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Park DY, Singireddy S, Mangalesh S, Fishman E, Ambrosini A, Jamil Y, Vij A, Sikand NV, Ahmad Y, Frampton J, Nanna MG. The association of timing of coronary artery bypass grafting for non-ST-elevation myocardial infarction and clinical outcomes in the contemporary United States. Coron Artery Dis 2024; 35:261-269. [PMID: 38164979 DOI: 10.1097/mca.0000000000001314] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 In contrast to the timing of coronary angiography and percutaneous coronary intervention, the optimal timing of coronary artery bypass grafting (CABG) in non-ST-elevation myocardial infarction (NSTEMI) has not been determined. Therefore, we compared in-hospital outcomes according to different time intervals to CABG surgery in a contemporary NSTEMI population in the USA. METHODS We identified all NSTEMI hospitalizations from 2016 to 2020 where revascularization was performed with CABG. We excluded NSTEMI with high-risk features using prespecified criteria. CABG was stratified into ≤24 h, 24-72 h, 72-120 h, and >120 h from admission. Outcomes of interest included in-hospital mortality, perioperative complications, length of stay (LOS), and hospital cost. RESULTS A total of 147 170 NSTEMI hospitalizations where CABG was performed were assessed. A greater percentage of females, Blacks, and Hispanics experienced delays to CABG surgery. No difference in in-hospital mortality was observed, but CABG at 72-120 h and at >120 h was associated with higher odds of non-home discharge and acute kidney injury compared with CABG at ≤24 h from admission. In addition to these differences, CABG at >120 h was associated with higher odds of gastrointestinal hemorrhage and need for blood transfusion. All 3 groups with CABG delayed >24 h had longer LOS and hospital-associated costs compared with hospitalizations where CABG was performed at ≤24 h. CONCLUSION CABG delays in patients with NSTEMI are more frequently experienced by women and minority populations and are associated with an increased burden of complications and healthcare cost.
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Affiliation(s)
- Dae Yong Park
- Department of Medicine, Cook County Health, Chicago, Illinois
| | | | - Sridhar Mangalesh
- Department of Medicine, Army College of Medical Sciences, New Delhi, Delhi, India
| | | | | | - Yasser Jamil
- Department of Medicine, Yale-Waterbury Hospital, New Haven, Connecticut
| | - Aviral Vij
- Division of Cardiology, Cook County Health
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois
| | - Nikhil V Sikand
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Frampton
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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2
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Kelham M, Vyas R, Ramaseshan R, Rathod K, de Winter RJ, de Winter RW, Bendz B, Thiele H, Hirlekar G, Morici N, Myat A, Michalis LK, Sanchis J, Kunadian V, Berry C, Mathur A, Jones DA. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J 2024:ehae245. [PMID: 38805681 DOI: 10.1093/eurheartj/ehae245] [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: 09/05/2023] [Revised: 03/20/2024] [Accepted: 04/07/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND AND AIMS A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. METHODS A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5-10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97-1.29), cardiac mortality (RR 1.05, 95% CI 0.70-1.58), myocardial infarction (RR 0.90, 95% CI 0.65-1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78-1.40). CONCLUSIONS This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.
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Affiliation(s)
- Matthew Kelham
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohan Vyas
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Rohini Ramaseshan
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Krishnaraj Rathod
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
| | - Robbert J de Winter
- Department of Cardiology Heart Center, Amsterdam UMC, Universiteit van Amsterdam, Amsterdam, The Netherlands
| | - Ruben W de Winter
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bjorn Bendz
- Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Geir Hirlekar
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nuccia Morici
- IRCCS S. Maria Nascente-Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy
| | - Aung Myat
- Medical Director (Cardiology), Medpace UK, London, UK
| | - Lampros K Michalis
- 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina, University Campus, Ioannina 45110, Greece
| | - Juan Sanchis
- Cardiology Department, University Clinic Hospital of València, INCLIVA University of València, CIBER CV, València, Spain
| | - Vijay Kunadian
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Berry
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Anthony Mathur
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - Daniel A Jones
- Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London, London, UK
- Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, UK
- NIHR Barts Biomedical Research Centre, Queen Mary University of London, Charterhouse Square, London, UK
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3
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Ergui I, Griffith N, Salama J, Ebner B, Dangl M, Vincent L, Razuk V, Marzouka G, Colombo R. In-Hospital Outcomes in Patients With Non-ST Segment Elevation Myocardial Infarction and Concomitant Neurodevelopmental Disorders in the United States: Insights From the National Inpatient Sample 2011-2020. Cureus 2024; 16:e60289. [PMID: 38746481 PMCID: PMC11093150 DOI: 10.7759/cureus.60289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 05/16/2024] Open
Abstract
Patients with neurodevelopmental disorders (NDDs) encounter significant barriers to receiving quality health care, particularly for acute conditions such as non-ST segment elevation myocardial infarction (NSTEMI). This study addresses the critical gap in knowledge regarding in-hospital outcomes and the use of invasive therapies in this demographic. By analyzing data from the National Inpatient Sample database from 2011 to 2020 using the International Classification of Diseases, Ninth Edition (ICD-9) and Tenth Edition (ICD-10) codes, we identified patients with NSTEMI, both with and without NDDs, and compared baseline characteristics, in-hospital outcomes, and the application of invasive treatments. The analysis involved a weighted sample of 7,482,216 NSTEMI hospitalizations, of which 30,168 (0.40%) patients had NDDs. There were significantly higher comorbidity-adjusted odds of in-hospital mortality, cardiac arrest, endotracheal intubation, infectious complications, ventricular arrhythmias, and restraint use among the NDD cohort. Conversely, this group exhibited lower adjusted odds of undergoing left heart catheterization, percutaneous coronary intervention, or coronary artery bypass graft surgery. These findings underscore the disparities faced by patients with NDDs in accessing invasive cardiac interventions, highlighting the need for further research to address these barriers and improve care quality for this vulnerable population.
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Affiliation(s)
- Ian Ergui
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Nayrana Griffith
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Joshua Salama
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Bertrand Ebner
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Michael Dangl
- Internal Medicine, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Louis Vincent
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - Victor Razuk
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
| | - George Marzouka
- Cardiology, Miami Department of Veterans Affairs, Miami, USA
| | - Rosario Colombo
- Cardiology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, USA
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Zhao W, Li S, Li C, Wu C, Wang J, Xing L, Wan Y, Qin J, Xu Y, Wang R, Wen C, Wang A, Liu L, Wang J, Song H, Feng W, Ma Q, Ji X. Effects of Tirofiban on Neurological Deterioration in Patients With Acute Ischemic Stroke: A Randomized Clinical Trial. JAMA Neurol 2024:2817537. [PMID: 38648030 PMCID: PMC11036313 DOI: 10.1001/jamaneurol.2024.0868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/23/2024] [Indexed: 04/25/2024]
Abstract
Importance Evidence supports using antiplatelet therapy in patients with acute ischemic stroke. However, neurological deterioration remains common under the currently recommended antiplatelet regimen, leading to poor clinical outcomes. Objective To determine whether intravenous tirofiban administered within 24 hours of stroke onset prevents early neurological deterioration in patients with acute noncardioembolic stroke compared with oral aspirin. Design, Setting, and Participants This investigator-initiated, multicenter, open-label, randomized clinical trial with blinded end-point assessment was conducted at 10 comprehensive stroke centers in China between September 2020 and March 2023. Eligible patients were aged 18 to 80 years with acute noncardioembolic stroke within 24 hours of onset and had a National Institutes of Health Stroke Scale (NIHSS) score of 4 to 20. Intervention Patients were assigned randomly (1:1) to receive intravenous tirofiban or oral aspirin for 72 hours using a central, web-based, computer-generated randomization schedule; all patients then received oral aspirin. Main Outcome The primary efficacy outcome was early neurological deterioration (increase in NIHSS score ≥4 points) within 72 hours after randomization. The primary safety outcome was symptomatic intracerebral hemorrhage within 72 hours after randomization. Results A total of 425 patients were included in the intravenous tirofiban (n = 213) or oral aspirin (n = 212) groups. Median (IQR) age was 64.0 years (56.0-71.0); 124 patients (29.2%) were female, and 301 (70.8%) were male. Early neurological deterioration occurred in 9 patients (4.2%) in the tirofiban group and 28 patients (13.2%) in the aspirin group (adjusted relative risk, 0.32; 95% CI, 0.16-0.65; P = .002). No patients in the tirofiban group experienced intracerebral hemorrhage. At 90-day follow-up, 3 patients (1.3%) in the tirofiban group and 3 (1.5%) in the aspirin group died (adjusted RR, 1.15; 95% CI, 0.27-8.54; P = .63), and the median (IQR) modified Rankin scale scores were 1.0 (0-1.25) and 1.0 (0-2), respectively (adjusted odds ratio, 1.28; 95% CI, 0.90-1.83; P = .17). Conclusions and Relevance In patients with noncardioembolic stroke who were seen within 24 hours of symptom onset, tirofiban decreased the risk of early neurological deterioration but did not increase the risk of symptomatic intracerebral hemorrhage or systematic bleeding. Trial Registration ClinicalTrials.gov Identifier: NCT04491695.
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Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Stroke Center, Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Junmei Wang
- Department of Neurology, Ordos Central Hospital, Ordos, Inner Mongolia, China
| | - Lifei Xing
- Department of Neurology, Sinopharm North Hospital, Baotou, Inner Mongolia, China
| | - Yue Wan
- Department of Neurology, The Third People’s Hospital of Hubei Province, Wuhan, Hubei, China
| | - Jinhui Qin
- Department of Neurology, Nanyang Second People’s Hospital, Nanyang, Henan, China
| | - Yaoming Xu
- Department of Neurology, Tongliao City Hospital, Tongliao, Inner Mongolia, China
- Department of Neurology, Affiliated Hospital of Inner Mongolia Minzu University, Inner Mongolia, China
| | - Ruixian Wang
- Department of Neurology, Traditional Chinese Medicine Hospital of Tianjin Beichen District, Tianjin, China
- Department of Neurology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, Henan, China
| | - Aihua Wang
- Department of Neurology, Qianfo Mountain Hospital of Shandong University, Jinan, China
| | - Lan Liu
- School of Statistics, University of Minnesota at Twin Cities, Minneapolis
| | - Jing Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wuwei Feng
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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5
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Elscot JJ, Kakar H, Scarparo P, den Dekker WK, Bennett J, Schotborgh CE, van der Schaaf R, Sabaté M, Moreno R, Ameloot K, van Bommel RJ, Forlani D, Van Reet B, Esposito G, Dirksen MT, Ruifrok WPT, Everaert BRC, Van Mieghem C, Pinar E, Alfonso F, Cummins P, Lenzen M, Brugaletta S, Daemen J, Boersma E, Van Mieghem NM, Diletti R. Timing of Complete Multivessel Revascularization in Patients Presenting With Non-ST-Segment Elevation Acute Coronary Syndrome. JACC Cardiovasc Interv 2024; 17:771-782. [PMID: 38538172 DOI: 10.1016/j.jcin.2024.01.278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/12/2024] [Accepted: 01/16/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Complete revascularization of the culprit and all significant nonculprit lesions in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD) reduces major adverse cardiac events, but optimal timing of revascularization remains unclear. OBJECTIVES This study aims to compare immediate complete revascularization (ICR) and staged complete revascularization (SCR) in patients presenting with NSTE-ACS and MVD. METHODS This prespecified substudy of the BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease) trial included patients with NSTE-ACS and MVD. Risk differences of the primary composite outcome of all-cause mortality, myocardial infarction (MI), unplanned ischemia-driven revascularization (UIDR), or cerebrovascular events and its individual components were compared between ICR and SCR at 1 year. RESULTS The BIOVASC trial enrolled 1,525 patients; 917 patients presented with NSTE-ACS, of whom 459 were allocated to ICR and 458 to SCR. Incidences of the primary composite outcome were similar in the 2 groups (7.9% vs 10.1%; risk difference 2.2%; 95% CI: -1.5 to 6.0; P = 0.15). ICR was associated with a significant reduction of MIs (2.0% vs 5.3%; risk difference 3.3%; 95% CI: 0.9 to 5.7; P = 0.006), which was maintained after exclusion of procedure-related MIs occurring during the index or staged procedure (2.0% vs 4.4%; risk difference 2.4%; 95% CI: 0.1 to 4.7; P = 0.032). UIDRs were also reduced in the ICR group (4.2% vs 7.8%; risk difference 3.5%; 95% CI: 0.4 to 6.6; P = 0.018). CONCLUSIONS ICR is safe in patients with NSTE-ACS and MVD and was associated with a reduction in MIs and UIDRs at 1 year.
