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Wang N, Hou Q, Wu S, Han Q, Li K. Patients with Atrial Fibrillation are Unlikely to Benefit from Aspirin Monotherapy. Int J Gen Med 2024; 17:2337-2345. [PMID: 38799197 PMCID: PMC11128224 DOI: 10.2147/ijgm.s444036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 05/17/2024] [Indexed: 05/29/2024] Open
Abstract
Background Aspirin (ASA), the mainstay antiplatelet treatment in patients with cardiovascular disease (CVD), has been received by a considerable number of AF patients. This study sought to examine the association between ASA monotherapy and the risk of major adverse cardiac and cerebrovascular events (MACCE) in patients with atrial fibrillation (AF). Methods A total of 850 patients with AF were identified from a community-based Kailuan study. All patients were assigned to two groups according to their medicine history: an aspirin therapy group (ASA group) (n = 174), and a non-aspirin therapy group (non-ASA group) (n = 676). The clinical endpoints are MACCE, including myocardial infarction (MI), ischemic stroke (IS), and hemorrhagic stroke (HS). Incidence curves for MACCE were plotted using the Kaplan-Meier method, and the Log rank test was used to assess the differences in incidence rates. The hazard ratios (HR) and 95% confidence intervals (CI) for MACCE were analyzed using Cox proportional-hazards analysis regression models. Results During the 7.2-year follow-up, 30 MACCE occurred in the ASA group, and 101 in the non-ASA group, with a cumulative incidence of 19.88% vs 17.27%, P = 0.511; 3 cases of MI occurred in the ASA group, and 18 cases in the non-ASA group, with a cumulative incidence of 1.78% vs 2.90%, P = 0.305. Twenty-seven cases of IS occurred in the ASA group, and 84 cases in the non-ASA group, with a cumulative incidence of 1.78% vs 2.90%, P = 0.305. Eight cases of HS occurred in the ASA group, and 13 cases in the non-ASA group, with a cumulative incidence of 5.01% vs 2.34%, P = 0.045. Multivariate regression analysis showed that ASA therapy was not associated with MACCE (HR: 1.130, 95% CI: 0.747-1.710, P = 0.562). In addition, ASA therapy was not associated with IS (HR: 1.309, 95% CI: 0.843-2.034, P = 0.231). However, ASA therapy was significantly associated with HS (HR: 2.563, 95% CI: 1.024-6.418, P = 0.044). Conclusion ASA monotherapy is not associated with a lower risk of ischemic events, while significantly associated with a higher risk of bleeding events. Patients with AF are unlikely to benefit from aspirin monotherapy.
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Affiliation(s)
- Nan Wang
- Catheterization Unit, Tangshan Gongren Hospital, Tangshan, People’s Republic of China
| | - Qiqi Hou
- Hebei Medical University, Shijiazhuang, People’s Republic of China
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, Tangshan, People’s Republic of China
| | - Quanle Han
- Department of Cardiology, Tangshan Gongren Hospital, Tangshan, People’s Republic of China
| | - Kangbo Li
- School of Clinical Medicine, North China University of Science and Technology, Tangshan, People’s Republic of China
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Khorsandi M, Blumenthal RS, Blaha MJ, Kohli P. The ABCs of the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. Clin Cardiol 2024; 47:e24284. [PMID: 38766996 PMCID: PMC11103637 DOI: 10.1002/clc.24284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/27/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The 2023 Multisociety Guideline for the Management of Chronic Coronary Disease (CCD) updates recommendations for CCD, formerly known as "stable ischemic heart disease." This condition encompasses a spectrum of coronary vascular pathologies from subclinical to clinical ischemic heart disease. HYPOTHESIS The new "ABC" mnemonic offers clinicians a streamlined framework for applying Class One Recommendations (COR1) and integrating recent updates into CCD management. METHODS A critical analysis of the 2023 CCD guidelines was conducted, with this review highlighting key elements. RESULTS The review outlines crucial changes, including novel recommendations supported by current clinical evidence. The focus is on these developments, clarifying their importance for day-to-day clinical practice. CONCLUSIONS The review encourages a synergistic approach between primary healthcare providers and cardiologists to develop comprehensive strategies for lifestyle modification and medication therapy in CCD care. Furthermore, it suggests that utilizing comprehensive risk assessment tools can refine medical decision-making, ultimately enhancing patient care and clinical outcomes.
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Affiliation(s)
- Michael Khorsandi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Payal Kohli
- Cardiology Division, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Alrabadi N, Al-Nusair M, Haddad R, Alburie L, Mhaidat N, Aljarrah M, Hamoudeh A. Cardiovascular medications used for comorbid diseases in patients with atrial fibrillation. The JoFib study. Eur J Clin Pharmacol 2024; 80:545-552. [PMID: 38253701 DOI: 10.1007/s00228-024-03622-8] [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: 12/03/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024]
Abstract
PURPOSE Many atrial fibrillation (AF) patients use cardiovascular medications for indications other than AF. These medications can affect morbidity and mortality. We aim to investigate the characteristics of AF patients who use different medication classes and their clinical course. METHODS We collected data from the prospective, multicenter registry, JoFib study. We identified classes of non-AF medications (medications not used for rate control, rhythm control, or anticoagulation), described demographic and clinical characteristics, and investigated AF-related outcomes according to these medication classes. RESULTS From a total of 2020 patients, five classes of cardiovascular non-AF medications were identified, aspirin, P2Y12 inhibitors, ACE inhibitors/ARBs, statins, and diuretics. The most commonly used non-AF medications were diuretics and ACE inhibitors/ARBs (39.2%, and 39%, respectively). 51% of AF patients took more than one non-AF medication. Multivariable Cox regression analysis demonstrated that ACE inhibitor/ARB therapy independently reduced the risks of all-cause mortality and cardiovascular mortality (aHR 0.50, 95%CI 0.37-0.68; aHR 0.51, 95%CI 0.34-0.75, respectively) and that statin therapy reduced the risk of cardiovascular mortality (aHR 0.68, 95%CI 0.48-0.98) in AF patients. Multivariable logistic regression analysis demonstrated a protective effect of statin therapy against the secondary outcome, clinically relevant non-major bleeding (CRNMB) (adjusted OR 0.62 95%CI 0.42-0.94). CONCLUSION Our findings suggest a protective effect of ACE inhibitors/ARBs against all-cause and cardiovascular mortality, statins against cardiovascular mortality, and CRNMB in patients with AF. Accordingly, these medications should be encouraged in patients with AF when indicated. Additionally, future research should explore whether these medications should be offered to AF patients more routinely. The study was registered with Clinicaltrials.gov (unique identifier number: NCT03917992, Registration date:14/4/2019).
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Affiliation(s)
- Nasr Alrabadi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Mohammed Al-Nusair
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Razan Haddad
- Department of Pharmaceutical Sciences, Faculty of Pharmacy, Jadara University, Irbid, Jordan
| | - Lama Alburie
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Nizar Mhaidat
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohamad Aljarrah
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ayman Hamoudeh
- Department of Cardiology, Istishari Hospital, Amman, Jordan
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 110] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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5
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Coisne A, Aghezzaf S, Butruille L, Woitrain E, Ninni S, Juthier F, Sudre A, Vincentelli A, Lamblin N, Lemesle G, Montaigne D, Bauters C. Incidence, source, and prognostic impact of major bleeding across the spectrum of aortic stenosis. Am Heart J 2023; 262:140-147. [PMID: 37100186 DOI: 10.1016/j.ahj.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/30/2023] [Accepted: 04/07/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Severe aortic stenosis (AS) has been associated with bleeding. However, there is a lack of prospective assessment of bleeding events and their clinical significance in a large population of outpatients with variable degree of AS severity. OBJECTIVES To assess the incidence, source, determinants, and prognostic impact of major bleeding in patients with variable degree of AS severity. METHODS Between May 2016 and December 2017, consecutive outpatients were included. Major bleeding was defined as type ≥3 bleed using the Bleeding Academic Research Consortium definition. Cumulative incidence was calculated with death as the competing event. Data was censored at time of aortic valve replacement. RESULTS Among 2,830 patients, 46 major bleeding events occurred (0.7%/year) during a median follow-up of 2.1 years (interquartile range: 1.4-2.7). Most frequent sites of bleeding were gastrointestinal (50%) and intracranial (30.4%). Major bleeding was significantly associated with all-cause mortality (hazard ratio: 5.93 (95% confidence interval 3.64-9.65); P < .001). AS severity was associated with major bleedings (P = .041). By multivariable analysis, severe AS was an independent determinant of major bleeding (hazard ratio vs mild AS: 3.59 [95% confidence interval 1.56-8.29]; P = .003). The increased risk of bleeding associated with severe AS was significantly exacerbated in patients using oral anticoagulation. CONCLUSION In AS patients, major bleeding is rare but a strong independent predictor of death. AS severity is a determinant of bleeding events. Severe AS and oral anticoagulation should be identified as an association at very high risk of major bleeding.
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Affiliation(s)
- Augustin Coisne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France; Cardiovascular Research Foundation, New York, NY.
| | - Samy Aghezzaf
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Laura Butruille
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Eloise Woitrain
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Sandro Ninni
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Francis Juthier
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Arnaud Sudre
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - André Vincentelli
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Nicolas Lamblin
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Gilles Lemesle
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France; Heart and Lung Institute, University hospital of Lille, Lille, France; FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - David Montaigne
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
| | - Christophe Bauters
- Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France
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7
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Shakir A, Khan A, Agarwal S, Clifton S, Reese J, Munir MB, Nasir UB, Khan SU, Gopinathannair R, DeSimone CV, Deshmukh A, Jackman WM, Stavrakis S, Asad ZUA. Dual therapy with oral anticoagulation and single antiplatelet agent versus monotherapy with oral anticoagulation alone in patients with atrial fibrillation and stable ischemic heart disease: a systematic review and meta-analysis. J Interv Card Electrophysiol 2023; 66:493-506. [PMID: 36085242 DOI: 10.1007/s10840-022-01347-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 08/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) and stable ischemic heart disease, recent guidelines recommend oral anticoagulant (OAC) monotherapy in preference to OAC + single antiplatelet agent (SAPT) dual therapy. However, these data are based on the results of only two randomized controlled trials (RCTs) and a relatively small group of patients. Thus, the safety and efficacy of this approach may be underpowered to detect a significant difference. We hypothesized that OAC monotherapy will have a reduced risk of bleeding, but similar all-cause mortality and ischemic outcomes as compared to dual therapy (OAC + SAPT). METHODS A systematic search of PubMed/MEDLINE, EMBASE, and Scopus was conducted. Safety outcomes included total bleeding, major bleeding, and others. Efficacy outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, stroke, and major adverse cardiovascular events (MACE). RCTs and observational studies were pooled separately (study design stratified meta-analysis). Subgroup analyses were performed for vitamin K antagonists and direct oral anticoagulants (DOACs). Pooled risk ratios (RR) with corresponding 95% confidence intervals (CI) were calculated using the Mantel-Haenszel method. RESULTS Meta-analysis of 2 RCTs comprising a total of 2905 patients showed that dual therapy (OAC + SAPT) vs. OAC monotherapy was associated with a statistically significant increase in major bleeding (RR 1.51; 95% CI [1.10, 2.06]). There was no significant reduction in MACE (RR 1.10; [0.71, 1.72]), stroke (RR 1.29; [0.85, 1.95]), myocardial infarction (RR 0.57; [0.28, 1.16]), cardiovascular mortality (RR 1.22; [0.63, 2.35]), or all-cause mortality (RR 1.18 [0.52, 2.68]). Meta-analysis of 20 observational studies comprising 47,451 patients showed that dual therapy (OAC + SAPT) vs. OAC monotherapy was associated with a statistically significant higher total bleeding (RR 1.50; [1.20, 1.88]), major bleeding (RR = 1.49; [1.38, 1.61]), gastrointestinal bleeding (RR = 1.62; [1.15, 2.28]), and myocardial infarction (RR = 1.15; [1.05, 1.26]), without significantly lower MACE (RR 1.10; [0.97, 1.24]), stroke (RR 0.93; [0.73, 1.19]), cardiovascular mortality (RR 1.11; [0.95, 1.29]), or all-cause mortality (RR 0.93; [0.78, 1.11]). Subgroup analysis showed similar results for both vitamin K antagonists and DOACs, except a statistically significant higher intracranial bleeding with vitamin K antagonist + SAPT vs. vitamin K antagonist monotherapy (RR 1.89; [1.36-2.63]). CONCLUSIONS In patients with AF and stable ischemic heart disease, OAC + SAPT as compared to OAC monotherapy is associated with a significant increase in bleeding events without a significant reduction in thrombotic events, cardiovascular mortality, and all-cause mortality.
