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Baker D, Cruddas L, Eveson T, Bakhai A, Penge J. Patient Acceptance and Adherence to the COMPASS Trial Drug Recommendations Following Symptomatic Carotid Endarterectomy. Ann Vasc Surg 2024; 108:403-409. [PMID: 39009129 DOI: 10.1016/j.avsg.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The COMPASS trial demonstrated that in patients with atherosclerotic diseases, low-dose rivaroxaban and aspirin provides greater protection against subsequent major adverse cardiovascular events (MACEs) than mono-antiplatelet therapy (MAPT) alone. Drug acceptance and adherence maximizes this benefit. We have assessed drug acceptance and adherence to the COMPASS drug regime in patients following carotid endarterectomy (CEA) for symptomatic carotid artery stenosis. METHODS Following CEA, the views of 63 patients on the COMPASS drug regime were assessed using the Beliefs about Medicine Questionnaire and drug adherence was determined using the Sidorkiewicz scoring system. These views were compared with those of 54 patients on MAPT. Side effects (bleeding and drug reactions) and new MACE were recorded. RESULTS Post-CEA patients on the COMPASS drug regimen had strong positive views on the necessity to take these drugs (necessity scale 19.6 ± 3.6). Although there were some concerns about the COMPASS drug regimen, these were not strongly held (concern cscale 11.8 ± 4.9) and the necessity-concerns differential was positive (7.8 ± 6.2). The Drug Adherence Score was "High" to "Good" (level of drug adherence 1.7 ± 1.0). The Beliefs about Medicine Questionnaire scales and Drug Adherence Score of post-CEA patients on the COMPASS drug regimen were similar to those on MAPT. The incidence of post-CEA MACE and side effects were similar for those on the COMPASS drug regimen and MAPT. CONCLUSIONS Post-CEA patients on the COMPASS drug regimen had positive views on taking the drugs and drug adherence was high. We did not identify any patient-related barriers to the use of the COMPASS drug regimen to further reduce cardiovascular events.
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Affiliation(s)
- Daryll Baker
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK; Vascular Surgery Service, The National Hospital for Neurology and, Neurosurgery, University College Hospitals NHS Foundation Trust, London, UK; UCL Division of Medicine, Royal Free Campus, University College London, London, UK.
| | - Lucinda Cruddas
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK; UCL Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Tom Eveson
- Department of Vascular Surgery, Royal Free London NHS Foundation, Trust, London, UK
| | - Ameet Bakhai
- UCL Division of Medicine, Royal Free Campus, University College London, London, UK; Department of Cardiology, Royal Free London NHS Foundation Trust, London, UK
| | - Justin Penge
- UCL Division of Medicine, Royal Free Campus, University College London, London, UK; Department of Stroke Medicine, Royal Free London NHS Foundation Trust, London, UK
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2
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Bastian-Pétrel K, Rohmann JL, Oertelt-Prigione S, Piccininni M, Gayraud K, Kelly-Irving M, Bajos N. Sex and gender bias in chronic coronary syndromes research: analysis of studies used to inform the 2019 European Society of Cardiology guidelines. THE LANCET REGIONAL HEALTH. EUROPE 2024; 45:101041. [PMID: 39279866 PMCID: PMC11402417 DOI: 10.1016/j.lanepe.2024.101041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 09/18/2024]
Abstract
Background Sex and gender inequalities in ischemic heart diseases persist. Although ischemic heart disease is less common in women, they experience worse clinical outcomes and are less likely to receive guideline-recommended treatments. The primary scientific literature from which clinical guideline recommendations are derived may not have considered potential sex- and gender biases. This study aims to determine whether the literature cited in recent cardiovascular guidelines' clinical recommendations contain sex and gender biases. Methods We analysed publications cited in the 2019 European Society of Cardiology (ESC) guideline recommendations on chronic coronary syndromes, using a checklist to guide data extraction and evaluate the individual studies for sex- and gender-related aspects, such as inclusion/exclusion criteria, outcome measures, and demographic data reporting. To assess representation over time, the proportion of women participants in each study was computed and analysed using a beta regression model. We also examined the associations between women's representation, journal impact factor and author gender. Findings Among the 20 ESC recommendations on chronic coronary syndromes, four contained sex-related statements; we did not identify any gender-specific suggestions. The referenced literature upon which these recommendations were based consisted of 108 articles published between 1991 and 2019, encompassing more than 1.6 million study participants (26.8%; 432,284 women). Only three studies incorporated sex-sensitive designs; none were gender-specific. The term "gender" did not occur in 84% (n = 91/108) of the publications; when used, it was exclusively to denote biological sex. The proportion of women (assumed by investigators) among study participants fluctuated over time. Having a woman as first (odds ratio (OR) = 1.68, 95% CI: 1.19-2.39) or last author (OR = 2.28, 95% CI: 1.31-3.97), was significantly associated with having more women participants in the study. Interpretation The data underlying ESC guideline recommendations largely lack reporting of possible sex- and gender-specific aspects, and women are distinctly underrepresented. To what extent these recommendations apply to members of specific population groups who are not well-represented in the underlying evidence base remains unknown. Funding This study is part of the Gender and Health Inequalities (GENDHI) project, ERC-2019-SyG. This project has received funding from the European Research Council (ERC).
