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Gritti V, Pierini S, Ferlini M, Mauri S, Barbieri L, Castiglioni B, Lettieri C, Mircoli L, Mortara A, Nassiacos D, Oltrona Visconti L, Paggi A, Soriano F, Sponzilli C, Corsini A. Atrial fibrillation and ischemic heart disease: (un)solved therapeutic dilemma? Minerva Cardiol Angiol 2024; 72:225-236. [PMID: 37870421 DOI: 10.23736/s2724-5683.23.06275-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Concomitant presence of atrial fibrillation and coronary artery disease requiring percutaneous coronary intervention is a frequent occurrence. The choice of optimal antithrombotic therapy, in this context, is still challenging. To offer the best protection both in terms of stroke and stent thrombosis, triple therapy with oral anticoagulation and dual antiplatelet therapy would be required. Several drug combinations have been tested in recent years, including direct oral anticoagulants, with the aim of balancing ischemic and bleeding risk. Both pharmacokinetic aspects of the molecules and patient's characteristics should be analyzed in choosing oral anticoagulation. Then, as suggested by guidelines, triple therapy should start with a seven-day duration and the aim to prolong to thirty days in high thrombotic risk patients. Dual therapy should follow to reach twelve months after coronary intervention. Even not fully discussed by the guidelines, in order to balance ischemic and bleeding risk it should also be considered: 1) integrated assessment of coronary artery disease and procedural complexity of coronary intervention; 2) appropriateness to maintain the anticoagulant drug dosage indicated in technical data sheet; the lack of data on the suspension of antiplatelet drugs one year after percutaneous intervention; 3) the possibility of combination therapy with ticagrelor; and 4) the need to treat the occurrence of paroxysmal atrial fibrillation during acute coronary syndrome. With data provided clinician should pursue a therapy as personalized as possible, both in terms of drug choice and treatment duration, in order to balance ischemic and bleeding risk.
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Affiliation(s)
- Valeria Gritti
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy -
| | - Simona Pierini
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Marco Ferlini
- Division of Cardiology, Foundation IRCCS Polyclinic San Matteo, Pavia, Italy
| | - Silvia Mauri
- Cardiology and Coronary Unit, ASST Ovest Milanese, Milan, Italy
| | - Lucia Barbieri
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | | | - Luca Mircoli
- Unit of Cardiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Mortara
- Department of Clinical Cardiology, Polyclinic of Monza, Monza, Monza-Brianza, Italy
| | - Daniele Nassiacos
- Unit of Cardiology and Cardiac Intensive Care, ASST Valle Olona, Saronno, Varese, Italy
| | | | - Anita Paggi
- Unit of Cardiology and Cardiac Intensive Care, ASST Nord Milano, Sesto San Giovanni, Milan, Italy
| | - Francesco Soriano
- Cardiothoracovascular Department, ASST Niguarda Hospital, Milan, Italy
| | | | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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2
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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3
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Laskar N, Bayliss CD, Kirmani BH, Chambers JB, Maier R, Briffa NP, Cartwright N, Kendall S, Shah BN, Akowuah E. Antithrombotic therapy after heart valve surgery: contemporary practice in the UK. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivae089. [PMID: 38704867 PMCID: PMC11109495 DOI: 10.1093/icvts/ivae089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/02/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES There is a lack of high-quality data informing the optimal antithrombotic drug strategy following bioprosthetic heart valve replacement or valve repair. Disparity in recommendations from international guidelines reflects this. This study aimed to document current patterns of antithrombotic prescribing after heart valve surgery in the UK. METHODS All UK consultant cardiac surgeons were e-mailed a custom-designed survey. The use of oral anticoagulant (OAC) and/or antiplatelet drugs following bioprosthetic aortic valve replacement or mitral valve replacement, or mitral valve repair (MVrep), for patients in sinus rhythm, without additional indications for antithrombotic medication, was assessed. Additionally, we evaluated anticoagulant choice following MVrep in patients with atrial fibrillation. RESULTS We identified 260 UK consultant cardiac surgeons from 36 units, of whom 103 (40%) responded, with 33 units (92%) having at least 1 respondent. The greatest consensus was for patients undergoing bioprosthetic aortic valve replacement, in which 76% of surgeons favour initial antiplatelet therapy and 53% prescribe lifelong treatment. Only 8% recommend initial OAC. After bioprosthetic mitral valve replacement, 48% of surgeons use an initial OAC strategy (versus 42% antiplatelet), with 66% subsequently prescribing lifelong antiplatelet therapy. After MVrep, recommendations were lifelong antiplatelet agent alone (34%) or following 3 months OAC (20%), no antithrombotic agent (20%), or 3 months OAC (16%). After MVrep for patients with established atrial fibrillation, surgeons recommend warfarin (38%), a direct oral anticoagulant (37%) or have no preference between the 2 (25%). CONCLUSIONS There is considerable variation in the use of antithrombotic drugs after heart valve surgery in the UK and a lack of high-quality evidence to guide practice, underscoring the need for randomized studies.
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Affiliation(s)
- Nabila Laskar
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Christopher D Bayliss
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Bilal H Kirmani
- Department of Cardiac Surgery, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - John B Chambers
- Department of Cardiology, Guys & St Thomas’ Hospitals, London, UK
| | - Rebecca Maier
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Norman P Briffa
- Department of Cardiac Surgery, Northern General Hospital, Sheffield, UK
| | - Neil Cartwright
- Department of Cardiac Surgery, Northern General Hospital, Sheffield, UK
| | - Simon Kendall
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Benoy Nalin Shah
- Department of Cardiology, Wessex Cardiac Centre, Southampton General Hospital, Southampton, UK
| | - Enoch Akowuah
- Newcastle University and the Academic Cardiovascular Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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4
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Hao Z, Liu B, Xie X, Fan Y, Wang J, Shao Q, Jiang L, He B. Combining catheter ablation and left atrial appendage occlusion in high-risk patients with atrial fibrillation: a propensity score-matched analysis. Hellenic J Cardiol 2024:S1109-9666(24)00057-5. [PMID: 38460616 DOI: 10.1016/j.hjc.2024.03.002] [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: 09/24/2023] [Revised: 12/23/2023] [Accepted: 03/03/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The safety and efficacy of a combined approach of catheter ablation (CA) and left atrial appendage occlusion (LAAO) compared to LAAO alone remain unknown. METHODS Patients with atrial fibrillation (AF) at increased stroke risk who underwent LAAO were divided into either combined (CA and LAAO) procedures or LAAO alone group. Propensity score matching was utilized to balance baseline characteristics. The primary endpoint of the study was a composite of death, thromboembolic events, major bleeding, heart failure (HF) rehospitalization, and major periprocedural complications. RESULTS A total of 707 AF patients who underwent LAAO were included. After 1:1 propensity score matching, 166 patients who underwent LAAO alone (n = 83) or the combined procedure (n = 83) were analyzed. Successful LAAO was achieved in all (100%) patients, with a low incidence of periprocedural complications in both groups (2.4% vs. 4.8%, LAAO vs. combined, p = 0.68). The incidence of peri-device leak post-LAAO was significantly higher in the combined group (25.3% vs. 43.4%, p = 0.01). After a median follow-up of 2 years, there were no significant differences in the rates of the primary composite endpoint between the two strategies (22.2% vs. 14.3%, HR: 1.24 [95% CI: 0.51-2.97], p = 0.63). However, the rate of HF rehospitalization was significantly lower in the combined group (19.6% vs. 3.6%, HR: 4.89 [95% CI: 1.50-15.97], p = 0.024). CONCLUSIONS Combining CA and LAAO in a "one-stop" approach is safe and brings additional benefits in relieving symptoms of heart failure, although peri-device leak was more common compared to LAAO alone.
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Affiliation(s)
- Ziyong Hao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyi Xie
- Department of Ultrasonography, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiting Fan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Shao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lisheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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5
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Reddy VY, Zhong Y, McGovern AM, Amorosi SL, Gavaghan MB, Hertz DS, Low K, Freeman S, Holmes Jr DR. Comparative Costs to Medicare and Medicare Beneficiaries of Alternative AF Stroke Risk Reduction Strategies. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:81-96. [PMID: 38374959 PMCID: PMC10875168 DOI: 10.2147/ceor.s440556] [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: 09/16/2023] [Accepted: 11/28/2023] [Indexed: 02/21/2024] Open
Abstract
Background As healthcare costs are increasingly being shifted from payers to patients, it is important to understand the economic consequences of therapeutic strategies to both payers and patients. Objective To determine the relative costs to Medicare and Medicare beneficiaries (patients) of warfarin, non-vitamin K oral anticoagulants (NOACs), and left atrial appendage closure (LAAC) for stroke risk reduction in nonvalvular atrial fibrillation. Methods An economic model was developed to assess costs at 5 and 10 years. For warfarin and NOACs, inputs were derived from published meta-analyses; for LAAC with the Watchman device, inputs were derived from pooled 5-year PROTECT AF and PREVAIL trial results. The model captured therapy costs vs clinical event costs, including procedural complications and follow-up clinical outcomes. Costs were based on 2023 Medicare reimbursement and copayment rates. Results At 10 years, overall LAAC costs ($48,337) were lower than those of NOACs ($81,198) and warfarin ($52,359). Overall LAAC costs were lower than those of NOACs by year 5 and warfarin by year 9. At 5 years, patient LAAC costs were lowest at $4,764, compared to $7,146 and $6,453 for NOACs and warfarin, respectively. LAAC patient costs were lower than those of NOACs by year 3 and warfarin by year 4. Clinical events comprised 96% of overall warfarin costs vs 48% for LAAC and 40% for NOACs. Conclusion LAAC yielded the lowest overall and patient costs. Warfarin costs were largely driven by clinical events, which may represent an unplanned financial burden for patients. These considerations should be incorporated into shared decision-making discussions about stroke prophylaxis strategies.
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Affiliation(s)
- Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yue Zhong
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Stacey L Amorosi
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
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Chan BPL, Wong LYH, Tan BYQ, Yeo LLL, Venketasubramanian N. Dual Antiplatelet Therapy for the Acute Management and Long-term Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack, An Updated Review. J Cardiovasc Dev Dis 2024; 11:48. [PMID: 38392262 PMCID: PMC10889184 DOI: 10.3390/jcdd11020048] [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: 12/07/2023] [Revised: 01/18/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
To improve the efficacy over antiplatelet monotherapy, dual antiplatelet therapy (DAPT) has been increasingly adopted in the management of non-cardioembolic stroke. For minor ischemic stroke and high-risk transient ischemic attack, the aspirin-clopidogrel combination is now recommended for acute short-term treatment, whereas aspirin-ticagrelor combination may be considered in selected patients, especially those with resistance to clopidogrel. For long-term stroke prevention, aspirin-dipyridamole combination has been used as an alternative to antiplatelet monotherapy, and aspirin or clopidogrel combined with cilostazole may be prescribed for added protection in high-risk patients. In this paper, we review the development of DAPT from a historical perspective and describe the findings from major clinical trials published up until the end of 2023. Using the 2021 American Heart Association guideline for secondary stroke prevention as a basis for our recommendations, we further discuss areas of controversy and more recent developments to provide an updated review for clinicians to consider in their daily practice.
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Affiliation(s)
- Bernard P L Chan
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Lily Y H Wong
- Division of Neurology, National University Hospital, National University Health System, Singapore 119228, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Leonard L L Yeo
- Division of Neurology, National University Hospital; and Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
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7
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Reiner MF, Bertschi DA, Werlen L, Wiencierz A, Aeschbacher S, Lee P, Rodondi N, Moutzouri E, Bonati L, Reichlin T, Moschovitis G, Rutishauser J, Kühne M, Osswald S, Conen D, Beer JH. Omega-3 Fatty Acids and Markers of Thrombosis in Patients with Atrial Fibrillation. Nutrients 2024; 16:178. [PMID: 38257071 PMCID: PMC10821080 DOI: 10.3390/nu16020178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/25/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Omega-3 fatty acids (n-3 FAs) are associated with a lower risk of ischemic stroke in patients with atrial fibrillation (AF). Antithrombotic mechanisms may in part explain this observation. Therefore, we examined the association of n-3 FAs with D-dimer and beta-thromboglobulin (BTG), markers for activated coagulation and platelets, respectively. The n-3 FAs eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), docosapentaenoic acid (DPA) and alpha-linolenic acid (ALA) were determined via gas chromatography in the whole blood of 2373 patients with AF from the Swiss Atrial Fibrillation cohort study (ClinicalTrials.gov Identifier: NCT02105844). In a cross-sectional analysis, we examined the association of total n-3 FAs (EPA + DHA + DPA + ALA) and the association of individual fatty acids with D-dimer in patients with detectable D-dimer values (n = 1096) as well as with BTG (n = 2371) using multiple linear regression models adjusted for confounders. Median D-dimer and BTG levels were 0.340 ug/mL and 448 ng/mL, respectively. Higher total n-3 FAs correlated with lower D-dimer levels (coefficient 0.94, 95% confidence interval (Cl) 0.90-0.98, p = 0.004) and lower BTG levels (coefficient 0.97, Cl 0.95-0.99, p = 0.003). Likewise, the individual n-3 FAs EPA, DHA, DPA and ALA showed an inverse association with D-dimer. Higher levels of DHA, DPA and ALA correlated with lower BTG levels, whereas EPA showed a positive association with BTG. In patients with AF, higher levels of n-3 FAs were associated with lower levels of D-dimer and BTG, markers for activated coagulation and platelets, respectively. These findings suggest that n-3 FAs may exert antithrombotic properties in patients with AF.