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Affiliation(s)
- Aamina Shakir
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Arsalan Khan
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Siddharth Agarwal
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Shari Clifton
- Robert M Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jessica Reese
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California Davis, Sacramento, CA, USA
| | | | - Safi U Khan
- Houston Methodist Hospital, Houston, TX, USA
| | | | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Warren M Jackman
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA.
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Greco A, Laudani C, Rochira C, Capodanno D. Antithrombotic Management in AF Patients Following Percutaneous Coronary Intervention: A European Perspective. Interv Cardiol 2023; 18:e05. [PMID: 37601736 PMCID: PMC10433110 DOI: 10.15420/icr.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 03/20/2022] [Indexed: 08/22/2023] Open
Abstract
AF is a highly prevalent disease, often requiring long-term oral anticoagulation to prevent stroke or systemic embolism. Coronary artery disease, which is common among AF patients, is often referred for myocardial revascularisation by percutaneous coronary intervention (PCI), which requires dual antiplatelet therapy to minimise the risk of stent-related complications. The overlap of AF and PCI is a clinical conundrum, especially in the early post-procedural period, when both long-term oral anticoagulation and dual antiplatelet therapy are theoretically indicated as a triple antithrombotic therapy. However, stacking drugs is not a desirable option because of the increased bleeding risk. Several strategies have been investigated to mitigate this concern, including shortening triple antithrombotic therapy duration and switching to a dual antithrombotic regimen. This review analyses the mechanisms underlying thrombotic complications in AF-PCI, summarises evidence surrounding antithrombotic therapy regimens and reports and comments on the latest European guidelines.
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Affiliation(s)
- Antonio Greco
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Claudio Laudani
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Carla Rochira
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
| | - Davide Capodanno
- Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico - San Marco', University of Catania Catania, Italy
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9
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Zhang X, Wu Y, Lv C, Zhang S, Liu H, Wang Y, Zou Y, Qin L, Zhang J, Yin T. Efficacy and safety of oral anticoagulants in elderly patients with stable coronary artery disease and atrial fibrillation. Thromb J 2022; 20:66. [PMID: 36316745 PMCID: PMC9620616 DOI: 10.1186/s12959-022-00426-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
Abstract
Background This study aimed to evaluate the efficacy and safety of oral anticoagulants (OACs) in real-world elderly patients with comorbidities of stable coronary artery disease (SCAD) and atrial fibrillation (AF). Methods Elderly patients (aged ≥ 65 years old) diagnosed with SCAD and AF were consecutively recruited and grouped into patients with or without oral anticoagulant (OAC) treatment. Follow-up was performed for 5 years. Major adverse cardiac events (MACEs) were defined as a composite of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, and systemic embolism. Major bleeding outcomes were defined as events that were type ≥ 3 based on the Bleeding Academic Research Consortium (BARC) criteria. The net clinical outcomes were defined as the combination of MACEs and bleeding of BARC type ≥ 3. Results A cohort of 832 eligible patients (78 ± 6.70 years) was included. Compared to the patients without OAC treatment (n = 531, 63.82%), the patients treated with OAC (n = 301, 36.18%) were much younger, had higher body mass index (BMI), and had lower prevalence of heart failure, chronic obstructive pulmonary disease (COPD), renal insufficiency, and previous myocardial infarction. During the follow-up of 5 years, compared to the patients without OAC treatment, patients with OAC had a significantly lower risk of MACEs (20.60% vs. 58.95%, adjusted HR: 0.21, 95% CI: 0.15–0.30, p < 0.001) but a higher risk of BARC ≥ 3 bleeding events (4.65% vs. 1.32%, adjusted HR: 4.71, 95% CI: 1.75–12.64, p = 0.002). In combination, a lower risk of net clinical outcomes could be observed in the patients with OACs (23.26% vs. 58.96%, adjusted HR: 0.27, 95% CI: 0.19–0.38, p < 0.001). Among the patients with OAC treatment, no significant difference was found for MACEs or BARC ≥ 3 bleeding events between the patients with or without comedications of oral antiplatelet agents. Conclusions A net clinical benefit of efficacy and safety could be observed in OAC-treated elderly patients with SCAD and AF. This benefit is independent of the comedications of oral antiplatelet treatment.
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Affiliation(s)
- Xu Zhang
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China ,grid.411337.30000 0004 1798 6937Department of Cardiology, First Hospital of Tsinghua University, Beijing, China
| | - Yangxun Wu
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Chao Lv
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Shizhao Zhang
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Haiping Liu
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Yuyan Wang
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Yuting Zou
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Liu’an Qin
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
| | - Junmeng Zhang
- grid.411337.30000 0004 1798 6937Department of Cardiology, First Hospital of Tsinghua University, Beijing, China
| | - Tong Yin
- grid.414252.40000 0004 1761 8894Institute of Geriatrics, Beijing Key Laboratory of Aging and Geriatrics, National Clinical Research Center for Geriatric Diseases, Second Medical Center of Chinese PLA General Hospital, No.28 Fu Xing Road, Beijing, 100853 China
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10
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Malladi S, Hamid K, Pendyala NC, Veerapaneni V, Deliwala S, Dubre D, Elian SA, Singh A. Management of stable coronary artery disease and atrial fibrillation with anti-thrombotic therapy: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27498. [PMID: 35049165 PMCID: PMC9191377 DOI: 10.1097/md.0000000000027498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/24/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Long term management of patients with stable coronary artery disease of >1 year after myocardial infarction (MI) or percutaneous coronary intervention and atrial fibrillation is unclear. Current guidelines recommend using oral anti-coagulation (OAC) alone although the recommendation is weak and there is low quality evidence. Two new randomized control trials (RCTs) were published recently. We conducted an updated meta-analysis to evaluate the effect of these studies on patient outcomes. OBJECTIVE To conduct a systematic review and meta-analysis of published RCTs and observational studies to compare OAC alone versus OAC plus single anti-platelet therapy. METHODS Electronic searches were conducted using appropriate terms from 3 databases. Relevant studies included. Data extracted and analysis were performed using STATA. MEASUREMENTS Summary statistics were pooled and measured for primary and secondary outcomes of both treatment arms. MAIN RESULTS Eight studies involving 10,120 patients were included for the analysis. Five thousand two hundred thirty-seven patients were on combination therapy while 4883 were on OAC alone. There was no statistically significant difference in the primary outcome of major adverse cardiac events (hazard ratio [HR] 1.067; 95% confidence interval [CI] 0.912-1.249; P value .417). There was no statistically significant difference even in the measured secondary outcomes namely all cause mortality (HR 1.048; 95% CI 0.830-1.323; P value .695), cardiovascular mortality (HR 0.863; 95% CI 0.593-1.254; P value .439). However, we found statistically significant difference between the 2 groups in the incidence of MI with higher incidence in mono therapy group (HR 1.229; 95% CI 1.011-1.495; P value .039) and higher incidence of major bleeding in the combination therapy group in the subgroup analysis (HR 0.649; 95% CI 0.464-0.907; P value .011). CONCLUSION We found no reduction of major adverse cardiac event between combination therapy and mono therapy. Although mono therapy showed increased risk of major bleeding overall, subgroup analysis of the RCTs showed increased risk of major bleeding in the combination therapy group. MI was higher in the mono therapy group compared to the combination therapy group, however this outcome was not reproducible in the subgroup analysis of the RCTs.
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Affiliation(s)
- Srikanth Malladi
- Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University, Flint, MI
| | - Kewan Hamid
- Division of pulmonary/Critical Care, University of South Alabama College of Medicine, Mobile, Alabama, USA
| | | | | | - Smit Deliwala
- Internal Medicine Department, Hurley Medical Center, Flint, MI
| | - Donald Dubre
- Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University, Flint, MI
| | - Samir A. Elian
- Division of Cardiology, Hurley Medical Center, Michigan State University, MI
| | - Adiraj Singh
- Department of Combined Internal Medicine-Pediatrics, Hurley Medical Center, Michigan State University, Flint, MI
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11
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Lemesle G, Bauters C, Bonello L, Fauchier L, Cayla G, Marijon E, Guenoun M, Schurtz G, Ninni S, Richardson M, Albert F, Cohen S, Lamblin N, Danchin N. Management of antithrombotics in situations with a gap in evidence: A national French survey focusing on patients with coronary artery disease and atrial fibrillation. Int J Cardiol 2021; 348:15-21. [PMID: 34864080 DOI: 10.1016/j.ijcard.2021.11.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/21/2021] [Accepted: 11/29/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND If several randomized studies allowed to better apprehend what should be the best antithrombotic strategy in patients with concomitant coronary artery disease (CAD) and atrial fibrillation (AF), there are still several clinical situations with a gap of evidence. METHODS We conducted a national French survey in September-October 2020 among cardiologists in order to assess what are daily practices regarding the antithrombotic management in several specific clinical settings where no or little scientific evidence is available. The questionnaires were built by a committee of 6 cardiologists routinely involved in the field of CAD and/or AF. RESULTS Among the 6388 French cardiologists, 483 (7.6%) cardiologists participated to the survey. The rate of participation was rather homogeneous across the country. The mean age of participants was 48 +/- 12.7. There were 134 women (27.7%) and 349 men. Altogether, 181 (37.5%) cardiologists worked in private, 153 (31.7%) in non-universitary public and 83 (17.2%) in universitary public centers. The remaining had shared activity. Among the participants, 150 were interventional (coronary) cardiologists (31.1%). Others were general cardiologists (n = 229), specialists in the field of rhythmology (n = 43), heart failure (n = 17) or imaging (n = 44). The survey consisted of 10 questions pertaining to 2 virtual clinical scenarios. CONCLUSIONS The present survey is an illustration of how therapeutic decisions may vary in such situations with little or no scientific evidence. Such surveys may help experts to build consensus (answers with little variability) and to target the need for future trials and more research (answers with a lot of variability).
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Affiliation(s)
- Gilles Lemesle
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Univ. Lille, F-59000, France; Institut Pasteur of Lille, Inserm U1011, F-59000 Lille, France; FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France.
| | - Christophe Bauters
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Institut Pasteur of Lille, Inserm U1167, F-59000 Lille, France; Univ. Lille, F-59000, France
| | - Laurent Bonello
- Aix-Marseille Univ, Intensive care unit, Department of Cardiology, Publique-Hôpitaux de Marseille, Hôpital Nord, Marseille, France; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), Marseille, France; Centre for CardioVascular and Nutrition research (C2VN), INSERM 1263, INRA 1260, Marseille, France
| | - Laurent Fauchier
- Department of Cardiology, CHU de Trousseau, University François-Rabelais, 37170 Chambray-lès-, Tours, France
| | - Guillaume Cayla
- Department of Cardiology, University Hospital of Nîmes, 30000 Nîmes, France
| | - Eloi Marijon
- Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, University of Paris, Paris, France
| | - Maxime Guenoun
- Department of Cardiology, Hôpital Européen de Marseille, 13003 Marseille, France
| | - Guillaume Schurtz
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France
| | - Sandro Ninni
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Univ. Lille, F-59000, France; Institut Pasteur of Lille, Inserm U1011, F-59000 Lille, France; FACT (French Alliance for Cardiovascular Trials), F-75000 Paris, France
| | - Marjorie Richardson
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France
| | - Franck Albert
- Department of Cardiology, Hospital of Chartres, 28000 Chartres, France
| | - Serge Cohen
- Department of Cardiology, Hôpital St Antoine, APHP, Paris, France
| | - Nicolas Lamblin
- Heart and Lung Institute, University hospital of Lille, F-59000 Lille, France; Institut Pasteur of Lille, Inserm U1167, F-59000 Lille, France; Univ. Lille, F-59000, France
| | - Nicolas Danchin
- Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, University of Paris, FACT (French Alliance for Cardiovascular Trials), Paris, France
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12
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Sato Y, Yoshihisa A, Takeishi R, Ohara H, Sugawara Y, Ichijo Y, Hotsuki Y, Watanabe K, Abe S, Misaka T, Sato T, Oikawa M, Kobayashi A, Nakazato K, Takeishi Y. Simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) Definition Predicts Bleeding Events in Patients With Heart Failure. Circ J 2021; 86:147-155. [PMID: 34707066 DOI: 10.1253/circj.cj-21-0686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND It has recently been reported that the simplified Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition, which excludes 6 rare criteria, is comparable to the original ARC-HBR definition in predicting major bleeding in patients with coronary artery disease (CAD) who undergo percutaneous coronary intervention. In this study, we investigated whether the simplified ARC-HBR definition could be applied to patients with heart failure (HF) to identify those at high bleeding risk (HBR).Methods and Results:In all, 2,437 patients hospitalized for HF were enrolled in this study. Patients were divided into 2 groups based on the simplified ARC-HBR definition: those at HBR (n=2,026; 83.1%) and those not (non-HBR group; n=411; 16.9%). The HBR group was older (72.0 vs. 61.0 years; P<0.001) and had a lower prevalence of CAD (31.1% vs. 36.5%; P=0.034) than the non-HBR group. Kaplan-Meier analysis showed that post-discharge bleeding events defined as hemorrhagic stroke or gastrointestinal bleeding were more frequent in the HBR than non-HBR group (log-rank P<0.001). The simplified ARC-HBR definition accurately predicted bleeding events (Fine-Gray model; hazard ratio 2.777, 95% confidence interval 1.464-5.270, P=0.001). CONCLUSIONS The simplified ARC-HBR definition predicts a high risk of bleeding events in patients with HF.