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Affiliation(s)
- Kathleen Bastian-Pétrel
- CERPOP-UMR1295, Université de Toulouse III, UPS, Inserm, Toulouse, France
- Institut de Recherche Interdisciplinaire sur les enjeux Sociaux - Sciences Sociales, Politique, Santé, IRIS (UMR 8156 CNRS - EHESS - U997 INSERM), Aubervilliers, France
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L Rohmann
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sabine Oertelt-Prigione
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
- AG 10 Sex- and Gender-Sensitive Medicine, Medical Faculty OWL, University of Bielefeld, Bielefeld, Germany
| | - Marco Piccininni
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Katja Gayraud
- Department of Aviation and Space Psychology, Institute of Aerospace Medicine, German Aerospace Center (DLR), Hamburg, Germany
| | | | - Nathalie Bajos
- Institut de Recherche Interdisciplinaire sur les enjeux Sociaux - Sciences Sociales, Politique, Santé, IRIS (UMR 8156 CNRS - EHESS - U997 INSERM), Aubervilliers, France
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Lin DSH, Wu HP, Chung WJ, Hsueh SK, Hsu PC, Lee JK, Chen CC, Huang HL. Dual Antithrombotic Therapy versus Anticoagulant Monotherapy for Major Adverse Limb Events in Patients with Concomitant Lower Extremity Arterial Disease and Atrial Fibrillation: A Propensity Score Weighted Analysis. Eur J Vasc Endovasc Surg 2024; 68:498-507. [PMID: 38754724 DOI: 10.1016/j.ejvs.2024.05.015] [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: 09/29/2023] [Revised: 03/18/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE Patients with symptomatic lower extremity arterial disease (LEAD) are recommended to receive antiplatelet therapy, while direct oral anticoagulants (DOACs) are standard for stroke prevention in patients with atrial fibrillation (AF). For patients with concomitant LEAD and AF, data comparing dual antithrombotic therapy (an antiplatelet agent used in conjunction with a DOAC) vs. DOAC monotherapy are scarce. This retrospective cohort study, based on data from the Taiwan National Health Insurance Research Database, aimed to compare the efficacy and safety of these antithrombotic strategies. METHODS Patients with AF who underwent revascularisation for LEAD between 2012 - 2020 and received any DOAC within 30 days of discharge were included. Patients were grouped by antiplatelet agent exposure into the dual antithrombotic therapy and DOAC monotherapy groups. Inverse probability of treatment weighting was used to mitigate selection bias. Major adverse limb events (MALEs), ischaemic stroke or systemic embolism, and bleeding outcomes were compared. Patients were followed until the occurrence of any study outcome, death, or up to two years. RESULTS A total of 1 470 patients were identified, with 736 in the dual antithrombotic therapy group and 734 in the DOAC monotherapy group. Among them, 1 346 patients received endovascular therapy as the index revascularisation procedure and 124 underwent bypass surgery. At two years, dual antithrombotic therapy was associated with a higher risk of MALEs than DOAC monotherapy (subdistribution hazard ratio [SHR] 1.34, 95% confidence interval [CI] 1.15 - 1.56), primarily driven by increased repeat revascularisation. Dual antithrombotic therapy was also associated with a higher risk of major bleeding (SHR 1.43, 95% CI 1.05 - 1.94) and gastrointestinal bleeding (SHR 2.17, 95% CI 1.42 - 3.33) than DOAC monotherapy. CONCLUSION In patients with concomitant LEAD and AF who underwent peripheral revascularisation, DOAC monotherapy was associated with a lower risk of MALEs and bleeding events than dual antithrombotic therapy.