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Affiliation(s)
- Martin F. Reiner
- Department of Cardiology, University Heart Center Zurich, 8091 Zurich, Switzerland;
| | - Daniela A. Bertschi
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland
| | - Laura Werlen
- Department of Clinical Research, University of Basel, University Hospital Basel, 3010 Basel, Switzerland
| | - Andrea Wiencierz
- Department of Clinical Research, University of Basel, University Hospital Basel, 3010 Basel, Switzerland
| | - Stefanie Aeschbacher
- Department of Cardiology, University Hospital Basel, 4056 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, 4056 Basel, Switzerland
| | - Pratintip Lee
- Center for Molecular Cardiology, Laboratory for Platelet Research, University of Zurich, 8952 Zurich, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, 3010 Bern, Switzerland
| | - Elisavet Moutzouri
- Institute of Primary Health Care (BIHAM), University of Bern, 3010 Bern, Switzerland
| | - Leo Bonati
- Department of Neurology and Stroke Center, University Hospital Basel, 4031 Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Giorgio Moschovitis
- Division of Cardiology, Ospedale Regionale di Lugano, 6900 Ticino, Switzerland
| | - Jonas Rutishauser
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland
- Center for Molecular Cardiology, Laboratory for Platelet Research, University of Zurich, 8952 Zurich, Switzerland
| | - Michael Kühne
- Department of Cardiology, University Hospital Basel, 4056 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, 4056 Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, 4056 Basel, Switzerland
- Cardiovascular Research Institute Basel, University Hospital Basel, 4056 Basel, Switzerland
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, ON L8L 2X2, Canada
| | - Jürg H. Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland
- Center for Molecular Cardiology, Laboratory for Platelet Research, University of Zurich, 8952 Zurich, Switzerland
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8
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Uchida M, Jo T, Okada A, Matsui H, Yasunaga H. Effectiveness and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation at low risk of stroke in japan: a retrospective cohort study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:20-26. [PMID: 37858298 DOI: 10.1093/ehjcvp/pvad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
AIMS Contemporary guidelines differ in their recommendations regarding initiating non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) at low risk of stroke. This study aimed to examine the effectiveness and safety of NOACs for low-risk AF in a Japanese cohort. METHODS AND RESULTS In this retrospective cohort study based on the JMDC Claims Database extracted between April 2011 and November 2022, we identified 13 291 patients with AF at low risk of stroke. We performed inverse probability of treatment weighting Cox regression analyses to compare the embolization and bleeding risks between the nontreatment and NOAC groups. Net clinical benefit was defined as the annual incidence of ischaemic stroke events prevented by NOACs after subtracting intracranial haemorrhage (ICH) events attributable to NOACs, multiplied by a weighting factor. The incidences of stroke and ICH in the nontreatment group were 0.47 and 0.15 per 100 person-years, respectively. The NOAC group had higher incidences of ICH (hazard ratio [HR]: 1.73, 95% confidence interval [CI]: 0.75-4.00) and stroke (HR: 1.41, 95% CI: 0.84-2.36). The net clinical benefit of NOAC treatment was -0.35% per year (95% CI: -0.99-0.29%). CONCLUSION Non-vitamin K antagonist oral anticoagulants treatment may be associated with a slightly high risk of ICH, and it yielded a neutral clinical benefit in the present Japanese population, which provides reassurance concerning the role of ethnicity in NOAC treatment for patients with AF and suggests a need to assess comprehensive weighting of the respective risk factors.
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Affiliation(s)
- Masato Uchida
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Taisuke Jo
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113033, Japan
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9
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 134] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Elsheikh S, Hill A, Irving G, Lip GYH, Abdul-Rahim AH. Atrial fibrillation and stroke: State-of-the-art and future directions. Curr Probl Cardiol 2024; 49:102181. [PMID: 37913929 DOI: 10.1016/j.cpcardiol.2023.102181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
Atrial fibrillation (AF) and stroke remain a major cause of morbidity and mortality. The two conditions shared common co-morbidities and risk factors. AF-related strokes are associated with worse clinical outcomes and higher mortality compared to non-AF-related. Early detection of AF is vital for prevention. While various scores have been developed to predict AF in such a high-risk group, they are yet to incorporated into clinical guidelines. Novel markers and predictors of AF including coronary and intracranial arterial calcification have also been studied. There are also ongoing debates on the management of acute stroke in patients with AF, and those who experienced breakthrough stroke while on oral anticoagulants. We provided an overview of the complex interplay between AF and stroke, as well as the treatment and secondary prevention of stroke in AF. We also comprehensively discussed the current evidence and the ongoing conundrums, and highlighted the future directions on the topic.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK.
| | - Andrew Hill
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
| | - Greg Irving
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Health Research Institute, Edge Hill University Faculty of Health and Social Care, Ormskirk, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Danish Centre for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Azmil H Abdul-Rahim
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK; Mersey and West Lancashire Teaching Hospitals NHS Trust, St Helens, UK
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Gao Y, Chen W, Pan Y, Jing J, Wang C, Johnston SC, Amarenco P, Bath PM, Jiang L, Yang Y, Wang T, Han S, Meng X, Lin J, Zhao X, Liu L, Zhao J, Li Y, Zang Y, Zhang S, Yang H, Yang J, Wang Y, Li D, Wang Y, Liu D, Kang G, Wang Y, Wang Y. Dual Antiplatelet Treatment up to 72 Hours after Ischemic Stroke. N Engl J Med 2023; 389:2413-2424. [PMID: 38157499 DOI: 10.1056/nejmoa2309137] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Dual antiplatelet treatment has been shown to lower the risk of recurrent stroke as compared with aspirin alone when treatment is initiated early (≤24 hours) after an acute mild stroke. The effect of clopidogrel plus aspirin as compared with aspirin alone administered within 72 hours after the onset of acute cerebral ischemia from atherosclerosis has not been well studied. METHODS In 222 hospitals in China, we conducted a double-blind, randomized, placebo-controlled, two-by-two factorial trial involving patients with mild ischemic stroke or high-risk transient ischemic attack (TIA) of presumed atherosclerotic cause who had not undergone thrombolysis or thrombectomy. Patients were randomly assigned, in a 1:1 ratio, within 72 hours after symptom onset to receive clopidogrel (300 mg on day 1 and 75 mg daily on days 2 to 90) plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 21) or matching clopidogrel placebo plus aspirin (100 to 300 mg on day 1 and 100 mg daily on days 2 to 90). There was no interaction between this component of the factorial trial design and a second part that compared immediate with delayed statin treatment (not reported here). The primary efficacy outcome was new stroke, and the primary safety outcome was moderate-to-severe bleeding - both assessed within 90 days. RESULTS A total of 6100 patients were enrolled, with 3050 assigned to each trial group. TIA was the qualifying event for enrollment in 13.1% of the patients. A total of 12.8% of the patients were assigned to a treatment group no more than 24 hours after stroke onset, and 87.2% were assigned after 24 hours and no more than 72 hours after stroke onset. A new stroke occurred in 222 patients (7.3%) in the clopidogrel-aspirin group and in 279 (9.2%) in the aspirin group (hazard ratio, 0.79; 95% confidence interval [CI], 0.66 to 0.94; P = 0.008). Moderate-to-severe bleeding occurred in 27 patients (0.9%) in the clopidogrel-aspirin group and in 13 (0.4%) in the aspirin group (hazard ratio, 2.08; 95% CI, 1.07 to 4.04; P = 0.03). CONCLUSIONS Among patients with mild ischemic stroke or high-risk TIA of presumed atherosclerotic cause, combined clopidogrel-aspirin therapy initiated within 72 hours after stroke onset led to a lower risk of new stroke at 90 days than aspirin therapy alone but was associated with a low but higher risk of moderate-to-severe bleeding. (Funded by the National Natural Science Foundation of China and others; INSPIRES ClinicalTrials.gov number, NCT03635749.).
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Affiliation(s)
- Ying Gao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Weiqi Chen
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuesong Pan
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jing Jing
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Chunjuan Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - S Claiborne Johnston
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Pierre Amarenco
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Philip M Bath
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Lingling Jiang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingying Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Tingting Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shangrong Han
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xia Meng
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinxi Lin
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Xingquan Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Liping Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jinguo Zhao
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Ying Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yingzhuo Zang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Shuo Zhang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Hongqin Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Jianbo Yang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yuanwei Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dali Li
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yanxia Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Dongqi Liu
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Guangming Kang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yongjun Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
| | - Yilong Wang
- From the Department of Neurology, Beijing Tiantan Hospital (Y.G., W.C., Y.P., J.J., C.W., Y.Y., T.W., S.H., X.M., X.Z., L.L., Yongjun Wang, Yilong Wang), the Advanced Innovation Center for Human Brain Protection (Yongjun Wang, Yilong Wang), Beijing Laboratory of Oral Health (Yilong Wang), and Beijing Municipal Key Laboratory of Clinical Epidemiology (Yilong Wang), Capital Medical University, the China National Clinical Research Center for Neurological Diseases (Y.P., J.J., C.W., L.J., X.M., J.L., X.Z., L.L., Yongjun Wang, Yilong Wang), the National Center for Neurological Disorders (Yongjun Wang, Yilong Wang), the Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences (Yongjun Wang), and the Chinese Institute for Brain Research (Yilong Wang), Beijing, the Department of Neurology, Weihai Wendeng District People's Hospital, Weihai (J.Z.), the Department of Neurology, Sui Chinese Medical Hospital, Shangqiu (Y.L.), the Department of Neurology, Qinghe People's Hospital, Xingtai (Y.Z.), the Department of Neurology, Biyang People's Hospital, Zhumadian (S.Z.), the Department of Neurology, Jiyuan Chinese Medical Hospital, Jiyuan (H.Y.), the Department of Neurology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an (J.Y.), the Department of Neurology, Affiliated Shuyang Hospital of Xuzhou Medical University, Suqian (Yuanwei Wang), the Department of Neurology, Mengzhou People's Hospital (D. Li), and the Department of Neurology, Xiuwu People's Hospital (G.K.), Jiaozuo, and the Department of Neurology, Hejian People's Hospital, Cangzhou (Yanxia Wang, D. Liu) - all in China; the Department of Neurology, University of California, San Francisco, San Francisco (S.C.J.); the Department of Neurology and Stroke Center, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, INSERM Laboratory for Vascular Translational Science-Unité 1148, University of Paris, Paris (P.A.); the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (P.A.); and the Stroke Trials Unit, Mental Health and Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom (P.M.B.)
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13
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Kailey BS, Koa-Wing M, Sutaria N, Mott T, Sohaib A, Qureshi N, Shi C, Padam P, Howard J, Kanagaratnam P. Left atrial appendage occlusion for atrial fibrillation and bleeding diathesis. J Cardiovasc Electrophysiol 2023; 34:2552-2562. [PMID: 37962263 DOI: 10.1111/jce.16105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and likelihood of bleeding can undergo left atrial appendage occlusion (LAAO) as an alternative method of stroke prophylaxis. Short-term anti-thrombotic drugs are used postprocedure to offset the risk of device-related thrombus, evidence for this practice is limited. OBJECTIVES To investigate optimal postimplant antithrombotic strategy in high bleeding-risk patients. METHODS Patients with AF and high-risk for both stroke and bleeding undergoing LAAO were advised their perioperative drug therapy by a multidisciplinary physician panel. Those deemed to be at higher risk of bleeding from anti-thrombotic drugs were assigned to minimal treatment with no antithrombotics or Aspirin-alone. The remaining patients received standard care (STG) with a 12 week course of dual-antiplatelets or anticoagulation postimplant. We compared mortality, device-related thrombus, ischemic stroke, and bleeding events during the 90 days postimplant and long-term. Event-free survival was assessed using Kaplan-Meier survival analysis, with logrank testing for statistical significance. RESULTS Seventy-five patients underwent LAAO of whom 63 patients (84%) had a prior serious bleeding event. The 42 patients on minimal treatment were older (74.3 ± 7.7 vs. 71.2 ± 7.2) with higher HASBLED score (3.6 ± 0.9 vs. 3.3 ± 1.2) than the 33 patients having standard care. There were no device-related thrombi or strokes in either group at 90 days postprocedure; STG had more bleeding events (5/33 vs. 0/42, p = 0.01) with associated deaths (3/33 vs. 0/42, p = 0.05). During long-term follow-up (median 2.2 years), all patients transitioned onto no antithrombotic drugs (43 patients [61%]) or a single-antiplatelet (29 patients [39%]). There was no evidence of early minimal treatment adversely affecting long-term outcomes. CONCLUSIONS Short-term anti-thrombotic drugs may not be needed after LAAO implant in patients with high bleeding risk and could be harmful. Larger, prospective studies would be warranted to test these findings.
