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Tarakji KG, Korantzopoulos P, Philippon F, Biffi M, Mittal S, Poole JE, Kennergren C, Lexcen DR, Lande JD, Hilleren G, Seshadri S, Wilkoff BL. Risk factors for hematoma in patients undergoing cardiac device procedures: A WRAP-IT trial analysis. Heart Rhythm O2 2022; 3:466-473. [PMID: 36340491 PMCID: PMC9626743 DOI: 10.1016/j.hroo.2022.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 05/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Implant site hematoma is a known complication of cardiac device procedures and can lead to major consequences. Objectives To evaluate risk factors for hematoma and further understand the relationship between anticoagulant (AC), antiplatelet (AP) use, and hematoma development. Methods We included 6800 patients from the WRAP-IT trial. To assess baseline and procedural characteristics associated with hematoma within the first 30 days postprocedure, a stepwise Cox regression model was implemented with minimal Akaike information criterion. Cox regressions were also used to evaluate AC/AP use and hematoma risk. Results The overall rate of hematoma was 2.2%. The model identified 11 baseline and procedural characteristics associated with hematoma risk. AC use (hazard ratio [HR]: 2.44, P < .001), lower body mass index (HR: 1.06, P < .001), and history of valve surgery (HR: 2.11, P < .001) were associated with the highest risk. AP use, male sex, history of coronary artery disease, existing pocket, history of nonischemic cardiomyopathy, number of previous cardiac implantable electronic device (CIED) procedures, procedure time, and lead revision were associated with moderate risk. Antithrombotic use was high overall (86%) and AC+AP use was highly predictive of hematoma risk. Regardless of AC status, AP use was associated with an almost doubling of risk vs no AP (HR = 1.85, P = .0006) in the general cohort. Interruption of AC was associated with the lowest hematoma risk (HR = 2.35) while heparin bridging (HR = 4.98) and AP use vs no AP use (HR = 1.85) was associated with the highest hematoma risk. Conclusion The results of this analysis highlight risk factors associated with the development of hematoma in patients undergoing CIED procedures and can inform antithrombotic management.
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Demir M, Özbek M, Polat N, Aktan A, Yıldırım B, Argun L, İldırımlı K, Dursun L, Öztürk C, Güzel T, Kılıç R, Toprak N. A comparison of postoperative complications following cardiac implantable electronic device procedures in patients treated with antithrombotic drugs. Pacing Clin Electrophysiol 2022; 45:733-741. [DOI: 10.1111/pace.14517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Muhammed Demir
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Mehmet Özbek
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Nihat Polat
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Adem Aktan
- Department of Cardiology Mardin Training and Research Hospital Mardin Turkey
| | - Bünyamin Yıldırım
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lokman Argun
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Kamran İldırımlı
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
| | - Lezgin Dursun
- Division of Cardiology Bingöl State Hospital Bingöl Turkey
| | - Cansu Öztürk
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Tuncay Güzel
- Department of Cardiology Gazi Yasargil Training and Research Hospital Diyarbakir Turkey
| | - Raif Kılıç
- Division of Cardiology Dagkapi Diyarlife Hospital Diyarbakir Turkey
| | - Nizamettin Toprak
- Department of Medicine Division of Cardiology Dicle University Heart Centre Diyarbakir Turkey
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Zhang ZX, Schroeder-Tanka J, Stooker W, Wissen S, Khorsand N. Management of combined oral antithrombotic therapy by an Antithrombotic Stewardship Program: a prospective study. Br J Clin Pharmacol 2022; 88:4092-4099. [PMID: 35384015 DOI: 10.1111/bcp.15346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 03/27/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022] Open
Abstract
AIMS Antithrombotic management initiatives could prevent inappropriate prescribing and improve patient outcomes especially in patients on combined antithrombotic therapy. To investigate this, a multidisciplinary antithrombotic stewardship program (ASP) was implemented in our hospital. The primary aim of this study was to determine the efficacy of this ASP by assessing the number of patients on combined antithrombotic therapy for whom one or more interventions were needed. METHODS A prospective cohort study in a large teaching hospital was conducted. Hospitalized patients were included who received combined antithrombotic therapy in which an oral anticoagulant was combined with one (double therapy) or two (triple therapy) platelet aggregation inhibitors. The ASP proactively evaluated the appropriateness of this combined antithrombotic therapy. If needed, ASP improved the concerned therapy. Each improvement measurement recommended by the ASP was counted as one intervention. RESULTS A total of 460 patients were included over a period of 12 months. 251 (54.6%) patients required at least one intervention from the ASP. The most common interventions were: 1) to define and document the maximum duration of the combined antithrombotic therapy needed instead of lifetime use of the combination (65.5%), 2) to discontinue antithrombotic therapy as the proper indication was lacking (19.4%), and 3) to adjust the dosage (8.1%). CONCLUSION An intervention was needed in more than half of the patients on combined antithrombotic therapy. Implementation of an dedicated ASP evaluating combined antithrombotic therapy improves the use and safety of antithrombotic medication.
