11/01/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Despite the high prevalence of ischemic heart disease in older patients, there is a substantial lack of evidence to guide clinical decision-making in this population. Hence, we performed a meta-analysis to determine the safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus bare-metal stents (BMS). METHODS Electronic databases were searched for randomized trials comparing DES with BMS in patients ≥70 years-old. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included different ischemic and bleeding events. Subgroup analyses for dual-antiplatelet therapy (DAPT) duration were conducted. RESULTS We included 7 trials with a total of 5449 patients. The use of DES compared with BMS was associated with a significant reduction in MACE (odds ratio [OR]:0.76; 95% confidence interval [CI]:0.62-0.93; P = 0.007) with no increased risk of bleeding events (OR: 1.07; 95% CI: 0.89-1.27; P = 0.48). However, longer duration of DAPT (>6 months) for the DES group increased bleeding events (OR: 1.52; 95% CI: 1.05-2.20; P = 0.03). In contrast, shorter DAPT showed persistent efficacy in reducing MACE in DES-treated patients with no increased bleeding events (OR: 0.72; 95% CI: 0.60-0.87; P < 0.01 and OR: 1.01; 95% CI: 0.84-1.22; P = 0.89, respectively). CONCLUSIONS In older patients who had undergone PCI, DES showed superior efficacy in reducing MACE with no increased risk of bleeding compared with BMS. Persistent MACE reduction was evident with shorter DAPT durations in DES-treated patients. SUMMARY This meta-analysis of randomized clinical trials demonstrated that drug-eluting stents were associated with a significant reduction in major adverse cardiovascular events with no increased risk of bleeding compared with bare-metal stents. The risk of bleeding was high with longer dual antiplatelet therapy duration for patients who underwent DES placement. However, short duration of dual antiplatelet therapy substantially reduced major adverse cardiovascular events with no increased bleeding risk.
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Affiliation(s)
- Babikir Kheiri
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV 26506, USA
| | - Ahmed Abdalla
- Division of Hematology & Oncology, St. John Hospital, Grosse Pointe Woods, MI 48236, USA
| | - Tarek Haykal
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Adam Chahine
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Meghan Gwinn
- Michigan State University, College of Human Medicine, Flint, MI 48502, USA
| | | | - Mustafa Hassan
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center, Michigan State University, Flint, MI 48503, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA 02115, USA.
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Mahmoud AN, Shah NH, Elgendy IY, Agarwal N, Elgendy AY, Mentias A, Barakat AF, Mahtta D, David Anderson R, Bavry AA. Safety and efficacy of second-generation drug-eluting stents compared with bare-metal stents: An updated meta-analysis and regression of 9 randomized clinical trials. Clin Cardiol 2018; 41:151-158. [PMID: 29369375 DOI: 10.1002/clc.22855] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 01/13/2023] Open
Abstract
The efficacy of second-generation drug-eluting stents (DES; eg, everolimus and zotarolimus) compared with bare-metal stents (BMS) in patients undergoing percutaneous coronary intervention was challenged recently by new evidence from large clinical trials. Thus, we aimed to conduct an updated systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the efficacy and safety of second-generation DES compared with BMS. Electronic databases were systematically searched for all RCTs comparing second-generation DES with BMS and reporting clinical outcomes. The primary efficacy outcome was major adverse cardiac events (MACE); the primary safety outcome was definite stent thrombosis. The DerSimonian and Laird method was used for estimation of summary risk ratios (RR). A total of 9 trials involving 17 682 patients were included in the final analysis. Compared with BMS, second-generation DES were associated with decreased incidence of MACE (RR: 0.78, 95% confidence interval [CI]: 0.69-0.88), driven by the decreased incidence of myocardial infarction (MI) (RR: 0.67, 95% CI: 0.48-0.95), target-lesion revascularization (RR: 0.47, 95% CI: 0.42-0.53), definite stent thrombosis (RR: 0.57, 95% CI: 0.41-0.78), and definite/probable stent thrombosis (RR: 0.54, 95% CI: 0.38-0.80). The incidence of all-cause mortality was similar between groups (RR: 0.94, 95% CI: 0.79-1.10). Meta-regression showed lower incidences of MI with DES implantation in elderly and diabetic patients (P = 0.026 and P < 0.0001, respectively). Compared with BMS, second-generation DES appear to be associated with a lower incidence of MACE, mainly driven by lower rates of target-lesion revascularization, MI, and stent thrombosis. However, all-cause mortality appears similar between groups.