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Affiliation(s)
- Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University.,Department of Clinical Laboratory Sciences, Fukushima Medical University School of Health Science
| | - Ryohei Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Himika Ohara
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yukiko Sugawara
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yasuhiro Ichijo
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Yu Hotsuki
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Satoshi Abe
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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13
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Outcomes after ticagrelor versus clopidogrel treatment in end-stage renal disease patients with acute myocardial infarction: a nationwide cohort study. Sci Rep 2021; 11:20826. [PMID: 34675293 PMCID: PMC8531372 DOI: 10.1038/s41598-021-00360-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/08/2021] [Indexed: 11/15/2022] Open
Abstract
Clinical outcomes are unknown after ticagrelor treatment in patients with end-stage renal disease (ESRD) who are diagnosed with acute myocardial infarction (AMI). ESRD patients who were on hemodialysis and received dual antiplatelet therapy (DAPT) for AMI between July 2013 and December 2016 were identified in Taiwan's National Health Insurance Research Database. Using stabilized inverse probability of treatment weighting, patients receiving aspirin plus ticagrelor (n = 530) were compared with those receiving aspirin plus clopidogrel (n = 2462) for the primary efficacy endpoint, a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke, and bleeding, defined according to the Bleeding Academic Research Consortium. Study outcomes were compared between the two groups using Cox proportional hazards model or competing risk model for the hazard ratio or subdistribution hazard ratio (SHR). During 9 months of follow-up, ticagrelor was comparable to clopidogrel with respect to the risks of primary efficacy endpoint [11.69 vs. 9.28/100 patient-months; SHR, 1.16; 95% confidence interval (CI) 0.97–1.4] and bleeding (5.55 vs. 4.36/100 patient-months; SHR 1.14; 95% CI 0.88–1.47). In conclusion, among hemodialysis patients receiving DAPT for AMI, ticagrelor was comparable to clopidogrel with regard to the composite efficacy endpoint and bleeding.
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14
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Long‐term antithrombotic therapy for patients with atrial fibrillation and stable coronary artery disease. Cochrane Database Syst Rev 2021; 2021:CD014819. [PMCID: PMC8543784 DOI: 10.1002/14651858.cd014819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2024]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the efficacy and safety of different long‐term antithrombotic regimens for people with AF and stable CAD.
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15
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Panov AV. Antithrombotic Management for Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-07-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Comprehensive protection of a patient with atrial fibrillation (AF) should not only reduce the risk of stroke and systemic embolism, but also reduce the risk coronary events and ensure high adherence to treatment. In accordance with consensus document issued by the European Heart Rhythm Association, European Society of Cardiology, European Association of Percutaneous Cardiovascular Interventions, as well as with other recent Russian Society of Cardiology Guidelines, the management of antithrombotic therapy of patients with AF undergoing percutaneous coronary intervention (PCI) requires that multiple and interconnected issues. The review article addresses questions about duration of initial triple antithrombotic therapy (TAT), selection of P2Y12 inhibitor, choice of oral anticoagulant to be combined with antiplatelet therapy, intensity of oral anticoagulation throughout combination therapy, and choice of oral anticoagulant for indefinite therapy. In general, it is recommended to refuse the routine use of TAT for most patients. Accordingly, for patients who need both anticoagulant and antiplatelet therapy, it is strongly recommended that the default strategy after recent PCI is a double antithrombotic therapy consisting of an anticoagulant and one antiplatelet, preferably from the group of P2Y12 inhibitors. When conducting combined antithrombotic therapy, preference should be given to clopidogrel compared to other, more powerful P2Y12 inhibitors and direct oral anticoagulant (DOAC) instead of vitamin K antagonists. The primary choice of DOAC in patients with AF who have undergone PCI should be carried out taking into account such factors as individual risk of stroke and bleeding, adherence to treatment, concomitant diseases, pharmacological characteristics and evidence base of a specific DOAC, taking other medications, etc. The pharmacokinetic features of rivaroxaban, which create the possibility of its single administration, the evidence base for reducing coronary risks in various variants of the course of coronary heart disease, determines the special positions of the drug for the comprehensive protection of patients with AF after PCI.
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16
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Choi Y, Lee Y, Kim SH, Kim S, Kim JY, Kim TS, Hwang Y, Kim JH, Jang SW, Lee MY, Oh YS. Single direct oral anticoagulant therapy in stable patients with atrial fibrillation beyond 1 year after coronary stent implantation. Heart 2021; 108:285-291. [PMID: 33990409 DOI: 10.1136/heartjnl-2020-318750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/01/2021] [Accepted: 04/04/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Optimal antithrombotic therapy in patients with atrial fibrillation (AF) beyond 1 year after coronary stent implantation has not been well established in the era of direct oral anticoagulant (DOAC). METHODS Using Korean National Health Insurance Service data, we analysed 4294 patients with AF who were prescribed DOAC beyond 1 year after coronary stent implantation. Subjects were classified into the monotherapy group (DOAC single therapy, n=1221) or the combination therapy group (DOAC with an antiplatelet agent, n=3073). The primary ischaemic endpoint was defined as a composite of cardiovascular death, myocardial infarction, stroke or systemic thromboembolism. The secondary endpoints were all-cause death, major bleeding defined as a bleeding event requiring hospitalisation and net adverse clinical events. Propensity score matching was performed to balance baseline covariates. RESULTS Among included patients, 94% had drug-eluting coronary stents. During a median follow-up of 19 (7-32) months, the monotherapy group had a similar risk of the primary ischaemic endpoint (HR 0.828, 95% CI 0.660 to 1.038) and all-cause death (HR 1.076, 95% CI 0.895 to 1.294) compared with the combination therapy group. Risk of major bleeding was lower in the monotherapy group (HR 0.690, 95% CI 0.481 to 0.989), which was mostly driven by reduced gastrointestinal bleeding (HR 0.562, 95% CI 0.358 to 0.883). There was no significant difference in net adverse clinical events between the two groups. CONCLUSIONS DOAC monotherapy showed similar efficacy in preventing ischaemic events and was associated with lower major bleeding events compared with combination therapy in patients with AF beyond 1 year after coronary stent implantation.
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Affiliation(s)
- Young Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yunhee Lee
- Department of Occupational and Environmental Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Hwan Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sunhwa Kim
- Division of Cardiology, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Ju Youn Kim
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, South Korea
| | - Tae-Seok Kim
- Division of Cardiology, Department of Internal Medicine, Daejeon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, South Korea
| | - Youmi Hwang
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Ji-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, South Korea
| | - Sung-Won Jang
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Man Young Lee
- Division of Cardiology, Department of Internal Medicine, Yeouido St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yong-Seog Oh
- Division of Cardiology, Department of Internal Medicine, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Glasgow-Blatchford Score Predicts Post-Discharge Gastrointestinal Bleeding in Hospitalized Patients with Heart Failure. J Clin Med 2020; 9:jcm9124083. [PMID: 33348860 PMCID: PMC7766138 DOI: 10.3390/jcm9124083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 12/20/2022] Open
Abstract
Background: The Glasgow-Blatchford Score (GBS) is one of the most widely used scoring systems for predicting clinical outcomes for gastrointestinal bleeding (GIB). However, the clinical significance of the GBS in predicting GIB in patients with heart failure (HF) remains unclear. Methods and Results: We conducted a prospective observational study in which we collected the clinical data of a total of 2236 patients (1130 men, median 70 years old) who were admitted to Fukushima Medical University Hospital for acute decompensated HF. During the post-discharge follow-up period of a median of 1235 days, seventy-eight (3.5%) patients experienced GIB. The GBS was calculated based on blood urea nitrogen, hemoglobin, systolic blood pressure, heart rate, and history of hepatic disease. The survival classification and regression tree analysis revealed that the accurate cut-off point of the GBS in predicting post-discharge GIB was six points. The patients were divided into two groups: the high GBS group (GBS > 6, n = 702, 31.4%) and the low GBS group (GBS ≤ 6, n = 1534, 68.6%). The Kaplan–Meier analysis showed that GIB rates were higher in the high GBS group than in the low GBS group. Multivariate Cox proportional hazards analysis adjusted for age, malignant tumor, and albumin indicated that a high GBS was an independent predictor of GIB (hazards ratio 2.258, 95% confidence interval 1.326–3.845, p = 0.003). Conclusions: A high GBS is an independent predictor and useful risk stratification score of post-discharge GIB in patients with HF.
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18
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Kageyama S, Murata K, Nawada R, Onodera T, Maekawa Y. Unique referral system contributes to long-term net clinical benefits in patients undergoing secondary prevention therapy after percutaneous coronary intervention. PLoS One 2020; 15:e0242707. [PMID: 33211778 PMCID: PMC7676744 DOI: 10.1371/journal.pone.0242707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/07/2020] [Indexed: 11/19/2022] Open
Abstract
Cardiovascular disease, including ischemic heart disease, is a leading cause of death worldwide. Improvement of the secondary prevention of ischemic heart disease is necessary. We established a unique referral system to connect hospitals and outpatient clinics to coordinate care between general practitioners and cardiologists. Here, we evaluated the impact and long-term benefits of our system for ischemic heart disease patients undergoing secondary prevention therapy after percutaneous coronary intervention. This single-center retrospective observational study included 3658 consecutive patients who underwent percutaneous coronary intervention at Shizuoka City Hospital between 2010 and 2019. After percutaneous coronary intervention, patients were considered conventional outpatients (conventional follow-up group) or subjected to our unique referral system (referral system group) at the attending cardiologist's discretion. To audit compliance of the treatment with the latest Japanese guidelines, we adopted a circulation-type referral system, whereby general practitioners needed to refer registered patients at least once a year, even if no cardiac events occurred. Clinical events in each patient were evaluated. Net adverse clinical events were defined as a combination of major adverse cardiac, cerebrovascular, and major bleeding events. There were 2241 and 1417 patients in the conventional follow-up and referral system groups, with mean follow-ups of 1255 and 1548 days and cumulative net adverse clinical event incidences of 27.6% and 21.5%, respectively. Kaplan-Meier analysis showed that the occurrence of net adverse clinical events was significantly lower in the referral system group than in the conventional follow-up group (log-rank: P<0.001). Univariate and multivariate analyses revealed that the unique referral system was a significant predictor of the net clinical benefits (hazard ratio: 0.56, 95% confidence interval: 0.37-0.83, P = 0.004). This result was consistent after propensity-score matching. In summary, our unique referral system contributed to long-term net clinical benefits for the secondary prevention of ischemic heart disease after percutaneous coronary intervention.
