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Numao Y, Takahashi S, Nakao YM, Tajima E, Noma S, Endo A, Honye J, Tsukada Y. Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention. Circ Rep 2024; 6:99-109. [PMID: 38606417 PMCID: PMC11004037 DOI: 10.1253/circrep.cr-24-0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.
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Affiliation(s)
- Yoshimi Numao
- Department of Cardiology, Itabashi Chuo Medical Center Tokyo Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Oiso Hospital Kanagawa Japan
| | - Yoko M Nakao
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University Kyoto Japan
| | - Emi Tajima
- Department of Cardiology, Tokyo General Hospital Tokyo Japan
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Ayaka Endo
- Department of Cardiology, Tokyo Saiseikai Central Hospital Tokyo Japan
| | - Junko Honye
- Cardiovascular Center, Kikuna Memorial Hospital Kanagawa Japan
| | - Yayoi Tsukada
- Department of General Medicine and Health Science, Nippon Medical School Tokyo Japan
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AlAgil J, AlDaamah Z, Khan A, Omar O. Risk of postoperative bleeding after dental extraction in patients on antiplatelet therapy: systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol 2024; 137:224-242. [PMID: 38155005 DOI: 10.1016/j.oooo.2023.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE To determine the risk of bleeding after minor extraction in patients on different antiplatelet therapy (APT) regimens. STUDY DESIGN A search was conducted using PubMed and Google Scholar. Thirty-five papers were included in the systematic review, of which 23 papers provided the requisite information for meta-analysis. Subgroups were created based on the controls, as follows: (1) no control, (2) healthy control, and (3) interrupted APT control. In a meta-analysis, the studies were further subdivided into immediate and delayed bleeding. RESULTS No immediate or delayed bleeding risk was found in patients treated with aspirin vs healthy controls (relative risk [RR] = 1.26; P = .5 and RR = 2.17; P = .09, respectively). A higher immediate bleeding was recorded for patients on single nonaspirin APT vs those in the healthy population (RR = 3.72; P = .0009). A high risk of bleeding was recorded in patients receiving dual APT compared with healthy controls for immediate (RR = 10.3; P < .0001) and delayed (RR = 7.72; P = .001) bleeding. Dual APT continuation showed a higher risk of immediate bleeding (RR = 2.13) than interrupted APT, but the difference was insignificant (P = .07). CONCLUSIONS Dental extraction can be performed safely in patients on aspirin monotherapy. In contrast, patients receiving dual APT should be considered at risk for immediate and continued bleeding.
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Affiliation(s)
- Jumana AlAgil
- Fellowship in Periodontics Program, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ziyad AlDaamah
- College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Assad Khan
- King Abdulaziz Hospital, Ministry of National Guard Health Affairs, Al Ahsa, Saudi Arabia
| | - Omar Omar
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
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Fisher M, Salottolo K, Carrick M, Corrigan CM, Banton KL, Madayag R, Bar-Or D. Association of sex and aspirin use with postoperative bleeding in patients with lower extremity long bone fractures. Trauma Surg Acute Care Open 2024; 9:e001282. [PMID: 38390470 PMCID: PMC10882358 DOI: 10.1136/tsaco-2023-001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Objective The perioperative management of patients on antiplatelet drugs is a rising challenge in orthopedic trauma because antiplatelet drugs are frequently encountered and carry an increased risk of hemorrhagic consequences. The study objective was to examine the effect of aspirin on bleeding outcomes for patients with lower extremity fractures. Methods This retrospective study included patients requiring surgical fixation of traumatic hip, femur, and tibia fractures from January 1, 2018, to March 1, 2020. Patients were excluded if they had a significant head injury, were on chronic anticoagulant therapy, or they did not receive venous thromboembolism chemoprophylaxis. Comparisons between aspirin users (patients on aspirin therapy preinjury) and non-aspirin users were examined using χ2 tests, Cochran-Mantel-Haenszel tests, and multivariate logistic