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Affiliation(s)
- Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsu-Ping Wu
- Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital Hsinchu Branch, Hsinchu, Taiwan
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Kai Hsueh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Cardiovascular Centre, National Taiwan University Hospital, Taipei, Taiwan; Telehealth Centre, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chun-Chi Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan; School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan
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Mazzone PM, Spagnolo M, Capodanno D. Antithrombotic Therapy in Patients with Chronic Coronary Syndromes. Interv Cardiol Clin 2024; 13:493-505. [PMID: 39245549 DOI: 10.1016/j.iccl.2024.06.004] [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] [Indexed: 09/10/2024]
Abstract
The antithrombotic management of chronic coronary syndrome (CCS) involves a 6-month course of dual antiplatelet therapy (DAPT), followed by chronic aspirin therapy. In patients with a baseline indication for anticoagulation, a variable duration of triple antithrombotic therapy is administered, followed by dual antithrombotic therapy until the sixth month post-percutaneous coronary intervention (PCI), and ultimately a transition to chronic anticoagulation. However, advancements in stent technology reducing the risk of stent thrombosis and a growing focus on the impact of bleeding on prognosis have prompted the development of new therapeutic strategies. These strategies aim to enhance protection against ischemic events in the initial stages after PCI while mitigating the risk of bleeding in the long term. This article delineates the therapeutic strategies outlined in European and American guidelines for CCS management, with special attention to investigational strategies.
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Affiliation(s)
- Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco" University of Catania, Via Santa Sofia, 78, Catania 95123, Italy.
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Abumoawad A, Okazaki RA, Behrooz L, Eberhardt RT. Medical Optimization of Patients with Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2024; 107:170-180. [PMID: 38582206 DOI: 10.1016/j.avsg.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/03/2024] [Indexed: 04/08/2024]
Abstract
Peripheral artery disease (PAD) is a progressive disease associated with the occurrence of major adverse cardiovascular and limb events and elevated mortality rates. Symptoms of PAD, including claudication and chronic limb-threatening ischemia, impair functional capacity and lead to lower quality of life. The focus of current therapies is to minimize symptoms, improve quality of life, and reduce adverse cardiovascular and limb events. Among the medical therapies are antiplatelets, anticoagulants, antihypertensives, lipid lowering therapies, cilostazol and pentoxifylline, and novel blood sugar-lowering therapies, plus exercise therapy and smoking cessation. In this review, we discuss these evidence-based medical therapies that are available for patients with symptomatic PAD.
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Affiliation(s)
| | - Ross A Okazaki
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Leili Behrooz
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Robert T Eberhardt
- Evans Department of Medicine/Section of Cardiovascular Medicine and Whitaker Cardiovascular Institute, Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
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Zwart B, Claessen BEPM, Damman P, Woudstra P, Vink MA, Balder JW, Dickinson MG, Badings EA, Appelman Y, van 't Hof AWJ, Ten Berg JM, Arslan F. 2023 European Society of Cardiology guidelines for the management of acute coronary syndromes : Statement of endorsement by the NVVC. Neth Heart J 2024; 32:338-345. [PMID: 39254829 DOI: 10.1007/s12471-024-01896-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2024] [Indexed: 09/11/2024] Open
Abstract
This review discusses the new recommendations in the 2023 European Society of Cardiology guidelines on the management of acute coronary syndrome and provides a perspective on topics specific to clinical practice in the Netherlands, including pre-treatment, antiplatelet agent strategies, the use of risk scores and logistical considerations with regard to the timing of coronary angiography.
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Affiliation(s)
- Bastiaan Zwart
- University Medical Centre Groningen, Groningen, The Netherlands.
| | | | - Peter Damman
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pier Woudstra
- Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | | | | | | | | | | | - Arnoud W J van 't Hof
- Maastricht University Medical Centre, Maastricht, The Netherlands
- Zuyderland MC, Heerlen, The Netherlands
| | - Jurriën M Ten Berg
- Maastricht University Medical Centre, Maastricht, The Netherlands
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Fatih Arslan
- Leiden University Medical Centre, Leiden, The Netherlands
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7
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Harm T, Lydia Mueller KA, Geisler T. Regulation of Platelet Activation and Coagulation: Current Concepts, Novel Targets, and Therapies. Interv Cardiol Clin 2024; 13:451-467. [PMID: 39245546 DOI: 10.1016/j.iccl.2024.06.001] [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] [Indexed: 09/10/2024]
Abstract
Antiplatelet and anticoagulant therapies are cornerstones of secondary prevention in high-risk cardiovascular patients. Whereas in former days the focus was set on effective antithrombotic effects, more recent trials and guidelines placed emphasis on a more balanced approach, thus including the bleeding risk for an individualized therapy. Type, strength, combination, and duration are important components to modify the individual bleeding risk. Novel antiplatelet and anticoagulant agents have shown promising results that might offer safer options in the future for high-risk cardiovascular patients. This review aims to give an overview about established drug target and pharmacologic approaches that are currently in the pipeline.