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Affiliation(s)
- Jacob J Elscot
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Hala Kakar
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Paola Scarparo
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospital Leuven, Leuven, Belgium
| | | | - René van der Schaaf
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Manel Sabaté
- Interventional Cardiology Department, Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Raúl Moreno
- Interventional Cardiology Unit, Cardiology Department, La Paz University Hospital, Madrid, Spain
| | - Koen Ameloot
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos, Belgium
| | | | - Daniele Forlani
- Department of Cardiology, Santo Spirito Hospital, Pescara, Italy
| | - Bert Van Reet
- Department of Cardiology, AZ Turnhout, Turnhout, Belgium
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurits T Dirksen
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | | | | | - Eduardo Pinar
- Department of Cardiology, Interventional Cardiology Unit, Virgen de la Arrixaca Hospital, Murcia, Spain
| | - Fernando Alfonso
- Department of Cardiology, Hospital Universitario de La Princesa Madrid, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
| | - Paul Cummins
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Mattie Lenzen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Joost Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands.
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6
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Chalkou K, Hamza T, Benkert P, Kuhle J, Zecca C, Simoneau G, Pellegrini F, Manca A, Egger M, Salanti G. Combining randomized and non-randomized data to predict heterogeneous effects of competing treatments. Res Synth Methods 2024. [PMID: 38501273 DOI: 10.1002/jrsm.1717] [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: 11/07/2022] [Revised: 01/26/2024] [Accepted: 02/16/2024] [Indexed: 03/20/2024]
Abstract
Some patients benefit from a treatment while others may do so less or do not benefit at all. We have previously developed a two-stage network meta-regression prediction model that synthesized randomized trials and evaluates how treatment effects vary across patient characteristics. In this article, we extended this model to combine different sources of types in different formats: aggregate data (AD) and individual participant data (IPD) from randomized and non-randomized evidence. In the first stage, a prognostic model is developed to predict the baseline risk of the outcome using a large cohort study. In the second stage, we recalibrated this prognostic model to improve our predictions for patients enrolled in randomized trials. In the third stage, we used the baseline risk as effect modifier in a network meta-regression model combining AD, IPD randomized clinical trial to estimate heterogeneous treatment effects. We illustrated the approach in the re-analysis of a network of studies comparing three drugs for relapsing-remitting multiple sclerosis. Several patient characteristics influence the baseline risk of relapse, which in turn modifies the effect of the drugs. The proposed model makes personalized predictions for health outcomes under several treatment options and encompasses all relevant randomized and non-randomized evidence.
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Affiliation(s)
- Konstantina Chalkou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Tasnim Hamza
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Pascal Benkert
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Multiple Sclerosis Centre, Neurologic Clinic and Policlinic, Department of Head, Spine and Neuromedicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Multiple Sclerosis Centre, Neurologic Clinic and Policlinic, Department of Biomedicine, University Hospital Basel, University of Basel, Basel, Switzerland
- Multiple Sclerosis Centre, Neurologic Clinic and Policlinic, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital, University of Basel, Basel, Switzerland
| | - Chiara Zecca
- Multiple Sclerosis Center, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | | | | | - Andrea Manca
- Centre for Health Economics, University of York, York, UK
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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7
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Starodubtseva I, Meshkova M, Zuikova A. Pathogenetic mechanisms of repeated adverse cardiovascular events development in patients with coronary heart disease: the role of chronic inflammation. Folia Med (Plovdiv) 2023; 65:863-870. [PMID: 38351773 DOI: 10.3897/folmed.65.e109433] [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: 07/12/2023] [Accepted: 08/03/2023] [Indexed: 02/16/2024] Open
Abstract
Stent restenosis is the most unfavorable complication of interventional treatment for coronary heart disease. We already know from various literature sources that the causes for stent restenosis in patients are both mechanical damage (partial opening, stent breakage, extended stented area, calcification, incomplete stent coverage of atherosclerotic plaque, weak radial stiffness of the stent metal frame, lack of stent drug coating), and the neointimal hyperplasia formation which is closely related to the de novo atherosclerosis development, being a predictor of the recurrent cardiovascular event.
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Affiliation(s)
| | - Maria Meshkova
- NN Burdenko Voronezh State Medical University, Voronezh, Russia
| | - Anna Zuikova
- NN Burdenko Voronezh State Medical University, Voronezh, Russia
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8
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Niazi SK. A Critical Analysis of the FDA's Omics-Driven Pharmacodynamic Biomarkers to Establish Biosimilarity. Pharmaceuticals (Basel) 2023; 16:1556. [PMID: 38004421 PMCID: PMC10675618 DOI: 10.3390/ph16111556] [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: 09/02/2023] [Revised: 09/25/2023] [Accepted: 09/29/2023] [Indexed: 11/26/2023] Open
Abstract
Demonstrating biosimilarity entails comprehensive analytical assessment, clinical pharmacology profiling, and efficacy testing in patients for at least one medical indication, as required by the U.S. Biologics Price Competition and Innovation Act (BPCIA). The efficacy testing can be waived if the drug has known pharmacodynamic (PD) markers, leaving most therapeutic proteins out of this concession. To overcome this, the FDA suggests that biosimilar developers discover PD biomarkers using omics technologies such as proteomics, glycomics, transcriptomics, genomics, epigenomics, and metabolomics. This approach is redundant since the mode-action-action biomarkers of approved therapeutic proteins are already available, as compiled in this paper for the first time. Other potential biomarkers are receptor binding and pharmacokinetic profiling, which can be made more relevant to ensure biosimilarity without requiring biosimilar developers to conduct extensive research, for which they are rarely qualified.
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Affiliation(s)
- Sarfaraz K Niazi
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Illinois, Chicago, IL 60612, USA
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9
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Patail H, Bali A, Sharma T, Frishman WH, Aronow WS. Review and Key Takeaways of the 2021 Percutaneous Coronary Intervention Guidelines. Cardiol Rev 2023:00045415-990000000-00151. [PMID: 37729589 DOI: 10.1097/crd.0000000000000608] [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] [Indexed: 09/22/2023]
Abstract
The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.
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Affiliation(s)
- Haris Patail
- From the Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT
| | - Atul Bali
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Tanya Sharma
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - William H Frishman
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York
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10
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Zhao YJ, Sun Y, Wang F, Cai YY, Alolga RN, Qi LW, Xiao P. Comprehensive evaluation of time-varied outcomes for invasive and conservative strategies in patients with NSTE-ACS: a meta-analysis of randomized controlled trials. Front Cardiovasc Med 2023; 10:1197451. [PMID: 37745128 PMCID: PMC10516546 DOI: 10.3389/fcvm.2023.1197451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023] Open
Abstract
Background Results from randomized controlled trials (RCTs) and meta-analyses comparing invasive and conservative strategies in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) are highly debatable. We systematically evaluate the efficacy of invasive and conservative strategies in NSTE-ACS based on time-varied outcomes. Methods The RCTs for the invasive versus conservative strategies were identified by searching PubMed, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov. Trial data for studies with a minimum follow-up time of 30 days were included. We categorized the follow-up time into six varied periods, namely, ≤6 months, 1 year, 2 years, 3 years, 5 years, and ≥10 years. The time-varied outcomes were major adverse cardiovascular event (MACE), death, myocardial infarction (MI), rehospitalization, cardiovascular death, bleeding, in-hospital death, and in-hospital bleeding. Risk ratios (RRs) and 95% confidence intervals (Cis) were calculated. The random effects model was used. Results This meta-analysis included 30 articles of 17 RCTs involving 12,331 participants. We found that the invasive strategy did not provide appreciable benefits for NSTE-ACS in terms of MACE, death, and cardiovascular death at all time points compared with the conservative strategy. Although the risk of MI was reduced within 6 months (RR 0.80, 95% CI 0.68-0.94) for the invasive strategy, no significant differences were observed in other periods. The invasive strategy reduced the rehospitalization rate within 6 months (RR 0.69, 95% CI 0.52-0.90), 1 year (RR 0.73, 95% CI 0.63-0.86), and 2 years (RR 0.77, 95% CI 0.60-1.00). Of note, an increased risk of bleeding (RR 1.80, 95% CI 1.28-2.54) and in-hospital bleeding (RR 2.17, 95% CI 1.52-3.10) was observed for the invasive strategy within 6 months. In subgroups stratified by high-risk features, the invasive strategy decreased MACE for patients aged ≥65 years within 6 months (RR 0.68, 95% CI 0.58-0.78) and 1 year (RR 0.75, 95% CI 0.62-0.91) and showed benefits for men within 6 months (RR 0.71, 95% CI 0.55-0.92). In other subgroups stratified according to diabetes, ST-segment deviation, and troponin levels, no significant differences were observed between the two strategies. Conclusions An invasive strategy is superior to a conservative strategy in reducing early events for MI and rehospitalizations, but the invasive strategy did not improve the prognosis in long-term outcomes for patients with NSTE-ACS. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021289579, identifier PROSPERO 2021 CRD42021289579.
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Affiliation(s)
- Yi-Jing Zhao
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Yangyang Sun
- Department of Pharmacy, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fan Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Yuan-Yuan Cai
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Raphael N. Alolga
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, China
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
| | - Lian-Wen Qi
- The Clinical Metabolomics Center, China Pharmaceutical University, Nanjing, China
- College of Traditional Chinese Medicine and Food Engineering, Shanxi University of Chinese Medicine, Taiyuan, China
| | - Pingxi Xiao
- Department of Cardiology, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, China
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11
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Boutaybi M, Aloutmani B, El-Azrak M, Ismaili N, El Ouafi N. Acute coronary syndromes in chronic hemodialysis patients: a series of 34 cases (case series). Ann Med Surg (Lond) 2023; 85:3791-3796. [PMID: 37554882 PMCID: PMC10406026 DOI: 10.1097/ms9.0000000000000941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/31/2023] [Indexed: 08/10/2023] Open
Abstract
UNLABELLED Cardiovascular diseases, particularly acute coronary syndrome, are the leading cause of death in chronic hemodialysis patients. Our study aims to analyze the pathophysiological, clinical, angiographic, and therapeutic characteristics of coronary heart disease in hemodialysis patients. PATIENTS AND METHODS This single-centered retrospective descriptive study included 34 hemodialysis patients hospitalized in the cardiovascular ICU. RESULTS The mean age of patients in our study was 64.4±11.3 years. The main cardiovascular risk factor found in our study was age, with a prevalence of 76.50%, followed by hypertension, with a prevalence of 67.60%. Diabetes was present in 55.90% of patients. The authors also found that 17.90% of patients were obese, and 29.40% had abdominal obesity. The main cause of renal disease in our study was diabetic nephropathy (52.90% of cases), followed by hypertensive nephropathy (23.50% of cases). ST segment elevation myocardial infarction was found in 14.70% of cases, and non-ST-segment elevation myocardial infarction in 85.30% of cases. Coronary angiography was performed in 76.40% of patients. Single-vessel coronary artery disease (CAD) was found in 20%, two-vessel CAD in 50%, and three-vessel CAD in 30% of the cases. Coronary artery calcifications were observed in 21.42% of cases. 38.23% had an angioplasty, and 20.58% were referred for a coronary artery bypass graft. CONCLUSION Despite the high mortality rate after acute coronary syndrome, hemodialysis patients are less likely to undergo diagnostic angiography or coronary revascularization. Patients on hemodialysis tend to have multiple, diffuse, calcified CAD.