regression. The primary outcome was an overt, actionable bleed (eg, blood transfusion for surgical site hemorrhage) within 24 hours postoperative. Results There were 864 patients with lower extremity long bone fractures and 24% were aspirin users. The incidence of postoperative bleeding was 8.8% and significantly differed for patients taking aspirin versus not (13.6% vs 7.3%, p=0.01). However, biological sex at birth (M/F) was a significant effect modifier (interaction p=0.04). Among women, there were significantly more postoperative bleeds for aspirin users (17.8% aspirin vs 7.4% no aspirin, adjusted OR (AOR): 2.48 (1.28-4.81), p=0.01). Among men, there were similar postoperative bleeding events by aspirin use (5.6% aspirin vs 7.2% no aspirin, AOR: 0.50 (0.14-1.82), p=0.30). Postoperative hemoglobin values <8 g/dL were more frequent among female aspirin users (21.5% aspirin vs 12.5% no aspirin, p=0.01), but this association was not observed in men (p=0.43). Conclusion Women taking aspirin who suffer lower extremity fractures have greater than twofold greater odds of a postoperative bleeding event. These findings suggest adequate perioperative planning to ensure blood availability, and increased awareness to monitor closely for hemorrhage in the 24-hour postoperative window for women taking aspirin preinjury. Level of evidence IV.
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Affiliation(s)
- Michael Fisher
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Kristin Salottolo
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Matthew Carrick
- Trauma Services Department, Medical City Plano, Plano, Texas, USA
| | - Chad M Corrigan
- Trauma Services Department, Wesley Medical Center, Wichita, Kansas, USA
| | - Kaysie L Banton
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - Robert Madayag
- Trauma Services Department, St Anthony Hospital, Lakewood, Colorado, USA
- Trauma services Department, Lutheran Medical Center, Wheat Ridge, CO, USA
| | - David Bar-Or
- Trauma Research Department, Swedish Medical Center, Englewood, Colorado, USA
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Cartland SP, Stanley CP, Bursill C, Passam F, Figtree GA, Patel S, Loa J, Golledge J, Robinson DA, Aitken SJ, Kavurma MM. Sex, Endothelial Cell Functions, and Peripheral Artery Disease. Int J Mol Sci 2023; 24:17439. [PMID: 38139267 PMCID: PMC10744086 DOI: 10.3390/ijms242417439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/24/2023] Open
Abstract
Peripheral artery disease (PAD) is caused by blocked arteries due to atherosclerosis and/or thrombosis which reduce blood flow to the lower limbs. It results in major morbidity, including ischemic limb, claudication, and amputation, with patients also suffering a heightened risk of heart attack, stroke, and death. Recent studies suggest women have a higher prevalence of PAD than men, and with worse outcomes after intervention. In addition to a potential unconscious bias faced by women with PAD in the health system, with underdiagnosis, and lower rates of guideline-based therapy, fundamental biological differences between men and women may be important. In this review, we highlight sexual dimorphisms in endothelial cell functions and how they may impact PAD pathophysiology in women. Understanding sex-specific mechanisms in PAD is essential for the development of new therapies and personalized care for patients with PAD.
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Affiliation(s)
- Siân P. Cartland
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
| | - Christopher P. Stanley
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
| | - Christina Bursill
- South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia;
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5005, Australia
| | - Freda Passam
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
| | - Gemma A. Figtree
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
- Kolling Institute of Medical Research, Sydney, NSW 2064, Australia
| | - Sanjay Patel
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
- Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia (D.A.R.)
| | - Jacky Loa
- Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia (D.A.R.)
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia;
- Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, QLD 4814, Australia
| | | | - Sarah J. Aitken
- Faculty of Health and Medicine, The University of Sydney, Sydney, NSW 2050, Australia; (F.P.); (G.A.F.); (S.J.A.)