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Affiliation(s)
- Ahmed N Mahmoud
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Nikhil H Shah
- Department of Medicine, University of Florida, Gainesville
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Nayan Agarwal
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Akram Y Elgendy
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa, Iowa City
| | - Amr F Barakat
- UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dhruv Mahtta
- Department of Medicine, University of Florida, Gainesville
| | - R David Anderson
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville
| | - Anthony A Bavry
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville.,North Florida/South Georgia Veterans Health System, Gainesville, Florida
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Morice MC, Talwar S, Gaemperli O, Richardt G, Eberli F, Meredith I, Zaman A, Fajadet J, Copt S, Greene S, Urban P. Drug-coated versus bare-metal stents for elderly patients: A predefined sub-study of the LEADERS FREE trial. Int J Cardiol 2017; 243:110-115. [DOI: 10.1016/j.ijcard.2017.04.079] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 02/03/2023]
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Bill V, El-Battrawy I, Schramm K, Ansari U, Hoffmann U, Haghi D, Kuschyk J, Borggrefe M, Akin I. Coincidental coronary artery disease impairs outcome in patients with takotsubo cardiomyopathy. QJM 2017; 110:483-488. [PMID: 28340038 DOI: 10.1093/qjmed/hcx035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND AIM Takotsubo cardiomyopathy (TC) is an important differential diagnosis of coronary artery disease (CAD), mimicking acute coronary syndrome in clinical symptoms, biomarker profiles and ST-elevation in ECG. Absence of occlusive coronary disease is an essential criterion distinguishing both diseases. The aim of the study was to explore the influence of co-existing incidental CAD on poorer clinical outcomes and all-cause mortality in TC. DESIGN, METHODS AND RESULTS Our mono-centric study cohort constituted 114 consecutive patients diagnosed with TC between 2003 and 2015. The primary endpoint was the all-cause mortality. Additionally, we compared the incidence of thromboembolic events, life-threatening arrhythmias, cardiogenic shock and in-hospital death. There was no significant difference in gender distribution or mean age in both groups. Patients diagnosed with a co-existing CAD (n = 22), had a more pronounced cardiovascular risk profile. The all-cause mortality among patients with co-existing CAD after a 2-year follow-up was higher than those diagnosed with lone TC (22.7 vs. 5.4 %, P = 0.07). In a multivariate cox regression analysis CAD (HR 3.5, 95 %CI 1.0-11.6; P = 0.04), LVEF ≤ 35% (HR 3.8, 95% CI 0.0-0.6, P = 0.01) and cardiogenic shock (HR 3.8, 95% CI 1.2-11.3; P = 0.01) were independent predictors of the primary endpoint. CONCLUSION Our study reveals that co-existing CAD impairs the outcome in patients with TC. The diagnostic work-up for TC should therefore not necessarily hinge on ruling out CAD.
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Affiliation(s)
- V Bill
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - I El-Battrawy
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - K Schramm
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - U Ansari
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - U Hoffmann
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - D Haghi
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - J Kuschyk
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - M Borggrefe
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
| | - I Akin
- First Department of Medicine Cardiology, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany and DZHK (German Centre for Cardiovascular Research) Partner Site Mannheim, Mannheim, Germany
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Discretionary decisions and disparities in receiving drug-eluting stents under a universal healthcare system: A population-based study. PLoS One 2017; 12:e0179127. [PMID: 28594876 PMCID: PMC5464647 DOI: 10.1371/journal.pone.0179127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 05/24/2017] [Indexed: 11/19/2022] Open
Abstract
Objectives One of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system. Design and participants We adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study. Results During the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38–4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06–2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24–4.09 and OR: 2.16, CI: 2.01–2.33, respectively). Conclusions Even under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.
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Misra SK, Ostadhossein F, Babu R, Kus J, Tankasala D, Sutrisno A, Walsh KA, Bromfield CR, Pan D. 3D-Printed Multidrug-Eluting Stent from Graphene-Nanoplatelet-Doped Biodegradable Polymer Composite. Adv Healthc Mater 2017; 6. [PMID: 28322012 DOI: 10.1002/adhm.201700008] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/16/2017] [Indexed: 11/11/2022]
Abstract
Patients with percutaneous coronary intervention generally receive either bare metal stents or drug-eluting stents to restore the normal blood flow. However, due to the lack of stent production with an individual patient in mind, the same level of effectiveness may not be possible in treating two different clinical scenarios. This study introduces for the first time the feasibility of a patient-specific stenting process constructed from direct 3D segmentation of medical images using direct 3D printing of biodegradable polymer-graphene composite with dual drug incorporation. A biodegradable polymer-carbon composite is prepared doped with graphene nanoplatelets to achieve controlled release of combinatorics as anticoagulation and antirestenosis agents. This study develops a technology prototyped for personalized stenting. An in silico analysis is performed to optimize the stent design for printing and its prediction of sustainability under force exerted by coronary artery or blood flow. A holistic approach covering in silico to in situ-in vivo establishes the structural integrity of the polymer composite, its mechanical properties, drug loading and release control, prototyping, functional activity, safety, and feasibility of placement in coronary artery of swine.
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Affiliation(s)
- Santosh K. Misra
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
| | - Fatemeh Ostadhossein
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
| | - Ramya Babu
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
| | - Joseph Kus
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
| | - Divya Tankasala
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
| | - Andre Sutrisno
- NMR/EPR Laboratory School of Chemical Sciences University of Illinois at Urbana–Champaign IL USA
| | - Kathleen A. Walsh
- Frederick Seitz Materials Research Laboratory University of Illinois at Urbana–Champaign IL USA
| | - Corinne R. Bromfield
- Agricultural Animal Care and Use Program University of Illinois at Urbana–Champaign IL USA
| | - Dipanjan Pan
- Department of Bioengineering Beckman Institute of Advanced Science and Technology Department of Materials Science and Engineering Institute for Sustainability in Energy and Environment University of Illinois at Urbana–Champaign Carle Foundation Hospital 611 West Park Street Urbana IL 61801 USA
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