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Affiliation(s)
- Shigetaka Kageyama
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tomoya Onodera
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yuichiro Maekawa
- Internal Medicine III, Hamamatsu University School of Medicine, Shizuoka, Japan
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19
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Ullah W, Sattar Y, Shaukat M, Fischman DL. Safety and efficacy of anticoagulant monotherapy in atrial fibrillation and stable coronary artery disease: A systematic review and meta-analysis. Eur J Intern Med 2020; 81:54-59. [PMID: 32709546 DOI: 10.1016/j.ejim.2020.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Adjunctive use of oral anticoagulant (OAC) and antiplatelet therapy (APT) in patients with stable coronary artery disease (CAD) and nonvalvular atrial fibrillation (AF) is a challenge of daily practice. METHODS A comprehensive literature search of databases was performed to identify studies comparing the safety and efficacy of OAC monotherapy and combined therapy (OAC plus single (S) APT). Events including major adverse cardiovascular events (MACE), all-cause mortality, stroke and major bleeding were analyzed. RESULTS Seven articles comprising 11,070 subjects were identified. Combined therapy was associated with a significantly higher risk of major bleeding (pooled hazard ratio (HR) of 1.62, 95% CI 1.40-1.86, p=<0.0001) compared to the OAC monotherapy. There was no significant difference between the two comparison arms in terms of MACE (HR 1.14; 95% CI 0.97-1.34, p = 0.11), stroke (HR 1.05; 95% CI 0.77-1.43, p = 0.78) and all-cause mortality (HR 1.15; 95% CI 0.94-1.40, p = 0.16). Stratified analysis by inclusion of only patients with coronary stents attenuated the safety effect of monotherapy. Subgroup analysis based on the study design, type of OAC, major bleeding criteria and APT revealed findings consistent with the pooled HR. The combined therapy group had a 19% and 38% higher risk of MACE in studies with a history of MI (p = 0.03) and with the use of rivaroxaban (p = 0.02), respectively. CONCLUSION OAC monotherapy might have a lower incidence of major bleeding events with no higher overall risk of MACE, ischemic stroke and all-cause mortality compared to the combined therapy group.
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Affiliation(s)
- Waqas Ullah
- Abington Jefferson Health, Abington, PA, USA.
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20
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Camaj A, Miller MS, Halperin JL, Giustino G. Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiol Clin 2020; 38:551-561. [PMID: 33036717 DOI: 10.1016/j.ccl.2020.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with atrial fibrillation who undergo percutaneous coronary intervention with drug-eluting stent implantation often require oral anticoagulation (OAC) and antiplatelet therapies. Triple antithrombotic therapy (OAC, a P2Y12-receptor inhibitor, and aspirin) has been the default antithrombotic strategy. Evidence from randomized trials indicates, however, that a dual antithrombotic therapy strategy (OAC plus a P2Y12-receptor inhibitor) reduces bleeding risk without increasing the risk of ischemic events. This review provides an overview of advancements in this field as well as European and North American guidelines and consensus documents to inform clinical decision making around antithrombotic therapies for patients with atrial fibrillation who undergo percutaneous coronary intervention.
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Affiliation(s)
- Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Michael S Miller
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Jonathan L Halperin
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, The Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA.
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21
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Lemesle G, Ninni S, de Groote P, Schurtz G, Lamblin N, Bauters C. Relative impact of bleedings over ischaemic events in patients with heart failure: insights from the CARDIONOR registry. ESC Heart Fail 2020; 7:3821-3829. [PMID: 32918405 PMCID: PMC7754769 DOI: 10.1002/ehf2.12971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023] Open
Abstract
AIMS Major bleeding events in heart failure (HF) patients are poorly described. We sought to investigate the importance of major bleeding and its impact on outcomes in HF patients. METHODS AND RESULTS We analysed incident bleeding and ischaemic events during a 3 year follow-up in 2910 HF outpatients included in a prospective multicentre registry. Major bleeding was defined as a Type ≥3 bleed using the Bleeding Academic Research Consortium definition. Ischaemic event was a composite of ischaemic stroke and myocardial infarction. Events were adjudicated by a blinded committee. At inclusion, most patients (89%) received at least one antithrombotic: anticoagulation (53.9%) and/or antiplatelet therapy (46.2%). Bleeding occurred in 111 patients {3 year cumulative incidence: 3.6% [95% confidence interval (CI) 3.0-4.3]} and ischaemic events in 102 patients [3 year cumulative incidence: 3.3% (95% CI 2.7-4.0)]. Most bleedings were Bleeding Academic Research Consortium 3a (32.5%) or 3b (31.5%). Most frequent sites of bleeding were gastrointestinal (40.6%) and intracranial (27.9%). Variables associated with bleeding were atrial fibrillation [hazard ratio (HR) = 2.63 (95% CI 1.66-4.19), P < 0.0001], diabetes [HR = 1.62 (95% CI 1.11-2.38), P = 0.012], and older age [HR = 1.19 per 10 year increase (95% CI 1.00-1.41), P = 0.049]. Anticoagulation use was associated with a two-fold increase in the bleeding risk. Bleeding events as well as ischaemic events were strongly associated with subsequent mortality [adjusted HRs: 5.67 (4.41-7.29), P < 0.0001 and 4.29 (3.18-5.78), P < 0.0001, respectively]. CONCLUSIONS In HF outpatients, antithrombotics are widely used. Bleeding occurs at a stable rate of 1.2% annually (as frequent as ischaemic events) and is associated with a dramatic increase in mortality (at least as severe as ischaemic events). Most events occurred in patients receiving anticoagulation. Knowledge of these findings may help physicians to manage antithrombotics in HF patients.
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Affiliation(s)
- Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Faculté de Médecine de Lille, Université de Lille, Lille, France.,Institut Pasteur de Lille, Inserm U1011, Lille, France.,FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Sandro Ninni
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Faculté de Médecine de Lille, Université de Lille, Lille, France.,Institut Pasteur de Lille, Inserm U1011, Lille, France
| | - Pascal de Groote
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Institut Pasteur de Lille, Inserm U1167, Lille, France
| | - Guillaume Schurtz
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Nicolas Lamblin
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Faculté de Médecine de Lille, Université de Lille, Lille, France.,Institut Pasteur de Lille, Inserm U1167, Lille, France
| | - Christophe Bauters
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Lille, France.,Faculté de Médecine de Lille, Université de Lille, Lille, France.,Institut Pasteur de Lille, Inserm U1167, Lille, France
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22
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Vitolo M, Javed S, Capodanno D, Rubboli A, Boriani G, Lip GYH. Antithrombotic treatment in atrial fibrillation patients undergoing percutaneous coronary interventions: focus on stent thrombosis. Expert Rev Cardiovasc Ther 2020; 18:587-600. [DOI: 10.1080/14779072.2020.1808463] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Saad Javed
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Davide Capodanno
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Andrea Rubboli
- Deparment of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, S. Maria Delle Croci Hospital, Ravenna, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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23
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Ninni S, Lemesle G, Meurice T, Tricot O, Lamblin N, Bauters C. Real-Life Incident Atrial Fibrillation in Outpatients with Coronary Artery Disease. J Clin Med 2020; 9:jcm9082367. [PMID: 32722139 PMCID: PMC7465814 DOI: 10.3390/jcm9082367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/29/2022] Open
Abstract
Background: The risk, correlates, and consequences of incident atrial fibrillation (AF) in patients with chronic coronary artery disease (CAD) are largely unknown. Methods and results: We analyzed incident AF during a 3-year follow-up in 5031 CAD outpatients included in the prospective multicenter CARDIONOR registry and with no history of AF at baseline. Incident AF occurred in 266 patients (3-year cumulative incidence: 4.7% (95% confidence interval (CI): 4.1 to 5.3)). Incident AF was diagnosed during cardiology outpatient visits in 177 (66.5%) patients, 87 of whom were asymptomatic. Of note, 46 (17.3%) patients were diagnosed at time of hospitalization for heart failure, and a few patients (n = 5) at the time of ischemic stroke. Five variables were independently associated with incident AF: older age (p < 0.0001), heart failure (p = 0.003), lower left ventricle ejection fraction (p = 0.008), history of hypertension (p = 0.010), and diabetes mellitus (p = 0.033). Anticoagulant therapy was used in 245 (92%) patients and was associated with an antiplatelet drug in half (n = 122). Incident AF was a powerful predictor of all-cause (adjusted hazard ratio: 2.04; 95% CI: 1.47 to 2.83; p < 0.0001) and cardiovascular mortality (adjusted hazard ratio: 2.88; 95% CI: 1.88 to 4.43; p < 0.0001). Conclusions: In CAD outpatients, real-life incident AF occurs at a stable rate of 1.6% annually and is frequently diagnosed in asymptomatic patients during cardiology outpatient visits. Anticoagulation is used in most cases, often combined with antiplatelet therapy. Incident AF is associated with increased mortality.
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Affiliation(s)
- Sandro Ninni
- CHU Lille, Department of Cardiology, University of Lille, F-59000 Lille, France; (G.L.); (N.L.); (C.B.)
- Institut Pasteur de Lille, U1011, F-59000 Lille, France
- Correspondence: ; Tel.: +33-320-429373
| | - Gilles Lemesle
- CHU Lille, Department of Cardiology, University of Lille, F-59000 Lille, France; (G.L.); (N.L.); (C.B.)
- Institut Pasteur de Lille, U1011, F-59000 Lille, France
| | | | - Olivier Tricot
- Centre Hospitalier de Dunkerque, 59240 Dunkerque, France;
| | - Nicolas Lamblin
- CHU Lille, Department of Cardiology, University of Lille, F-59000 Lille, France; (G.L.); (N.L.); (C.B.)
- Institut Pasteur de Lille, U1167, F-59000 Lille, France
| | - Christophe Bauters
- CHU Lille, Department of Cardiology, University of Lille, F-59000 Lille, France; (G.L.); (N.L.); (C.B.)
- Institut Pasteur de Lille, U1167, F-59000 Lille, France
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24
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Wei L, Su E, Liu W, Xing W, Liu X, Zhang Y, Wang S, Cheng Q, Qi D, Gao C. Antithrombotic therapy in coronary artery disease patients with atrial fibrillation. BMC Cardiovasc Disord 2020; 20:323. [PMID: 32631244 PMCID: PMC7339421 DOI: 10.1186/s12872-020-01609-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background Coronary artery disease (CAD) and atrial fibrillation (AF) frequently coexist in clinical practice, making it challenging for the treating physician to choose anticoagulation and antiplatelet therapies. The aim of this study was to investigate antithrombotic strategies and assess related adverse outcomes in stable coronary artery disease (SCAD) and acute coronary syndrome (ACS) patients with AF when the CHA2DS2-VASc score was ≥2. Methods We performed a retrospective study and collected data from a computer-based patient record management system in Zhengzhou University People’s Hospital in China. In total, 2978 patients with a hospital discharge diagnosis of CAD and concomitant AF who met the inclusion criteria were enrolled from January 1, 2012 to December 31, 2016, and data from 2050 patients were finally analysed. The χ2 test was used to compare the incidences of clinical endpoints between the SCAD+AF group and the ACS + AF group. Multivariable Cox regression analysis was performed to identify independent predictive factors of adverse outcomes in both groups. Results Oral anticoagulant (OAC) monotherapy was the most common antithrombotic therapy in SCAD+AF patients (49.55%), while double antiplatelet therapy (DAPT) was the most common treatment in ACS + AF patients (54.19%) at discharge. OAC monotherapy significantly increased and the use of single antiplatelet therapy (SAPT) decreased during follow-up (34 ± 13 months) when compared to their use at discharge in the SCAD+AF group (all p < 0.001). In the ACS + AF group, the proportion of patients using DAPT decreased notably, while the proportions of patients using SAPT and dual therapy (DT) combining OAC with SAPT increased significantly during follow-up (all p < 0.001) compared to the proportions at discharge. According to multivariable Cox regression analysis, age, hypertension and prior stroke were independent risk factors for ischaemic stroke in the SCAD+AF group and ACS + AF group (all p < 0.05). OAC was an independent protective factor for ischaemic stroke in both groups (all p < 0.05). Previous bleeding independently increased the risk of haemorrhage in both groups (all p < 0.01). Conclusions In this study, the proportion of anticoagulant-antiplatelet combined therapy was low in ACS + AF patients with high stroke risk. In clinical practice, the awareness of anticoagulation needs to be strengthened regarding patients with CAD and AF.