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Affiliation(s)
- Balrik Singh Kailey
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | | | | | | | - Afzal Sohaib
- Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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14
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Li J, Xin H, Zhang B, Guo Y, Ding Y, Wu X. Identification of Molecular Markers Predicting the Outcome of Anti-thrombotic Therapy After Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome and Atrial fibrillation: Evidence from a Meta-analysis and Experimental Study. J Cardiovasc Transl Res 2023; 16:1408-1416. [PMID: 37672183 DOI: 10.1007/s12265-023-10416-3] [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: 03/07/2023] [Accepted: 07/21/2023] [Indexed: 09/07/2023]
Abstract
Acute coronary syndrome (ACS) and atrial fibrillation (AF) often coexist in clinical practice, and patients with these conditions often have a critical illness with high risk of both ischemia and bleeding. This study aims to report potential molecular markers for predicting the efficacy based on a meta-analysis of microarray data from the GEO database. In 40 patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) treated with PCI, P2RX1's effects on platelet aggregation, medication resistance, and predictive value were examined. Twenty up-regulated genes in peripheral blood samples of ACS and AF patients were down-regulated after PCI, while 7 down-regulated genes were up-regulated. ACS affected eight potential genes. P2RX1, one of the four LASSO analysis-retrieved disease characteristic genes, accurately predicted AF patients' thrombosis risk and PCI's anti-thrombotic impact. Therefore, P2RX1 may be a molecular marker to predict the effect of anti-thrombotic therapy in patients with ACS and AF after PCI.
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Affiliation(s)
- Jingrui Li
- The Fourth Department of Cardiovascular, The Second Affiliated Hospital of Qiqihar Medical University, No. 37 Zhonghua West Road, Jianhua District, Qiqihar, 161005, Heilongjiang Province, People's Republic of China
| | - Hongwei Xin
- The Fourth Department of Cardiovascular, The Second Affiliated Hospital of Qiqihar Medical University, No. 37 Zhonghua West Road, Jianhua District, Qiqihar, 161005, Heilongjiang Province, People's Republic of China
| | - Baihui Zhang
- The Fourth Department of Cardiovascular, The Second Affiliated Hospital of Qiqihar Medical University, No. 37 Zhonghua West Road, Jianhua District, Qiqihar, 161005, Heilongjiang Province, People's Republic of China
| | - Yanhong Guo
- Department of Biochemistry, Qiqihar Medical University, Qiqihar, 161005, People's Republic of China
| | - Yuanyuan Ding
- The Fourth Department of Cardiovascular, The Second Affiliated Hospital of Qiqihar Medical University, No. 37 Zhonghua West Road, Jianhua District, Qiqihar, 161005, Heilongjiang Province, People's Republic of China
| | - Xiaojie Wu
- The Fourth Department of Cardiovascular, The Second Affiliated Hospital of Qiqihar Medical University, No. 37 Zhonghua West Road, Jianhua District, Qiqihar, 161005, Heilongjiang Province, People's Republic of China.
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15
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [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: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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16
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Verheugt FWA, Fox KAA, Virdone S, Ambrosio G, Gersh BJ, Haas S, Pieper KS, Kayani G, Camm AJ, Parkhomenko A, Misselwitz F, Ragy H, Ten Cate H, Keltai M, Kakkar AK. Outcomes of Oral Anticoagulation in Atrial Fibrillation Patients With or Without Comorbid Vascular Disease: Insights From the GARFIELD-AF Registry. Am J Med 2023; 136:1187-1195.e15. [PMID: 37704071 DOI: 10.1016/j.amjmed.2023.08.019] [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: 04/11/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation suffer from comorbid vascular disease. The comparative efficacy and safety of different types of oral anticoagulation (OAC) in this patient group have not been widely studied. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed for 24 months. Associations of vascular disease with clinical outcomes were analyzed using adjusted hazard ratios (HR) obtained via Cox proportional-hazard modeling. Outcomes of OAC vs no OAC, and of non-vitamin K antagonist OAC (NOAC) vs vitamin K antagonist (VKA) treatment, were compared by overlap propensity-weighted Cox proportional-hazard models. RESULTS Of 51,574 atrial fibrillation patients, 25.9% had vascular disease. Among eligible atrial fibrillation patients, those with vascular disease received OAC less frequently than those without (63% vs 73%). Over 2-year follow-up, patients with vascular disease showed a higher risk of all-cause mortality (HR 1.30; 95% confidence interval [CI], 1.16-1.47) and cardiovascular mortality (HR 1.59; 95% CI, 1.28-1.97). OAC was associated with a significant decrease in all-cause mortality and non-hemorrhagic stroke, and increased risk of major bleeding in non-vascular disease. In vascular disease, similar but non-significant trends existed for stroke and major bleeding. A significantly lower risk of all-cause mortality (HR 0.74; 95% CI, 0.61-0.90) and major bleeding (HR 0.45; 95% CI, 0.29-0.70) was observed in vascular disease patients treated with NOACs, compared with VKAs. CONCLUSIONS Atrial fibrillation patients with a history of vascular disease have worse long-term outcomes than those without. The association of NOACs vs VKA with clinical outcomes was more evident in atrial fibrillation patients with vascular disease.
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Affiliation(s)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine Cardiology, Italy
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn, USA
| | - Sylvia Haas
- [Formerly] Department of Medicine, Technical University of Munich, Germany
| | | | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, UK
| | - Alexandr Parkhomenko
- National Scientific Centre "MD Strazhesko Institute of Cardiology", Kyiv, Ukraine
| | | | - Hany Ragy
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Hugo Ten Cate
- Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute (CARIM), Maastricht University, Netherlands; Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany
| | - Matyas Keltai
- Semmelweis University, Hungarian Cardiovascular Institute, Budapest, Hungary
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17
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Coylewright M, Holmes DR, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Yeh RW, Piccini JP, Price MJ, Allocco DJ, Nair DG. DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis. JACC Cardiovasc Interv 2023; 16:2708-2718. [PMID: 37943200 DOI: 10.1016/j.jcin.2023.08.013] [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: 03/24/2023] [Revised: 07/18/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding. OBJECTIVES This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO. METHODS Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45 days were evaluated. RESULTS In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT = 3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT = 3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT = 2.48% vs DOAC/aspirin = 3.25%; P = 0.04 and DAPT = 2.25% vs warfarin/aspirin = 2.22%; P = 0.93). CONCLUSIONS In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.
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Affiliation(s)
- Megan Coylewright
- University of Tennessee Health Science Center College of Medicine-Chattanooga and Erlanger Health System, Chattanooga, Tennessee, USA.
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | | | - Devi G Nair
- Department of Cardiac Electrophysiology, St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
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18
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Carciotto G, Costa F, Garcia-Ruiz V, Galli M, Soraci E, Magliarditi A, Teresi L, Nasso E, Carerj S, Di Bella G, Micari A, De Luca G. Individualization of Duration of Dual Antiplatelet Therapy after Coronary Stenting: A Comprehensive, Evidence-Based Review. J Clin Med 2023; 12:7144. [PMID: 38002756 PMCID: PMC10672070 DOI: 10.3390/jcm12227144] [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: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is the cornerstone of post-percutaneous coronary intervention treatment to prevent stent thrombosis and reduce the risk of adverse cardiovascular events. The selection of an optimal DAPT regimen, considering the interplay of various antiplatelet agents, patient profiles, and procedural characteristics, remains an evolving challenge. Traditionally, a standard duration of 12 months has been recommended for DAPT in most patients. While contemporary guidelines provide general frameworks, DAPT modulation with longer or shorter treatment courses followed by aspirin or P2Y12 inhibitor monotherapy are evolving towards an individualized strategy to optimize the balance between efficacy and safety. This review comprehensively examines the current landscape of DAPT strategies after coronary stenting, with a focus on emerging evidence for treatment individualization.
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Affiliation(s)
- Gabriele Carciotto
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Francesco Costa
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | | | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy;
| | - Emmanuele Soraci
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Alberto Magliarditi
- U.O.S. Emodinamica, Department of Medicine, Ospedale Barone Romeo di Patti, 98066 Messina, Italy; (E.S.); (A.M.)
| | - Lucio Teresi
- Division of Cardiology, Policlinico G Martino, 98125 Messina, Italy; (G.C.); (L.T.)
| | - Enrica Nasso
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
| | - Antonio Micari
- BIOMORF Department, University of Messina, 98122 Messina, Italy; (F.C.); (A.M.)
| | - Giuseppe De Luca
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy; (E.N.); (S.C.); (G.D.B.)
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant’Ambrogio, 20157 Milan, Italy
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19
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Santagata D, Donadini MP, Ageno W. Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon? Blood Rev 2023; 62:101119. [PMID: 37580207 DOI: 10.1016/j.blre.2023.101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.
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Affiliation(s)
- D Santagata
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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20
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Tiosano S, Banai A, Mulla W, Goldenberg I, Bayshtok G, Amit U, Shlomo N, Nof E, Rosso R, Glikson M, Guetta V, Barbash I, Beinart R. Left Atrial Appendage Occlusion versus Novel Oral Anticoagulation for Stroke Prevention in Atrial Fibrillation-One-Year Survival. J Clin Med 2023; 12:6693. [PMID: 37892833 PMCID: PMC10607551 DOI: 10.3390/jcm12206693] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/06/2023] [Accepted: 09/11/2023] [Indexed: 10/29/2023] Open
Abstract
Aim To compare the 1-year survival rate of patients with atrial fibrillation (AF) following left atrial appendage occluder (LAAO) implantation vs. treatment with novel oral anticoagulants (NOACs). METHODS We have conducted an indirect, retrospective comparison between LAAO and NOAC registries. The LAAO registry is a national prospective cohort of 419 AF patients who underwent percutaneous LAAO between January 2008 and October 2015. The NOACs registry is a multicenter prospective cohort of 3138 AF patients treated with NOACs between November 2015 and August 2018. Baseline patient characteristics were retrospectively collected from coded diagnoses of hospitalization and outpatient clinic notes. Follow-up data was sorted from coded diagnoses and the national civil registry. Subjects were matched according to propensity score. Baseline characteristics were compared using Chi-Square and student's t-test. Survival analysis was performed using Kaplan-Meier survival curves, log-rank test, and multivariable Cox regression, adjusting for possible confounding variables. RESULTS This study included 114 subjects who underwent LAAO implantation and 342 subjects treated with NOACs. The mean age of participants was 77.9 ± 7.44 and 77.1 ± 11.2 years in the LAAO and NOAC groups, respectively (p = 0.4). The LAAO group had 70 (61%) men compared to 202 (59%) men in the NOAC group (p = 0.74). No significant differences were found in baseline comorbidities, renal function, or CHA2DS2-VASc score. One-year mortality was observed in 5 (4%) patients and 32 (9%) patients of the LAAO and NOAC groups, respectively. After adjusting for confounders, LAAO was significantly associated with a lower risk for 1-year mortality (HR 0.38, 95%CI 0.14-0.99). In patients with impaired renal function, this difference was even more prominent (HR 0.21 for creatinine clearance (CrCl) < 60 mL/min). CONCLUSIONS In a pooled analysis of two registries, we found a significantly lower risk for 1-year mortality in patients with AF who were implanted with LAAO than those treated with NOACs. This finding was more prominent in patients with impaired renal function. Future prospective direct studies should further investigate the efficacy and adverse effects of both treatment strategies.
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Affiliation(s)
- Shmuel Tiosano
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Ariel Banai
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Wesam Mulla
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Surgeon General Headquarters, Israel Defense Forces, Ramat Gan 5262000, Israel
| | - Ido Goldenberg
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Gabriella Bayshtok
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Arrow Program, Sheba Medical Center, Ramat Gan 5266202, Israel
| | - Uri Amit
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Nir Shlomo
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Eyal Nof
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Raphael Rosso
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
- Department of Cardiology, Tel Aviv Sourasky Medical Center, Tel Aviv 64239, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem 9103102, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9574425, Israel
| | - Victor Guetta
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Israel Barbash
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
| | - Roy Beinart
- Leviev Heart Center, Sheba Medical Center, Ramat Gan 52621, Israel (W.M.)
- Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv 6997801, Israel; (A.B.)