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Affiliation(s)
| | | | | | - Nabila Ismaili
- Department of Cardiology, Mohammed VI University Hospital
- Epidemiological Laboratory of Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
| | - Noha El Ouafi
- Department of Cardiology, Mohammed VI University Hospital
- Epidemiological Laboratory of Clinical Research and Public Health, Faculty of Medicine and Pharmacy of Oujda, Mohammed First University, Oujda, Morocco
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12
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Miller CD, Mahler SA, Snavely AC, Raman SV, Caterino JM, Clark CL, Jones AE, Hall ME, Koehler LE, Lovato JF, Hiestand BC, Stopyra JP, Park CJ, Vasu S, Kutcher MA, Hundley WG. Cardiac Magnetic Resonance Imaging Versus Invasive-Based Strategies in Patients With Chest Pain and Detectable to Mildly Elevated Serum Troponin: A Randomized Clinical Trial. Circ Cardiovasc Imaging 2023; 16:e015063. [PMID: 37339173 PMCID: PMC10287041 DOI: 10.1161/circimaging.122.015063] [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] [Received: 11/08/2022] [Accepted: 04/25/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The optimal diagnostic strategy for patients with chest pain and detectable to mildly elevated serum troponin is not known. The objective was to compare clinical outcomes among an early decision for a noninvasive versus an invasive-based care pathway. METHODS The CMR-IMPACT trial (Cardiac Magnetic Resonance Imaging Strategy for the Management of Patients with Acute Chest Pain and Detectable to Elevated Troponin) was conducted at 4 United States tertiary care hospitals from September 2013 to July 2018. A convenience sample of 312 participants with acute chest pain symptoms and a contemporary troponin between detectable and 1.0 ng/mL were randomized early in their care to 1 of 2 care pathways: invasive-based (n=156) or cardiac magnetic resonance (CMR)-based (n=156) with modification allowed as the patient condition evolved. The primary outcome was a composite including death, myocardial infarction, and cardiac-related hospital readmission or emergency visits. RESULTS Participants (N=312, mean age, 60.6 years, SD 11.3; 125 women [59.9%]), were followed over a median of 2.6 years (95% CI, 2.4-2.9). Early assigned testing was initiated in 102 out of 156 (65.3%) CMR-based and 110 out of 156 (70.5%) invasive-based participants. The primary outcome (CMR-based versus invasive-based) occurred in 59% versus 52% (hazard ratio, 1.17 [95% CI, 0.86-1.57]), acute coronary syndrome after discharge 23% versus 22% (hazard ratio, 1.07 [95% CI, 0.67-1.71]), and invasive angiography at any time 52% versus 74% (hazard ratio, 0.66 [95% CI, 0.49-0.87]). Among patients completing CMR imaging, 55 out of 95 (58%) were safely identified for discharge based on a negative CMR and did not have angiography or revascularization within 90 days. Therapeutic yield of angiography was higher in the CMR-based arm (52 interventions in 81 angiographies [64.2%] versus 46 interventions in 115 angiographies [40.0%] in the invasive-based arm [P=0.001]). CONCLUSIONS Initial management with CMR or invasive-based care pathways resulted in no detectable difference in clinical and safety event rates. The CMR-based pathway facilitated safe discharge, enriched the therapeutic yield of angiography, and reduced invasive angiography utilization over long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01931852.
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Affiliation(s)
- Chadwick D Miller
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna C Snavely
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Subha V Raman
- Division of Cardiovascular Medicine (S.V.R.), The Ohio State University, Columbus, OH
- Now with Indiana University Krannert Institute of Cardiology, Indianapolis, IN (S.V.R.)
| | - Jeffrey M Caterino
- Department of Emergency Medicine (J.M.C.), The Ohio State University, Columbus, OH
| | - Carol L Clark
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (C.L.C.)
| | - Alan E Jones
- Department of Emergency Medicine (A.E.J.), University of Mississippi Medical Center, Jackson, MS
| | - Michael E Hall
- Department of Medicine (M.E.H.), University of Mississippi Medical Center, Jackson, MS
| | - Lauren E Koehler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - James F Lovato
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason P Stopyra
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn J Park
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sujethra Vasu
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael A Kutcher
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Radiology (W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine/Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (W.G.H.)
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13
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Sang H, Xie D, Tian Y, Nguyen TN, Saver JL, Nogueira RG, Wu J, Long C, Tian Z, Hu Z, Wang T, Li R, Ke Y, Zhu X, Peng D, Chang M, Li L, Ruan J, Wu D, Zi W, Yang Q, Li F, Qiu Z. Association of Tirofiban With Functional Outcomes After Thrombectomy in Acute Ischemic Stroke Due to Intracranial Atherosclerotic Disease. Neurology 2023; 100:e1996-e2006. [PMID: 36941074 PMCID: PMC10186214 DOI: 10.1212/wnl.0000000000207194] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/01/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVE To investigate the efficacy and safety of IV infusion of tirofiban before endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerotic disease. The secondary objective was to identify potential mediators for the clinical effect of tirofiban. METHODS Post hoc exploratory analysis of the Endovascular Treatment With versus Without Tirofiban for Patients with Large Vessel Occlusion Stroke (RESCUE BT) trial, which was a randomized, double-blinded, placebo-controlled trial at 55 centers in China from October 2018 to October 2021. Patients with occlusion of the internal carotid artery or middle cerebral artery due to intracranial atherosclerosis were included. The primary efficacy outcome was the proportion of patients achieving functional independence (defined as modified Rankin scale 0-2) at 90 days. Binary logistic regression and causal mediation analyses were used to estimate the treatment effect of tirofiban and the potential mediators. RESULTS This study included 435 patients, of whom 71.5% were men. The median age was 65 (interquartile range [IQR] 56-72) years, with a median NIH Stroke Scale of 14 (IQR 10-19). Patients in the tirofiban group had higher rates of functional independence at 90 days than patients in the placebo group (adjusted odds ratio 1.68; 95% CI 1.11-2.56, p = 0.02) without an increased risk of mortality or symptomatic intracranial hemorrhage. Tirofiban was associated with fewer thrombectomy passes (median [IQR] 1 [1-2] vs 1 [1-2], p = 0.004), which was an independent predictor of functional independence. Mediation analysis showed tirofiban-reduced thrombectomy passes explained 20.0% (95% CI 4.1%-76.0%) of the effect of tirofiban on functional independence. DISCUSSION In this post hoc analysis of the RESCUE BT trial, tirofiban was an effective and well-tolerated adjuvant medication of endovascular thrombectomy for patients with large vessel occlusion due to intracranial atherosclerosis. These findings need to be confirmed in future trials. TRIAL REGISTRATION INFORMATION The RESCUE BT trial was registered on the Chinese Clinical Trial Registry: chictr.org.cn, ChiCTR-INR-17014167. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tirofiban plus endovascular therapy improves 90-day outcome for patients with large vessel occlusion due to intracranial atherosclerosis.
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Affiliation(s)
- Hongfei Sang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Dongjing Xie
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Thanh N Nguyen
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jeffrey L Saver
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Raul G Nogueira
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Junxiong Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Chen Long
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhenxuan Tian
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhizhou Hu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Tao Wang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Rongzong Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Yingbing Ke
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Xiurong Zhu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Daizhou Peng
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Mingze Chang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Lingfei Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Jie Ruan
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Deping Wu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Wenjie Zi
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Qingwu Yang
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Fengli Li
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- From the Department of Neurology (H.S., L.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine; Department of Neurology (D.X., Y.T., D.W., W.Z., Q.Y., F.L.), Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China; Department of Neurology and Radiology (T.N.N.), Boston Medical Center, MA; Department of Neurology (J.L.S.), David Geffen School of Medicine at UCLA; Department of Neurology and Neurosurgery (R.G.N.), University of Pittsburgh School of Medicine, PA; Department of Emergency (J.W., C.L.), Xiangtan Central Hospital; Department of Neurology (Z.T.), Sichuan Mianyang 404 Hospital; Department of Neurology (Z.H.), Longyan First Hospital of Fujian Medical University; Department of Neurology (T.W.), Huainan First People's Hospital; Department of Neurology (R.L.), The 924th Hospital of The People's Liberation Army, Guilin; Department of Neurology (Y.K.), Yangluo Branch of Hubei Zhongshan Hospital, Wuhan; Department of Neurology (X.Z.), Chongzhou People's Hospital; Department of Neurology (D.P.), Qianxinan People's Hospital; Department of Neurology (M.C.), Xi'an Third Hospital; Department of Clinical Pharmacy (J.R.), Zhejiang Provincial Key Laboratory for Drug Evaluation and Clinical Research, the First Affiliated Hospital, Zhejiang University School of Medicine; and Department of Neurology (Z.Q.), The 903th Hospital of The People's Liberation Army, Hangzhou, China.
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Sang H, Huang J, Jiang B, Guo Q, Nguyen TN, Abdalkader M, Han Q, Zhou S, Tao Z, Mao A, Yan Z, Du J, Jin Y, Huang C, Liu T, Zhao W, Gu G, Wang L, Liu S, Luo S, Pu J, Hu J, Yang J, Li F, Zi W, Hu X, Qiu Z. Association between intravenous tirofiban and intracranial hemorrhage in acute large vessel occlusion stroke: insight from the RESCUE BT randomized placebo-controlled trial. J Neurol 2023; 270:2246-2255. [PMID: 36697890 DOI: 10.1007/s00415-023-11579-4] [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: 12/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND The aim of this study is to investigate the association between intravenous tirofiban and symptomatic intracranial hemorrhage (SICH) in patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) receiving endovascular thrombectomy (EVT) within 24 h of time last known well (LKW). METHODS Patients with AIS-LVO who were randomly assigned to receive intravenous tirofiban or placebo before EVT within 24 h of time LKW and had follow-up brain non-contrast computed tomography within 24 h after stopping tirofiban treatment were derived from "RESCUE BT": a multicenter, randomized, placebo-controlled, double-blind trial. All eligible patients were divided into SICH and NO-SICH groups. Subgroup analyses were performed to explore for heterogeneity. RESULTS Of 945 patients included in this cohort, there were 76 (8.0%) in the SICH group and 869 (92.0%) in the NO-SICH group. The incidence of SICH was not higher in patients receiving intravenous tirofiban compared with placebo (adjusted risk ratio (RR), 1.51; 95% confidence interval (CI), 0.97-2.36; P = 0.07). Subgroup analyses showed that age greater than 67-year-old (adjusted RR, 2.18; 95% CI 1.18-4.00), NIHSS greater than 16 (adjusted RR, 1.88; 95% CI 1.06-3.34), and cardioembolism (adjusted RR, 3.73; 95% CI 1.66-8.35) were associated with increased SICH risk. CONCLUSIONS In patients with acute large vessel occlusion stroke, intravenous tirofiban before EVT within 24 h of time from last known well is not associated with increased risk of SICH. Patients who are older, have more severe neurological deficits, or with cardioembolism are at higher risk of SICH with intravenous tirofiban. TRIAL REGISTRATION NUMBER URL: http://www.chictr.org.cn ; Unique identifier: ChiCTR-INR-17014167.
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Affiliation(s)
- Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Bingwu Jiang
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Qifeng Guo
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, 725 Albany St, Neurology 7Th Floor, Boston, MA, 02118, USA
- Department of Radiology, Boston Medical Center, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA, 02118, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA, 02118, USA
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Simin Zhou
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Zhaojun Tao
- Department of Medical Engineering, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, 310007, China
| | - An Mao
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Zhizhong Yan
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, 214000, China
| | - Jie Du
- Department of Neurology, Kaizhou District People's Hospital, Chongqing, 405400, China
| | - Ying Jin
- Department of Neurology, Songyuan Jilin Oilfield Hospital, 138000, Songyuan, China
| | - Chuming Huang
- Department of Neurology, Shantou Central Hospital, Shantou, 515000, China
| | - Tianzhu Liu
- Department of Neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, 646000, China
| | - Wenlong Zhao
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, China
| | - Gangfeng Gu
- Department of Neurology, Ya'an People's Hospital, 625000, Ya'an, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, 643000, China
| | - Shugai Liu
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, 628000, China
| | - Shiwei Luo
- Department of Neurology, Jieyang People's Hospital, Jieyang, 522000, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, 430000, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Xiaogang Hu
- Department of Military Patient Management, The 904th Hospital of The People's Liberation Army, Wuxi, 214000, China.
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China.
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China.
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15
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Balasubramanian RN, Mills GB, Wilkinson C, Mehran R, Kunadian V. Role and relevance of risk stratification models in the modern-day management of non-ST elevation acute coronary syndromes. Heart 2023; 109:504-510. [PMID: 36104217 DOI: 10.1136/heartjnl-2022-321470] [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: 06/02/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022] Open
Abstract
We summarise the international guidelines surrounding risk stratification as well as discuss new emerging data for future development of a new risk model in the management of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). NSTE-ACS accounts for the bulk of acute coronary syndrome presentations in the UK, but management strategies in this group of patients have remained a subject of debate for decades. Patients with NSTE-ACS represent a heterogeneous population with a wide variation in short-term and long-term clinical outcomes, which makes a uniform, standardised treatment approach ineffective and inappropriate. Studies in the modern era have provided some guidance in treating this subset of patients: the provision of early, more potent therapies has been shown to improve outcomes in patients at a particularly elevated risk of adverse outcomes. International guidelines recommend adopting an individualised treatment approach through the use of validated risk prediction models to identify such patients at high risk of adverse outcomes. The present available evidence, however, is based on dated demographics, different diagnostic thresholds and outdated therapies. In particular, the evidence has limited applicability to female patients and older people with frailty. Moreover, the current risk models do not capture key prognostic variables, leading to an inaccurate estimation of patients' baseline risk and subsequent mistreatment. Therefore, the current risk models are no longer fit for purpose and there is a need for risk prediction scores that account for different population demographics, higher sensitivity troponin assays and contemporary treatment options.