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Affiliation(s)
- Lili Wei
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Health Management, Henan Provincial People's Hospital, No. 7 Weiwu Road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Enyong Su
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China.,Department of Cardiology, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China
| | - Weili Liu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Wenlu Xing
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Xinyun Liu
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - You Zhang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Shan Wang
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Qianqian Cheng
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Datun Qi
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China.,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China
| | - Chuanyu Gao
- Department of Cardiology, Zhengzhou University People's Hospital, No.7 Weiwu road, Jinshui District, Zhengzhou, 450003, Henan, China. .,Department of Cardiology, Huazhong Fuwai Hospital, No. 1 Fuwai Road, Zhengzhou, 451464, Henan, China.
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25
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Numasawa Y, Sawano M, Fukuoka R, Ejiri K, Kuno T, Shoji S, Kohsaka S. Antithrombotic Strategy for Patients with Acute Coronary Syndrome: A Perspective from East Asia. J Clin Med 2020; 9:jcm9061963. [PMID: 32585929 PMCID: PMC7356748 DOI: 10.3390/jcm9061963] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 12/21/2022] Open
Abstract
Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga 326-0843, Japan
- Correspondence: ; Tel.: +81-284-21-0121; Fax: +81-284-21-6810
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Ryoma Fukuoka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan;
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY 10003, USA;
| | - Satoshi Shoji
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo 160-8582, Japan; (M.S.); (R.F.); (S.S.); (S.K.)
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26
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Kawashima H, Gao C, Takahashi K, Tomaniak M, Ono M, Hara H, Wang R, Chichareon P, Suryapranata H, Walsh S, Cotton J, Koning R, Rensing B, Wykrzykowska J, de Winter RJ, Garg S, Anderson R, Hamm C, Steg PG, Onuma Y, Serruys PW. Comparative Assessment of Predictive Performance of PRECISE-DAPT, CRUSADE, and ACUITY Scores in Risk Stratifying 30-Day Bleeding Events. Thromb Haemost 2020; 120:1087-1095. [PMID: 32572864 PMCID: PMC8289707 DOI: 10.1055/s-0040-1712449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background
The utility of the PRECISE-DAPT score in predicting short-term major bleeding, either alone, or in comparison with the CRUSADE and ACUITY scores, has not been investigated. This analysis compared the predictive performances of the three bleeding scores in stratifying the risk of 30-day major bleeding postpercutaneous coronary intervention in patients with dual-antiplatelet therapy.
Methods
In this post hoc subanalysis of the GLOBAL LEADERS trial, the primary safety objective (bleeding according to the Bleeding Academic Research Consortium [BARC] criteria [type 3 or 5]) was assessed at 30 days according to the three scores in the overall population, and in patients with acute (ACS) and chronic coronary syndrome (CCS).
Results
In a total of 15,968 patients, we calculated all three scores in 14,709 (92.1%). Irrespective of clinical presentation, the PRECISE-DAPT (
c
-statistics: 0.648, 0.653, and 0.641, respectively), CRUSADE (
c
-statistics: 0.641, 0.639, and 0.644, respectively), and ACUITY (
c
-statistics: 0.633, 0.638, and 0.623, respectively) scores were no significant between-score differences in discriminatory performance for BARC 3 or 5 bleeding up to 30 days, and similarly the PRECISE-DAPT score had a comparable discriminative capacity according to the integrated discrimination improvement when compared with the other scores. In ACS, the CRUSADE score had a poor calibration ability (Hosmer–Lemeshow goodness-of-fit [GOF] chi-square = 15.561,
p
= 0.049), whereas in CCS, the PRECISE-DAPT score had poor calibration (GOF chi-square = 15.758,
p
= 0.046).
Conclusion
The PRECISE-DAPT score might be clinically useful in the overall population and ACS patients for the prediction of short-term major bleeding considering its discriminative and calibration abilities.
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Affiliation(s)
- Hideyuki Kawashima
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Kuniaki Takahashi
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Mariusz Tomaniak
- First Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Masafumi Ono
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Hironori Hara
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Rutao Wang
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboudumc, Nijmegen, The Netherlands
| | - Ply Chichareon
- Cardiology Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Simon Walsh
- Department of Cardiology, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - James Cotton
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | | | - Benno Rensing
- Sint-Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Joanna Wykrzykowska
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Clinical and Experimental Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Heart Center, Amsterdam, The Netherlands
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, United Kingdom
| | | | - Christian Hamm
- Kerckhoff Heart Center, Campus University of Giessen, Bad Nauheim, Germany
| | - Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, INSERM U-1148, FACT (French Alliance for Cardiovascular Trials), Hôpital Bichat, Université de Paris, Paris, France.,Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,NHLI, Imperial College London, London, United Kingdom
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27
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Evaluating Effectiveness and Safety in Chronic Kidney Disease with Atrial Flutter Using an Anticoagulation Strategy. ACTA ACUST UNITED AC 2020; 56:medicina56060266. [PMID: 32481685 PMCID: PMC7353883 DOI: 10.3390/medicina56060266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022]
Abstract
Background and objectives: Recent randomized trials of oral antithrombotic drugs with atrial flutter (AFL) excluded patients with renal impairment because of their increased risk of bleeding. To date, no relevant studies have assessed the effectiveness and safety of different antithrombotic drugs in chronic kidney disease (CKD) patients with AFL. This cohort study evaluated the effectiveness and safety of different antithrombotic drugs in CKD patients with AFL. This study also investigated the risk of cardiovascular events from antithrombotic drugs through different risk profiles of stroke stratified by the CHA2DS2-VASc score. Materials and Methods: This cohort study was performed in patients with AFL and CKD who were extracted from the National Health Insurance (NHI) Database in Taiwan. Oral antithrombotic therapy (oral anticoagulants (OAC) or antiplatelets (APT)) was administered to patients who had been diagnosed with AFL after being diagnosed with CKD between 2011 and 2015. Primary outcomes, including ischemic stroke, systemic embolism, and composite of stroke, and secondary outcomes, including major adverse cardiac events (MACEs), major bleeding, all-cause mortality, and cardiovascular-related death, were examined. Results: A total of 2468 patients were included in this study. The results showed no statistically significant differences in the risk of primary outcomes. For the secondary outcomes, there were also no statistically significant differences in the risk of MACEs and major bleeding. However, the pooled results indicated that the hazard ratio (HR) for all-cause mortality with OAC was 0.24 (95% confidence interval (CI) = 0.10–0.55) compared with combination therapy, and the HR for APT compared with OAC was 2.86 (95% CI = 1.48–5.53). Conclusions: In the studied population, OAC or APT alone were proved equally effective for stroke prophylaxis. Furthermore, OAC might reduce the all-cause mortality rate compared with APT and should be considered as the first choice of oral antithrombotic drugs in patients with AFL and CKD.
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28
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Rubboli A, Valgimigli M, Capodanno D, Lip GYH. Choices in antithrombotic management for patients with atrial fibrillation undergoing percutaneous coronary intervention: questions (and answers) in chronological sequence. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:68-73. [PMID: 32379867 DOI: 10.1093/ehjcvp/pvaa047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/07/2020] [Accepted: 04/29/2020] [Indexed: 01/06/2023]
Abstract
In accordance with the 2018 joint consensus document issued by the European Heart Rhythm Association (EHRA), European Society of Cardiology (ESC) Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA), and endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA), as well as with other recent ESC Guidelines, the management of antithrombotic therapy of patients with atrial fibrillation undergoing percutaneous coronary intervention requires that multiple and interconnected issues, including, duration of initial triple antithrombotic therapy, selection of P2Y12 inhibitor, choice of oral anticoagulant to be combined with antiplatelet therapy, intensity of oral anticoagulation throughout combination therapy, and choice of oral anticoagulant for indefinite therapy, are addressed. To assist the responsible physician in clinical decision making, a series of practical questions are proposed and discussed in the chronological sequence they should likely be answered.
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Affiliation(s)
- Andrea Rubboli
- Department of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, Ravenna 48121, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Center, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Davide Capodanno
- Division of Cardiology, A.O.U. Policlinico Vittorio Emanuele, University of Catania, Catania, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
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29
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Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention; insights from a meta-analysis. Coron Artery Dis 2020; 32:31-35. [PMID: 32310855 DOI: 10.1097/mca.0000000000000900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The optimal antithrombotic regimen for patients undergoing percutaneous coronary intervention in acute coronary syndrome with concomitant atrial fibrillation is largely under investigation. METHOD PUBMED and EMBASE were searched through October 2019 for randomized trials or subgroup analyses of randomized trials investigating different antithrombotic strategies in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention. We compared dual antithrombotic therapy versus triple antithrombotic therapy. Dual antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus P2Y12 inhibitor. Triple antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus dual antiplatelet therapy (aspirin plus P2Y12 inhibitor). The primary safety outcome was trial outcome was trial defined major adverse cardiovascular events. RESULTS Our search identified 5 eligible subgroup analyses of randomized controlled trials that enrolled a total of 4733 patients. Dual antithrombotic therapy significantly decreased the bleeding risk when compared with triple antithrombotic therapy (hazard ratio: 0.61; 95% confidential interval [0.51-0.71], P < 0.001, I = 31%). However, there were no significant differences in major adverse cardiovascular event between dual antithrombotic therapy versus triple antithrombotic therapy (hazard ratio: 1.08; 95% confidential interval: 0.89-1.31, P = 0.44, I = 0%). CONCLUSION In patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention, dual antithrombotic therapy was associated with lower bleeding risk compared with triple antithrombotic therapy while conferring similar major adverse cardiovascular event risk. Our results should be interpreted cautiously because we did not analyze the risk of stent thrombosis.
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Kuno T, Ueyama H, Takagi H, Ando T, Numasawa Y, Briasoulis A, Fox J, Bangalore S. Meta-analysis of Antithrombotic Therapy in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2020; 125:521-527. [PMID: 31839147 DOI: 10.1016/j.amjcard.2019.11.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 12/24/2022]
Abstract
For patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), antithrombotic therapy including oral anticoagulants and antiplatelets are indicated. The optimal combination is not known. We investigated the efficacy and safety of different antithrombotic strategies in patients with AF undergoing PCI. PUBMED and EMBASE were searched through September 2019 for randomized trials investigating the efficacy and safety of different antithrombotic strategies in patients with AF who underwent PCI and/or acute coronary syndrome. Nine antithrombotic strategies were compared including combinations of vitamin K antagonist (VKA) with dual antiplatelet therapy (DAPT) or P2Y12 inhibitor, combinations of direct oral anticoagulants (DOAC) (apixaban, dabigatran, rivaroxaban, and edoxaban) with DAPT or P2Y12 inhibitor (clopidogrel, prasugrel, and ticagrelor). The primary safety outcome was trial defined primary bleeding outcome. The primary efficacy outcome was trial defined major adverse cardiovascular events. Our search identified 5 eligible trials that enrolled a total of 11,532 patients and compared 9 treatment strategies. VKA + DAPT significantly increased bleeding when compared with most combinations (for example, vs VKA + P2Y12 inhibitor: odds ratio 2.11; 95% confidence interval [1.76 to 2.52], p <0.001). Of all the combinations, apixaban + P2Y12 inhibitor showed the lowest bleeding risk (for example, vs VKA + P2Y12 inhibitor: odds ratio 0.63; 95% confidence interval [0.51 to 0.78], p <0.001) and was ranked the best treatment. There were no significant differences in ischemic outcome of major adverse cardiovascular events between various antithrombotic regimens. In conclusion, in patients with AF undergoing PCI, apixaban + P2Y12 inhibitors were associated with lowest bleeding compared with other regimens including other DOACs + P2Y12 inhibitors with no increase in ischemic outcomes.