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21
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Greco A, Occhipinti G, Giacoppo D, Agnello F, Laudani C, Spagnolo M, Mauro MS, Rochira C, Finocchiaro S, Mazzone PM, Faro DC, Landolina D, Ammirabile N, Imbesi A, Raffo C, Capodanno D. Antithrombotic Therapy for Primary and Secondary Prevention of Ischemic Stroke: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1538-1557. [PMID: 37793752 DOI: 10.1016/j.jacc.2023.07.025] [Citation(s) in RCA: 1] [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: 04/20/2023] [Revised: 07/05/2023] [Accepted: 07/12/2023] [Indexed: 10/06/2023]
Abstract
Stroke is a devastating condition with significant morbidity and mortality worldwide. Antithrombotic therapy plays a crucial role in both primary and secondary prevention of stroke events. Single or dual antiplatelet therapy is generally preferred in cases of large-artery atherosclerosis and small-vessel disease, whereas anticoagulation is recommended in conditions of blood stasis or hypercoagulable states that mostly result in red thrombi. However, the benefit of antithrombotic therapies must be weighed against the increased risk of bleeding, which can pose significant challenges in the pharmacological management of this condition. This review provides a comprehensive summary of the currently available evidence on antithrombotic therapy for ischemic stroke and outlines an updated therapeutic algorithm to support physicians in tailoring the strategy to the individual patient and the underlying mechanism of stroke.
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Affiliation(s)
- Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy. https://twitter.com/AGrecoMD
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Carmelo Raffo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy.
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22
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AlSawy NS, ElKady EF, Mostafa EA. AGREE and ESA for Greenness Assessment of a Novel Validated RP-HPLC Method for Simultaneous Determination of Aspirin, Warfarin and Clopidogrel in Rat Plasma: Application to Pharmacokinetic Study of the Possible Interaction between the Three Drugs. J Chromatogr Sci 2023:bmad078. [PMID: 37791421 DOI: 10.1093/chromsci/bmad078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 07/23/2023] [Accepted: 09/07/2023] [Indexed: 10/05/2023]
Abstract
The green profile of the developed method is assessed and compared with previously reported methods. Percutaneous coronary intervention is a procedure where a catheter is utilized to place a stent in order to facilitate opening of the blood vessels in the heart. Triple antithrombotic therapy includes oral anticoagulation as warfarin and dual antiplatelet therapy (composed of aspirin and clopidogrel bisulfate). The aim of the current study was to evaluate the pharmacokinetic parameters of ASP, WAR and CLP and to investigate the possible interaction between the three drugs upon co-administration in rats. A selective and precise RP-HPLC method was developed for the simultaneous determination of ASP, WAR and CLP in rat plasma. Pharmacokinetic study was conducted in rats that received ASP, WAR and CLP as an application of the developed method. From the statistical evaluation of the pharmacokinetic parameters, it was observed that the co-administration of ASP, WAR and CLP significantly increased the ASP and CLP bioavailability in rats. A significant drug-drug interaction was confirmed in the current study. The elevated Cmax of ASP and CLP upon the co-administration of ASP, WAR and CLP may explain the reported bleeding.
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Affiliation(s)
- Norhan S AlSawy
- Pharmaceutical Chemistry, Kasr El-Aini Hospital, Kasr El-Aini St., Cairo 11562, Egypt
| | - Ehab F ElKady
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini St., Cairo 11562, Egypt
| | - Eman A Mostafa
- Pharmaceutical Chemistry Department, Faculty of Pharmacy, Cairo University, Kasr El-Aini St., Cairo 11562, Egypt
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23
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Rottura M, Drago SFA, Molonia A, Irrera N, Marino S, Scoglio R, Orlando L, Gigliotti De Fazio M, Squadrito F, Arcoraci V, Imbalzano E. Prescriptive behavior of non-vitamin K oral anticoagulants in patients affected by atrial fibrillation in general practice. Biomed Pharmacother 2023; 165:115020. [PMID: 37352701 DOI: 10.1016/j.biopha.2023.115020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 06/25/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide and in recent years the pharmacological approach has been strongly implemented; in Italy, the prescription of the non-vitamin K oral anticoagulants (NOAC) was also extended to General Practitioners (GPs) since 2020. The aim of the present study was to investigate the GPs prescribing behaviour of NOACs. An observational study was performed by using the computerized medical record of 14 GPs in Sicily: patients affected by AF were selected and stratified according to the prescribed antithrombotic drugs. Patients were considered inadequately managed if antithrombotic treatment was not adherent to recent ESC guidelines. A total of 467 (2.7 %) patients were affected by AF, 276 (59.1 %) were treated with an oral anticoagulant (OAC) regardless the high stroke risk (OR 1.64; 95 %CI 0.74-3.62; p = 0.226). The NOAC users were 236 patients as follow: Rivaroxaban 33.5 %, Apixaban 33,1 %, Dabigatran 17,4 %, Edoxaban 16.1 %. In 7 patients an inappropriate NOAC treatment was observed. Among Vitamin-K antagonist users, 25.0 % were considered inappropriate. Patients not treated with OAC were 191, of them 81.7 % were at high stroke risk and did not receive any OAC despite the indication to treat. In addition, the probability to be not properly managed significantly increased in older and in patients with atherosclerosis. Conversely, patients with at least one reported cardiology counselling significantly reduced the likelihood to be not properly managed (OR 0.38, 95 %CI 0.25-0.58; p 0.01). Our results suggest the need to optimize the management of real-life AF patients by improving prescribing adherence to ESC guidelines.
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Affiliation(s)
- M Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S F A Drago
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - A Molonia
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - N Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - S Marino
- Italian Society of General Practice (SIMG), Messina, Italy
| | - R Scoglio
- Italian Society of General Practice (SIMG), Messina, Italy
| | - L Orlando
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - M Gigliotti De Fazio
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - F Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
| | - V Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy.
| | - E Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Via C. Valeria, 98125 Messina, Italy
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Dye C, Dela Cruz M, Larsen T, Nair G, Marinescu K, Suboc T, Engelstein E, Marsidi J, Patel P, Sharma P, Volgman AS. A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 33:100309. [PMID: 38510554 PMCID: PMC10946048 DOI: 10.1016/j.ahjo.2023.100309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 03/22/2024]
Abstract
Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have increased mortality and increased risk of stroke. Due to the heterogeneous nature of both disease processes, it is difficult to ascertain whether the diagnosis and progression of AF is the cause of deterioration or if it is a symptom of worsening heart failure. This presents physicians with a clinical conundrum of whether optimizing their heart failure will decrease the overall AF burden or if restoration of sinus rhythm is necessary to optimize patients with HFpEF. In this paper, we will review the impact of AF in patients with HFpEF, the pathophysiology and heterogeneity of HFpEF and AF, and the management of these patients. As HFpEF and AF become more prevalent, managing these disease processes needs standardization to improve outcomes. Further research is needed to understand the complex interplay between AF and HFpEF to help determine the best management strategy.
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Affiliation(s)
- Cicely Dye
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Mark Dela Cruz
- Advocate Heart Institute, Advocate Christ Medical Center, Chicago, IL 60453, USA
| | - Timothy Larsen
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Gatha Nair
- Division of Cardiology, University of Washington, Seattle, WA 98105, USA
| | - Karolina Marinescu
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Tisha Suboc
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Erica Engelstein
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Jennifer Marsidi
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Priya Patel
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
| | - Parikshit Sharma
- Division of Cardiology, Rush University Medical Center, Chicago, IL 60612, USA
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25
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Frederiksen TC, Dahm CC, Preis SR, Lin H, Trinquart L, Benjamin EJ, Kornej J. The bidirectional association between atrial fibrillation and myocardial infarction. Nat Rev Cardiol 2023; 20:631-644. [PMID: 37069297 DOI: 10.1038/s41569-023-00857-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 04/19/2023]
Abstract
Atrial fibrillation (AF) is associated with an increased risk of myocardial infarction (MI) and vice versa. This bidirectional association relies on shared risk factors as well as on several direct and indirect mechanisms, including inflammation, atrial ischaemia, left ventricular remodelling, myocardial oxygen supply-demand mismatch and coronary artery embolism, through which one condition can predispose to the other. Patients with both AF and MI are at greater risk of stroke, heart failure and death than patients with only one of the conditions. In this Review, we describe the bidirectional association between AF and MI. We discuss the pathogenic basis of this bidirectional relationship, describe the risk of adverse outcomes when the two conditions coexist, and review current data and guidelines on the prevention and management of both conditions. We also identify important gaps in the literature and propose directions for future research on the bidirectional association between AF and MI. The Review also features a summary of methodological approaches for the study of bidirectional associations in population-based studies.
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Affiliation(s)
- Tanja Charlotte Frederiksen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Sarah R Preis
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Honghuang Lin
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ludovic Trinquart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Emelia J Benjamin
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
- Framingham Heart Study, Framingham, MA, USA
| | - Jelena Kornej
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
- Framingham Heart Study, Framingham, MA, USA.
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Jyotsna F, Mahfooz K, Sohail H, Kumar S, Adeeb M, Anand D, Kumar R, Rekha F, Varrassi G, Khatri M, Kumar S. Deciphering the Dilemma: Anticoagulation for Heart Failure With Preserved Ejection Fraction (HFpEF). Cureus 2023; 15:e43279. [PMID: 37692595 PMCID: PMC10492587 DOI: 10.7759/cureus.43279] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Impairment in ventricular relaxation and preserved left ventricular ejection fraction are the two main features of heart failure with preserved ejection fraction (HFpEF) a difficult clinical condition. Therapeutic choices for HFpEF patients are still scarce despite its rising frequency and negative effects on morbidity and mortality, necessitating creative methods to enhance results. The increased thromboembolic risk seen in these individuals raises questions about the relevance of anticoagulation in the therapy of HFpEF. Although anticoagulation has been shown to be beneficial in heart failure with decreased ejection fraction (HFrEF) and other high-risk cardiovascular disorders, its efficacy and safety in HFpEF present a challenging therapeutic challenge. Anticoagulants have been the subject of clinical trials in HFpEF, but the results have been conflicting, giving clinicians only a little information with which to make decisions. The decision-making process is made more difficult by worries about potential bleeding hazards, particularly in susceptible elderly HFpEF patients with other comorbidities. The link between heart failure and anticoagulant medication in HFpEF is thoroughly analyzed in this narrative review. In HFpEF, cardiac fibrosis and endothelial dysfunction create a prothrombotic milieu, as is highlighted in this passage. Also covered are recent developments in innovative biomarker research and cutting-edge imaging techniques, which may provide ways to spot HFpEF patients who might benefit from anticoagulation. This therapeutic conundrum may be resolved by using precision medicine strategies based on risk classification and individualized therapy choices. This review emphasizes the need for more research to establish the best use of anticoagulation in HFpEF within the framework of personalized therapy and shared decision-making. To successfully manage thromboembolic risk and reduce bleeding consequences in HFpEF patients, it is essential to perform well-designed clinical studies and advance our understanding of the pathophysiology of HFpEF. These developments may ultimately improve the prognosis and quality of life for people who suffer from this difficult and mysterious ailment.
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Affiliation(s)
- Fnu Jyotsna
- Medicine, Dr. Bhim Rao Ambedkar Medical College and Hospital, Sahibzada Ajit Singh Nagar, IND
| | - Kamran Mahfooz
- Internal Medicine, Lincoln Medical Center, New York City, USA
| | - Haris Sohail
- Medicine, Lincoln Medical Center, New York City, USA
| | - Sumeet Kumar
- Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Maham Adeeb
- Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Dev Anand
- Medicine, Bahria University Medical and Dental College, Karachi, USA
| | - Rahul Kumar
- Medicine, Liaquat University of Medical and Health Sciences, Karachi, PAK
| | - Fnu Rekha
- Medicine, Liaquat University of Medical and Health Sciences, Karachi, PAK
| | | | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
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27
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Nakano Y, Matoba T, Yamamoto M, Katsuki S, Koga Y, Mukai Y, Inoue S, Suematsu N, Higo T, Takemoto M, Miyata K, Usui M, Kadokami T, Tashiro H, Morishige K, Hironaga K, Tsutsui H. Temporal Trends in Antithrombotic Therapy for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention From 2014 to 2022 in Japan. Circ Rep 2023; 5:282-288. [PMID: 37435100 PMCID: PMC10329913 DOI: 10.1253/circrep.cr-23-0047] [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: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 07/13/2023] Open
Abstract
Background: Recent revisions of clinical guidelines by the Japanese Circulation Society, American Heart Association/American College of Cardiology, and European Society of Cardiology updated the management of antithrombotic strategies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, the extent to which these guidelines have been implemented in real-world daily clinical practice is unclear. Methods and Results: We conducted surveys on the status of antithrombotic therapy for patients with AF undergoing PCI every 2 years from 2014 to 2022 in 14 cardiovascular centers in Japan. The primary use of drug-eluting stents increased from 10% in 2014 to 95-100% in 2018, and the use of direct oral anticoagulants increased from 15% in 2014 to 100% in 2018, in accordance with the revised practice guidelines. In patients with acute coronary syndrome, the duration of triple therapy within 1 month was approximately 10% until 2018, and increased to >70% from 2020. In patients with chronic coronary syndrome, the duration of triple therapy within 1 month was approximately 10% until 2016, and >75% from 2018. Since 2020, the most common timing of discontinuation of dual antiplatelet therapy to transition to anticoagulation monotherapy during the chronic phase of PCI has been 1 year after PCI. Conclusions: Japanese interventional cardiologists have updated their treatment strategies for patients with AF undergoing PCI according to revisions of clinical practice guidelines.