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Affiliation(s)
| | - Greg B Mills
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK .,Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Towards a biomarker for acute arterial thrombosis using complete blood count and white blood cell differential parameters in mice. Sci Rep 2023; 13:4043. [PMID: 36899036 PMCID: PMC10006076 DOI: 10.1038/s41598-023-31122-9] [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: 06/30/2022] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
There is no blood biomarker diagnostic of arterial thrombosis. We investigated if arterial thrombosis per se was associated with alterations in complete blood count (CBC) and white blood cell (WBC) differential count in mice. Twelve-week-old C57Bl/6 mice were used for FeCl3-mediated carotid thrombosis (n = 72), sham-operation (n = 79), or non-operation (n = 26). Monocyte count (/µL) at 30-min after thrombosis (median 160 [interquartile range 140-280]) was ~ 1.3-fold higher than at 30-min after sham-operation (120 [77.5-170]), and twofold higher than in non-operated mice (80 [47.5-92.5]). At day-1 and -4 post-thrombosis, compared with 30-min, monocyte count decreased by about 6% and 28% to 150 [100-200] and 115 [100-127.5], which however were about 2.1-fold and 1.9-fold higher than in sham-operated mice (70 [50-100] and 60 [30-75], respectively). Lymphocyte counts (/µL) at 1- and 4-days after thrombosis (mean ± SD; 3513 ± 912 and 2590 ± 860) were ~ 38% and ~ 54% lower than those in the sham-operated mice (5630 ± 1602 and 5596 ± 1437, respectively), and ~ 39% and ~ 55% lower than those in non-operated mice (5791 ± 1344). Post-thrombosis monocyte-lymphocyte-ratio (MLR) was substantially higher at all three time-points (0.050 ± 0.02, 0.046 ± 0.025, and 0.050 ± 0.02) vs. sham (0.003 ± 0.021, 0.013 ± 0.004, and 0.010 ± 0.004). MLR was 0.013 ± 0.005 in non-operated mice. This is the first report on acute arterial thrombosis-related alterations in CBC and WBC differential parameters.
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Chen Q, Meng R, Wu D, Hu J, Tao Z, Xie D, Tian Y, Han Q, Fu Y, Zuo L, Zhang M, Dai W, Deng W, Huang X, Sang H, Feng X, Qiu Z, Wang T, Yuan J. Association of Intravenous Tirofiban with Functional Outcomes in Acute Ischemic Stroke Patients with Acute Basilar Artery Occlusion Receiving Endovascular Thrombectomy. Cerebrovasc Dis 2022; 52:451-459. [PMID: 36481613 PMCID: PMC10568592 DOI: 10.1159/000527483] [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: 08/24/2022] [Accepted: 10/05/2022] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION The aim of this study was to test the hypothesis that intravenous tirofiban improves functional outcomes without promoting the risk of intracranial hemorrhage (ICH) in stroke secondary to basilar artery occlusion (BAO) receiving endovascular thrombectomy. METHODS Patients with acute BAO stroke who were treated with endovascular thrombectomy and had tirofiban treatment information were derived from "BASILAR": a nationwide, prospective registry. All eligible patients were divided into tirofiban and no-tirofiban groups according to whether tirofiban was used intravenously. The primary endpoint was the 90-day severity of disability as assessed by the modified Rankin scale score. Safety outcomes were the frequency of ICH and mortality. RESULTS Of 645 patients included in this cohort, 363 were in the tirofiban group and 282 were in the no-tirofiban group. Thrombectomy with intravenous tirofiban reduced the 90-day disability level over the range of the modified Rankin scale (adjusted common odds ratio, 2.08; 95% confidence interval (CI), 1.45-2.97; p < 0.001). The 90-day mortality of patients in the tirofiban group was lower than that in the no-tirofiban group (41.6% vs. 52.1%; adjusted hazard ratio, 0.60; 95% CI, 0.47-0.77; p < 0.001). The frequency of any ICH (6.7% vs. 13.7%; p = 0.004) and symptomatic ICH (4.8% vs. 10.1%; p = 0.01) in the tirofiban group was significantly lower than that in the no-tirofiban group. CONCLUSIONS In patients with acute BAO stroke who underwent endovascular treatment, intravenous tirofiban might be associated with favorable outcome, reduced mortality, and a decreased frequency of ICH.
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Affiliation(s)
- Qiong Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Guangyang Bay Laboratory, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Renliang Meng
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Huaian Medical District of Jingling Hospital, Medical School of Nanjing University, Huaian, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhaojun Tao
- Department of Medical Engineering, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Yuan Fu
- Department of Second Outpatient, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Ling Zuo
- Central Sterile Supply Department, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Min Zhang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Weipeng Dai
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinggang Feng
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Tao Wang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology (Huainan First People’s Hospital), Huainan, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, The 925th Hospital of The Chinese People’s Liberation Army, Guiyang, China
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Acute Coronary Syndromes Among Patients with Prior Coronary Artery Bypass Surgery. Curr Cardiol Rep 2022; 24:1755-1763. [PMID: 36094755 DOI: 10.1007/s11886-022-01784-4] [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] [Accepted: 08/29/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Acute coronary syndromes (ACS) often occur in individuals with prior coronary artery bypass graft surgery (CABG). Our goal was to describe the prevalence, clinical characteristics, prognosis, and treatment strategies in this group of patients. RECENT FINDINGS Studies demonstrate that both acute and long-term major adverse cardiovascular outcomes are increased in patients with ACS and prior CABG compared to those without CABG. Much of this risk is attributed to the greater comorbid conditions present in patients with prior CABG. Data regarding optimal management of ACS in patients with prior CABG are limited, but most observational studies favor an early invasive approach for treatment. Native vessel percutaneous coronary intervention (PCI), if feasible, is generally preferred to bypass graft PCI. Patients with ACS and prior CABG represent a high-risk group of individuals, and implementing optimal preventive and treatment strategies are critically important to reduce the risk.
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Pustjens TFS, Timmermans MJC, Rasoul S, van ‘t Hof AWJ. Multivessel versus Culprit-Only Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Acute Coronary Syndrome. J Clin Med 2022; 11:jcm11206144. [PMID: 36294466 PMCID: PMC9605400 DOI: 10.3390/jcm11206144] [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: 09/27/2022] [Revised: 10/10/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: There is uncertainty whether multivessel (MV-PCI) or culprit-only percutaneous coronary intervention (CO-PCI) should be the treatment of choice in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). Aims: To evaluate clinical characteristics and outcomes in these patients undergoing MV-PCI or CO-PCI at the index procedure. Methods: Data were retrieved from the nationwide Netherlands Heart Registration. All NSTE-ACS patients with MVD undergoing PCI between 1 January 2017 and 1 October 2019 were grouped into a MV-PCI or CO-PCI group. The primary endpoint was all-cause mortality at long-term follow-up (median 756 days (593−996)). Secondary endpoints were reinterventions, urgent CABG, myocardial infarction (MI) < 30 days, target vessel revascularisation (TVR) and mortality at 1 year. Propensity score matching analyses were performed. Results: In total, 10,507 NSTE-ACS patients with MVD were included into the MV-PCI (N = 4235) and CO-PCI group (N = 6272). Analysing crude data, mortality rates at long-term follow-up (10.7% vs. 10.2%; p = 0.383), mortality at 1 year (6.0% vs. 5.6%; p = 0.412) and MI <30 days (0.8% vs. 0.9%; p = 0.513) were similar between both groups. Reinterventions (11.1% vs. 20.0%; p < 0.001), urgent CABG (0.1% vs. 0.4%; p = 0.001) and TVR (5.2% vs. 6.7%; p = 0.003) occurred less often in the MV-PCI group. Survival analysis after multiple imputation and propensity score matching showed similar mortality rates at long-term follow-up (log-rank p = 0.289), but a significant reduction for reinterventions in the MV-PCI group (log-rank p < 0.001). Conclusion: NSTE-ACS patients with MVD undergoing MV-PCI have similar mortality rates at long-term follow-up compared to CO-PCI. However, improved event-free survival in terms of fewer coronary reinterventions was observed.
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Affiliation(s)
- Tobias F. S. Pustjens
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
- Correspondence: ; Tel.: +31-884597777
| | | | - Saman Rasoul
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
| | - Arnoud W. J. van ‘t Hof
- Department of Cardiology, Zuyderland Medical Centre, 6419 PC Heerlen, The Netherlands
- Department of Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
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Coronary Stenting: Reflections on a 35-Year Journey. Can J Cardiol 2022; 38:S17-S29. [PMID: 34375695 DOI: 10.1016/j.cjca.2021.07.224] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 01/09/2023] Open
Abstract
Stenting was introduced as a therapy for coronary artery disease 35 years ago, and is currently the most commonly performed minimally invasive procedure globally. Percutaneous coronary revascularization, initially with plain old balloon angioplasty and later with stenting, has dramatically affected the outcomes of acute myocardial infarction and acute coronary syndromes. Coronary stenting is probably the most intensively studied therapy in medicine on the basis of the number of randomized clinical trials for a broad range of indications. Continuous improvements in stent materials, design, and coatings concurrent with procedural innovations have truly been awe-inspiring. The story of stenting is replete with high points and some low points, such as the initial experience with stent thrombosis and restenosis, and the more recent disappointment with bioabsorbable scaffolds. History has shown rapid growth of stent use with expansion of indications followed by contraction of some uses in response to clinical trial evidence in support of bypass surgery or medical therapy. In this review we trace the constantly evolving story of the coronary stent from the earliest experience until the present time. Undoubtedly, future iterations of stent design and materials will continue to move the stent story forward.
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21
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Herling de Oliveira LL, Correia VM, Nicz PFG, Soares PR, Scudeler TL. MINOCA: One Size Fits All? Probably Not—A Review of Etiology, Investigation, and Treatment. J Clin Med 2022; 11:jcm11195497. [PMID: 36233366 PMCID: PMC9571924 DOI: 10.3390/jcm11195497] [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: 08/22/2022] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of conditions that include both atherosclerotic (coronary plaque disruption) and non-atherosclerotic (spontaneous coronary artery dissection, coronary artery spasm, coronary artery embolism, coronary microvascular dysfunction, and supply–demand mismatch) causes resulting in myocardial damage that is not due to obstructive coronary artery disease. Failure to identify the underlying cause may result in inadequate and inappropriate therapy in these patients. The cornerstone of managing MINOCA patients is to identify the underlying mechanism to achieve the target treatment. Intravascular imaging is able to identify different morphologic features of coronary plaques, while cardiac magnetic resonance is the gold standard for detection of myocardial infarction in the setting of MINOCA. In this review, we summarize the relevant clinical issues, contemporary diagnosis, and treatment options of MINOCA.
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22
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Rashid M, Stevens C, Wijeysundera HC, Curzen N, Khoo CW, Mohamed MO, Aktaa S, Wu J, Ludman P, Mamas MA. Rates of Elective Percutaneous Coronary Intervention in England and Wales: Impact of COURAGE and ORBITA Trials. J Am Heart Assoc 2022; 11:e025426. [DOI: 10.1161/jaha.122.025426] [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] [Indexed: 01/09/2023]
Abstract
Background
There are limited data about how COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trials have impacted percutaneous coronary intervention (PCI) practices at regional or national level. We evaluated temporal trends in elective PCI rates for stable angina and, specifically, examined the impact of the COURAGE and ORBITA trials on PCI practices in England and Wales.