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Affiliation(s)
- Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York.
| | - Hiroki Ueyama
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Tomo Ando
- Center for Interventional Vascular Therapy, New York-Presbyterian Hospital/Columbia University Medical Center, New York
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, Iowa
| | - John Fox
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York
| | - Sripal Bangalore
- Division of Cardiovascular Medicine, New York University School of Medicine, New York
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Madika AL, Lemesle G, Lamblin N, Meurice T, Tricot O, Mounier-Vehier C, Bauters C. Gender differences in clinical characteristics, medical management, risk factor control, and long-term outcome of patients with stable coronary artery disease: from the CORONOR registry. Panminerva Med 2020; 61:432-438. [DOI: 10.23736/s0031-0808.18.03525-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Franchina AG, Calderone D, D'Arrigo P, Ingala S, Milluzzo RP, Greco A, Spagnolo M, Tamburino C, Capodanno D. Mechanisms of ST-segment elevation myocardial infarction in patients with atrial fibrillation, prior stenting and long-standing chronic coronary syndrome. Cardiol J 2020; 27:8-15. [PMID: 31960945 DOI: 10.5603/cj.a2020.0002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 01/09/2020] [Accepted: 12/12/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The optimal antithrombotic regimen for patients with atrial fibrillation (AF) and chronic coronary syndromes beyond 1 year after percutaneous coronary intervention (PCI) is a matter of debate. For these patients, guidelines recommend oral anticoagulation (OAC) alone, but the risk of thrombotic complications remains a concern. The aim of this study was to characterize the incidence, presentation and use of antithrombotic therapy in patients with AF, prior stenting > 12 months and new ST-segment elevation myocardial infarction (STEMI). METHODS Consecutive patients were selected from an institutional registry over a 3-year period if they matched the following criteria: 1) STEMI undergoing primary PCI; 2) AF; 3) chronic coronary syndrome with prior stenting > 12 months. RESULTS Among 852 consecutive STEMI patients undergoing primary PCI, the prevalence of AF was 4.1%, and 6 (0.9%) patients met all the inclusion criteria. Substantial heterogeneity in antithrombotic treatment for these patients was noted (e.g., OAC alone, OAC plus a single antiplatelet agent, no antithrombotic therapy). In 50% of patients, the STEMI episode was linked to a previously stented lesion or documented plaque. CONCLUSIONS This case review illustrates the wide heterogeneity in antithrombotic pharmacotherapy among AF patients presenting with STEMI > 12 months after PCI. The underlying reason for STEMI is only partly related to disease progression or stent-related events. This finding suggests that multiple mechanisms of recurrence may be advocated, and are not only limited to antithrombotic therapy but may be explained by the natural history of coronary artery disease in remote vessels.
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Treatment of Acute Nonvariceal Upper Gastrointestinal Bleeding in Chinese Patients on Antithrombotic Therapy. Gastroenterol Res Pract 2019; 2019:9190367. [PMID: 31933633 PMCID: PMC6942860 DOI: 10.1155/2019/9190367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/29/2019] [Accepted: 12/02/2019] [Indexed: 02/07/2023] Open
Abstract
Objective To assess the treatment of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) in Chinese patients on antithrombotic therapy. Methods The clinical data of patients with ANVUGIB who underwent upper gastrointestinal endoscopy 24 h after bleeding at Beijing Anzhen Hospital, Capital Medical University, from 2016 to 2018, were analyzed retrospectively. The patients were divided into antithrombotic therapy and control groups and into high-risk (Forrest Ia, Ib, IIa, and IIb) and low-risk (Forrest IIc and III) bleeding groups according to the results of endoscopy. Results In all, 230 patients were enrolled, with 99 cases in the antithrombotic group (antiplatelet therapy 80 patients, anticoagulant therapy 19 patients) and 131 cases in the control group (without antithrombotic therapy). A total of 78 and 21 and 84 and 47 patients were at high- and low- risk for bleeding (P = 0.019) in the antithrombotic and control groups, respectively; 12.1% and 4.6% had esophageal bleeding (P = 0.047), and 8 and 2 patients received interventional therapy (P = 0.021). Overall, 21 patients with hemodynamic instability were treated via endoscopy with anesthesia under tracheal intubation and ventilator support: 20 patients in the antithrombotic group (13 patients within 1 month after coronary intervention, 5 patients within 1 month of cardiac-valve replacement, and 2 patients within 4 years of cardiac-valve replacement) and 1 patient with third-degree atrioventricular block in the control group. Ten patients received interventional therapy: eight and two in the two groups, respectively. Multidisciplinary consultation was conducted to regulate the use of antithrombotic drugs. Conclusion Compared to the controls, patients in the antithrombotic group had a significantly higher incidence of critical and active bleeding. Patients with hemodynamic instability should be examined and treated via upper gastrointestinal endoscopy under anesthesia with tracheal intubation and ventilator support.
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Pasea L, Chung SC, Pujades-Rodriguez M, Shah AD, Alvarez-Madrazo S, Allan V, Teo JT, Bean D, Sofat R, Dobson R, Banerjee A, Patel RS, Timmis A, Denaxas S, Hemingway H. Bleeding in cardiac patients prescribed antithrombotic drugs: electronic health record phenotyping algorithms, incidence, trends and prognosis. BMC Med 2019; 17:206. [PMID: 31744503 PMCID: PMC6864929 DOI: 10.1186/s12916-019-1438-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Clinical guidelines and public health authorities lack recommendations on scalable approaches to defining and monitoring the occurrence and severity of bleeding in populations prescribed antithrombotic therapy. METHODS We examined linked primary care, hospital admission and death registry electronic health records (CALIBER 1998-2010, England) of patients with newly diagnosed atrial fibrillation, acute myocardial infarction, unstable angina or stable angina with the aim to develop algorithms for bleeding events. Using the developed bleeding phenotypes, Kaplan-Meier plots were used to estimate the incidence of bleeding events and we used Cox regression models to assess the prognosis for all-cause mortality, atherothrombotic events and further bleeding. RESULTS We present electronic health record phenotyping algorithms for bleeding based on bleeding diagnosis in primary or hospital care, symptoms, transfusion, surgical procedures and haemoglobin values. In validation of the phenotype, we estimated a positive predictive value of 0.88 (95% CI 0.64, 0.99) for hospitalised bleeding. Amongst 128,815 patients, 27,259 (21.2%) had at least 1 bleeding event, with 5-year risks of bleeding of 29.1%, 21.9%, 25.3% and 23.4% following diagnoses of atrial fibrillation, acute myocardial infarction, unstable angina and stable angina, respectively. Rates of hospitalised bleeding per 1000 patients more than doubled from 1.02 (95% CI 0.83, 1.22) in January 1998 to 2.68 (95% CI 2.49, 2.88) in December 2009 coinciding with the increased rates of antiplatelet and vitamin K antagonist prescribing. Patients with hospitalised bleeding and primary care bleeding, with or without markers of severity, were at increased risk of all-cause mortality and atherothrombotic events compared to those with no bleeding. For example, the hazard ratio for all-cause mortality was 1.98 (95% CI 1.86, 2.11) for primary care bleeding with markers of severity and 1.99 (95% CI 1.92, 2.05) for hospitalised bleeding without markers of severity, compared to patients with no bleeding. CONCLUSIONS Electronic health record bleeding phenotyping algorithms offer a scalable approach to monitoring bleeding in the population. Incidence of bleeding has doubled in incidence since 1998, affects one in four cardiovascular disease patients, and is associated with poor prognosis. Efforts are required to tackle this iatrogenic epidemic.
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Affiliation(s)
- Laura Pasea
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Sheng-Chia Chung
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | | | - Anoop D Shah
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Samantha Alvarez-Madrazo
- Health Data Research UK Scotland, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Victoria Allan
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - James T Teo
- Department of Stroke and Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Reecha Sofat
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Richard Dobson
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Amitava Banerjee
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Riyaz S Patel
- Institute of Health Informatics, University College London, London, UK
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Adam Timmis
- Bart's Heart Centre, Queen Mary University London, London, UK
| | - Spiros Denaxas
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Harry Hemingway
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK.
- Institute of Health Informatics, University College London, London, UK.
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK.
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Lee SR, Rhee TM, Kang DY, Choi EK, Oh S, Lip GYH. Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation. Am J Cardiol 2019; 124:879-885. [PMID: 31311662 DOI: 10.1016/j.amjcard.2019.05.072] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 11/18/2022]
Abstract
Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.
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Affiliation(s)
- So-Ryoung Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Tae-Min Rhee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Do-Yoon Kang
- Heart Institute, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eue-Keun Choi
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seil Oh
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Chest & Heart Hospital, University of Liverpool, Liverpool, United Kingdom; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Mitsuse T, Kaikita K, Ishii M, Oimatsu Y, Nakanishi N, Ito M, Arima Y, Sueta D, Iwashita S, Fujisue K, Kanazawa H, Takashio S, Araki S, Usuku H, Suzuki S, Sakamoto K, Yamamoto E, Soejima H, Tsujita K. Total Thrombus-Formation Analysis System can Predict 1-Year Bleeding Events in Patients with Coronary Artery Disease. J Atheroscler Thromb 2019; 27:215-225. [PMID: 31391352 PMCID: PMC7113144 DOI: 10.5551/jat.49700] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims: The assessment of bleeding risk in patients with coronary artery disease (CAD) is clinically important. We recently developed the Total Thrombus-Formation Analysis System (T-TAS) for the quantitative analysis of thrombus formation using microchips with thrombogenic surfaces. Here, we assessed the utility of T-TAS parameters in predicting 1-year bleeding events in patients with CAD. Methods: The study subjects were 561 consecutive patients who underwent coronary angiography (CAG) between August 2013 and September 2016 for suspected CAD. Blood samples collected at the time of CAG were used for T-TAS to compute the area under the curve (AUC) (AR10-AUC30) in the AR chip. Patients were divided into three groups according to AR10-AUC30 (low: ≤ 1603, intermediate, and high: > 1765, n = 187 each). One-year bleeding events were defined by the Platelet Inhibition and Patient Outcomes criteria. Results: Bleeding occurred in 21 (3.7%) patients and was classified as major (8 [1.4%]) and minor (13 [2.3%]). The AR10-AUC30 levels were significantly lower in the bleeding group than the non-bleeding group (median [interquartile range] 1590 [1442–1734] vs. 1687 [1546–1797], p = 0.04). Univariate Cox regression analysis demonstrated that low AR10-AUC30, high prothrombin time-international normalized ratio levels, and diabetes correlated with bleeding events. Multivariate Cox regression analysis identified low AR10-AUC30 levels as a significant determinant of bleeding events. Kaplan-Meier survival curves showed a higher rate of bleeding events in the low than the high AR10-AUC30 group (p = 0.007). Conclusions: The results highlight the potential usefulness of the AR10-AUC30 levels in the prediction of 1-year bleeding events in patients with CAD treated with various antithrombotic therapies.
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Affiliation(s)
- Tatsuro Mitsuse
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Yu Oimatsu
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Nobuhiro Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Miwa Ito
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Yuichiro Arima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satomi Iwashita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Koichiro Fujisue
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satoshi Araki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Satoru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Kenji Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Hirofumi Soejima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, and Center for Metabolic Regulation of Healthy Aging Kumamoto University
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Albeiruti R, Chaudhary F, Alqahtani F, Kupec J, Balla S, Alkhouli M. Incidence, Predictors, and Outcomes of Gastrointestinal Bleeding in Patients Admitted With ST-Elevation Myocardial Infarction. Am J Cardiol 2019; 124:343-348. [PMID: 31182211 DOI: 10.1016/j.amjcard.2019.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
Abstract
Gastrointestinal bleeding (GIB) complicating ST-elevation myocardial infarction (STEMI) poses significant management challenges and may be associated with poor outcomes. We sought to evaluate the incidence and outcomes of GIB in STEMI patients using a nationwide database. We identified adults admitted with STEMI between in the National Inpatient Sample (2003 to 2016), and compared the morbidity, mortality, resource utilization, and cost in patients with and without GIB. We assessed rates of endoscopy referral and its associated with mortality. Among 1,450,696 weighted STEMI hospitalizations, 32,624 (2.2%) were complicated with GIB. Patients with GIB were older, and had distinctive characteristics compared to those without GIB. Older age, cardiogenic shock; history of peptic ulcer disease, cirrhosis, anemia, or alcohol use disorder were the strongest predictors of GIB during STEMI hospitalizations. In-hospital mortality was higher in the GIB group (28.2% vs 11.1%, p <0.001). The excess mortality associated with GIB persisted after propensity-score matching, and in sensitivity analyses excluding patients who underwent coronary intervention >24-hours after admission, and those transferred to another hospital. Post-STEMI GIB was associated with more strokes and acute kidney injury, longer hospitalizations, and higher cost. In a logistic regression analysis, GIB was independently associated with mortality (odds ratios [OR] 1.91, 95% confidence interval [CI] 1.85 to 1.97, p <0.001). There was a correlation between undergoing endoscopy and lower in-hospital mortality (unadjusted OR 0.27; 95% CI, 0.24 to 0.29; adjusted-OR 0.30; 95% CI, 0.27 to 0.33; p <0.001). In conclusion, GIB complicating STEMI is uncommon but is associated with excess morbidity, mortality, resource utilization and cost. Referral to endoscopy in this cohort may be associated with reduced in-hospital mortality.