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Affiliation(s)
- Yasuhiro Nakano
- Department of Cardiovascular Medicine, Kyushu University Hospital Fukuoka Japan
| | - Tetsuya Matoba
- Department of Cardiovascular Medicine, Kyushu University Hospital Fukuoka Japan
| | - Mitsutaka Yamamoto
- Department of Cardiovascular Medicine, Harasanshin Hospital Fukuoka Japan
| | - Shunsuke Katsuki
- Department of Cardiovascular Medicine, Kyushu University Hospital Fukuoka Japan
| | - Yasuaki Koga
- Department of Cardiovascular Medicine, Oita Prefectural Hospital Oita Japan
| | - Yasushi Mukai
- Department of Cardiovascular Medicine, Japanese Red Cross Fukuoka Hospital Fukuoka Japan
| | - Shujiro Inoue
- Department of Cardiovascular Medicine, Aso Iizuka Hospital Iizuka Japan
| | - Nobuhiro Suematsu
- Department of Cardiovascular Medicine, Saiseikai Fukuoka General Hospital Fukuoka Japan
| | - Taiki Higo
- Department of Cardiovascular Medicine, National Hospital Organization Kyushu Medical Centre Fukuoka Japan
| | - Masao Takemoto
- Cardiovascular Center, Steel Memorial Yawata Hospital Kitakyushu Japan
| | - Kenji Miyata
- Department of Cardiovascular Medicine, Japan Community Health Care Organization, Kyushu Hospital Kitakyushu Japan
| | - Makoto Usui
- Department of Cardiovascular Medicine, Hamanomachi Hospital Fukuoka Japan
| | - Toshiaki Kadokami
- Department of Cardiovascular Medicine, Saiseikai Futsukaichi Hospital Futsukaichi Japan
| | - Hideki Tashiro
- Department of Cardiology, St. Mary's Hospital Kurume Japan
| | - Kunio Morishige
- Department of Cardiovascular Medicine, Matsuyama Red Cross Hospital Matsuyama Japan
| | - Kiyoshi Hironaga
- Department of Cardiovascular Medicine, Fukuoka City Hospital Fukuoka Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital Fukuoka Japan
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences Fukuoka Japan
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Golemi L, Kumar S, Ahmad A, Ghani A, Srinivasamurthy R, Kumari S, Nasir A, Harjai K. Sex-Based Outcomes in Patients Undergoing WATCHMAN Device Implantation. Am J Cardiol 2023; 201:58-61. [PMID: 37352665 DOI: 10.1016/j.amjcard.2023.05.037] [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: 01/04/2023] [Revised: 05/19/2023] [Accepted: 05/21/2023] [Indexed: 06/25/2023]
Abstract
Sex-based disparities in outcomes are reported for various cardiovascular procedures. This study aimed to assess the difference in outcomes in patients who underwent WATCHMAN device implant based on sex. Patients who underwent WATCHMAN device placement, from 2016 to 2018, were identified from the National Inpatient Sample database. The primary outcome was inpatient mortality, and the secondary outcomes were the length of stay (LOS), hospitalization cost (HOC), and periprocedural complications. A logistic regression model was built to perform an adjusted analysis for the outcomes. A total of 12,327 patients underwent WATCHMAN device placement. Female patients were older and more likely to have hypertension (p <0.01) and less likely to have peripheral arterial disease (5.6 vs 7.2, p <0.01), chronic kidney disease (21% vs 26%, p <0.01), and diabetes (18% vs 20%, p = 0.03) and were also at a higher risk for certain periprocedural complications, including pericardiocentesis and anemia requiring blood transfusion (p <0.01 for all). In the unadjusted analysis, the female sex was associated with longer LOS (1.5 vs 1.3 days, p <0.01) and inpatient mortality (0.23 vs 0.10, p = 0.05). The HOC was numerically higher in women but statistically nonsignificant ($120,791 vs $118,554, p = 0.1). In the stepwise, backward, multivariate regression analysis, the female sex was an independent risk factor for higher LOS (1.5 vs 1.3 days, p <0.01, 95% confidence interval 1.3 to 1.4) after adjusting for potential confounders. The inpatient mortality and HOC were similar between 2 groups after adjusting for potential cofounders in the multivariate regression analysis. Our study suggests that the female sex is an independent risk factor for longer LOS among patients hospitalized for WATCHMAN device placement.
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Affiliation(s)
- Lolita Golemi
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Sundeep Kumar
- Division of Cardiology, Case Western Reserve University, Cleveland, Ohio
| | - Ali Ahmad
- Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ali Ghani
- Division of Cardiology, University of Connecticut, Farmington, Connecticut
| | | | - Sarika Kumari
- Division of Cardiology, Jinnah Post Graduate Medical Center, Karachi, Pakistan
| | - Ammar Nasir
- Division of Cardiology, St. Louis University Hospital, St. Louis, Missouri
| | - Kishore Harjai
- Division of Cardiology, St. Louis University Hospital, St. Louis, Missouri.
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Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, Hoang Trinh K, O'Hara G, Rodés-Cabau J. Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives. Circ Cardiovasc Interv 2023; 16:e012812. [PMID: 37192309 DOI: 10.1161/circinterventions.122.012812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Pedro Cepas-Guillén
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Xavier Freixa
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Eduardo Flores-Umanzor
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
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Berteotti M, Gori AM, Giusti B, Fortini A, Grossi G, Ciardetti N, Migliorini A, Lotti E, Valenti R, Di Mario C, Marchionni N, Marcucci R. Clinical impact of high platelet reactivity in patients with atrial fibrillation and concomitant percutaneous coronary intervention on dual or triple antithrombotic therapy. J Thromb Thrombolysis 2023; 55:667-679. [PMID: 36905562 PMCID: PMC10147742 DOI: 10.1007/s11239-023-02784-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/05/2023] [Indexed: 03/12/2023]
Abstract
High platelet reactivity (HPR) on clopidogrel is an established thrombotic risk factor after percutaneous coronary intervention (PCI). The introduction of more potent antiplatelet drugs has partially surpassed this issue. However, in the setting of concomitant atrial fibrillation (AF) and PCI clopidogrel is still the most adopted P2Y12 inhibitor. In the present study all consecutive patients with history of AF discharged from our cardiology ward with dual (DAT) or triple (TAT) antithrombotic therapy after a PCI from April 2018 to March 2021 were enrolled in an observational registry. For all subjects, blood serum samples were collected and tested for platelet reactivity by arachidonic acid and ADP (VerifyNow system) and genotyping of the CYP2C19*2 loss-of-function polymorphism. We recorded at 3 and 12-months follow-up: (1) major adverse cardiac and cerebrovascular events (MACCE), (2) major hemorrhagic or clinically relevant non-major bleeding and (3) all-cause mortality. A total of 147 patients were included (91, 62% on TAT). In 93.4% of patients, clopidogrel was chosen as P2Y12 inhibitor. P2Y12 dependent HPR resulted an independent predictor of MACCE both at 3 and 12 months (HR 2.93, 95% C.I. 1.03 to 7.56, p = 0.027 and HR 1.67, 95% C.I. 1.20 to 2.34, p = 0.003, respectively). At 3-months follow-up the presence of CYP2C19*2 polymorphism was independently associated with MACCE (HR 5.21, 95% C.I. 1.03 to 26.28, p = 0.045). In conclusion, in a real-world unselected population on TAT or DAT, the entity of platelet inhibition on P2Y12 inhibitor is a potent predictor of thrombotic risk, suggesting the clinical utility of this laboratory evaluation for a tailored antithrombotic therapy in this high-risk clinical scenario. The present analysis was performed in patients with AF undergoing PCI on dual or triple antithrombotic therapy. At 1 year follow-up MACCE incidence was consistent, and it was not different in different antithrombotic pattern groups. P2Y12 dependent HPR was a potent independent predictor of MACCE both at 3- and 12-months follow-up. In the first 3 months after stenting the carriage of CYP2C19*2 allele was similarly associated with MACCE. Abbreviation: DAT, dual antithrombotic therapy; HPR, high platelet reactivity; MACCE, major adverse cardiac and cerebrovascular events; PRU, P2Y12 reactive unit; TAT, triple antithrombotic therapy. Created with BioRender.com.
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Affiliation(s)
- M Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy.
| | - A M Gori
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - B Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - A Fortini
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - G Grossi
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - N Ciardetti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - A Migliorini
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - E Lotti
- Thrombosis Center, Careggi University Hospital, Florence, Italy
| | - R Valenti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - C Di Mario
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - N Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
| | - R Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134, Florence, Italy
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31
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Mir JF, Rodríguez-Caba C, Estrada-Campmany M, Fernández de Gamarra-Martínez E, Mangues MA, Bagaría G, Riera P. An Integrated Multidisciplinary Circuit Led by Hospital and Community Pharmacists to Implement Clopidogrel Pharmacogenetics in Clinical Practice. PHARMACY 2023; 11:pharmacy11020076. [PMID: 37104082 PMCID: PMC10146470 DOI: 10.3390/pharmacy11020076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/28/2023] Open
Abstract
The use of pharmacogenetics to optimize pharmacotherapy is growing rapidly. This study evaluates the feasibility and operability of a collaborative circuit involving hospital and community pharmacists to implement clopidogrel pharmacogenetics in Barcelona, Catalonia, Spain. We aimed to enroll patients with a clopidogrel prescription from cardiologists at the collaborating hospital. Community pharmacists collected patients' pharmacotherapeutic profiles and saliva samples, which were then sent to the hospital for CYP2C19 genotyping. Hospital pharmacists collated the obtained data with patients' clinical records. Data were analyzed jointly with a cardiologist to assess the suitability of clopidogrel. The provincial pharmacists' association coordinated the project and provided IT and logistic support. The study began in January 2020. However, it was suspended in March 2020 due to the COVID-19 pandemic. At that moment, 120 patients had been assessed, 16 of whom met the inclusion criteria and were enrolled in the study. The processing of samples obtained before the pandemic had an average delay of 13.8 ± 5.4 days. A total of 37.5% patients were intermediate metabolizers and 18.8% were ultrarapid metabolizers. No poor metabolizers were detected. Pharmacists rated their experience with a 7.3 ± 2.7 likelihood of recommending that fellow pharmacists participate. The net promoter score among participating pharmacists was +10%. Our results show that the circuit is feasible and operable for further initiatives.
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Affiliation(s)
- Joan Francesc Mir
- Professional Projects and Research Area, Col·legi de Farmacèutics de Barcelona/Barcelona Pharmacists' Association, 08009 Barcelona, Spain
- Blanquerna School of Health Sciences, Universitat Ramon Llull, 08022 Barcelona, Spain
| | - Cristina Rodríguez-Caba
- Professional Projects and Research Area, Col·legi de Farmacèutics de Barcelona/Barcelona Pharmacists' Association, 08009 Barcelona, Spain
| | - Maria Estrada-Campmany
- Professional Projects and Research Area, Col·legi de Farmacèutics de Barcelona/Barcelona Pharmacists' Association, 08009 Barcelona, Spain
| | | | - Maria Antònia Mangues
- Pharmacy Department, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Guillermo Bagaría
- Professional Projects and Research Area, Col·legi de Farmacèutics de Barcelona/Barcelona Pharmacists' Association, 08009 Barcelona, Spain
| | - Pau Riera
- Pharmacy Department, Institut d'Investigació Biomèdica Sant Pau (IIB-Sant Pau), Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain
- CIBER de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 28029 Madrid, Spain
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32
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Scridon A, Balan AI. Challenges of Anticoagulant Therapy in Atrial Fibrillation-Focus on Gastrointestinal Bleeding. Int J Mol Sci 2023; 24:ijms24086879. [PMID: 37108042 PMCID: PMC10138869 DOI: 10.3390/ijms24086879] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
The rising prevalence and the complexity of atrial fibrillation (AF) pose major clinical challenges. Stroke prevention is accompanied by non-negligible risks, making anticoagulant treatment an ongoing challenge for the clinician. Current guidelines recommend direct oral anticoagulants (DOACs) over warfarin for stroke prevention in most AF patients, mainly due to the ease of their use. However, assessing the bleeding risk in patients receiving oral anticoagulants remains-particularly in the case of DOACs-highly challenging. Using dose-adjusted warfarin increases threefold the risk of gastrointestinal bleeding (GIB). Although the overall bleeding risk appears to be lower, the use of DOACs has been associated with an increased risk of GIB compared to warfarin. Accurate bleeding (including GIB-specific) risk scores specific for DOACs remain to be developed. Until then, the assessment of bleeding risk factors remains the only available tool, although the extent to which each of these factors contributes to the risk of bleeding is unknown. In this paper, we aim to provide a comprehensive review of the bleeding risk associated with oral anticoagulant therapy in AF patients, with a highlight on the latest insights into GIB associated with oral anticoagulation; we emphasize questions that remain to be answered; and we identify hotspots for future research.