Methods and Results
We used national PCI data comprising >1.2 million patients undergoing PCI between January 2006 and December 2019. Patient demographics, procedural details, and clinical outcomes were analyzed, and temporal trends in PCI rates for stable angina were compared before and after the publication of the COURAGE and ORBITA trials. Of 1 245 802 PCI procedures, 430 248 (34.5%) were performed for stable angina. Over the study period, the number of elective PCI procedures per year (30 823 in 2006 to 34 103 in 2019) and per 100 000 population estimates (50.7 in 2006 to 58.4 in 2019) remained stable. The proportion of patients undergoing elective PCI without angina symptoms almost doubled from 5.1% to 9.7%. The incidence rate of elective PCI volume after the COURAGE trial, published in 2007, was not different from before the trial was published (incidence rate ratio, 1.06 [95% CI, 0.69–1.62]). It also remained stable after the publication of the ORBITA trial in 2017 (incidence rate ratio, 0.96 [95% CI, 0.74–1.23]).
Conclusions
In this nationwide analysis, rates of elective PCI for stable angina remained stable over 14 years. Publication of the COURAGE and ORBITA trials had no impact on elective PCI activity.
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Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Chris Stevens
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton & Department of Cardiology University Hospital NHS Trust Southampton UK
| | - Chee Wah Khoo
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Mohamed Osama Mohamed
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | - Suleman Aktaa
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
- School of Dentistry University of Leeds UK
| | - Peter F. Ludman
- Department of Cardiology Queen Elizabeth University Hospital Birmingham UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
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Comparison of 3-Year Outcomes between Early and Delayed Invasive Strategies in Older and Younger Adults with Non-ST-Segment Elevation Myocardial Infarction Undergoing New-Generation Drug-Eluting Stent Implantation. J Clin Med 2022; 11:jcm11164780. [PMID: 36013019 PMCID: PMC9410439 DOI: 10.3390/jcm11164780] [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: 06/23/2022] [Revised: 08/01/2022] [Accepted: 08/13/2022] [Indexed: 11/17/2022] Open
Abstract
We evaluated the 3-year clinical outcomes of early invasive (EI) and delayed invasive (DI) strategies in older and younger adults with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing successful new-generation drug-eluting stent (DES) implantation to reflect current real-world practice. Overall, 4513 patients with NSTEMI were recruited from the Korea Acute Myocardial Infarction Registry-National Institute of Health and divided into two groups according to age: group A (age ≥ 65 years, n = 2253) and group B (age < 65 years, n = 2260). These two groups were further divided into two subgroups: group EI (A1 and B1) and DI (A2 and B2). The primary clinical outcome was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), defined as all-cause death, recurrent MI (re-MI), any repeat coronary revascularization, or stroke. The secondary clinical outcome was definite or probable stent thrombosis (ST). In both groups A and B, after multivariable-adjusted and propensity score-adjusted analyses, MACCE (group A, p = 0.137 and p = 0.255, respectively; group B, p = 0.171 and p = 0.135, respectively), all-cause death, cardiac death (CD), non-CD, re-MI, any repeat revascularization, stroke, and ST rates were similar between the EI and DI groups. When including only those with complex lesions, the primary and secondary clinical outcomes were not significantly different between the EI and DI groups. In the era of new-generation DESs, major clinical outcomes were not significantly different between the EI and DI strategies in both older and younger adults with NSTEMI.
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Qiu Z, Li F, Sang H, Luo W, Liu S, Liu W, Guo Z, Li H, Sun D, Huang W, Zhang M, Zhang M, Dai W, Zhou P, Deng W, Zhou Z, Huang X, Lei B, Li J, Yuan Z, Song B, Miao J, Liu S, Jin Z, Zeng G, Zeng H, Yuan J, Wen C, Yu Y, Yuan G, Wu J, Long C, Luo J, Tian Z, Zheng C, Hu Z, Wang S, Wang T, Qi L, Li R, Wan Y, Ke Y, Wu Y, Zhu X, Kong W, Huang J, Peng D, Chang M, Ge H, Shi Z, Yan Z, Du J, Jin Y, Ju D, Huang C, Hong Y, Liu T, Zhao W, Wang J, Zheng B, Wang L, Liu S, Luo X, Luo S, Xu X, Hu J, Pu J, Chen S, Sun Y, Jiang S, Wei L, Fu X, Bai Y, Yang S, Hu W, Zhang G, Pan C, Zhang S, Wang Y, Cao W, Yang S, Zhang J, Guo F, Wen H, Zhang J, Song J, Yue C, Li L, Wu D, Tian Y, Yang J, Lu M, Saver JL, Nogueira RG, Zi W, Yang Q. Effect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy on Functional Outcomes in Large Vessel Occlusion Stroke: The RESCUE BT Randomized Clinical Trial. JAMA 2022; 328:543-553. [PMID: 35943471 PMCID: PMC9364124 DOI: 10.1001/jama.2022.12584] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Tirofiban is a highly selective nonpeptide antagonist of glycoprotein IIb/IIIa receptor, which reversibly inhibits platelet aggregation. It remains uncertain whether intravenous tirofiban is effective to improve functional outcomes for patients with large vessel occlusion ischemic stroke undergoing endovascular thrombectomy. OBJECTIVE To assess the efficacy and adverse events of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke secondary to large vessel occlusion. DESIGN, SETTING, AND PARTICIPANTS This investigator-initiated, randomized, double-blind, placebo-controlled trial was implemented at 55 hospitals in China, enrolling 948 patients with stroke and proximal intracranial large vessel occlusion presenting within 24 hours of time last known well. Recruitment took place between October 10, 2018, and October 31, 2021, with final follow-up on January 15, 2022. INTERVENTIONS Participants received intravenous tirofiban (n = 463) or placebo (n = 485) prior to endovascular thrombectomy. MAIN OUTCOMES AND MEASURES The primary outcome was disability level at 90 days as measured by overall distribution of the modified Rankin Scale scores from 0 (no symptoms) to 6 (death). The primary safety outcome was the incidence of symptomatic intracranial hemorrhage within 48 hours. RESULTS Among 948 patients randomized (mean age, 67 years; 391 [41.2%] women), 948 (100%) completed the trial. The median (IQR) 90-day modified Rankin Scale score in the tirofiban group vs placebo group was 3 (1-4) vs 3 (1-4). The adjusted common odds ratio for a lower level of disability with tirofiban vs placebo was 1.08 (95% CI, 0.86-1.36). Incidence of symptomatic intracranial hemorrhage was 9.7% in the tirofiban group vs 6.4% in the placebo group (difference, 3.3% [95% CI, -0.2% to 6.8%]). CONCLUSIONS AND RELEVANCE Among patients with large vessel occlusion acute ischemic stroke undergoing endovascular thrombectomy, treatment with intravenous tirofiban, compared with placebo, before endovascular therapy resulted in no significant difference in disability severity at 90 days. The findings do not support use of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR-IOR-17014167.
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Affiliation(s)
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Department of Cardiovascular diseases, The General Hospital of Tibet Military Area Command, Lhasa, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Dong Sun
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Wenguo Huang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Min Zhang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Min Zhang
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Weipeng Dai
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Peiyang Zhou
- Department of Neurology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Wei Deng
- Department of Neurology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Jinglun Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bo Song
- Department of Neurosurgery, Xianyang Hospital of Yan'an University, Xianyang, China
| | - Jian Miao
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan, China
| | - Zhenglong Jin
- Department of Neurology, Wuyi Hospital of Traditional Chinese Medicine, Jiangmen, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
| | - Zhenxuan Tian
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
| | - Chong Zheng
- Department of Neurology, Longyan First Affliated Hospital of Fujian Medical University, Longyan, China
| | - Zhizhou Hu
- Department of Neurology, Longyan First Affliated Hospital of Fujian Medical University, Longyan, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Tao Wang
- Department of Neurology, Huainan First People's Hospital, Huainan, China
| | - Li Qi
- Department of Neurology, The 924th Hospital of The People's Liberation Army, Guilin, China
| | - Rongzong Li
- Department of Neurology, The 924th Hospital of The People's Liberation Army, Guilin, China
| | - Yue Wan
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Yingbing Ke
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Youlin Wu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Mingze Chang
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Zhizhong Yan
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Jie Du
- Department of Neurology, Kaizhou District People's Hospital, Kaizhou, China
| | - Ying Jin
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Chuming Huang
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Tianzhu Liu
- Department of Neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, China
| | - Wenlong Zhao
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Bo Zheng
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, China
| | - Shugai Liu
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Xiaojun Luo
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Shiwei Luo
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Department of Neurology, People's Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Shengli Chen
- Department of Neurology, Chongqing University Three Gorges Central Hospital, Wanzhou, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Shunfu Jiang
- Department of Neurology, Jingdezhen First People's Hospital, Jingdezhen, China
| | - Liping Wei
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Luoyang, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Guling Zhang
- Department of Neurology, Danzhai County People's Hospital, Danzhai, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Banan, China
| | - Shuai Zhang
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yan Wang
- Department of Neurology, The Fifth People's Hospital of Chengdu, Chengdu, China
| | - Wenfeng Cao
- Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Shiquan Yang
- Department of Neurology, The 902nd Hospital of The People's Liberation Army, Bengbu, China
| | - Jun Zhang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Hubei Arts and Science University, Xiangyang, China
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital affiliated to Zhejiang University, Hangzhou, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Mengjie Lu
- School of Public Health, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Centre, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Chongqing Institute for Brain and Intelligence, Guangyang Bay Laboratory, Chongqing 400064, China
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25
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Ndrepepa G, Lahu S, Aytekin A, Scalamogna M, Coughlan JJ, Gewalt S, Pellegrini C, Mayer K, Kastrati A. One-Year Ischemic and Bleeding Events According to Renal Function in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention and Third-Generation Antiplatelet Drugs. Am J Cardiol 2022; 176:15-23. [PMID: 35606172 DOI: 10.1016/j.amjcard.2022.04.040] [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: 02/04/2022] [Revised: 03/28/2022] [Accepted: 04/05/2022] [Indexed: 11/01/2022]
Abstract
The optimal antiplatelet therapy of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and chronic kidney disease (CKD) remains unknown. This study included 2,364 patients with NSTE-ACS undergoing predominantly percutaneous coronary intervention (PCI), who were randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The primary end point was 1-year mortality. Overall, there were 85 deaths (3.6%): 6 deaths (17.1%) in patients with eGFR <30, 31 deaths (6.9%) in patients with eGFR 30 to <60, 34 deaths (3.0%) in patients with eGFR 60 to <90, and 14 deaths (2.0%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted hazard ratio (HR)=1.15, 95% confidence interval (CI) 1.01 to 1.31; p = 0.033 for 10 ml/min/1.73 m2 decrement in the eGFR. Bleeding occurred in 129 patients (5.5%): 7 bleeds (20.2%) in patients with eGFR <30, 36 bleeds (8.0%) in patients with eGFR 30 to <60, 64 bleeds (5.6%) in patients with eGFR 60 to <90, and 22 bleeds (3.1%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted HR=1.11 (1.01 to 1.23); p = 0.045 for 10 ml/min/1.73 m2 decrement in the eGFR. One-year mortality and bleeding did not differ significantly between ticagrelor and prasugrel in all categories of impaired renal function. In conclusion, in patients with NSTE-ACS undergoing PCI with drug-eluting stents and third-generation antiplatelet drugs, impaired renal function was independently associated with higher risk of 1-year mortality and bleeding. The ischemic and bleeding risks appear to differ little between ticagrelor and prasugrel in all categories of impaired renal function.