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Affiliation(s)
- Tobias Harm
- Department of Cardiology and Angiology, University Hospital Tübingen, Germany
| | | | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Germany.
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8
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Zhu A, Rajendran S, Hajian H, Aitken S. Patient Factors Influencing Prescription of Antithrombotic Medication After Lower Limb Endovascular Intervention. Eur J Vasc Endovasc Surg 2024; 68:510-518. [PMID: 38802038 DOI: 10.1016/j.ejvs.2024.05.034] [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: 11/27/2023] [Revised: 04/21/2024] [Accepted: 05/22/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE There is significant practice variation in the use of antithrombotic therapy after endovascular intervention for lower limb peripheral arterial disease, with differences in medication choice and duration. Prescriber decision making is complex, and patient factors have been shown to substantially contribute to prescribing variation. To determine the influence of patient factors on antithrombotic prescribing, a discrete choice experiment was distributed to vascular surgeons and trainees across Australia and Aotearoa New Zealand. METHODS After pilot testing, the discrete choice experiment questionnaire was distributed to 300 vascular surgeons and trainee members of the Australian and New Zealand Society for Vascular Surgery. Multinomial logistic regression models were used to analyse patient factors that had the most influence on decisions to prescribe a second antithrombotic agent, and the preferred choice of antithrombotic (clopidogrel 75 mg daily or rivaroxaban 2.5 mg twice daily) in addition to aspirin 100 mg daily. The odds ratio (OR) with 95% confidence interval (CI) reported preference strength. RESULTS A total of 44 questionnaires were completed between September and October 2023, reaching the 15% targeted response rate. Prescribing a second antithrombotic was more likely after femoropopliteal stenting compared with angioplasty (OR 1.89, 95% CI 1.20 - 2.13), and in chronic limb threatening ischaemia compared with intermittent claudication (OR 1.58, 95% CI 1.20 - 2.13). Most respondents preferred clopidogrel over rivaroxaban (62%), with over a third of respondents exclusively prescribing clopidogrel. Patients with stents (OR 1.77, 95% CI 1.32 - 2.37) or moderate bleeding risk (OR 1.38, 95% CI 0.97 - 1.84) were more likely to receive clopidogrel than rivaroxaban. CONCLUSION This study demonstrates that vascular surgeons primarily prioritise antithrombotic prescribing decisions by procedure type. Clopidogrel is more likely to be prescribed than rivaroxaban as a second agent in combination with aspirin, especially after stenting. Knowing these clinician preferences can target implementation strategies towards supporting decision making in subgroups of patients according to individual risk profiles.
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Affiliation(s)
- Alison Zhu
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia.