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
| | - Mary M. Kavurma
- Heart Research Institute, The University of Sydney, Sydney, NSW 2042, Australia; (S.P.C.); (C.P.S.); (S.P.)
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Abstract
Antiplatelet therapy is a cornerstone of secondary prevention of cardiovascular diseases (CVDs). However, current guidelines are based on data derived primarily from men, as women are generally underrepresented in trials. Consequently, there are insufficient and inconsistent data on the effect of antiplatelet drugs in women. Sex differences were reported in platelet reactivity, patient management, and clinical outcomes after treatment with aspirin, P2Y12 inhibitor, or dual antiplatelet therapy. To evaluate whether sex-specific antiplatelet therapy is needed, in this review we discuss (i) how sex affects platelet biology and response to antiplatelet agents, (ii) how sex and gender differences translate into clinical challenges and (iii) how the cardiological care in women might be improved. Finally, we highlight the challenges faced in clinical practice regarding the different needs and characteristics of female and male patients with CVD and address issues requiring further investigation.
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Affiliation(s)
- Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Jakub M Zimodro
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
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Oliveira GMMD, Almeida MCCD, Rassi DDC, Bragança ÉOV, Moura LZ, Arrais M, Campos MDSB, Lemke VG, Avila WS, Lucena AJGD, Almeida ALCD, Brandão AA, Ferreira ADDA, Biolo A, Macedo AVS, Falcão BDAA, Polanczyk CA, Lantieri CJB, Marques-Santos C, Freire CMV, Pellegrini D, Alexandre ERG, Braga FGM, Oliveira FMFD, Cintra FD, Costa IBSDS, Silva JSN, Carreira LTF, Magalhães LBNC, Matos LDNJD, Assad MHV, Barbosa MM, Silva MGD, Rivera MAM, Izar MCDO, Costa MENC, Paiva MSMDO, Castro MLD, Uellendahl M, Oliveira Junior MTD, Souza OFD, Costa RAD, Coutinho RQ, Silva SCTFD, Martins SM, Brandão SCS, Buglia S, Barbosa TMJDU, Nascimento TAD, Vieira T, Campagnucci VP, Chagas ACP. Position Statement on Ischemic Heart Disease - Women-Centered Health Care - 2023. Arq Bras Cardiol 2023; 120:e20230303. [PMID: 37556656 PMCID: PMC10382148 DOI: 10.36660/abc.20230303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | - Walkiria Samuel Avila
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Andreia Biolo
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | | | | | | | - Celi Marques-Santos
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Hospital São Lucas Rede D'Or São Luis, Aracaju, SE - Brasil
| | | | - Denise Pellegrini
- Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | - Fabiana Goulart Marcondes Braga
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Lara Terra F Carreira
- Cardiologia Nuclear de Curitiba, Curitiba, PR - Brasil
- Hospital Pilar, Curitiba, PR - Brasil
| | | | | | | | | | | | | | | | | | | | | | - Marly Uellendahl
- Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
- DASA - Diagnósticos da América S/A, São Paulo, SP - Brasil
| | - Mucio Tavares de Oliveira Junior
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | - Ricardo Quental Coutinho
- Faculdade de Ciências Médicas da Universidade de Pernambuco (UPE), Recife, PE - Brasil
- Hospital Universitário Osvaldo Cruz da Universidade de Pernambuco (UPE), Recife, PE - Brasil
| | | | - Sílvia Marinho Martins
- Pronto Socorro Cardiológico de Pernambuco da Universidade de Pernambuco (PROCAPE/UPE), Recife, PE - Brasil
| | | | - Susimeire Buglia
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | - Thais Vieira
- Universidade Tiradentes (UNIT), Aracaju, SE - Brasil
- Rede D'Or, Aracaju, SE - Brasil
- Hospital Universitário da Universidade Federal de Sergipe (UFS), Aracaju, SE - Brasil
| | | | - Antonio Carlos Palandri Chagas
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