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Affiliation(s)
- Gjin Ndrepepa
- German Heart Center Munich, Technical University of Munich, Germany.
| | - Shqipdona Lahu
- German Heart Center Munich, Technical University of Munich, Germany
| | - Alp Aytekin
- German Heart Center Munich, Technical University of Munich, Germany
| | - Maria Scalamogna
- German Heart Center Munich, Technical University of Munich, Germany
| | | | - Senta Gewalt
- German Heart Center Munich, Technical University of Munich, Germany
| | | | - Katharina Mayer
- German Heart Center Munich, Technical University of Munich, Germany
| | - Adnan Kastrati
- German Heart Center Munich, Technical University of Munich, Germany; German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany
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26
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Luizzi AB, Le AV, Gill GS, Walters RW, Del Core M. Medical versus invasive management of non-ST segment elevation myocardial infarction in diabetes mellitus. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:32-36. [PMID: 35840457 DOI: 10.1016/j.carrev.2022.07.002] [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: 05/01/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION While management guidelines clearly indicate treatment algorithms for ST-segment elevation myocardial infarction, evidence behind treatment of other forms of acute coronary syndrome among diabetic patients has been inconclusive. This study examines diabetic patients with non ST-segment elevation myocardial infarction (NSTEMI) who were subsequently treated conservatively or with an invasive approach. METHODS Diabetic patients admitted to our health network with NSTEMI between January 2013-2018 were identified. Data collected included demographics, treatment, survival, recurrence of myocardial infarction (MI), stroke and additional revascularization procedures. Historical data including comorbid factors present at time of NSTEMI and history of revascularization procedures were also collected. RESULTS A total of 357 patients met exclusion criteria. 172 were treated medically and 185 with PCI. A total of 78 deaths occurred over the five year observation period. 48 patients who were treated medically died while 30 patients treated with PCI died. After initial medical management, nine patients went on to require PCI while 19 patients treated with PCI required additional PCI. Recurrence of MI occurred in 19.8 % in medically managed patients and 18.6 % in patients who underwent PCI. Multivariable analysis was completed with the Kaplan-Meier method to estimate the survival function and Cox proportional-hazard models to investigate association between the variables and survival time. CONCLUSIONS In this single center study, diabetic patients treated with PCI had lower rates of all-cause mortality over the five-year study period compared to medical management. There was no difference in stroke events, recurrent MI, or revascularization between the two groups although patients from the PCI group showed a trend towards higher risk for repeat interventions. Treatment selection bias remains the major limitation of this study and thus, the results of the comparison of therapeutic choices should be viewed as hypothesis generating.
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Affiliation(s)
- Alexander B Luizzi
- School of Medicine, Creighton University, Omaha, NE, United States of America
| | - Austin V Le
- School of Medicine, Creighton University, Omaha, NE, United States of America.
| | - Gauravpal S Gill
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE, United States of America
| | - Ryan W Walters
- Department of Clinical Research, School of Medicine, Creighton University, Omaha, NE, United States of America
| | - Michael Del Core
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE, United States of America
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27
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Udell JA, Jones WS, Petrie MC, Harrington J, Anker SD, Bhatt DL, Hernandez AF, Butler J. Sodium Glucose Cotransporter-2 Inhibition for Acute Myocardial Infarction: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:2058-2068. [PMID: 35589167 DOI: 10.1016/j.jacc.2022.03.353] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 12/15/2022]
Abstract
Sodium glucose cotransporter-2 (SGLT2) inhibitors improve cardiorenal outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and chronic heart failure. SGLT2 inhibitors also reduce the risk of cardiovascular mortality and hospitalization for heart failure among patients with type 2 diabetes mellitus and a remote history of myocardial infarction (MI). As a result of the growing body of evidence in diverse disease states, and the hypothesized mechanisms of action, it is reasonable to consider the potential of SGLT2 inhibition to improve outcomes in patients with acute MI as well if initiated early after presentation. Whether these therapies are efficacious and safe to use early in the course of acute coronary heart disease remains relatively unexplored. Here, we describe the contemporary data and continuing evidence gap for considering the use of SGLT2 inhibitors early following an acute MI to reduce cardiovascular morbidity and mortality.
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Affiliation(s)
- Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Josephine Harrington
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; University of Mississippi, Jackson, Mississippi, USA
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28
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Tapias AH, Oliveira GBDF, França JID, Ramos RF. Universal Definition of Myocardial Infarction 99th Percentile versus Diagnostic Cut-off Value of Troponin I for Acute Coronary Syndromes. Arq Bras Cardiol 2022; 118:S0066-782X2022005005201. [PMID: 35544848 PMCID: PMC9345147 DOI: 10.36660/abc.20210191] [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: 03/31/2021] [Revised: 08/18/2021] [Accepted: 09/01/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Contemporary diagnosis of ACS and risk stratification are essential for appropriate management and reduction of mortality and recurrent ischemic events, in the acute phase of disease and after hospitalization. The Universal Definition of Myocardial Infarction recommends the detection of troponin levels above the 99th percentile. OBJECTIVES To evaluate the occurrence of early death and acute myocardial infarction (AMI) in patients without elevation of troponin (<0.034 ng/mL), patients with mild elevation (above the 99th percentile [>0.034 ng/mL and <0.12 ng/mL)], and patients with significant elevation of troponin (above the diagnostic cutoff for AMI defined by the troponin kit (≥0.12 ng/mL)]; and to analyze the impact of troponin on the indication for invasive strategy and myocardial revascularization. METHODS Cross-sectional cohort study of patients with ACS with assessment of peak troponin I, risk score, prospective analysis of 30-day clinical outcomes and two-sided statistical tests, with statistical significance set at p<0.05. RESULTS A total of 494 patients with ACS were evaluated. Troponin > 99th percentile and below the cutoff point, as well as values above the cutoff, were associated with higher incidence of composite endpoint (p<0.01) and higher rates of percutaneous or surgical revascularization procedures (p<0.01), without significative difference in 30-day mortality. CONCLUSIONS Troponin levels above the 99th percentile defined by the universal definition of AMI play a prognostic role and add useful information to the clinical diagnosis and risk scores by identifying those patients who would most benefit from invasive risk stratification and coronary revascularization procedures.
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Affiliation(s)
- Antonio Haddad Tapias
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | | | - João Italo Dias França
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Rui Fernando Ramos
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
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29
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Acute coronary syndromes in diabetic patients, outcome, revascularization, and antithrombotic therapy. Biomed Pharmacother 2022; 148:112772. [PMID: 35245735 DOI: 10.1016/j.biopha.2022.112772] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/21/2022] [Accepted: 02/27/2022] [Indexed: 01/08/2023] Open
Abstract
Diabetes exacerbates the progression of atherosclerosis and is associated with increased risk of developing acute coronary syndrome (ACS). Approximatively 25-30% of patients admitted for ACS have diabetes. ACS occurs earlier in diabetics and is associated with increased mortality and a higher risk of recurrent ischemic events. An increased proinflammatory and prothrombotic state is involved in the poorer outcomes of diabetic patients. In the past decade advancement in both percutaneous coronary intervention (PCI) and coronary artery by-pass graft (CABG) techniques and more potent antiplatelet drugs like prasugrel and ticagrelor improved outcomes of diabetic patients with ACS, but this population still experiences worse outcomes compared to non-diabetic patients. While in ST elevation myocardial infarction urgent PCI is the method of choice for revascularization, in patients with non-ST elevation ACS an early invasive approach is suggested by the guidelines, but in the setting of multivessel (MV) or complex coronary artery disease (CAD) the revascularization strategy is less clear. This review describes the accumulating evidence regarding factors involved in promoting increased incidence and poor prognosis of ACS in patients with diabetes, the evolution over time of prognosis and outcomes, revascularization strategies and antithrombotic therapy studied until now.
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30
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Gulati G, Upshaw J, Wessler BS, Brazil RJ, Nelson J, van Klaveren D, Lundquist CM, Park JG, McGinnes H, Steyerberg EW, Van Calster B, Kent DM. Generalizability of Cardiovascular Disease Clinical Prediction Models: 158 Independent External Validations of 104 Unique Models. Circ Cardiovasc Qual Outcomes 2022; 15:e008487. [PMID: 35354282 PMCID: PMC9015037 DOI: 10.1161/circoutcomes.121.008487] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: While clinical prediction models (CPMs) are used increasingly commonly to guide patient care, the performance and clinical utility of these CPMs in new patient cohorts is poorly understood. Methods: We performed 158 external validations of 104 unique CPMs across 3 domains of cardiovascular disease (primary prevention, acute coronary syndrome, and heart failure). Validations were performed in publicly available clinical trial cohorts and model performance was assessed using measures of discrimination, calibration, and net benefit. To explore potential reasons for poor model performance, CPM-clinical trial cohort pairs were stratified based on relatedness, a domain-specific set of characteristics to qualitatively grade the similarity of derivation and validation patient populations. We also examined the model-based C-statistic to assess whether changes in discrimination were because of differences in case-mix between the derivation and validation samples. The impact of model updating on model performance was also assessed. Results: Discrimination decreased significantly between model derivation (0.76 [interquartile range 0.73–0.78]) and validation (0.64 [interquartile range 0.60–0.67], P<0.001), but approximately half of this decrease was because of narrower case-mix in the validation samples. CPMs had better discrimination when tested in related compared with distantly related trial cohorts. Calibration slope was also significantly higher in related trial cohorts (0.77 [interquartile range, 0.59–0.90]) than distantly related cohorts (0.59 [interquartile range 0.43–0.73], P=0.001). When considering the full range of possible decision thresholds between half and twice the outcome incidence, 91% of models had a risk of harm (net benefit below default strategy) at some threshold; this risk could be reduced substantially via updating model intercept, calibration slope, or complete re-estimation. Conclusions: There are significant decreases in model performance when applying cardiovascular disease CPMs to new patient populations, resulting in substantial risk of harm. Model updating can mitigate these risks. Care should be taken when using CPMs to guide clinical decision-making.
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Affiliation(s)
- Gaurav Gulati
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Jenica Upshaw
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Benjamin S Wessler
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Division of Cardiology, Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W.)
| | - Riley J Brazil
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - David van Klaveren
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.).,Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.)
| | - Christine M Lundquist
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Jinny G Park
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Hannah McGinnes
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.)
| | - Ben Van Calster
- Department of Biomedical Data Sciences, Leiden University Medical Centre, Netherlands (D.v.K., E.W.S., B.V.C.).,KU Leuven, Department of Development and Regeneration, Belgium (B.V.C.).,EPI-Center, KU Leuven, Belgium (B.V.C.)
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA (G.G., J.U., B.S.W., R.J.B., J.N., D.v.K., C.M.L., J.G.P., H.M., D.M.K.)
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31
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Outcomes with revascularization and medical therapy in patients with coronary disease and chronic kidney disease: A meta-analysis. Atherosclerosis 2022; 351:41-48. [DOI: 10.1016/j.atherosclerosis.2022.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 11/28/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022]
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Qiu Z, Li F, Sang H, Liu W, Huang W, Li H, Zhang M, Zhou P, Lei B, Zhou Z, Saver JL, Nogueira RG, Zi W, Yang Q. Endovascular treatment with versus without tirofiban for stroke patients with large vessel occlusion: The multicenter, randomized, placebo-controlled, double-blind RESCUE BT study protocol. Int J Stroke 2022; 17:1151-1155. [PMID: 35083951 DOI: 10.1177/17474930211069510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tirofiban, a glycoprotein IIb/IIIa receptor inhibitor, has been shown to reduce the risk of thrombotic complications during percutaneous coronary intervention. However, it remains unknown whether tirofiban improves outcomes in large vessel occlusion stroke patients undergoing endovascular treatment. OBJECTIVE This trial aims to assess whether additional intravenous tirofiban therapy can improve the clinical outcomes in large vessel occlusion stroke patients who undergo endovascular treatment within 24 h of symptom onset. METHODS AND DESIGN The Endovascular Treatment With versus Without Tirofiban for Stroke Patients With Large Vessel Occlusion (RESCUE BT) Trial is an investigator-initiated, randomized, placebo-controlled, double-blind, multicenter trial. Up to 930 eligible patients will be consecutively randomized to intravenous tirofiban or placebo in 1:1 ratio over 3 years across 50 endovascular-capable stroke centers in China. OUTCOMES The primary end point is the disability level as measured by overall distribution of the 90-day modified Rankin Scale scores. Primary safety end points include symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. TRIAL REGISTRY NUMBER ChiCTR-INR-17014167 (www.chictr.org.cn).
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Affiliation(s)
- Zhongming Qiu
- Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenhua Liu
- Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Wenguo Huang
- Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Huagang Li
- Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Min Zhang
- Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Peiyang Zhou
- Neurology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Bo Lei
- Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Zhiming Zhou
- Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Jeffrey L Saver
- Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, School of Medicine, Emory University, Atlanta, GA, USA
| | - Wenjie Zi
- Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qingwu Yang
- Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Jackson J, Alkhalil M, Ratcovich H, Wilkinson C, Mehran R, Kunadian V. Evidence base for the management of women with non-ST elevation acute coronary syndrome. BRITISH HEART JOURNAL 2022; 108:1682-1689. [DOI: 10.1136/heartjnl-2021-320533] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
According to the Global Burden of Disease study, in 2019, there were an estimated 275.2 million cases of cardiovascular disease (CVD) in women worldwide. Although there was a decrease in the global age-standardised prevalence of CVD in women between 1990 and 2010 (–5.8%), there has been a slight increase (1.0%) since 2010. There were an estimated 6.10 million deaths from CVD in women in 1990, rising to 8.94 million in 2019. Hospital admissions of young women with acute myocardial infarction (AMI) steadily increased from 27% in 1995–1999 to 32% in 2010–2014. Women with AMI compared with men are less likely to receive guideline-indicated pharmacological (aspirin 93.4% vs 94.7%, P2Y12 inhibitors 79.3% vs 86.1% and statins 73.7% vs 77.5%) and revascularisation treatments (angiography (adjusted OR (aOR) 0.71), percutaneous coronary intervention (aOR 0.73)). Women represent <39% of clinical cardiovascular trial participants between 2010 and 2017. Major factors of under-representation in studies included concerns about the burden of participation on health and time. Women were more likely than men to document caring responsibilities as reasons for not participating in a clinical trial. Current clinical practice guidelines recommending risk stratification to guide the appropriateness of an invasive strategy in the context of acute coronary syndrome (ACS) may not be applicable to women given lack of studies specifically evaluating women using contemporary treatment strategies. In our review, we identify significant limitations in the evidence base for the best care of women with ACS, emphasising the need for well-designed clinical trials specifically recruiting women.