| | - Saissan Rajendran
- Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia
| | - Hamid Hajian
- Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia
| | - Sarah Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; Department of Vascular Surgery, Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Concord West, NSW, Australia; Centre for PAD Research, Heart Research Institute, Camperdown, NSW, Australia
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9
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Handelsman Y, Anderson JE, Bakris GL, Ballantyne CM, Bhatt DL, Bloomgarden ZT, Bozkurt B, Budoff MJ, Butler J, Cherney DZI, DeFronzo RA, Del Prato S, Eckel RH, Filippatos G, Fonarow GC, Fonseca VA, Garvey WT, Giorgino F, Grant PJ, Green JB, Greene SJ, Groop PH, Grunberger G, Jastreboff AM, Jellinger PS, Khunti K, Klein S, Kosiborod MN, Kushner P, Leiter LA, Lepor NE, Mantzoros CS, Mathieu C, Mende CW, Michos ED, Morales J, Plutzky J, Pratley RE, Ray KK, Rossing P, Sattar N, Schwarz PEH, Standl E, Steg PG, Tokgözoğlu L, Tuomilehto J, Umpierrez GE, Valensi P, Weir MR, Wilding J, Wright EE. DCRM 2.0: Multispecialty practice recommendations for the management of diabetes, cardiorenal, and metabolic diseases. Metabolism 2024; 159:155931. [PMID: 38852020 DOI: 10.1016/j.metabol.2024.155931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/10/2024]
Abstract
The spectrum of cardiorenal and metabolic diseases comprises many disorders, including obesity, type 2 diabetes (T2D), chronic kidney disease (CKD), atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), dyslipidemias, hypertension, and associated comorbidities such as pulmonary diseases and metabolism dysfunction-associated steatotic liver disease and metabolism dysfunction-associated steatohepatitis (MASLD and MASH, respectively, formerly known as nonalcoholic fatty liver disease and nonalcoholic steatohepatitis [NAFLD and NASH]). Because cardiorenal and metabolic diseases share pathophysiologic pathways, two or more are often present in the same individual. Findings from recent outcome trials have demonstrated benefits of various treatments across a range of conditions, suggesting a need for practice recommendations that will guide clinicians to better manage complex conditions involving diabetes, cardiorenal, and/or metabolic (DCRM) diseases. To meet this need, we formed an international volunteer task force comprising leading cardiologists, nephrologists, endocrinologists, and primary care physicians to develop the DCRM 2.0 Practice Recommendations, an updated and expanded revision of a previously published multispecialty consensus on the comprehensive management of persons living with DCRM. The recommendations are presented as 22 separate graphics covering the essentials of management to improve general health, control cardiorenal risk factors, and manage cardiorenal and metabolic comorbidities, leading to improved patient outcomes.
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Affiliation(s)
| | | | | | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Zachary T Bloomgarden
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Biykem Bozkurt
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - David Z I Cherney
- Division of Nephrology, Department of Medicine, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | | | - Stefano Del Prato
- Interdisciplinary Research Center "Health Science", Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Robert H Eckel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Francesco Giorgino
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | | | - Jennifer B Green
- Division of Endocrinology, Metabolism, and Nutrition, Duke University School of Medicine, Durham, NC, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Per-Henrik Groop
- Department of Nephrology, University of Helsinki, Finnish Institute for Health and Helsinki University HospitalWelfare, Folkhälsan Research Center, Helsinki, Finland; Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia
| | - George Grunberger
- Grunberger Diabetes Institute, Bloomfield Hills, MI, USA; Wayne State University School of Medicine, Detroit, MI, USA; Oakland University William Beaumont School of Medicine, Rochester, MI, USA; Charles University, Prague, Czech Republic
| | | | - Paul S Jellinger
- The Center for Diabetes & Endocrine Care, University of Miami Miller School of Medicine, Hollywood, FL, USA
| | | | - Samuel Klein
- Washington University School of Medicine, Saint Louis, MO, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | | | - Norman E Lepor
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Chantal Mathieu
- Department of Endocrinology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Christian W Mende
- University of California San Diego School of Medicine, La Jolla, CA, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Javier Morales
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, Advanced Internal Medicine Group, PC, East Hills, NY, USA
| | - Jorge Plutzky
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | - Peter E H Schwarz
- Department for Prevention and Care of Diabetes, Faculty of Medicine Carl Gustav Carus at the Technische Universität/TU Dresden, Dresden, Germany
| | - Eberhard Standl
- Munich Diabetes Research Group e.V. at Helmholtz Centre, Munich, Germany
| | - P Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, AP-HP, Hôpital Bichat, Cardiology, Paris, France
| | | | - Jaakko Tuomilehto
- University of Helsinki, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Paul Valensi
- Polyclinique d'Aubervilliers, Aubervilliers and Paris-Nord University, Paris, France
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John Wilding
- University of Liverpool, Liverpool, United Kingdom
| | - Eugene E Wright