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Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI. J Am Coll Cardiol 2019; 74:83-99. [DOI: 10.1016/j.jacc.2019.05.016] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
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Yoshihisa A, Kanno Y, Ichijo Y, Sato Y, Takiguchi M, Yokokawa T, Abe S, Misaka T, Sato T, Oikawa M, Kobayashi A, Yamaki T, Kunii H, Takeishi Y. Incidence and subsequent prognostic impacts of gastrointestinal bleeding in patients with heart failure. Eur J Prev Cardiol 2019; 27:664-666. [DOI: 10.1177/2047487319843069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University, Japan
| | - Yuki Kanno
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yasuhiro Ichijo
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yu Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Mai Takiguchi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Satoshi Abe
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University, Japan
| | - Takamasa Sato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
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Schaefer JK, Li Y, Gu X, Souphis NM, Haymart B, Kline-Rogers E, Almany SL, Kaatz S, Kozlowski JH, Krol GD, Sood SL, Froehlich JB, Barnes GD. Association of Adding Aspirin to Warfarin Therapy Without an Apparent Indication With Bleeding and Other Adverse Events. JAMA Intern Med 2019; 179:533-541. [PMID: 30830172 PMCID: PMC6450296 DOI: 10.1001/jamainternmed.2018.7816] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE It is not clear how often patients receive aspirin (acetylsalicylic acid) while receiving oral anticoagulation with warfarin sodium without a clear therapeutic indication for aspirin, such as a mechanical heart valve replacement, recent percutaneous coronary intervention, or acute coronary syndrome. The clinical outcomes of such patients treated with warfarin and aspirin therapy compared with warfarin monotherapy are not well defined to date. OBJECTIVE To evaluate the frequency and outcomes of adding aspirin to warfarin for patients without a clear therapeutic indication for combination therapy. DESIGN, SETTING, AND PARTICIPANTS A registry-based cohort study of adults enrolled at 6 anticoagulation clinics in Michigan (January 1, 2010, to December 31, 2017) who were receiving warfarin therapy for atrial fibrillation or venous thromboembolism without documentation of a recent myocardial infarction or history of valve replacement. EXPOSURE Aspirin use without therapeutic indication. MAIN OUTCOMES AND MEASURES Rates of any bleeding, major bleeding events, emergency department visits, hospitalizations, and thrombotic events at 1, 2, and 3 years. RESULTS Of the study cohort of 6539 patients (3326 men [50.9%]; mean [SD] age, 66.1 [15.5] years), 2453 patients (37.5%) without a clear therapeutic indication for aspirin were receiving combination warfarin and aspirin therapy. Data from 2 propensity score-matched cohorts of 1844 patients were analyzed (warfarin and aspirin vs warfarin only). At 1 year, patients receiving combination warfarin and aspirin compared with those receiving warfarin only had higher rates of overall bleeding (cumulative incidence, 26.0%; 95% CI, 23.8%-28.3% vs 20.3%; 95% CI, 18.3%-22.3%; P < .001), major bleeding (5.7%; 95% CI, 4.6%-7.1% vs 3.3%; 95% CI, 2.4%-4.3%; P < .001), emergency department visits for bleeding (13.3%; 95% CI, 11.6%-15.1% vs 9.8%; 95% CI, 8.4%-11.4%; P = .001), and hospitalizations for bleeding (8.1%; 6.8%-9.6% vs 5.2%; 4.1%-6.4%; P = .001). Rates of thrombosis were similar, with a 1-year cumulative incidence of 2.3% (95% CI, 1.6%-3.1%) for those receiving combination warfarin and aspirin therapy compared with 2.7% (95% CI, 2.0%-3.6%) for those receiving warfarin alone (P = .40). Similar findings persisted during 3 years of follow-up as well as in sensitivity analyses. CONCLUSIONS AND RELEVANCE Compared with warfarin monotherapy, receipt of combination warfarin and aspirin therapy was associated with increased bleeding and similar observed rates of thrombosis. Further research is needed to better stratify which patients may benefit from aspirin while anticoagulated with warfarin for atrial fibrillation or venous thromboembolism; clinicians should be judicious in selecting patients for combination therapy.
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Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Yun Li
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Xiaokui Gu
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Nicole M Souphis
- College Student, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Eva Kline-Rogers
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Steven L Almany
- Department of Internal Medicine, Beaumont Health, Oakland University School of Medicine, Royal Oak, Michigan
| | - Scott Kaatz
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jay H Kozlowski
- Department of Cardiovascular Medicine, Huron Valley Sinai Hospital, Commerce Township, Michigan
| | - Gregory D Krol
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Suman L Sood
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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First Hospitalization for Heart Failure in Outpatients With Stable Coronary Artery Disease: Determinants, Role of Incident Myocardial Infarction, and Prognosis. J Card Fail 2018; 24:815-822. [DOI: 10.1016/j.cardfail.2018.09.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 09/03/2018] [Accepted: 09/27/2018] [Indexed: 11/27/2022]
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Clarke A, Ibrahim A, Kiernan TJ. Triple antithrombotic therapy in patients with atrial fibrillation undergoing PCI: current evidence and practice. Expert Rev Cardiovasc Ther 2018; 16:715-723. [PMID: 30213212 DOI: 10.1080/14779072.2018.1521721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Patients with atrial fibrillation taking oral anticoagulation and undergoing percutaneous coronary intervention with stent insertion are recommended to receive antithrombotic therapy with aspirin and P2Y12 receptor antagonist. This combinatory regime encompasses triple therapy (TT). Although TT reduces the risk of ischemic events such as stroke and stent thrombosis, it is associated with an increased bleeding risk. Areas covered: The efficacy and safety profile of TT is uncertain with undetermined optimal duration and therapeutic combination. This review summarizes relevant trials evaluating TTs application and introduces exploration of duration and dosage in addition to other contributory factors including stent type and choice of antithrombotic agents. Expert commentary: TT has shown to be effective for reduction of ischemic risk. However, trials have failed to demonstrate the regime's superiority in efficacy over alternatives such as dual therapy (single antiplatelet plus anticoagulant) and continue to denote an increased bleeding risk. Further research driven by a balance between thromboembolic and bleeding end points is required to demonstrate TTs potential beneficence, along with optimal duration identification and antithrombotic choice. Individualized patient risk stratification, along with risk factor optimization should also be incorporated.
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Affiliation(s)
- Alice Clarke
- a University of Limerick, Graduate Entry Medical School (GEMS) , Castletroy , Ireland
| | - Abdalla Ibrahim
- b Cardiology Department , University Hospital Limerick , Dooradoyle , Ireland
| | - Thomas J Kiernan
- c Division of Cardiology, Department of Medicine , University Hospital Limerick, Graduate Entry Medical School (GEMS), University of Limerick , Limerick , Ireland
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Fischer Q, Georges J, Le Feuvre C, Sharma A, Hammoudi N, Berman E, Cohen S, Jolivet I, Silvain J, Helft G. Optimal long-term antithrombotic treatment of patients with stable coronary artery disease and atrial fibrillation: “OLTAT registry”. Int J Cardiol 2018; 264:64-69. [DOI: 10.1016/j.ijcard.2018.03.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 02/26/2018] [Accepted: 03/05/2018] [Indexed: 11/25/2022]
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Lip GYH, Collet JP, Haude M, Byrne R, Chung EH, Fauchier L, Halvorsen S, Lau D, Lopez-Cabanillas N, Lettino M, Marin F, Obel I, Rubboli A, Storey RF, Valgimigli M, Huber K, Potpara T, Blomström Lundqvist C, Crijns H, Steffel J, Heidbüchel H, Stankovic G, Airaksinen J, Ten Berg JM, Capodanno D, James S, Bueno H, Morais J, Sibbing D, Rocca B, Hsieh MH, Akoum N, Lockwood DJ, Gomez Flores JR, Jardine R. 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the European Heart Rhythm Association (EHRA), European Society of Cardiology Working Group on Thrombosis, European Association of Percutaneous Cardiovascular Interventions (EAPCI), and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2018; 21:192-193. [DOI: 10.1093/europace/euy174] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Jean-Phillippe Collet
- Sorbonne Université Paris 6, ACTION Study Group (www.action-coeur.org), Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS, Paris, France
| | - Michael Haude
- Städtische Kliniken Neuss Lukaskrankenhaus Gmbh Kardiologie, Nephrologie, Pneumologie, Neuss, Germany
| | - Robert Byrne
- Deutsches Herzzentrum Muenchen, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Eugene H Chung
- University of North Carolina at Chapel Hill, Medicine, Cardiology, Electrophysiology, Chapel Hill, NC, USA
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Faculté de Médecine—Université François Rabelais, Tours, France
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Dennis Lau
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | - Maddalena Lettino
- Cardiology Department, Humanitas Research Hospital, Rozzano, MI, Italy
| | - Francisco Marin
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Israel Obel
- Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital Vienna, Vienna, Austria
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Harry Crijns
- Cardiology Department, Maastricht UMC+, Maastricht, Netherlands
| | - Jan Steffel
- University Heart Center Zurich, Zurich, Switzerland
| | - Hein Heidbüchel
- Antwerp University and University Hospital, Antwerp, Belgium
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Juhani Airaksinen
- Turku University Hospital, Cardiology, Department of Internal Medicine, Turku, Finland
| | | | - Davide Capodanno
- Ferrarotto Hospital, Azienda Ospedaliero-Univ, Policlinico-Vittorio Emanuele, University of Catania, Cardiologia Department, University of Catania, Catania, Italy
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Senior Interventional Cardiologist, Uppsala University Hospital, Uppsala, Sweden
| | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro, Madrid, Spain
- Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Portugal
| | - Dirk Sibbing
- Oberarzt, Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität (LMU), Campus Großhadern, München, Germany
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | | | - Nazem Akoum
- Cardiology Department, University of Washington, Seattle, USA
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Hamon M, Lemesle G, Meurice T, Tricot O, Lamblin N, Bauters C. Elective Coronary Revascularization Procedures in Patients With Stable Coronary Artery Disease: Incidence, Determinants, and Outcome (From the CORONOR Study). JACC Cardiovasc Interv 2018; 11:868-875. [PMID: 29747917 DOI: 10.1016/j.jcin.2018.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 02/08/2018] [Accepted: 02/13/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The authors sought to describe the incidence, determinants, and outcome of elective coronary revascularization (ECR) in patients with stable coronary artery disease (CAD). BACKGROUND Observational data are lacking regarding the practice of ECR in patients with stable CAD receiving modern secondary prevention. METHODS The authors analyzed coronary revascularization procedures performed during a 5-year follow-up in 4,094 stable CAD outpatients included in the prospective multicenter CORONOR (Suivi d'une cohorte de patients COROnariens stables en région NORd-Pas-de-Calais) registry. RESULTS Secondary prevention medications were widely prescribed at inclusion (antiplatelet agents 96.4%, statins 92.2%, renin-angiotensin system antagonists 81.8%). A total of 481 patients underwent ≥1 coronary revascularization procedure (5-year cumulative incidences of 3.6% [0.7% per year] for acute revascularizations and 8.9% [1.8% per year] for ECR); there were 677 deaths during the same period. Seven baseline variables were independently associated with ECR: prior coronary stent implantation (p < 0.0001), absence of prior myocardial infarction (p < 0.0001), higher low-density lipoprotein cholesterol (p < 0.0001), lower age (p < 0.0001), multivessel CAD (p = 0.003), diabetes mellitus (p = 0.005), and absence of treatment with renin-angiotensin system antagonists (p = 0.020). Main indications for ECR were angina associated with a positive stress test (31%), silent ischemia (31%), and angina alone (25%). The use of ECR had no impact on the subsequent risk of death, myocardial infarction, or ischemic stroke (hazard ratio: 1.04; 95% confidence interval: 0.76 to 1.41). CONCLUSIONS These real-life data show that ECR is performed at a rate of 1.8% per year in stable CAD patients widely treated by secondary medical prevention. ECR procedures performed in patients without noninvasive stress tests are not rare. Having an ECR was not associated with the risk of ischemic adverse events.