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Affiliation(s)
- Alina Scridon
- Physiology Department, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Târgu Mureș, 540142 Târgu Mureș, Romania
| | - Alkora Ioana Balan
- Physiology Department, University of Medicine, Pharmacy, Science and Technology "George Emil Palade" of Târgu Mureș, 540142 Târgu Mureș, Romania
- Emergency Institute for Cardiovascular Diseases and Transplantation of Târgu Mureș, 540136 Târgu Mureș, Romania
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33
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Choi HJ, Lee Y, Park S, Je NK. Utilization of triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Eur J Clin Pharmacol 2023; 79:541-551. [PMID: 36823470 DOI: 10.1007/s00228-023-03468-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Triple antithrombotic therapy (TAT), a combination of an oral anticoagulant and dual antiplatelet therapy (DAPT), is a key treatment for prevention of ischemic events in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). However, TAT is not extensively used because of the risk of bleeding. This study aimed to determine the utilization and influencing factors of TAT using real-world data in the non-vitamin K antagonist oral anticoagulants (NOACs) era. METHODS We analyzed National Inpatient Sample data compiled by the Health Insurance Review & Assessment Service (HIRA-NIS) from 2011 to 2020. Patients with AF who underwent PCI with stent implantation and with an increased stroke risk were selected as candidates for TAT therapy. Demographic and clinical factors associated with TAT use were investigated using the chi-squared test and the Student t-test, and influencing factors were identified using multiple logistic regression. RESULTS The TAT utilization rate steadily increased from 30.3% in 2011 to 65.4% in 2020 (Cochran-Armitage trend test: p < 0.001) with an average of 45.9%. Positive influencing factors for TAT use were identified as congestive heart failure, history of previous stroke/transient ischemic attack/thromboembolism, valvular heart disease, and year. Negative influencing factors included insurance type (medical aid or Patriots & Veterans Insurance), type of medical institution (general hospitals or primary medical institutions), and comorbidities such as renal disease, liver disease, and history of the previous hemorrhage. CONCLUSIONS The utilization of TAT following PCI among high-stroke risk AF patients steadily increased from 2011 to 2020, reaching 65.4% by the end of the study period. However, in 2020, a significant proportion of 29.4% of patients still received DAPT, indicating that many AF patients undergoing PCI did not receive adequate antithrombotic therapy.
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Affiliation(s)
- Hye-Jeong Choi
- College of Pharmacy, Pusan National University, Busandaehakro 63 Bungil 2, Geumjeong-Gu, Busan, 46241, Republic of Korea
| | - Yonghyuk Lee
- College of Pharmacy, Pusan National University, Busandaehakro 63 Bungil 2, Geumjeong-Gu, Busan, 46241, Republic of Korea
| | - Susin Park
- College of Pharmacy, Woosuk University, Samnye-ro 443 Samnye-eup, Wanju-gun, Jeollabuk-do, 55338, Republic of Korea.
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busandaehakro 63 Bungil 2, Geumjeong-Gu, Busan, 46241, Republic of Korea.
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Stroke Prevention with Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Prior Intracranial Haemorrhage. CJC Open 2023. [DOI: 10.1016/j.cjco.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
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35
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Zeymer U, Toelg R, Wienbergen H, Hobbach HP, Cuneo A, Bekeredjian R, Ritter O, Hailer B, Hertting K, Hennersdorf M, Scholtz W, Lanzer P, Mudra H, Schwefer M, Schwimmbeck PL, Liebetrau C, Thiele H, Claas C, Riemer T, Zahn R. Current status of antithrombotic therapy and in-hospital outcomes in patients with atrial fibrillation undergoing percutaneous coronary intervention in Germany. Herz 2023; 48:134-140. [PMID: 35243515 DOI: 10.1007/s00059-022-05099-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 12/06/2021] [Accepted: 01/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Little is known about current patterns of antithrombotic therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) in clinical practice in Germany. METHODS The RIVA-PCI is a prospective, non-interventional, multicenter study with follow-up until hospital discharge including consecutive patients with AF undergoing PCI. RESULTS Between January 2018 and March 2020, 1636 patients (elective in 52.6%, non-ST elevation acute coronary syndrome [NSTE-ACS] in 39.3%, ST-elevation myocardial infarction in 8.2%) from 51 German hospitals were enrolled in the study. After PCI a dual antithrombotic therapy (DAT) consisting of OAC and a P2Y12 inhibitor was given to 66.0%, triple antithrombotic therapy (TAT) to 26.0%, dual antiplatelet therapy to 5.5%, and a mono-therapy to 2.5% of the patients. Non-vitamin K antagonist oral anticoagulants (NOACs) were given to 82.4% and vitamin K antagonists to 11.5% of the patients. In-hospital events included death in 12 cases (0.7%), myocardial infarction, stent thrombosis, and ischemic stroke in four (0.2%) patients each, while 2.8% of patients had bleeding complications. The recommended durations for DAT or TAT at discharge were 1 month (1.5%), 3 months (2.1%), 6 months (43.1%), and 12 months (45.6%), with a 6-month course of DAT (47.7%) most often recommended after elective PCI and a 12-month course of DAT (40.1%) after ACS. CONCLUSION The preferred therapy after PCI in patients with AF is DAT with a NOAC and clopidogrel. In-hospital ischemic and bleeding events were rare. The recommended durations for combination therapy vary considerably.
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Affiliation(s)
- Uwe Zeymer
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany. .,Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
| | - Ralph Toelg
- Segeberger Kliniken GmbH, Bad Segeberg, Germany
| | | | | | | | | | | | - Birgit Hailer
- Katholische Kliniken Essen-Nord-West gGmbH, Essen, Germany
| | | | | | | | - Peter Lanzer
- Gesundheitszentrum Bitterfeld Wolfen, Bitterfeld, Germany
| | - Harald Mudra
- Städtisches Krankenhaus Neuperlach-München, München, Germany
| | | | | | | | - Holger Thiele
- Herzzentrum Leipzig und Universität Leipzig, Leipzig, Germany
| | - Christoph Claas
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Thomas Riemer
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany
| | - Ralf Zahn
- Medizinische Klinik B, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany
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Skibniewski M, Venetsanos D, Ahlsson A, Batra G, Friberg Ö, Hofmann R, Janzon M, Karlsson LO, Lawesson SS, Nielsen SJ, Jeppsson A, Alfredsson J. Long-term antithrombotic therapy after coronary artery bypass grafting in patients with preoperative atrial fibrillation. A nationwide observational study from the SWEDEHEART registry. Am Heart J 2023; 257:69-77. [PMID: 36481448 DOI: 10.1016/j.ahj.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
AIMS To provide data guiding long-term antithrombotic therapy after coronary artery by-pass grafting (CABG) in patients with preoperative atrial fibrillation (AF). METHODS AND RESULTS From the SWEDEHEART registry, we included all patients, between January 2006 and September 2016, with preoperative AF and CHA2DS2-VASC score ≥2, undergoing CABG. Based on dispensed prescriptions 12 to 18 months after CABG, patients were divided in 3 groups: use of platelet inhibitors (PI) only, oral anticoagulant (OAC) only or a combination of OAC + PI. Outcomes were: Major adverse cardiac and cerebrovascular events (MACCE, [all-cause death, myocardial infarction, or stroke]), net adverse clinical events (NACE, [MACCE or bleeding]) and the individual components of NACE. Inverse probability of treatment weighting was used to adjust for the non-randomized study design. Among 2,564 patients, 1,040 (41%) were treated with PI alone, 1,064 (41%) with OAC alone, and 460 (18%) with PI + OAC. Treatment with PI alone was associated with higher risk for MACCE (adjusted HR 1.43, 95% CI 1.09-1.88), driven by higher risk for stroke and MI, compared with OAC alone. Treatment with PI + OAC, was associated with higher risk for NACE (adjusted HR 1.40, 95% CI 1.06-1.85), driven by higher risk for bleeds, compared with OAC alone. CONCLUSION In this real-world observational study, a high proportion of patients with AF, undergoing CABG, did not receive a long-term OAC therapy. Treatment with OAC alone was associated with a net clinical benefit, compared with PI alone or PI + OAC.
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Affiliation(s)
- Mikolaj Skibniewski
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Dimitrios Venetsanos
- Division of Cardiology, Department of Medicine, Karolinska Institutet Solna and Karolinska University hospital, Stockholm, Sweden
| | - Anders Ahlsson
- Dept of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Örjan Friberg
- Department of Health, Medicine and Caring Sciences and Department of Cardiothoracic and Vascular Surgery, Linköping University, Linköping, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Magnus Janzon
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Lars O Karlsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Sofia Sederholm Lawesson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden
| | - Susanne J Nielsen
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences and Department of Cardiology, Linköping University, Linköping, Sweden.
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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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Reduced- or Half-Dose Rivaroxaban Following Left Atrial Appendage Closure: A Feasible Antithrombotic Therapy in Patients at High Risk of Bleeding? J Clin Med 2023; 12:jcm12030847. [PMID: 36769499 PMCID: PMC9917793 DOI: 10.3390/jcm12030847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
The optimal antithrombotic strategy after percutaneous left atrial appendage closure (LAAC) has not yet been established. The advisability of administering low-dose direct oral anticoagulation after LAAC to patients at high risk of bleeding is uncertain. Thus, in the present study, we evaluated the safety and effectiveness of reduced-(15 mg) or half-dose rivaroxaban (10 mg) versus warfarin regarding real-world risks of thromboembolism, bleeding, and device-related thrombosis (DRT) after LAAC. Patients with non-valvular atrial fibrillation and HASBLED ≥ 3 who had undergone successful LAAC device implantation from October 2014 to April 2020 were screened and those who had received 10 mg or 15 mg rivaroxaban or warfarin therapy were enrolled. The patients were followed up 45 days and 6 months after LAAC to evaluate outcomes, including death, thromboembolism, major bleeding, and DRT. Of 457 patients with HASBLED ≥ 3 who had undergone LAAC, 115 had received warfarin and 342 rivaroxaban (15 mg: N = 164; 10 mg: N = 178). There were no significant differences in the incidence of thromboembolism or DRT between the warfarin and both doses of rivaroxaban groups (all p > 0.05). The incidence of major bleeding was significantly higher in the warfarin group than in either the reduced- or half-dose rivaroxaban groups (warfarin vs. rivaroxaban 15 mg: 2.6% vs. 0%, p = 0.030; warfarin vs. rivaroxaban 10 mg: 2.6% vs. 0%, p = 0.038). Either reduced- or half-dose rivaroxaban may be an effective and safe alternative to warfarin therapy in patients with LAAC and who are at high risk of bleeding, the risk of thromboembolism being similar and of major bleeding lower for both doses of rivaroxaban.
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Rusin G, Kubica J, Malinowski KP, Słowik A, Undas A. Factors affecting self-reported bleeding acceptance in acute ischemic stroke survivors on various types of antithrombotic therapy. J Stroke Cerebrovasc Dis 2023; 32:106894. [PMID: 36402092 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106894] [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: 08/04/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Prior ischemic cerebrovascular event and younger age have been shown to increase bleeding acceptance among anticoagulated outpatients with atrial fibrillation (AF). We sought to determine factors affecting bleeding acceptance in acute ischemic stroke (AIS) survivors on various types of antithrombotic therapy. MATERIALS AND METHODS We enrolled 173 consecutive patients hospitalized for AIS (aged 68.2±11.7 years, 54.9% male), including 54 (31.2%) with AF, who had favorable functional outcome. On discharge, the Bleeding ratio, defined as the declared maximum number of major bleedings that a patient is willing to accept to prevent one major stroke, was evaluated. We assessed the predicted bleeding risk in non-cardioembolic and cardioembolic stroke survivors using S2TOP-BLEED and HAS-BLED scores, respectively. RESULTS Patients with the low Bleeding ratio, defined as 5 (median) or less accepted bleeds (n=92; 53.2%), were older and more likely to receive thrombolysis and/or thrombectomy, with no impact of previous stroke. Prior major bleed (odds ratio [OR] 4.67; 95% confidence interval [CI] 0.92-23.72), AF with use of oral anticoagulants (OR 2.35, 95% CI 1.12-4.93), reperfusion treatment (OR 1.95, 95% CI 1.02-3.76), and hospitalization ≤10 days (OR 4.56; 95% CI 1.50-13.87) were associated with the low Bleeding Ratio. Prior use of anticoagulants or aspirin as well as HAS-BLED and S2TOP-BLEED scores did not affect the bleeding acceptance. CONCLUSIONS Lower bleeding acceptance declared on discharge by AIS survivors is determined by prior bleeding, anticoagulation in AF, reperfusion treatment, and duration of hospitalization, which might affect medication adherence. The results might help optimize post-discharge management and educational efforts in patients on antithrombotic therapy.
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Affiliation(s)
- Gabriela Rusin
- Department of Neurology, University Hospital, Krakow, Poland
| | - Jadwiga Kubica
- Department of Neurology, University Hospital, Krakow, Poland; Institute of Physiotherapy, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Piotr Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland; Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Słowik
- Department of Neurology, University Hospital, Krakow, Poland; Department of Neurology, Jagiellonian University Medical College, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland; Center for Research and Innovative Technology John Paul II Hospital, Kraków, Poland.