- Centro Universitário Faculdade de Medicina ABC, Santo André, SP - Brasil
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7
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Cordero A, Escribano D, García-Acuña JM, Alvarez-Alvarez B, Cid-Alvarez B, Rodriguez-Mañero M, Agra-Bermejo R, Quintanilla MA, Zuazola P, González-Juanatey JR. Differential prognosis of patients that are candidates for standard, short or prolonged dual antiplatelet treatment discharged after an acute coronary syndrome. Thromb Res 2023; 224:46-51. [PMID: 36841157 DOI: 10.1016/j.thromres.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Current evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT) for patients at high-ischemic risk and low bleeding risk as well as the efficacy and safety of short DAPT in high-bleeding risk (HBR) patients. METHODS We evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of the BARC consortium definitions. RESULTS We included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119 (37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences were observed between the 3 categories beyond the bleeding risk. Median follow-up was 57 months. Multivariate analysis identified higher risk of all-cause mortality (HR: 1.96 95 % CI 1.45-2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI 1.39-3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50-2.02; p < 0.001) and MB (sHR: 3.41 95 % CI 1.45-8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02-1.35; p = 0.027). CONCLUSIONS Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - David Escribano
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - José Mª García-Acuña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Belén Alvarez-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Belén Cid-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Moisés Rodriguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Rosa Agra-Bermejo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Mª Amparo Quintanilla
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - Pilar Zuazola
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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Graipe A, Ulvenstam A, Irevall AL, Söderström L, Mooe T. Incidence and predictors of serious bleeding during long-term follow-up after acute coronary syndrome in a population-based cohort study. Sci Rep 2021; 11:21967. [PMID: 34754030 PMCID: PMC8578330 DOI: 10.1038/s41598-021-01525-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Abstract
Progress in decreasing ischemic complications in acute coronary syndrome (ACS) has come at the expense of increased bleeding risk. We estimated the long-term, post-discharge incidence of serious bleeding, characterized bleeding type, and identified predictors of bleeding and its impact on mortality in an unselected cohort of patients with ACS. In this population-based study, we included 1379 patients identified with an ACS, 2010–2014. Serious bleeding was defined as intracranial hemorrhage (ICH), bleeding requiring hospital admission, or bleeding requiring transfusion or surgery. During a median 4.6-year follow-up, 85 patients had ≥ 1 serious bleed (cumulative incidence, 8.6%; 95% confidence interval (CI) 8.3–8.9). A subgroup of 557 patients, aged ≥ 75 years had a higher incidence (13.4%) than younger patients (6.0%). The most common bleeding site was gastrointestinal (51%), followed by ICH (27%). Sixteen percent had a recurrence. Risk factors for serious bleeding were age ≥ 75 years, lower baseline hemoglobin (Hb) value, previous hypertension or heart failure. Serious bleeding was associated with increased mortality. Bleeding after ACS was fairly frequent and the most common bleeding site was gastrointestinal. Older age, lower baseline Hb value, hypertension and heart failure predicted bleeding. Bleeding did independently predict mortality.
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Affiliation(s)
- Anna Graipe
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden.