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Affiliation(s)
- Martial Hamon
- University Hospital of Caen, Caen University, Caen, France
| | - Gilles Lemesle
- University of Lille, Inserm, CHU Lille, Institut Pasteur, U1011, Lille, France
| | | | | | - Nicolas Lamblin
- University of Lille, Inserm, CHU Lille, Institut Pasteur, U1167, Lille, France
| | - Christophe Bauters
- University of Lille, Inserm, CHU Lille, Institut Pasteur, U1167, Lille, France.
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Lemesle G, Meurice T, Tricot O, Lamblin N, Bauters C. Association of Diabetic Status and Glycemic Control With Ischemic and Bleeding Outcomes in Patients With Stable Coronary Artery Disease: The 5-Year CORONOR Registry. J Am Heart Assoc 2018; 7:JAHA.117.008354. [PMID: 29728374 PMCID: PMC6015307 DOI: 10.1161/jaha.117.008354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background The relation between diabetes mellitus, glycemic control, and ischemic and bleeding events is poorly described in outpatients with stable coronary artery disease receiving modern secondary prevention. Methods and Results The multicenter CORONOR (Suivi d'une cohorte de patients Coronariens stables en région Nord‐pas‐de‐Calais) registry enrolled 4184 outpatients with stable coronary artery disease, including 1297 patients (31%) with diabetes mellitus. A recent glycosylated hemoglobin (HbA1c) was available for 1146 diabetic patients, and 48% had HbA1c ≥7%. We analyzed 5‐year ischemic (cardiovascular death, myocardial infarction, and stroke) and bleeding (Bleeding Academic Research Consortium ≥3) outcomes, according to diabetic status and glycemic control. When compared with nondiabetic patients, the ischemic risk was higher in diabetic patients with HbA1c ≥7% (hazard ratio [HR], 1.57; 95% confidence interval [CI], 1.25–1.93) but not in diabetic patients with HbA1c <7% (HR, 1.06; 95% CI, 0.83–1.36). Diabetic patients with HbA1c ≥7% were at higher risk than diabetic patients with HbA1c <7% (HR, 1.47; 95% CI, 1.09–1.98). When compared with nondiabetic patients, the bleeding risk was higher in diabetic patients, with HbA1c <7% (HR, 1.66; 95% CI, 1.04–2.67) and in those with HbA1c ≥7% (HR, 1.75; 95% CI, 1.07–2.86). No difference in bleeding risk was observed between diabetic patients with HbA1c ≥7% versus those with HbA1c <7%. Similar results were obtained when adjusted for baseline characteristics. Conclusions The 5‐year increased risk of ischemic events in patients with stable coronary artery disease with diabetes mellitus was restricted to those with HbA1c ≥7%. By contrast, the increase in bleeding risk associated with diabetes mellitus was observed in patients with HbA1c ≥7% and in patients with HbA1c <7%. The level of HbA1c should be taken into account for future research and may help physicians to manage prolonged antithrombotic therapies in this high‐risk subgroup.
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Affiliation(s)
- Gilles Lemesle
- Inserm units 1011 and 1167, CHU Lille, Institut Pasteur, University of Lille, Lille, France
| | | | | | - Nicolas Lamblin
- Inserm units 1011 and 1167, CHU Lille, Institut Pasteur, University of Lille, Lille, France
| | - Christophe Bauters
- Inserm units 1011 and 1167, CHU Lille, Institut Pasteur, University of Lille, Lille, France
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Cordonnier C, Lemesle G, Casolla B, Bic M, Caparros F, Lamblin N, Bauters C. Incidence and determinants of cerebrovascular events in outpatients with stable coronary artery disease. Eur Stroke J 2018; 3:272-280. [PMID: 31008358 DOI: 10.1177/2396987318772684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/26/2018] [Indexed: 01/25/2023] Open
Abstract
Introduction There are limited data on cerebrovascular events in patients with stable coronary artery disease. To study the risk of cerebrovascular event, the relative proportion of ischaemic stroke and intracranial haemorrhage, and their prognostic factors in stable coronary artery disease are investigated. Patients and methods The CORONOR registry prospectively recruited, between February 2010 and April 2011, 4184 unselected stable coronary artery disease outpatients. All events occurring during a five-year follow-up were adjudicated. Results Ninety-six patients had an ischaemic stroke and 34 had an intracranial haemorrhage, reaching a cumulative incidence after five years of 3.2 (2.7-3.8)%. During the same period, 677 deaths and 170 myocardial infarctions (ST-elevation MI, n = 55; non-ST-elevation MI, n = 115) occurred. In elderly individuals, the number of cerebrovascular events was higher than that of myocardial infarctions and largely exceeded that of ST-elevation myocardial infarctions. Predictors of ischaemic stroke were: previous history of stroke (subhazard ratio (SHR)=3.16(1.95-5.14)), absence of statin therapy at inclusion (SHR = 2.45(1.47-4.10), increasing age (SHR = 1.45(1.16-1.82) per 10-year increase) and diabetes mellitus (SHR = 1.65(1.10-2.49)). Predictors of intracranial haemorrhage were: combination of vitamin K antagonists with an antiplatelet agent at inclusion (SHR = 5.41(2.49-11.75), single antiplatelet therapy as reference), and increasing age (SHR = 1.47(1.12-1.93) per 10-year increase). Discussion In stable coronary artery disease patients, the brain deserves attention. In patients at high risk of ischaemic stroke, secondary prevention could be intensified. Our results raise awareness of the hazard of the association of antiplatelet drugs with oral anticoagulants in stable coronary artery disease patients. Conclusion While improving the prevention of future vaso-occlusive events should be our ultimate goal in coronary artery disease patients, the net clinical benefit of our treatments should carefully be studied.
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Affiliation(s)
- Charlotte Cordonnier
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Gilles Lemesle
- Université de Lille, Inserm U1011, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
| | - Barbara Casolla
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Matthieu Bic
- Department of Cardiology, Centre Hospitalier, Lens, France
| | - François Caparros
- Université de Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Lille, France
| | - Nicolas Lamblin
- Université de Lille, Inserm U1167, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
| | - Christophe Bauters
- Université de Lille, Inserm U1167, Institut Pasteur, CHU Lille, Department of Cardiology, Lille, France
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Bauters C, Tricot O, Lemesle G, Meurice T, Hennebert O, Farnier M, Lamblin N. Reaching low-density lipoprotein cholesterol treatment targets in stable coronary artery disease: Determinants and prognostic impact. Arch Cardiovasc Dis 2017; 111:634-643. [PMID: 29198936 DOI: 10.1016/j.acvd.2017.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/24/2017] [Accepted: 07/29/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Low-density lipoprotein cholesterol (LDL-C) reduction is an integral part of the management of patients with coronary artery disease (CAD). AIMS To assess attainment of LDL-C goals during long-term treatment of patients with stable CAD, and to determine predictors of goal attainment and the prognostic impact of reaching LDL-C<70mg/dL (1.8mmol/L) in a real-life setting. METHODS Data were obtained for 4080 outpatients with stable CAD included in the multicentre CORONOR study. Five-year follow-up was achieved for 3991 (97.8%) patients. RESULTS At inclusion, a recent (<1 year) measurement of LDL-C was available in 3757 (92.1%) patients. LDL-C<70mg/dL was reached by 885 (23.6%) patients. Independent predictors of LDL-C<70mg/dL were diabetes mellitus, statin treatment, treatment with renin-angiotensin system inhibitors, previous myocardial infarction and short time since last coronary event. The adjusted hazard ratio (HR) for the composite endpoint (cardiovascular death, myocardial infarction, ischemic stroke or coronary revascularization) during the 5-year follow-up was 1.31 (95% confidence interval [CI]: 1.09-1.58; P=0.004) for LDL-C≥70mg/dL versus<70mg/dL. When compared with patients with LDL-C<70mg/dL, the adjusted HRs for LDL-C 70-99mg/dL and ≥100mg/dL (2.6mmol/L) were 1.27 (95% CI: 1.05-1.55; P=0.016) and 1.38 (95% CI: 1.12-1.70; P=0.003), respectively. When LDL-C was used as a continuous variable, the adjusted HRs for increases of 10mg/dL (0.3mmol/L) and 1mmol/L were 1.05 (95% CI: 1.03-1.08) and 1.21 (95% CI: 1.10-1.33), respectively. CONCLUSIONS In this observational study, only a minority of stable CAD patients had LDL-C<70mg/dL. The patients who reached their LDL-C goal had the lowest risk of cardiovascular events.
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Affiliation(s)
- Christophe Bauters
- U1167, Inserm, Institut Pasteur, université de Lille, CHU de Lille, 59000 Lille, France.
| | - Olivier Tricot
- Centre hospitalier de Dunkerque, 59240 Dunkerque, France
| | - Gilles Lemesle
- U1011, Inserm, Institut Pasteur, université de Lille, CHU de Lille, 59000 Lille, France
| | | | | | | | - Nicolas Lamblin
- U1167, Inserm, Institut Pasteur, université de Lille, CHU de Lille, 59000 Lille, France
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Rivera-Caravaca JM, Roldán V, Esteve-Pastor MA, Valdés M, Vicente V, Lip GYH, Marín F. Cessation of oral anticoagulation is an important risk factor for stroke and mortality in atrial fibrillation patients. Thromb Haemost 2017; 117:1448-1454. [DOI: 10.1160/th16-12-0961] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/23/2017] [Indexed: 12/15/2022]
Abstract
SummaryOral anticoagulation (OAC) is highly effective preventing stroke and mortality in AF, but withdrawal is common in the elderly, when high bleeding risk and when are difficulties achieving an optimal time in therapeutic range (TTR). We analysed the rate of OAC cessation, predisposing factors to cessation and the relation to clinical outcomes in a large ‘real world’ cohort of AF patients over a long follow-up period. Consecutive non-valvular AF outpatients clinically stables for six months were recruited. Rates of cardiovascular events, major bleeding and mortality were recorded and related to OAC cessation. We included 1361 patients (48.7 % male; aged 76, IQR 71–81), followed-up for a median of 6.5 years. During follow-up, 244 patients suffered thrombotic events, 250 suffered from major bleeding and 551 patients died. 10 % of patients stopped OAC. After OAC withdrawal, there were 36 thromboembolic events (22 strokes), 10 major bleedings and 75 deaths. OAC cessation was independently associated with adverse cardiovascular events (HR 1.45; 95 % CI 1.01–2.08), stroke/TIA (HR 1.85; 1.17–2.94) and all-cause mortality (HR 1.30; 1.02–1.67). Independent predictors of OAC cessation were age ≥80 (HR 2.29; 1.60–3.29), previous coronary artery disease (HR 0.32; 0.15–0.71), major bleeding (HR 5.00; 3.49–7.15), heart failure (HR 2.38; 1.26–4.47), cancer (HR 5.24; 3.25–8.44) and renal impairment developed during follow-up (HR 2.70; 1.26–5.75). In conclusion, in non-valvular AF patients, cessation of OAC was independently associated with the risk of stroke, adverse cardiovascular events and mortality. Bleeding events and some variables associated with higher bleeding risk are responsible for OAC cessation.Note: The review process for this manuscript was fully handled by Christian Weber, Editor in Chief.Supplementary Material to this article is available online at www.thrombosis-online.com.
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