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Kang J, Park SH, Park KW, Koo BK, Lee H, Han M, Hwang D, Yang HM, Chae IH, Shin WY, Oh JH, Kim YH, Park TH, Kim BS, Han JK, Shin ES, Kim HS. Clopidogrel Versus Aspirin as Chronic Maintenance Antiplatelet Monotherapy in Patients After Percutaneous Coronary Intervention With Chronic Kidney Disease: A Post Hoc Analysis of the HOST-EXAM Trial. J Am Heart Assoc 2024; 13:e035269. [PMID: 39248265 DOI: 10.1161/jaha.124.035269] [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: 02/29/2024] [Accepted: 08/08/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Clopidogrel monotherapy improved clinical outcomes compared with aspirin monotherapy during a chronic maintenance period in patients who underwent coronary stenting in the HOST-EXAM (Harmonizing Optimal Strategy for Treatment of Coronary Artery Stenosis-Extended Antiplatelet Monotherapy) trial. However, it is uncertain whether the beneficial effect of clopidogrel over aspirin is different according to the renal function. METHODS AND RESULTS We conducted a post hoc analysis of the HOST-EXAM trial. Chronic kidney disease (CKD) was defined as baseline estimated glomerular filtration rate <60 mL/min per 1.73 m2. The primary end point was a composite of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and Bleeding Academic Research Consortium bleeding type ≥3, during the 2-year follow up. Among the 5438 patients enrolled in the HOST-EXAM trial, 4844 patients (mean age, 63.3±10.6 years; 74.9% men) with a baseline creatinine value were analyzed in this study. A total of 508 (10.5%) patients had CKD, who were at higher risk of the primary end point compared with those without CKD (hazard ratio [HR], 2.01 [95% CI, 1.51-2.67]). Clopidogrel monotherapy was associated with a lower rate of the primary end point in both patients with CKD (HR, 0.74 [95% CI, 0.44-1.25]) and patients without CKD (HR, 0.71 [95% CI, 0.56-0.91]). No significant interaction was observed between the treatment effect and CKD status (P for interaction=0.889). CONCLUSIONS During the chronic maintenance period after coronary stenting, the risk of thrombotic and bleeding events was significantly higher in patients with CKD compared with those without CKD. There was no statistical difference in the treatment effect of clopidogrel monotherapy in those with versus without CKD.
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Affiliation(s)
- Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Sang-Hyeon Park
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Huijin Lee
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Minju Han
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Doyeon Hwang
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - In-Ho Chae
- Department of Internal Medicine Seoul National University Bundang Hospital Seongnam South Korea
| | - Won-Yong Shin
- Department of Internal Medicine Soonchunhyang University Cheonan Hospital Cheonan South Korea
| | - Ju Hyeon Oh
- Department of Cardiology, Samsung Changwon Hospital Sungkyunkwan University School of Medicine Changwon South Korea
| | - Yong Hoon Kim
- Department of Internal Medicine Kangwon National University School of Medicine Chuncheon South Korea
| | - Tae-Ho Park
- Department of Internal Medicine Dong-A University Hospital Busan South Korea
| | - Bum Soo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital Sungkyunkwan University Seoul South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Eun-Seok Shin
- Department of Internal Medicine Ulsan University Hospital Ulsan South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center Seoul National University Hospital Seoul South Korea
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Moreau M, Auger S, Picard P, Lacoursière J, Segura PA. Development and validation of an ultrafast method of quantification of rivaroxaban in human serum using laser diode thermal desorption coupled to triple quadrupole mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2024; 38:e9855. [PMID: 38988294 DOI: 10.1002/rcm.9855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 05/13/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024]
Abstract
RATIONALE Rivaroxaban is an anticoagulant prescribed to patients who are at risk of medical conditions such as deep-vein thrombosis, pulmonary embolisms, and strokes caused by blood clots. The administration of this drug is monitored to adjust the dosage and evaluate patients' blood concentration. Rapid quantification of this drug in plasma could make it possible to ensure that the dose present in the blood of patients does not represent a danger for the medical intervention to be carried out. METHODS Liquid chromatography-tandem mass spectrometry is usually employed to quantify rivaroxaban in blood, plasma, and serum. Here, an alternative method of analysis based on laser diode thermal desorption-triple quadrupole mass spectrometry (LDTD-QqQMS) was developed and comprehensively validated. This new method allows the quantification of rivaroxaban in less than 13 s from sample to sample. The extraction of rivaroxaban in human serum was done by a salting-out liquid-liquid extraction with acetonitrile and a saturated sodium chloride solution. RESULTS The proposed method allows the quantification of rivaroxaban in less than 13 s from sample to sample. During validation, all criteria were respected. The accuracy was <15% of the nominal value, the precision was <15%CV, and the recovery was ≥89.9%. There were no observed carryover or matrix effects. Analysis of the extracted samples established the stability of dry (24 h) and wet samples (1 week) when samples cannot be analyzed immediately, a considerable advantage in a clinical setting. CONCLUSIONS This method improves sample throughput by more than 1200% compared to liquid chromatography-tandem mass spectrometry methods of analysis of rivaroxaban and decreases analysis costs by reducing solvent consumption and instrument time.