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Lin WC, Hsiung MC, Yin WH, Tsao TP, Lai WT, Huang KC. Electrocardiography Score for Left Ventricular Systolic Dysfunction in Non-ST Segment Elevation Acute Coronary Syndrome. Front Cardiovasc Med 2022; 8:764575. [PMID: 35071347 PMCID: PMC8777009 DOI: 10.3389/fcvm.2021.764575] [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: 08/25/2021] [Accepted: 12/07/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Few studies have characterized electrocardiography (ECG) patterns correlated with left ventricular (LV) systolic dysfunction in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). Objectives: This study aims to develop ECG pattern-derived scores to predict LV systolic dysfunction in NSTE-ACS patients. Methods: A total of 466 patients with NSTE-ACS were retrospectively enrolled. LV ejection fraction (LVEF) was assessed by echocardiography within 72 h after the first triage ECG acquisition; there was no coronary intervention in between. ECG score was developed to predict LVEF < 40%. Performance of LVEF, the Global Registry of Acute Coronary Events (GRACE), Thrombolysis in Myocardial Infarction (TIMI) and ECG scores to predict 24-month all-cause mortality were analyzed. Subgroups with varying LVEF, GRACE and TIMI scores were stratified by ECG score to identify patients at high risk of mortality. Results: LVEF < 40% was present in 20% of patients. We developed the PQRST score by multivariate logistic regression, including poor R wave progression, QRS duration > 110 ms, heart rate > 100 beats per min, and ST-segment depression ≥ 1 mm in ≥ 2 contiguous leads, ranging from 0 to 6.5. The score had an area under the curve (AUC) of 0.824 in the derivation cohort and 0.899 in the validation cohort for discriminating LVEF < 40%. A PQRST score ≥ 3 could stratify high-risk patients with LVEF ≥ 40%, GRACE score > 140, or TIMI score ≥ 3 regarding 24-month all-cause mortality. Conclusions: The PQRST score could predict LVEF < 40% in NSTE-ACS patients and identify patients at high risk of mortality in the subgroups of patients with LVEF ≥ 40%, GRACE score > 140 or TIMI score ≥ 3.
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Affiliation(s)
- Wei-Chen Lin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Department of Internal Medicine, Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | | | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tien-Ping Tsao
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Wei-Tsung Lai
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Kuan-Chih Huang
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Section of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- *Correspondence: Kuan-Chih Huang
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Rymer JA, Li S, Pun PH, Thomas L, Wang TY. Racial Disparities in Invasive Management for Patients With Acute Myocardial Infarction With Chronic Kidney Disease. Circ Cardiovasc Interv 2021; 15:e011171. [PMID: 34915722 DOI: 10.1161/circinterventions.121.011171] [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: 11/16/2022]
Abstract
BACKGROUND Due to increased risks of contrast nephropathy, chronic kidney disease (CKD) can deter consideration of invasive management for patients with myocardial infarction (MI). Black patients have a higher prevalence of CKD. Whether racial disparities exist in the use of invasive MI management for patients with CKD presenting with MI is unknown. METHODS We examined 717 012 White and 99 882 Black patients with MI treated from 2008 to 2017 at 914 hospitals in the National Cardiovascular Data Registry Chest Pain-MI Registry. CKD status was defined as estimated glomerular filtration rate (eGFR) ≥90 mL/(min·1.73 m2; no CKD), eGFR <90 but ≥60 (mild), eGFR <60 but ≥30 (moderate), and eGFR <30 or dialysis (severe). We used multivariable logistic regression models to examine the interaction of race and CKD severity in invasive MI management. RESULTS Among those with MI, Black patients were more likely than White patients to have CKD (eGFR <90; 61.4% versus 58.5%; P<0.001). Among those with MI and CKD, Black patients were more likely than White patients to have severe CKD (21.2% versus 12.4%; P<0.001). Patients with CKD were more likely than those without CKD to have diabetes or heart failure; Black patients with CKD were more likely to have these comorbidities when compared with White patients with CKD (all P<0.0001). Black race and CKD were associated with a lower likelihood of invasive management (adjusted odds ratio, 0.78 [95% CI, 0.75-0.81]; adjusted odds ratio, 0.72 [95% CI, 0.70-0.74]; P<0.001 for both). At eGFR levels ≥10, Black patients were significantly less likely than White patients to undergo invasive management. CONCLUSIONS Black patients with MI and mild or moderate CKD were less likely to undergo invasive management compared with White patients with similar CKD severity. National efforts are needed to address racial disparities that may remain in the invasive management of MI.
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Affiliation(s)
- Jennifer A Rymer
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Shuang Li
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Patrick H Pun
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 455] [Impact Index Per Article: 151.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Staples JA, Wiksyk B, Liu G, Desai S, van Walraven C, Sutherland JM. External validation of the modified LACE+, LACE+, and LACE scores to predict readmission or death after hospital discharge. J Eval Clin Pract 2021; 27:1390-1397. [PMID: 33963605 DOI: 10.1111/jep.13579] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. METHODS We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. RESULTS Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. CONCLUSION The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada.,Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada.,Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
| | - Bradley Wiksyk
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Sameer Desai
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Carl van Walraven
- Ottawa Hospital Research Institute (OHRI), Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Jason M Sutherland
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.,Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Nef HM, Achenbach S, Birkemeyer R, Bufe A, Dörr O, Elsässer A, Gaede L, Gori T, Hoffmeister HM, Hofmann FJ, Katus HA, Liebetrau C, Massberg S, Pauschinger M, Schmitz T, Süselbeck T, Voelker W, Wiebe J, Zahn R, Hamm C, Zeiher AM, Möllmann H. Manual der Arbeitsgruppe Interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e.V. (DGK). DER KARDIOLOGE 2021. [DOI: 10.1007/s12181-021-00504-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Kalita B, Saviola AJ, Samuel SP, Mukherjee AK. State-of-the-art review - A review on snake venom-derived antithrombotics: Potential therapeutics for COVID-19-associated thrombosis? Int J Biol Macromol 2021; 192:1040-1057. [PMID: 34656540 PMCID: PMC8514616 DOI: 10.1016/j.ijbiomac.2021.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/03/2021] [Accepted: 10/04/2021] [Indexed: 12/30/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent responsible for the Coronavirus Disease-2019 (COVID-19) pandemic, has infected over 185 million individuals across 200 countries since December 2019 resulting in 4.0 million deaths. While COVID-19 is primarily associated with respiratory illnesses, an increasing number of clinical reports indicate that severely ill patients often develop thrombotic complications that are associated with increased mortality. As a consequence, treatment strategies that target COVID-associated thrombosis are of utmost clinical importance. An array of pharmacologically active compounds from natural products exhibit effects on blood coagulation pathways, and have generated interest for their potential therapeutic applications towards thrombotic diseases. In particular, a number of snake venom compounds exhibit high specificity on different blood coagulation factors and represent excellent tools that could be utilized to treat thrombosis. The aim of this review is to provide a brief summary of the current understanding of COVID-19 associated thrombosis, and highlight several snake venom compounds that could be utilized as antithrombotic agents to target this disease.
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Affiliation(s)
- Bhargab Kalita
- Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; National Centre for Cell Science, Pune 411007, Maharashtra, India
| | - Anthony J Saviola
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Stephen P Samuel
- Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, King's Lynn, Norfolk PE30 4ET, UK
| | - Ashis K Mukherjee
- Department of Molecular Biology and Biotechnology, Tezpur University, Tezpur 784028, Assam, India; Institute of Advanced Study in Science and Technology, Guwahati 781035, Assam, India.
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Hamaya R, Chang YT, Chewcharat A, Chiu N, Yonetsu T, Kakuta T, Papatheodorou S. Comparison of invasive treatment strategies in patients with non–ST elevation acute coronary syndrome: A systematic review and meta-analysis. JTCVS OPEN 2021; 8:323-335. [PMID: 36004105 PMCID: PMC9390253 DOI: 10.1016/j.xjon.2021.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 08/20/2021] [Indexed: 11/24/2022]
Abstract
Objective To compare the mortality associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with non–ST elevation acute coronary syndrome (NSTE-ACS). Methods We searched publications from PubMed, Embase, Web of Science, and the Cochrane Library from inception until December 23, 2020. All randomized clinical trials (RCTs) and observational studies comparing all-cause mortality after treatment with CABG versus PCI for patients with NSTE-ACS with minimum follow-up of 6 months were included. Restricted mean survival time (RMST) differences from RCTs and adjusted RMST differences from observational studies were computed by reconstructing time-to-event data from published Kaplan–Meier curves. Extracted hazard ratios (HRs) were also assessed as a secondary analysis. Results Our systematic review included an individual participant data analysis of 3 RCTs and 8 observational studies. A meta-regression showed a significant association between log-transformed HRs and duration of follow-up (−0.009 [95% confidence interval (CI), −0.002 to −0.016] log-HR per 1-year longer follow-up; P = .037), suggesting a violation of the proportional hazard assumption. Analysis of 6 studies with available RMST data showed a significant inverse association between adjusted RMST differences and cutoff years (slope, −0.028 [95% CI, −0.042 to −0.013] year difference per 1-year longer cutoff; P < .005), suggesting a longer survival benefit in the CABG arm compared with the PCI arm with longer follow-up. Conclusions There was a trend toward a benefit of CABG compared with PCI in the longer follow-up in patients with NSTE-ACS. A large, well-designed RCT with longer follow-up is needed to obtain definitive evidence on this topic.
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Jentzer JC, Rossello X. Past, present, and future of mortality risk scores in the contemporary cardiac intensive care unit. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:940-946. [PMID: 34453848 DOI: 10.1093/ehjacc/zuab072] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 08/09/2021] [Indexed: 12/17/2022]
Abstract
Risk stratification dates to the dawn of the cardiac intensive care unit (CICU). As the CICU has evolved from a dedicated unit caring for patients with acute myocardial infarction to a complex healthcare environment encompassing a broad array of acute and chronic cardiovascular pathology, an expanding array of risk scores are available that can be applied to CICU patients. Most of these scores were designed for use either in patients with a specific acute cardiovascular diagnosis or unselected critically ill patients, and risk scores developed in other populations often underperform in the CICU. More recently, risk scores have been developed specific to the CICU population, demonstrating improved performance. All existing risk scores have relevant limitations, both in terms of performance and applicability to patient care. Risk scores have been predominantly developed to predict short-term mortality, either by quantifying severity of illness or by incorporating other risk factors for mortality. It is essential to distinguish mortality risk attributable to severity of illness, which may be modifiable through intervention, from mortality risk attributable to non-modifiable risk factors. This review discusses established risk scores applicable to the CICU population, details how risk score performance is characterized, describes how new risk scores can be developed, explains how the information provided by risk scores can be used in clinical practice, and highlights how novel risk stratification approaches can be developed.