| | - Anders Ulvenstam
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Anna-Lotta Irevall
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Lars Söderström
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
| | - Thomas Mooe
- Institution of Public Health and Clinical Medicine, Östersund, Umeå University, Umeå, Sweden
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9
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Kodaira M, Sawano M, Tanaka M, Kuno T, Numasawa Y, Ueda I, Fukuda K, Kohsaka S. Female sex as an independent predictor of high bleeding risk among East Asian percutaneous coronary intervention patients: A sex difference analysis. J Cardiol 2021; 78:431-438. [PMID: 34172350 DOI: 10.1016/j.jjcc.2021.05.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/12/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sex differences in the outcomes following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have been identified in Western countries. However, data on the long-term outcomes for bleeding events, particularly in East Asia where the aging population is growing rapidly and consists predominantly of women, remain scarce. METHODS We analyzed 2,494 ACS survivors from a multicenter PCI registry who underwent PCI between 2009 and 2012. The primary outcome was readmission for major bleeding at 2 years. Survival curves were generated with the cumulative incidence function. The adjusted hazard ratios were evaluated for the primary outcomes by sex using (1) Fine-Gray models and (2) Cox regression models. RESULTS There were 548 women (22.0%) in this cohort. The women were older (73.7 ± 10.8 years vs. 65.4 ± 11.8 years, p < 0.001), had a lower body mass index (23.0 ± 3.9 vs. 24.3 ± 3.6, p < 0.001), and had more comorbidities such as renal failure (49.4% vs. 36.3%, p < 0.001) and previous heart failure (8.4% vs. 4.5%, p < 0.001). Fewer women were discharged with statins (81.9% vs. 86.5%, p = 0.025) or beta blockers (70.6% vs. 77.1%, p = 0.007). During the 2-year follow-up, the unadjusted readmission rates for bleeding were higher among women (4.9% versus 2.4% at 2 years after discharge). Multivariable competing risk analysis with the Fine-Gray model and Cox regression model further demonstrated that female sex was associated with a higher risk of bleeding. CONCLUSIONS Among patients treated with PCI, women had a higher incidence of bleeding events requiring readmission. Sex disparities in the etiologies of readmission following PCI suggest the need for targeted treatment strategies. A strict follow-up after discharge could be beneficial for women to further reduce their risk.
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Affiliation(s)
- Masaki Kodaira
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan.
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Tanaka
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Toshiki Kuno
- Department of Medicine, Mount Sinai Beth Israel Medical Center, New York, NY, USA
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Tochigi, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Cortesi PA, Maloberti A, Micale M, Pagliarin F, Antonazzo IC, Mazzaglia G, Giannattasio C, Mantovani LG. Costs and effects of cardiovascular risk reclassification using the ankle-brachial index (ABI) in addition to the Framingham risk scoring in women. Atherosclerosis 2020; 317:59-66. [PMID: 33213858 DOI: 10.1016/j.atherosclerosis.2020.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/01/2020] [Accepted: 11/05/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS Ankle brachial index (ABI) is a simple and cheap parameter to assess the presence of atherosclerosis. It could also help correctly reclassify the cardiovascular risk when added to the Framingham risk score (FRS). Recent evidence has demonstrated improvement in prediction performance of ABI when added to FRS, particularly in women. However, no studies have been published yet evaluating the cost-effectiveness of this approach. This study attempts to fill in this gap by assessing the cost-effectiveness of ABI measurements in primary prevention in women. METHODS We developed a Markov model to compare two different strategies for assessing the cardiovascular risk (low, intermediate and high) among women in the general population: 1) FRS strategy, and 2) FRS + ABI strategy; and the relative impact associated with interventions for preventing CV events in intermediate and high-risk categories. RESULTS In the base-case analysis, FRS + ABI reported an additional cost of € 110 and a gain of 0.0039 QALYs per patient, resulting in an ICER of € 27.986/QALY, when compared to FRS alone. The ICER improved to €1.641/QALY when using a lifetime horizon. The effectiveness of preventive CV disease interventions reported also a significant impact. A 32% reduction of CV events was the minimum value estimated to maintain FRS + ABI as a cost-effective strategy. CONCLUSIONS The addition of ABI to FRS is a cost-effective approach in women classified at low and intermediate risk with FRS only. This new approach gives the possibility to reclassify and allocate them into the appropriate risk group and treatment.