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Affiliation(s)
- Mégane Moreau
- Department of Chemistry, Université de Sherbrooke, Sherbrooke, QC, Canada
| | | | | | | | - Pedro A Segura
- Department of Chemistry, Université de Sherbrooke, Sherbrooke, QC, Canada
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12
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Nolte CH. Factor XI inhibitors - Rising stars in anti-thrombotic therapy? J Neurol Sci 2024; 464:123157. [PMID: 39094433 DOI: 10.1016/j.jns.2024.123157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/27/2024] [Indexed: 08/04/2024]
Abstract
The "holy grail" of preventing and treating thrombosis and thromboembolism would be a drug that was highly effective (preventing clots) and at the same time had a low risk of bleeding. From a hemostasiological perspective, the inhibition of factor XI represents a promising target because a reduced level of factor XI protects against thrombosis without significantly increasing the risk of spontaneous bleeding. Currently, three different classes of drugs of factor XI-inhibition are tested. These are (1) monoclonal antibodies (mAbs), (2) so-called synthetic, small molecules and (3) antisense oligonucleotides (ASOs). This article provides a narrative overview of the current status of studies on all three classes of drugs. Tests with mAbs have been conducted primarily in DVT prevention after knee replacement surgery. One large phase 3 study is testing the mAbs Abelacimab in patients with atrial fibrillation. The synthetic, small molecules Asundexian and Milvexian are tested in several phase 3 trials, mainly in patients with non-cardioembolic ischemic stroke. Results can be expected in the coming years. Clinical testing of ASOs to inhibit factor XI are still in their infancies.
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Affiliation(s)
- Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany; Center for Stroke Research Berlin (CSB), Berlin, Germany; Berlin Institute of Health (BiH), Berlin, Germany; German Center for cardiovascular Research (DZHK), Berlin, Germany.
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13
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Chandiramani R, Mehta A, Blumenthal RS, Williams MS. Should We Use Aspirin or P2Y 12 Inhibitor Monotherapy in Stable Ischemic Heart Disease? Curr Atheroscler Rep 2024:10.1007/s11883-024-01234-2. [PMID: 39243345 DOI: 10.1007/s11883-024-01234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2024] [Indexed: 09/09/2024]
Abstract
PURPOSE OF REVIEW To summarize the recent evidence and guideline recommendations on aspirin or P2Y12 inhibitor monotherapy in patients with stable ischemic heart disease and provide insights into future directions on this topic, which involves transition to a personalized assessment of bleeding and thrombotic risks. RECENT FINDINGS It has been questioned whether the evidence for aspirin as the foundational component of secondary prevention in patients with coronary artery disease aligns with contemporary pharmaco-invasive strategies. The recent HOST-EXAM study randomized patients who had received dual antiplatelet therapy for 6 to 18 months without ischemic or major bleeding events to either clopidogrel or aspirin for a further 24 months, and demonstrated that the patients in the clopidogrel arm had significantly lower rates of both thrombotic and bleeding complications compared to those in the aspirin arm. The patient-level PANTHER meta-analysis showed that in patients with established coronary artery disease, P2Y12 inhibitor monotherapy was associated with lower rates of myocardial infarction, stent thrombosis as well as gastrointestinal bleeding and hemorrhagic stroke compared to aspirin monotherapy, albeit with similar rates of all-cause mortality, cardiovascular mortality and major bleeding. Long-term low-dose aspirin is recommended for secondary prevention in patients with stable ischemic heart disease, with clopidogrel monotherapy being acknowledged as a feasible alternative. Dual antiplatelet therapy for six months after percutaneous coronary intervention remains the standard recommendation for patients with stable ischemic heart disease. However, the duration of dual antiplatelet therapy may be shortened and followed by P2Y12 inhibitor monotherapy or prolonged based on individualized evaluation of the patient's risk profile.
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Affiliation(s)
| | - Adhya Mehta
- Department of Internal Medicine, Albert Einstein College of Medicine/Jacobi Medical Center, Bronx, NY, USA
| | | | - Marlene S Williams
- Department of Medicine, Division of Cardiology, The Johns Hopkins University, 301 Mason Lord Drive, Suite 2400, Baltimore, MD, 21224, USA.