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Affiliation(s)
- Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Facultad de Medicina, Universitat de les Illes Balears (UIB), Palma de Mallorca, Balearic Islands, Spain.,Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
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Arora S, Jaswaney R, Jani C, Zuzek Z, Thakkar S, Patel M, Panaich SS, Tripathi B, Arora N, Josephson R, Osman MN, Hoit BD, Zidar D, Shishehbor MH. Invasive Approaches in the Management of Cocaine-Associated Non-ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2021; 14:623-636. [PMID: 33736770 DOI: 10.1016/j.jcin.2021.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to determine the impact of invasive approaches and revascularization in patients with cocaine-associated non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND The role of invasive approaches in cocaine-associated NSTEMI is uncertain. METHODS This retrospective cohort study identified 3,735 patients with NSTEMI and history of cocaine use from the Nationwide Readmissions Database from 2016 to 2017. Invasive approaches were defined as coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG). Revascularization was defined as PCI and CABG. The primary efficacy outcome was major adverse cardiac events (MACE), and the primary safety outcome was emergent revascularization. Nonadherence was identified using appropriate International Classification of Diseases-Tenth Revision codes. Two propensity-matched cohorts were generated (noninvasive vs. invasive and noninvasive vs. revascularization) through multivariate logistic regression. RESULTS In the propensity score-matched cohorts, an invasive approach (hazard ratio [HR]: 0.72; 95% confidence interval [CI]: 0.56 to 0.92; p = 0.008) and revascularization (HR: 0.54; 95% CI: 0.40 to 0.73; p < 0.001) (compared with a noninvasive approach) were associated with a lower rate of MACE, without an increase in emergent revascularization. On stratification, PCI and CABG individually were associated with a lower rate of MACE. Emergent revascularization was increased with PCI (HR: 1.78; 95% CI: 1.12 to 2.81; p = 0.014) but not with CABG. Nonadherent patients after PCI and CABG did not have significant difference in rate of MACE. PCI in nonadherent patients was associated with an increase in emergent revascularization (HR: 4.45; 95% CI: 2.07 to 9.57; p < 0.001). CONCLUSIONS Invasive approaches and revascularization for cocaine-associated NSTEMI are associated with lower morbidity. A history of medical nonadherence was not associated with a difference in morbidity but was associated with an increased risk for emergent revascularization with PCI.
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Affiliation(s)
- Shilpkumar Arora
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Rahul Jaswaney
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Chinmay Jani
- Mount Auburn Hospital-Harvard Medical School, Cambridge, Massachusetts, USA
| | - Zachary Zuzek
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Mohini Patel
- Boston University School of Public Health, Boston, Massachusetts, USA
| | | | | | | | - Richard Josephson
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mohammed Najeeb Osman
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Brian D Hoit
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - David Zidar
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA.
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Mehta SR. Achieving Complete Revascularization for Multivessel Coronary Artery Disease. Circulation 2021; 144:110-112. [PMID: 34251888 DOI: 10.1161/circulationaha.120.050379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Ontario, Canada
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Nicolau JC, Feitosa Filho GS, Petriz JL, Furtado RHDM, Précoma DB, Lemke W, Lopes RD, Timerman A, Marin Neto JA, Bezerra Neto L, Gomes BFDO, Santos ECL, Piegas LS, Soeiro ADM, Negri AJDA, Franci A, Markman Filho B, Baccaro BM, Montenegro CEL, Rochitte CE, Barbosa CJDG, Virgens CMBD, Stefanini E, Manenti ERF, Lima FG, Monteiro Júnior FDC, Correa Filho H, Pena HPM, Pinto IMF, Falcão JLDAA, Sena JP, Peixoto JM, Souza JAD, Silva LSD, Maia LN, Ohe LN, Baracioli LM, Dallan LADO, Dallan LAP, Mattos LAPE, Bodanese LC, Ritt LEF, Canesin MF, Rivas MBDS, Franken M, Magalhães MJG, Oliveira Júnior MTD, Filgueiras Filho NM, Dutra OP, Coelho OR, Leães PE, Rossi PRF, Soares PR, Lemos Neto PA, Farsky PS, Cavalcanti RRC, Alves RJ, Kalil RAK, Esporcatte R, Marino RL, Giraldez RRCV, Meneghelo RS, Lima RDSL, Ramos RF, Falcão SNDRS, Dalçóquio TF, Lemke VDMG, Chalela WA, Mathias Júnior W. Brazilian Society of Cardiology Guidelines on Unstable Angina and Acute Myocardial Infarction without ST-Segment Elevation - 2021. Arq Bras Cardiol 2021; 117:181-264. [PMID: 34320090 PMCID: PMC8294740 DOI: 10.36660/abc.20210180] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- José Carlos Nicolau
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Gilson Soares Feitosa Filho
- Escola Bahiana de Medicina e Saúde Pública, Salvador, BA - Brasil
- Centro Universitário de Tecnologia e Ciência (UniFTC), Salvador, BA - Brasil
| | - João Luiz Petriz
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
| | | | | | - Walmor Lemke
- Clínica Cardiocare, Curitiba, PR - Brasil
- Hospital das Nações, Curitiba, PR - Brasil
| | | | - Ari Timerman
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | - José A Marin Neto
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Ribeirão Preto, SP - Brasil
| | | | - Bruno Ferraz de Oliveira Gomes
- Hospital Barra D'Or, Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração (HCor), São Paulo, SP - Brasil
- Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Edson Stefanini
- Escola Paulista de Medicina da Universidade Federal de São Paulo (UNIFESP), São Paulo, SP - Brasil
| | | | - Felipe Gallego Lima
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | - José Maria Peixoto
- Universidade José do Rosário Vellano (UNIFENAS), Belo Horizonte, MG - Brasil
| | - Juliana Ascenção de Souza
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Lilia Nigro Maia
- Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP - Brasil
| | | | - Luciano Moreira Baracioli
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luís Alberto de Oliveira Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Luis Augusto Palma Dallan
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Luiz Carlos Bodanese
- Pontifícia Universidade Católica do Rio Grande do Sul (PUC-RS), Porto Alegre, RS - Brasil
| | | | | | - Marcelo Bueno da Silva Rivas
- Rede D'Or São Luiz, Rio de Janeiro, RJ - Brasil
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Múcio Tavares de Oliveira Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Nivaldo Menezes Filgueiras Filho
- Universidade do Estado da Bahia (UNEB), Salvador, BA - Brasil
- Universidade Salvador (UNIFACS), Salvador, BA - Brasil
- Hospital EMEC, Salvador, BA - Brasil
| | - Oscar Pereira Dutra
- Instituto de Cardiologia - Fundação Universitária de Cardiologia do Rio Grande do Sul, Porto Alegre, RS - Brasil
| | - Otávio Rizzi Coelho
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP - Brasil
| | | | | | - Paulo Rogério Soares
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - Roberto Esporcatte
- Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Talia Falcão Dalçóquio
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - William Azem Chalela
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Wilson Mathias Júnior
- Instituto do Coração (InCor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GC. Guía ESC 2020 sobre el diagnóstico y tratamiento del síndrome coronario agudo sin elevación del segmento ST. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sabatine MS, Braunwald E. Thrombolysis In Myocardial Infarction (TIMI) Study Group: JACC Focus Seminar 2/8. J Am Coll Cardiol 2021; 77:2822-2845. [PMID: 34082913 DOI: 10.1016/j.jacc.2021.01.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 01/14/2023]
Abstract
In 1984, the National Heart, Lung, and Blood Institute (NHLBI) decided to study the efficacy and safety of the treatment of acute myocardial infarction with an emerging therapy, coronary thrombolysis, and thus the TIMI (Thrombolysis In Myocardial Infarction) Study Group was born. Following completion of 3 clinical trials of thrombolytic therapy supported by the NHLBI, TIMI became an academic research organization headquartered at Brigham and Women's Hospital and subsequently branched out to study a wide range of patients, including those with stable coronary, cerebrovascular, and peripheral arterial disease; dyslipidemia; heart failure; atrial fibrillation; diabetes; and obesity. TIMI also began to study a wide range of interventions including thrombolytic, antithrombotic, lipid-modifying, anti-inflammatory, heart failure, glucose-lowering, and weight loss agents. TIMI, now in its 37th year, has completed >70 trials. This review describes the origins of the TIMI Study Group, summarizes several of its completed trials and the major lessons learned from them, and discusses ongoing trials and future directions.
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Affiliation(s)
- Marc S Sabatine
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.
| | - Eugene Braunwald
- TIMI (Thrombolysis In Myocardial Infarction) Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, and Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Haghbayan H, Gale CP, Chew DP, Brieger D, Fox KA, Goodman SG, Yan AT. Clinical risk prediction models for the prognosis and management of acute coronary syndromes. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 7:222-228. [PMID: 33693493 DOI: 10.1093/ehjqcco/qcab018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/04/2021] [Indexed: 06/12/2023]
Abstract
Patients with acute coronary syndromes (ACS), particularly non-ST-segment elevation ACS, represent a spectrum of patients at variable risk of short- and long-term adverse clinical outcomes. Accurate prognostic assessment in this population requires the simultaneous consideration of multiple clinical and laboratory variables which may be under-recognized by the treating physicians, leading to an observed risk-treatment paradox in the use of invasive and pharmacological therapies. The routine application of established clinical risk scores, such as the Global Registry of Acute Coronary Events risk score, is recommended by major international clinical practice guidelines for structured risk stratification at the time of presentation, but uptake remains inconsistent. This article discusses the methodology of designing, deriving, and validating clinical risk scores, reviews the major validated risk scores for assessing prognosis in ACS, and examines their role in guiding clinical decision-making in ACS management, especially the timing of invasive coronary angiography. We also discuss emerging data on the impact of the routine use of such risk scores on patient management and clinical outcomes, as well as future directions for investigation in this field.
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Affiliation(s)
- Hourmazd Haghbayan
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
| | - Chris P Gale
- School of Medicine, Faculty of Medicine and Health, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - David Brieger
- Faculty of Medicine and Health, Concord Hospital, University of Sydney, Sydney,NSW 2050 Australia
| | - Keith A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Shaun G Goodman
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
| | - Andrew T Yan
- Division of Cardiology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto M5B 1W8,Ontario, Canada
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Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, Dendale P, Dorobantu M, Edvardsen T, Folliguet T, Gale CP, Gilard M, Jobs A, Jüni P, Lambrinou E, Lewis BS, Mehilli J, Meliga E, Merkely B, Mueller C, Roffi M, Rutten FH, Sibbing D, Siontis GCM. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2021; 42:1289-1367. [PMID: 32860058 DOI: 10.1093/eurheartj/ehaa575] [Citation(s) in RCA: 2554] [Impact Index Per Article: 851.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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50
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Reynolds MR, Gong T, Li S, Herzog CA, Charytan DM. Cost-Effectiveness of Coronary Artery Bypass Grafting and Percutaneous Coronary Intervention in Patients With Chronic Kidney Disease and Acute Coronary Syndromes in the US Medicare Program. J Am Heart Assoc 2021; 10:e019391. [PMID: 33787323 PMCID: PMC8174359 DOI: 10.1161/jaha.120.019391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/24/2021] [Indexed: 01/24/2023]
Abstract
Background Coronary revascularization provides important long-term clinical benefits to patients with high-risk presentations of coronary artery disease, including those with chronic kidney disease. The cost-effectiveness of coronary interventions in this setting is not known. Methods and Results We developed a Markov cohort simulation model to assess the cost-effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease who were hospitalized with acute myocardial infarction or unstable angina. Model inputs were primarily drawn from a sample of 14 300 patients identified using the Medicare 20% sample. Survival, quality-adjusted life-years, costs, and cost-effectiveness were projected over a 20-year time horizon. Multivariable models indicated higher 30-day mortality and end-stage renal disease with both PCI and CABG, and higher stroke with CABG, relative to medical therapy. However, the model projected long-term gains of 0.72 quality-adjusted life-years (0.97 life-years) for PCI compared with medical therapy, and 0.93 quality-adjusted life-years (1.32 life-years) for CABG compared with PCI. Incorporation of long-term costs resulted in incremental cost-effectiveness ratios of $65 326 per quality-adjusted life-year gained for PCI versus medical therapy, and $101 565 for CABG versus PCI. Results were robust to changes in input parameters but strongly influenced by the background costs of the population, and the time horizon. Conclusions For patients with chronic kidney disease and high-risk coronary artery disease presentations, PCI and CABG were both associated with markedly increased costs as well as gains in quality-adjusted life expectancy, with incremental cost-effectiveness ratios indicating intermediate value in health economic terms.
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Affiliation(s)
- Matthew R. Reynolds
- Lahey Hospital & Medical CenterBurlingtonMA
- Baim Institute for Clinical ResearchBostonMA
| | - Tingting Gong
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Shuling Li
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
| | - Charles A. Herzog
- Chronic Disease Research GroupHennepin Healthcare Research InstituteMinneapolisMN
- Department of MedicineHennepin Healthcare and University of MinnesotaMinneapolisMN
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