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Affiliation(s)
- Paolo Angelo Cortesi
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Alessandro Maloberti
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Cardiology 4, "A. De Gasperis" Department, Niguarda Ca Granda Hospital, Milan, Italy.
| | - Mariangela Micale
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Federica Pagliarin
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | | | - Giampiero Mazzaglia
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Cristina Giannattasio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy; Cardiology 4, "A. De Gasperis" Department, Niguarda Ca Granda Hospital, Milan, Italy
| | - Lorenzo Giovanni Mantovani
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy; IRCCS Multimedica, Sesto San Giovanni, Italy
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Cordero A, Escribano D, García-Acuña JM, Rodriguez-Mañero M, Agra-Bermejo R, Bertomeu-González V, Cid-Alvarez B, Alvarez-Alvarez B, Zuazola P, González-Juanatey JR. Long-term bleeding risk vs. mortality risk in acute coronary syndrome patients according to the 2019 ARC-HBR definition. Thromb Res 2020; 196:516-8. [PMID: 33096439 DOI: 10.1016/j.thromres.2020.10.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 09/18/2020] [Accepted: 10/09/2020] [Indexed: 11/20/2022]
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Gasperi V, Catani MV, Savini I. Platelet Responses in Cardiovascular Disease: Sex-Related Differences in Nutritional and Pharmacological Interventions. Cardiovasc Ther 2020; 2020:2342837. [PMID: 32547635 DOI: 10.1155/2020/2342837] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/09/2020] [Indexed: 12/12/2022] Open
Abstract
Cardiovascular diseases (CVD) represent one of the biggest causes of death globally, and their prevalence, aetiology, and outcome are related to genetic, metabolic, and environmental factors, among which sex- and age-dependent differences may play a key role. Among CVD risk factors, platelet hyperactivity deserves particular mention, as it is involved in the pathophysiology of main cardiovascular events (including stroke, myocardial infarction, and peripheral vascular injury) and is closely related to sex/age differences. Several determinants (e.g., hormonal status and traditional cardiovascular risk factors), together with platelet-related factors (e.g., plasma membrane composition, receptor signaling, and platelet-derived microparticles) can elucidate sex-related disparity in platelet functionality and CVD onset and outcome, especially in relation to efficacy of current primary and secondary interventional strategies. Here, we examined the state of the art concerning sex differences in platelet biology and their relationship with specific cardiovascular events and responses to common antiplatelet therapies. Moreover, as healthy nutrition is widely recognized to play a key role in CVD, we also focused our attention on specific dietary components (especially polyunsaturated fatty acids and flavonoids) and patterns (such as Mediterranean diet), which also emerged to impact platelet functions in a sex-dependent manner. These results highlight that full understanding of gender-related differences will be useful for designing personalized strategies, in order to prevent and/or treat platelet-mediated vascular damage.
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13
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Ismail N, Jordan KP, Kadam UT, Edwards JJ, Kinnaird T, Mamas MA. Bleeding After Hospital Discharge Following Acute Coronary Syndrome: Incidence, Types, Timing, and Predictors. J Am Heart Assoc 2019; 8:e013679. [PMID: 31657257 PMCID: PMC6898798 DOI: 10.1161/jaha.119.013679] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background The incidence and predictors of bleeding after acute coronary syndrome are unclear within the real‐world setting. Our objective was to determine the incidence, types, timing, and predictors of bleeding complications following hospital discharge after acute coronary syndrome. Methods and Results We used the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics, to determine the incidence, timing, and types of bleeding events within 12 months after hospital discharge for acute coronary syndrome. We assessed independent associations between postdischarge bleeding and baseline patient characteristics using a competing risk regression model, accounting for death as a competing event. Among 27 660 patients surviving to hospital discharge, 3620 (13%) experienced bleeding complications at a median time of 123 days (interquartile range, 45–223 days) after discharge. The incidence of bleeding was 162/1000 person‐years (95% CI, 157–167/1000 person‐years) within the first 12 months after hospital discharge. Bruising (949 bleeds [26%]) was the most common type of first bleeding event, followed by gastrointestinal bleed (705 bleeds [20%]), whereas intracranial bleed was relatively rare (81 bleeds [2%]). Significant predictors of postdischarge bleeding included history of bleeding complication, oral anticoagulant prescription, history of peripheral vascular disease, chronic obstructive pulmonary disease, and advanced age (>80 years). Predictors for postdischarge bleeding varied, depending on the anatomic site of the bleeding event. Conclusions Bleeding complications after hospital discharge for acute coronary syndrome are common. Patients who experience these bleeding events have distinct baseline characteristics, which vary by anatomic site of the bleed. These characteristics can inform risk‐benefit considerations in deciding on favorable combination and duration of secondary antithrombotic therapy.