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Sagris M, Theofilis P, Papanikolaou A, Antonopoulos AS, Tsioufis C, Tousoulis D. Direct Oral Anticoagulants use in Patients with Stable Coronary Artery Disease, Acute Coronary Syndrome or Undergoing Percutaneous Coronary Intervention. Curr Pharm Des 2023; 29:2787-2794. [PMID: 38038010 DOI: 10.2174/0113816128259508231118141831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
The investigation for the optimal anticoagulation strategy for patients with stable coronary artery disease, acute coronary syndromes, and undergoing percutaneous coronary intervention constitutes a great challenge for physicians and is a field of extensive research. Although aspirin is commonly recommended as a protective measure for all patients with coronary artery disease and dual antiplatelet therapy for those undergoing procedures, such as percutaneous coronary intervention or coronary artery bypass graft surgery, the risk of recurrent cardiovascular events remains significant. In this context, the shortcomings associated with the use of vitamin K antagonists have led to the assessment of direct oral anticoagulants as promising alternatives. This review will explore and provide a comprehensive analysis of the existing data regarding the use of direct oral anticoagulants in patients with stable coronary artery disease or acute coronary syndrome, as well as their effectiveness in those undergoing percutaneous coronary intervention or coronary artery bypass graft surgery.
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Affiliation(s)
- Marios Sagris
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Angelos Papanikolaou
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Constantinos Tsioufis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
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41
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Hammett C, Badve SV, Kerr PG, Tran HA, Dundon BK, Lo S, Wong A, Joseph JE, Deague J, Perkovic V. Oral Anticoagulant Use in Patients With Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence With Recommendations for Australian Clinical Practice. Heart Lung Circ 2022; 31:1604-1611. [PMID: 36336614 DOI: 10.1016/j.hlc.2022.09.003] [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: 05/17/2022] [Revised: 08/10/2022] [Accepted: 09/01/2022] [Indexed: 11/05/2022]
Abstract
Chronic kidney disease is common in patients with atrial fibrillation (AF) and is associated with heightened risks of stroke/systemic embolisation and bleeding. In this review we outline the evidence for AF stroke prevention in kidney disease, identify current knowledge gaps, and give recommendations for anticoagulation at various stages of chronic kidney disease. Overall, anticoagulation is underused. Warfarin use becomes increasingly difficult with advancing kidney disease, with difficulty maintaining international normalised ratio (INR) in therapeutic range, increased risk of intracranial and fatal bleeding compared to non-vitamin K oral anticoagulants (NOACs), and high rates of discontinuation. Similarly, the direct thrombin inhibitor dabigatran is not recommended as it is predominantly renally excreted with consequent increased plasma levels and bleeding risk with advanced kidney disease. The Factor Xa inhibitors apixaban and rivaroxaban have less renal excretion (25-35%), modest increases in plasma levels with advancing kidney disease, and are the preferred first line choice for anticoagulation in moderate kidney disease based on strong evidence from randomised clinical trials (RCTs). In severe kidney disease there is a paucity of RCT data, but extrapolation of the pharmacokinetic and RCT data for moderate kidney disease, and observational studies, support the considered use of dose-adjusted Factor Xa inhibitors unless the bleeding risk is prohibitive. In Australia, apixaban is approved for creatinine clearance down to 25 mL/min, and rivaroxaban down to 15 mL/min. For end-stage kidney disease warfarin is the only agent approved, but we recommend against anticoagulation (except in selected cases) due to high bleeding risk, multiple co-morbidities, and questionable benefit.
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Affiliation(s)
| | - Sunil V Badve
- Department of Nephrology, St George Hospital, and Renal and Metabolic Division, The George Institute for Global Health, Sydney, NSW, Australia
| | - Peter G Kerr
- Department of Nephrology, Monash Medical Centre and Monash University, Melbourne, Vic, Australia
| | - Huyen A Tran
- The Alfred Hospital & Monash University, Melbourne, Vic, Australia
| | - Benjamin K Dundon
- MonashHeart, Monash Health and Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| | - Sidney Lo
- Liverpool Hospital, SouthWest Sydney Local Health District and University of New South Wales, Sydney, NSW, Australia
| | - Andrew Wong
- Royal Brisbane and Women's Hospital and The University of Queensland, Brisbane, Qld, Australia
| | | | | | - Vlado Perkovic
- Royal North Shore Hospital and The George Institute for Global Health, Sydney, NSW, Australia
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Lyth J, Svennberg E, Bernfort L, Aronsson M, Frykman V, Al-Khalili F, Friberg L, Rosenqvist M, Engdahl J, Levin LÅ. Cost-effectiveness of population screening for atrial fibrillation: the STROKESTOP study. Eur Heart J 2022; 44:196-204. [PMID: 36349968 PMCID: PMC9839418 DOI: 10.1093/eurheartj/ehac547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 08/24/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Previous studies on the cost-effectiveness of screening for atrial fibrillation (AF) are based on assumptions of long-term clinical effects. The STROKESTOP study, which randomised 27 975 persons aged 75/76 years into a screening invitation group and a control group, has a median follow-up time of 6.9 years. The aim of this study was to estimate the cost-effectiveness of population-based screening for AF using clinical outcomes. METHODS AND RESULTS The analysis is based on a Markov cohort model. The prevalence of AF, the use of oral anticoagulation, clinical event data, and all-cause mortality were taken from the STROKESTOP study. The cost for clinical events, age-specific utilities, utility decrement due to stroke, and stroke death was taken from the literature. Uncertainty in the model was considered in a probabilistic sensitivity analysis. Per 1000 individuals invited to the screening, there were 77 gained life years and 65 gained quality-adjusted life years. The incremental cost was €1.77 million lower in the screening invitation group. Gained quality-adjusted life years to a lower cost means that the screening strategy was dominant. The result from 10 000 Monte Carlo simulations showed that the AF screening strategy was cost-effective in 99.2% and cost-saving in 92.7% of the simulations. In the base-case scenario, screening of 1000 individuals resulted in 10.6 [95% confidence interval (CI): -22.5 to 1.4] fewer strokes (8.4 ischaemic and 2.2 haemorrhagic strokes), 1.0 (95% CI: -1.9 to 4.1) more cases of systemic embolism, and 2.9 (95% CI: -18.2 to 13.1) fewer bleedings associated with hospitalization. CONCLUSION Based on the STROKESTOP study, this analysis shows that a broad AF screening strategy in an elderly population is cost-effective. Efforts should be made to increase screening participation.
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Affiliation(s)
- Johan Lyth
- Corresponding authors. Tel: +46739584822, (E.S.); Tel: +46 13 28 29 84, (J.L.)
| | - Emma Svennberg
- Corresponding authors. Tel: +46739584822, (E.S.); Tel: +46 13 28 29 84, (J.L.)
| | - Lars Bernfort
- Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Mattias Aronsson
- Department of Health, Medicine and Caring Sciences, Linköping University, SE-581 83 Linköping, Sweden,AstraZeneca Nordics, SE-18257 Södertälje, Sweden
| | - Viveka Frykman
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Faris Al-Khalili
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Leif Friberg
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
| | - Mårten Rosenqvist
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Stockholm, Sweden
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Basmaji S, Samuel M, Shohoudi A, Hamilton RM, Aboulhosn J, Broberg CS, Chaix MA, Cohen S, Cook S, Dore A, Fernandes SM, Fortier A, Fournier A, Guertin MC, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Time in Therapeutic Range With Vitamin K Antagonists in Congenital Heart Disease: A Multicentre Study. Can J Cardiol 2022; 38:1751-1758. [PMID: 35964887 DOI: 10.1016/j.cjca.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs) are frequently prescribed to patients with congenital heart disease (CHD) for atrial arrhythmias or Fontan palliation, but there is a paucity of data regarding time spent in the therapeutic range (TTR). We sought to determine the TTR in patients with CHD and atrial arrhythmias or Fontan palliation prescribed VKAs and explore associations with thromboembolic and bleeding events. METHODS A multicentre North American cohort study was conducted on patients with CHD who received VKAs for sustained atrial arrhythmia or Fontan palliation. TTR was calculated using the Rosendaal linear interpolation method. Generalized estimating equations were used to explore factors associated with time outside the therapeutic range. RESULTS A total of 567 patients, aged 33 ± 17 years, 56% female, received VKAs for 11.5 ± 8.4 years for atrial arrhythmias (63.0%) or Fontan palliation (58.0%). CHD was simple, moderate, and complex in 10.8%, 20.3%, and 69.0%, respectively. Site investigators perceived good control over international normalized ratio (INR) levels in most patients (75.3%), with no or minor compliance or adherence issues (85.6%). The mean TTR was 41.9% (95% confidence interval [CI], 39.0%-44.8%). Forty-seven (8.3%) and 34 (6.0%) patients had thromboembolic and bleeding events, respectively. Thromboembolic events were associated with a higher proportion of time below the therapeutic range (31.3% vs 19.1%, P = 0.003) and bleeding complications with a higher proportion of time above the therapeutic range (32.5% vs 19.5%, P = 0.006). CONCLUSIONS Patients with CHD who receive VKAs spend < 42% of their time with INR levels in the therapeutic range, with repercussions regarding thromboembolic and bleeding complications.
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Affiliation(s)
- Samir Basmaji
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Azadeh Shohoudi
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen Cook
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Annik Fortier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Proietti
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jennifer Ting
- Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Ye C, Han X, Chen Y, Liu F, Ma H, Yang Y, Liu Y, Hu Q, Yao Q, Xie W, Xu D. Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial. BMJ Open 2022; 12:e063931. [PMID: 36307161 PMCID: PMC9621168 DOI: 10.1136/bmjopen-2022-063931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA2DS2-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population. METHODS AND ANALYSIS This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up. ETHICS AND DISSEMINATION The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences. TRIAL REGISTRATION NUMBER ChiCTR2200058109.
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Affiliation(s)
- Cong Ye
- Department of Cardiac Surgery, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Xuesong Han
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yiming Chen
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Fei Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Hao Ma
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yu Yang
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Yang Liu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qingfeng Hu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Qing Yao
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Wenting Xie
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
| | - Dong Xu
- Department of Cardiac Surgery, Beijing Tiantan Hospital, Beijing, China
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Platelets and Their Role in Hemostasis and Thrombosis-From Physiology to Pathophysiology and Therapeutic Implications. Int J Mol Sci 2022; 23:ijms232112772. [PMID: 36361561 PMCID: PMC9653660 DOI: 10.3390/ijms232112772] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 02/21/2023] Open
Abstract
Hemostasis is a physiological process critical for survival. Meanwhile, thrombosis is amongst the leading causes of death worldwide, making antithrombotic therapy one of the most crucial aspects of modern medicine. Although antithrombotic therapy has progressed tremendously over the years, it remains far from ideal, and this is mainly due to the incomplete understanding of the exceptionally complex structural and functional properties of platelets. However, advances in biochemistry, molecular biology, and the advent of 'omics' continue to provide crucial information for our understanding of the complex structure and function of platelets, their interactions with the coagulation system, and their role in hemostasis and thrombosis. In this review, we provide a comprehensive view of the complex role that platelets play in hemostasis and thrombosis, and we discuss the major clinical implications of these fundamental blood components, with a focus on hemostatic platelet-related disorders and existing and emerging antithrombotic therapies. We also emphasize a number of questions that remain to be answered, and we identify hotspots for future research.
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Connolly SJ, Karthikeyan G, Ntsekhe M, Haileamlak A, El Sayed A, El Ghamrawy A, Damasceno A, Avezum A, Dans AML, Gitura B, Hu D, Kamanzi ER, Maklady F, Fana G, Gonzalez-Hermosillo JA, Musuku J, Kazmi K, Zühlke L, Gondwe L, Ma C, Paniagua M, Ogah OS, Molefe-Baikai OJ, Lwabi P, Chillo P, Sharma SK, Cabral TTJ, Tarhuni WM, Benz A, van Eikels M, Krol A, Pattath D, Balasubramanian K, Rangarajan S, Ramasundarahettige C, Mayosi B, Yusuf S. Rivaroxaban in Rheumatic Heart Disease-Associated Atrial Fibrillation. N Engl J Med 2022; 387:978-988. [PMID: 36036525 DOI: 10.1056/nejmoa2209051] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Testing of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease-associated atrial fibrillation has been limited. METHODS We enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA2DS2VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating a higher risk of stroke), a mitral-valve area of no more than 2 cm2, left atrial spontaneous echo contrast, or left atrial thrombus. Patients were randomly assigned to receive standard doses of rivaroxaban or dose-adjusted vitamin K antagonist. The primary efficacy outcome was a composite of stroke, systemic embolism, myocardial infarction, or death from vascular (cardiac or noncardiac) or unknown causes. We hypothesized that rivaroxaban therapy would be noninferior to vitamin K antagonist therapy. The primary safety outcome was major bleeding according to the International Society of Thrombosis and Hemostasis. RESULTS Of 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, -76 days; 95% confidence interval [CI], -121 to -31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, -72 days; 95% CI, -117 to -28). No significant between-group difference in the rate of major bleeding was noted. CONCLUSIONS Among patients with rheumatic heart disease-associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.).