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Affiliation(s)
| | | | - Wim Stooker
- Department of Cardiothoracic Surgery, Department of Intensive Care, OLVG, Amsterdam, The Netherlands
| | - Sanne Wissen
- Department of Internal Medicine, OLVG, Amsterdam, The Netherlands
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Anfinogenova ND, Trubacheva IA, Popov SV, Efimova EV, Ussov WY. Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases. Expert Opin Drug Saf 2021; 20:1191-1206. [PMID: 33970732 DOI: 10.1080/14740338.2021.1928632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.
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Affiliation(s)
- Nina D Anfinogenova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Irina A Trubacheva
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Sergey V Popov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Elena V Efimova
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
| | - Wladimir Y Ussov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, Russian Federation
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Dual to the Death? Combined Anticoagulant and Antiplatelet Therapy in the Postoperative ICU Setting. Crit Care Med 2021; 48:1083-1085. [PMID: 32568905 DOI: 10.1097/ccm.0000000000004374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dahal K, Mosleh W, Almnajam M, Khaddr M, Adeel MY, Vashist A, Robinson P, Azrin M, Lee J. NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1202-1208. [DOI: 10.1016/j.carrev.2020.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/04/2020] [Accepted: 03/05/2020] [Indexed: 12/24/2022]
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Essebag V, Healey JS, Joza J, Nery PB, Kalfon E, Leiria TLL, Verma A, Ayala-Paredes F, Coutu B, Sumner GL, Becker G, Philippon F, Eikelboom J, Sandhu RK, Sapp J, Leather R, Yung D, Thibault B, Simpson CS, Ahmad K, Toal S, Sturmer M, Kavanagh K, Crystal E, Wells GA, Krahn AD, Birnie DH. Effect of Direct Oral Anticoagulants, Warfarin, and Antiplatelet Agents on Risk of Device Pocket Hematoma: Combined Analysis of BRUISE CONTROL 1 and 2. Circ Arrhythm Electrophysiol 2019; 12:e007545. [PMID: 31610718 DOI: 10.1161/circep.119.007545] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Oral anticoagulant use is common among patients undergoing pacemaker or defibrillator surgery. BRUISE CONTROL (Bridge or Continue Coumadin for Device Surgery Randomized Controlled Trial; NCT00800137) demonstrated that perioperative warfarin continuation reduced clinically significant hematomas (CSH) by 80% compared with heparin bridging (3.5% versus 16%). BRUISE-CONTROL-2 (NCT01675076) observed a similarly low risk of CSH when comparing continued versus interrupted direct oral anticoagulant (2.1% in both groups). Using patient level data from both trials, the current study aims to: (1) evaluate the effect of concomitant antiplatelet therapy on CSH, and (2) understand the relative risk of CSH in patients treated with direct oral anticoagulant versus continued warfarin. METHODS We analyzed 1343 patients included in BRUISE-CONTROL-1 and BRUISE-CONTROL-2. The primary outcome for both trials was CSH. There were 408 patients identified as having continued either a single or dual antiplatelet agent at the time of device surgery. RESULTS Antiplatelet use (versus nonuse) was associated with CSH in 9.8% versus 4.3% of patients (P<0.001), and remained a strong independent predictor after multivariable adjustment (odds ratio, 1.965; 95% CI, 1.202-3.213; P=0.0071). In multivariable analysis, adjusting for antiplatelet use, there was no significant difference in CSH observed between direct oral anticoagulant use compared with continued warfarin (odds ratio, 0.858; 95% CI, 0.375-1.963; P=0.717). CONCLUSIONS Concomitant antiplatelet therapy doubled the risk of CSH during device surgery. No difference in CSH was found between direct oral anticoagulant versus continued warfarin. In anticoagulated patients undergoing elective or semi-urgent device surgery, the patient specific benefit/risk of holding an antiplatelet should be carefully considered. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00800137, NCT01675076.