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Affiliation(s)
- Nafiu Ismail
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom.,Keele Cardiovascular Research Group Keele University Staffordshire United Kingdom
| | - Kelvin P Jordan
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom
| | - Umesh T Kadam
- Department of Health Sciences University of Leicester Leicester United Kingdom
| | - John J Edwards
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom
| | - Tim Kinnaird
- Department of Cardiology University Hospital of Wales Cardiff Wales United Kingdom
| | - Mamas A Mamas
- Centre for Prognosis Research Research Institute for Primary Care and Health Sciences Keele University Staffordshire United Kingdom.,Keele Cardiovascular Research Group Keele University Staffordshire United Kingdom
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14
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Baart SJ, Dam V, Scheres LJJ, Damen JAAG, Spijker R, Schuit E, Debray TPA, Fauser BCJM, Boersma E, Moons KGM, van der Schouw YT. Cardiovascular risk prediction models for women in the general population: A systematic review. PLoS One 2019; 14:e0210329. [PMID: 30620772 PMCID: PMC6324808 DOI: 10.1371/journal.pone.0210329] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/20/2018] [Indexed: 12/17/2022] Open
Abstract
AIM To provide a comprehensive overview of cardiovascular disease (CVD) risk prediction models for women and models that include female-specific predictors. METHODS We performed a systematic review of CVD risk prediction models for women in the general population by updating a previous review. We searched Medline and Embase up to July 2017 and included studies in which; (a) a new model was developed, (b) an existing model was validated, or (c) a predictor was added to an existing model. RESULTS A total of 285 prediction models for women have been developed, of these 160 (56%) were female-specific models, in which a separate model was developed solely in women and 125 (44%) were sex-predictor models. Out of the 160 female-specific models, 2 (1.3%) included one or more female-specific predictors (mostly reproductive risk factors). A total of 591 validations of sex-predictor or female-specific models were identified in 206 papers. Of these, 333 (56%) validations concerned nine models (five versions of Framingham, SCORE, Pooled Cohort Equations and QRISK). The median and pooled C statistics were comparable for sex-predictor and female-specific models. In 260 articles the added value of new predictors to an existing model was described, however in only 3 of these female-specific predictors (reproductive risk factors) were added. CONCLUSIONS There is an abundance of models for women in the general population. Female-specific and sex-predictor models have similar predictors and performance. Female-specific predictors are rarely included. Further research is needed to assess the added value of female-specific predictors to CVD models for women and provide physicians with a well-performing prediction model for women.
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Affiliation(s)
- Sara J. Baart
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Veerle Dam
- Netherlands Heart Institute, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Luuk J. J. Scheres
- Netherlands Heart Institute, Utrecht, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - Johanna A. A. G. Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - René Spijker
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, the Netherlands
- Clinical Library, Academic Medical Center, Amsterdam, the Netherlands
| | - Ewoud Schuit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Thomas P. A. Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Bart C. J. M. Fauser
- Department of Reproductive Medicine & Gynaecology, University Medical Center, Utrecht University, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Karel G. M. Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Yvonne T. van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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Romano S, Buccheri S, Mehran R, Angiolillo DJ, Capodanno D. Gender differences on benefits and risks associated with oral antithrombotic medications for coronary artery disease. Expert Opin Drug Saf 2018; 17:1041-1052. [DOI: 10.1080/14740338.2018.1524869] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sara Romano
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Sergio Buccheri
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Davide Capodanno
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
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