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Affiliation(s)
- Stuart J Connolly
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Ganesan Karthikeyan
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Mpiko Ntsekhe
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Abraham Haileamlak
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Ahmed El Sayed
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alaa El Ghamrawy
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Albertino Damasceno
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alvaro Avezum
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Antonio M L Dans
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Bernard Gitura
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Dayi Hu
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Emmanuel R Kamanzi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Fathi Maklady
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Golden Fana
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - J Antonio Gonzalez-Hermosillo
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - John Musuku
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Khawar Kazmi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Liesl Zühlke
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Lillian Gondwe
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Changsheng Ma
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Maria Paniagua
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Okechukwu S Ogah
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Onkabetse J Molefe-Baikai
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Peter Lwabi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Pilly Chillo
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Sanjib K Sharma
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Tantchou T J Cabral
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Wadea M Tarhuni
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Alexander Benz
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Martin van Eikels
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Amy Krol
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Divya Pattath
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Kumar Balasubramanian
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Sumathy Rangarajan
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Chinthanie Ramasundarahettige
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Bongani Mayosi
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
| | - Salim Yusuf
- From the Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.J.C., A.B., A.K., D.P., K.B., S.R., C.R., S.Y.); the All India Institute of Medical Sciences, New Delhi (G.K.); the Division of Cardiology, Faculty of Health Sciences, University of Cape Town (M.N., B.M.), and the South African Medical Research Council (L.Z.) - both in Cape Town, South Africa; Jimma University Medical Center, Jimma, Ethiopia (A.H.); the University of Gazira, Wad Madani, Sudan (A.E.S.); Mahalla Heart Center, El Mahalla El Kubra (A.E.G.), and Suez Canal University Hospital, Ismailia (F.M.) - both in Egypt; the Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique (A.D.); the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); the College of Medicine, University of the Philippines, Manila (A.M.L.D.); Kenyatta National Hospital, Nairobi (B.G.); the People's Hospital of Peking University (D.H.) and the Beijing Anzhen Hospital (C.M.) - both in Beijing; the University Teaching Hospital of Kigali, Kigali, Rwanda (E.R.K.); the University of Zimbabwe, College of Health Sciences, Harare (G.F.); Instituto Nacional de Cardiología Ignacio Chávez, Mexico City (J.A.G.-H.); the University Teaching Hospital, Lusaka, Zambia (J.M.); the National Institute of Cardiovascular Diseases, Karachi, Pakistan (K.K.); Kamuzu Central Hospital, Lilongwe, Malawi (L.G.); Barrio Obrero Hospital, Asuncion, Paraguay (M.P.); the Department of Medicine, University of Ibadan-College Hospital, Ibadan, Nigeria (O.S.O.); Princess Marina Hospital, University of Botswana, Gaborone (O.J.M.-B.); Uganda Heart Institute, Kampala (P.L.); Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (P.C.); the B.P. Koirala Institute of Health Sciences, Dharan, Nepal (S.K.S.); St. Elizabeth Catholic General Hospital, Kumbo, Cameroon (T.T.J.C.); the Department of Medicine, University of Saskatchewan, Saskatoon, the Department of Medicine, Western University, London, ON, and the Windsor Cardiac Centre, Windsor, ON - all in Canada (W.M.T.); the Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg University, Mainz (A.B.), and Bayer, Berlin (M.E.) - both in Germany
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Weller JM, Dorn F, Meissner JN, Stösser S, Beckonert NM, Nordsiek J, Kindler C, Riegler C, Keil F, Petzold GC, Bode FJ, Reich A, Nikoubashman O, Röther J, Eckert B, Braun M, Hamann GF, Siebert E, Nolte CH, Bohner G, Eckert RM, Borggrefe J, Schellinger P, Berrouschot J, Bormann A, Kraemer C, Leischner H, Petersen M, Stögbauer F, Boeck-Behrens T, Wunderlich S, Ludolph A, Henn KH, Gerloff C, Fiehler J, Thomalla G, Alegiani A, Schäfer JH, Tiedt S, Kellert L, Trumm C, Ernemann U, Poli S, Liman J, Ernst M, Gröschel K, Uphaus T. Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation. Neurol Res Pract 2022; 4:42. [PMID: 36089621 PMCID: PMC9465921 DOI: 10.1186/s42466-022-00207-7] [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: 05/23/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background Oral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear.
Methods This is a subgroup analysis of the German Stroke Registry—Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days. Results Among 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high. Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3–10.5] vs 7 [4–11], p = 0.73, mRS 4 [IQR 3–4] vs. 4 [IQR 3–5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02). Conclusions In AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC. Registration: https://www.clinicaltrials.gov; Unique identifier: NCT03356392. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-022-00207-7.
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Sciahbasi A, Gargiulo G, Talarico GP, Cesaro A, Zilio F, De Rosa S, Talanas G, Tebaldi M, Andò G, Rigattieri S, Misuraca L, Cortese B, Imperadore F, Lucci V, Guiducci V, Renda G, Zezza L, Versaci F, Giannico MB, Caruso M, Spaccarotella C, Calabrò P, Esposito G, Tarantini G, Musumeci G, Rubboli A. Design of the PERSEO Registry on the management of patients treated with oral anticoagulants and coronary stent. J Cardiovasc Med (Hagerstown) 2022; 23:738-743. [PMID: 36166340 DOI: 10.2459/jcm.0000000000001372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Percutaneous coronary intervention with stent implantation (PCI-S) in patients requiring chronic oral anticoagulant therapy (OAC) is associated with an increased risk of bleeding and ischemic complications. Different randomized studies showed a significant advantage of a double antithrombotic therapy and superiority of direct oral anticoagulant (DOAC) compared with warfarin, but real-world data are limited. Aim is to evaluate the antithrombotic management and clinical outcome of patients with an indication for OAC who undergo PCI-S in a 'real-world' setting. METHODS The multicentre prospective observational PERSEO (PERcutaneouS coronary intErventions in patients treated with Oral anticoagulant therapy) Registry (ClinicalTrials.gov Identifier: NCT03392948) has been designed to enrol patients requiring OAC treated by PCI-S in 25 Italian centres. A target of at least 1080 patients will be followed for 1 year and data on thromboembolic and bleeding events and changes in antithrombotic therapy will be registered. The primary end point is a combined measure of efficacy and safety outcome (NACE), including major bleeding events and major adverse cardiac and cerebral events at 1-year follow-up in patients treated with DOAC (and dual or triple antiplatelet therapy) compared with the corresponding strategies with vitamin K antagonists. A secondary prespecified analysis has been defined to evaluate NACE in dual versus triple antithrombotic therapy after hospital discharge at 1-year follow-up. CONCLUSION The PERSEO Registry will investigate in a 'real world' setting the safety and efficacy of DOAC versus warfarin and dual versus triple antithrombotic therapy in patients with indication for oral anticoagulant therapy who undergo PCI-S.
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Affiliation(s)
| | - Giuseppe Gargiulo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | | | - Arturo Cesaro
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano,' Caserta
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento
| | - Salvatore De Rosa
- Division of Cardiology, Research Center for Cardiovascular Diseases, University Magna Graecia, Catanzaro
| | - Giuseppe Talanas
- Clinical and Interventional Cardiology, Sassari University Hospital
| | - Matteo Tebaldi
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, Cona
| | - Giuseppe Andò
- Cardiology, Department of Clinical and Experimental Medicine, University of Messina
| | | | | | - Bernardo Cortese
- Department of Cardiology, San Carlo Clinic, Fondazione Ricerca e Innovazione Cardiovascolare Milan
| | | | - Valerio Lucci
- Interventional Cardiology San Filippo and Nicola Hospital, Avezzano
| | | | - Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences, G. D'Annunzio University of Chieti-Pescara
| | | | | | | | - Marco Caruso
- Division of Interventional Cardiology, ARNAS Civico Hospital, Palermo
| | - Carmen Spaccarotella
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | - Paolo Calabrò
- Division of Clinical Cardiology, A.O.R.N. 'Sant'Anna e San Sebastiano,' Caserta
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua
| | - Giuseppe Musumeci
- Division of Cardiology, Azienda Ospedaliera Ordine Mauriziano di Torino, Turin
| | - Andrea Rubboli
- Department of Cardiovascular Diseases-AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
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Pevzner DV, Kostritca NS, Alieva AK, Merkulova IA, Yavelov IS, Merkulov EV, Chazova IE. Prevention of Cardioembolic Complications in Patients with Atrial Fibrillation: Efficacy and Safety of Left Atrial Appendage Isolation and Oral Anticoagulants. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-08-09] [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
Aim. To study the outcomes frequency and structure in patients with atrial fibrillation (AF) depending on the cardioembolic events preventing method: left atrial appendage (LAA) isolation, direct oral anticoagulants (DOACs) or warfarin.Material and methods. A prospective observational study included patients with AF and high risk of cardioembolic complications and without contraindications to anticoagulants. Patients who refused long-term oral anticoagulants taking underwent LAA isolation, the rest of the patients received DOACs or warfarin. The observation period was 3 years. Mortality, cardioembolic complications and major bleeding (according to GARFIELD criteria) cumulative incidence was assessed.Results. We included 245 patients: 46 patients were treated with LAA isolation, 100 with warfarin, and 99 with DOACs. Multivariate regression analysis demonstrated a statistically significant advantage of LAA occluder in terms of combined endpoint achieving frequency compared to warfarin (hazard ratio [HR] 3.10; 95% confidence interval [CI] 1.01-9.54; p=0.049), and to DOACs (HR 3.44, 95% CI 1.15-10.29; p=0.027). A similar result was obtained for all-cause mortality (HR 5.24; 95% CI 1.12-24.55; p=0.036 and HR 5.58; 95% CI 1.22-25.49; p=0.027, respectively). There were no significant differences in bleeding rates between the groups.Conclusion. This observational study demonstrates the superiority of LAA isolation as a first-line therapy over DOACs and warfarin in patients with AF and high risk of cardioembolic complications. Randomized trials are required to confirm these observations.
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Affiliation(s)
- D. V. Pevzner
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
| | - N. S. Kostritca
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
| | - A. K. Alieva
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
| | - I. A. Merkulova
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
| | - I. S. Yavelov
- Federal State Budgetary Institution National Medical Research Centre for Therapy and Preventive Medicine of the Ministry of Health of the Russian Federation
| | - E. V. Merkulov
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
| | - I. E. Chazova
- National Medical Research Centre of Cardiology named after academician E.I. Chazov
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Oraii A, Healey JS, Benz AP, Pandey AK, Wong JA, Fonguh S, Wang J, Conen D, Gerstein HC, Connolly SJ, McIntyre WF. Association of Eligibility for a Sodium-Glucose Cotransporter 2 Inhibitor and Cardiovascular Events in Patients With Atrial Fibrillation. Can J Cardiol 2022; 38:1434-1441. [PMID: 35562018 DOI: 10.1016/j.cjca.2022.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce heart failure (HF) in a broad range of populations, but they have not been studied specifically in patients with atrial fibrillation (AF). We aimed to examine the association between SGLT2i eligibility and cardiovascular events in patients with AF to evaluate the potential utility of SGLT2is for AF management. METHODS We pooled data from 2 randomized controlled trials (RCTs) of patients with AF (RE-LY and ACTIVE-W). Among patients assigned to anticoagulation arms, those meeting the enrollment criteria from at least 1 of the phase 3 SGLT2i RCTs were classified as "SGLT2i eligible" and the remainder as "SGLT2i ineligible." The primary outcome was the composite of HF hospitalization or cardiovascular death. RESULTS A total of 21,484 patients with AF (mean age: 71.2 ± 8.8, 36.1% women, median CHA2DS2-VASc Score = 3) were included. The proportion of patients with AF eligible for SGLT2i was 41.2%. SGLT2i-eligible patients had higher rates of cardiovascular death or hospitalization for HF (5.8 vs 3.2 per 100 person-years, Plog-rank < 0.001), cardiovascular death (3.9 vs 1.5 per 100 person-years, Plog-rank < 0.001), and hospitalization for HF (2.5 vs 1.9 per 100 person-years, Plog-rank < 0.001). The age- and sex-adjusted model showed that SGLT2i-eligible patients were at a higher risk of cardiovascular death and hospitalization for HF (hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.79-2.17; P < 0.001), cardiovascular death (HR, 2.75; 95% CI, 2.41-3.13; P < 0.001), and hospitalization for HF (HR, 1.41; 95% CI, 1.23-1.62; P < 0.001) than ineligible patients. CONCLUSIONS Most patients with AF do not currently have indications for SGLT2is but still have substantial risk of cardiovascular events. Future randomized trials should evaluate the efficacy of SGLT2is in patients with AF.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Arjun K Pandey
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sylvanus Fonguh
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Hertzel C Gerstein
- Population Health Research Institute, Hamilton, Ontario, Canada; Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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