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Affiliation(s)
- Vidal Essebag
- McGill University, McGill University Health Centre and Hôpital Sacré-Coeur de Montréal, QC, Canada (V.E.)
| | - Jeff S Healey
- McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, ON, Canada (J.S.H., J.E.,)
| | - Jacqueline Joza
- McGill University, McGill University Health Centre, Montreal, QC, Canada (J.J.)
| | - Pablo B Nery
- Department of Medicine, University of Ottawa, University of Ottawa Heart Institute, ON, Canada (P.B.N., G.A.W., D.H.B.)
| | - Eli Kalfon
- Galilee Medical Centre, Naharyia, Israel (E.K.)
| | - Tiago L L Leiria
- Instituto de Cardiologia, Fundacao Universidade de Cardiologia, Porte Alegre, RS, Brazil (T.L.L.L)
| | - Atul Verma
- Southlake Regional Health Centre, Newmarket, ON, Canada (A.V.)
| | | | - Benoit Coutu
- Centre Hospitalier de L'Université de Montreal, Hopital Hotel-Dieu, QC, Canada (B.C.)
| | - Glen L Sumner
- University of Calgary, Libin Cardiovascular Institute, Foothills Medical Centre, AB, Canada (G.L.S., K.K.)
| | | | | | - John Eikelboom
- McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, ON, Canada (J.S.H., J.E.,)
| | | | - John Sapp
- Dalhousie University, QEII Health Sciences Centre, Halifax, NS, Canada (J.S.)
| | - Richard Leather
- Department of Medicine, University of British Columbia, Vancouver, Canada (R.L.)
| | - Derek Yung
- Scarborough Health Network, University of Toronto, Clinical Adjunct, ON, Canada (D.Y.)
| | - Bernard Thibault
- Montreal Heart Institute, Université de Montreal, QC, Canada (B.T.)
| | | | - Kamran Ahmad
- University of Toronto, St Michael's Hospital, ON, Canada (K.A.)
| | - Satish Toal
- Saint John Regional Hospital, NB, Canada (S.T.)
| | - Marcio Sturmer
- Hôpital du Sacré-Coeur de Montréal, QC, Canada (G.B., M.S.)
| | - Katherine Kavanagh
- University of Calgary, Libin Cardiovascular Institute, Foothills Medical Centre, AB, Canada (G.L.S., K.K.)
| | - Eugene Crystal
- Arrhythmia Services, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada (E.C.)
| | - George A Wells
- Department of Medicine, University of Ottawa, University of Ottawa Heart Institute, ON, Canada (P.B.N., G.A.W., D.H.B.)
| | - Andrew D Krahn
- University of British Columbia, Vancouver, Canada (A.D.K.)
| | - David H Birnie
- Department of Medicine, University of Ottawa, University of Ottawa Heart Institute, ON, Canada (P.B.N., G.A.W., D.H.B.)
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Vranckx P, Valgimigli M, Eckardt L, Tijssen J, Lewalter T, Gargiulo G, Batushkin V, Campo G, Lysak Z, Vakaliuk I, Milewski K, Laeis P, Reimitz PE, Smolnik R, Zierhut W, Goette A. Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial. Lancet 2019; 394:1335-1343. [PMID: 31492505 DOI: 10.1016/s0140-6736(19)31872-0] [Citation(s) in RCA: 408] [Impact Index Per Article: 81.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND We aimed to assess the safety of edoxaban in combination with P2Y12 inhibition in patients with atrial fibrillation who had percutaneous coronary intervention (PCI). METHODS ENTRUST-AF PCI was a randomised, multicentre, open-label, non-inferiority phase 3b trial with masked outcome evaluation, done at 186 sites in 18 countries. Patients had atrial fibrillation requiring oral anticoagulation, were aged at least 18 years, and had a successful PCI for stable coronary artery disease or acute coronary syndrome. Participants were randomly assigned (1:1) from 4 h to 5 days after PCI using concealed, stratified, and blocked web-based central randomisation to either edoxaban (60 mg once daily) plus a P2Y12 inhibitor for 12 months or a vitamin K antagonist (VKA) in combination with a P2Y12 inhibitor and aspirin (100 mg once daily, for 1-12 months). The edoxaban dose was reduced to 30 mg per day if one or more factors (creatinine clearance 15-50 mL/min, bodyweight ≤60 kg, or concomitant use of specified potent P-glycoprotein inhibitors) were present. The primary endpoint was a composite of major or clinically relevant non-major (CRNM) bleeding within 12 months. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of their assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02866175, is closed to new participants, and follow-up is completed. FINDINGS From Feb 24, 2017, through May 7, 2018, 1506 patients were enrolled and randomly assigned to the edoxaban regimen (n=751) or VKA regimen (n=755). Median time from PCI to randomisation was 45·1 h (IQR 22·2-76·2). Major or CRNM bleeding events occurred in 128 (17%) of 751 patients (annualised event rate 20·7%) with the edoxaban regimen and 152 (20%) of 755 patients (annualised event rate 25·6%) patients with the VKA regimen; hazard ratio 0·83 (95% CI 0·65-1·05; p=0·0010 for non-inferiority, margin hazard ratio 1·20; p=0·1154 for superiority). INTERPRETATION In patients with atrial fibrillation who had PCI, the edoxaban-based regimen was non-inferior for bleeding compared with the VKA-based regimen, without significant differences in ischaemic events. FUNDING Daiichi Sankyo.
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Affiliation(s)
- Pascal Vranckx
- Department of Cardiology and Intensive Care, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium.
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars Eckardt
- Atrial Fibrillation Network, Munster, Germany; Department of Cardiology and Angiology, Division of Electrophysiology, University of Munster, Munster, Germany
| | - Jan Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands; Cardialysis, Rotterdam, Netherlands
| | - Thorsten Lewalter
- Atrial Fibrillation Network, Munster, Germany; Department of Cardiology, Hospital Munich South, Munich, Germany; University of Bonn, Bonn, Germany
| | - Giuseppe Gargiulo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Valerii Batushkin
- Department of Cardiology, Kyiv City Clinical Hospital #5, Kiev, Ukraine
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Venice, Italy; Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Zoreslava Lysak
- Department of Cardiac Rehabilitation, Oleksandrivska Kyiv City Clinical Hospital, Kiev, Ukraine
| | - Igor Vakaliuk
- Department Internal Medicine No2 and Nursing, Ivano-Frankivsk National Medical University, Ivano-Frankivsk, Ukraine; Department of Anesthesiology with Wards of Intensive Care, Ivano-Frankivsk Regional Clinical Cardiological Clinic, Ivano-Frankivsk, Ukraine
| | - Krzysztof Milewski
- Center for Cardiovascular Research and Development, American Heart of Poland Katowice, Poland; The Jerzy Kukuczka Academy of Physical Education, Faculty of Physiotherapy, Katowice, Katowice, Poland
| | | | | | | | | | - Andreas Goette
- Atrial Fibrillation Network, Munster, Germany; Cardiology and Intensive Care Medicine, St Vincenz-Hospital, Paderborn, Germany; Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany.
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DeSimone CV, DeSimone DC, Cha YM. Contemporary Management of Antiplatelet and Anticoagulation for Cardiac Implantable Device Procedures. Circ Arrhythm Electrophysiol 2019; 12:e007863. [DOI: 10.1161/circep.119.007863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Daniel C. DeSimone
- Department of Cardiovascular Diseases (C.V.D., D.C.D., Y.-M.C.), Mayo Clinic, Rochester, MN
- Division of Infectious Disease, Department of Internal Medicine (D.C.D.), Mayo Clinic, Rochester, MN
| | - Yong-Mei Cha
- Department of Cardiovascular Diseases (C.V.D., D.C.D., Y.-M.C.), Mayo Clinic, Rochester, MN
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