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14
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Vallejo-Vaz AJ, Dharmayat KI, Nzeakor N, Carrasco CP, Fatoba ST, Fonseca MJ, Tolani E, Lee C, Ray KK. Recurrent cardiovascular and limb events in 294,428 patients with coronary or peripheral artery disease or ischemic stroke on antiplatelet monotherapy: The RESRISK cohort study. Atherosclerosis 2024; 398:118589. [PMID: 39277962 DOI: 10.1016/j.atherosclerosis.2024.118589] [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: 03/01/2024] [Revised: 07/29/2024] [Accepted: 09/03/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND AND AIMS Utilising real-world data, we quantified the burden of cardiovascular risk factors and long-term residual risk of atherothrombotic events among routine care cohorts with coronary (CAD) or peripheral (PAD) artery disease or ischemic stroke (IS) on guideline-recommended antiplatelet monotherapy (APMT). METHODS Retrospective cohort study using data (2010-2020) from the United Kingdom Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics, including adults with CAD, PAD or IS who were first prescribed APMT (CAD/IS: aspirin; PAD: clopidogrel). Primary outcomes (recurrent events): major adverse cardiovascular events (MACE) for CAD/PAD/IS cohorts, major adverse limb events (MALE) for PAD. RESULTS 266,478 CAD, 13,162 PAD, and 14,788 IS patients were included (mean age: 71 years; women 37.7%-47.5 %). Risk factor burden was high and attainment of recommended goals was low. There were 73,691, 3,121 and 7,137 MACE among CAD, PAD and IS patients, respectively (median follow-up: 89.9, 42.4 and 75.9 months, respectively), and 4,767 MALE among PAD patients. MACE incidence rate per 1000 person-years was higher in IS (268.7; 95%CI 265.3-272.0) than CAD (92.9; 95%CI 92.5-93.4) or PAD cohorts (97.2; 95%CI 94.6-99.8). MALE incidence rate was 195.9 (95%CI 192.2-199.6) per 1000 person-years. IS patients presented a lower rate of hospitalisations and longer time-to-first hospitalisation, but once hospitalised, they had a longer length-of-stay. PAD patients had the highest hospitalisation rate. CONCLUSIONS Among a contemporary cohort with cardiovascular disease on APMT, long-term residual atherothrombotic risk remains high despite being on APMT. Greater attention to risk factor control and use of appropriate evidence-based therapy is required to reduce residual risk among this very high-risk population.
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Affiliation(s)
- Antonio J Vallejo-Vaz
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom; Department of Medicine, Faculty of Medicine, Universidad de Sevilla, Sevilla, Spain; Clinical Epidemiology and Vascular Risk, Instituto de Biomedicina de Sevilla (IBiS), IBiS/Hospital Universitario Virgen Del Rocío/Universidad de Sevilla/CSIC, Sevilla, Spain; Centro de Investigación Biomédica en Red (CIBER) de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Spain.
| | - Kanika I Dharmayat
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | | | | | | | - Maria J Fonseca
- EMEA Real World Methods & Evidence Generation, IQVIA, Lisbon, Portugal
| | - Esther Tolani
- EMEA Real World Methods & Evidence Generation, IQVIA, London, United Kingdom
| | - Christopher Lee
- EMEA Real World Methods & Evidence Generation, IQVIA, London, United Kingdom
| | - Kausik K Ray
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
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Bonaca MP, Barnes GD, Bauersachs R, Bessada Y, Conte MS, Dua A, Hess CN, Serhal M, Mena-Hurtado C, Weitz JI, Beckman JA. Antithrombotic Strategies for Patients With Peripheral Artery Disease: JACC Scientific Statement. J Am Coll Cardiol 2024; 84:936-952. [PMID: 39197984 DOI: 10.1016/j.jacc.2024.06.027] [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: 02/26/2024] [Revised: 06/06/2024] [Accepted: 06/21/2024] [Indexed: 09/01/2024]
Abstract
Patients with peripheral artery disease (PAD) experience major cardiovascular and limb events. Antithrombotic strategies including antiplatelets and anticoagulants remain a cornerstone of treatment and prevention. Recent trials have shown heterogeneity in the response to antithrombotic therapies in patients presenting primarily with PAD when compared to those presenting primarily with coronary artery disease. In addition, there is observed heterogeneity with regards to the effects of antiplatelets and anticoagulants with respect to different outcomes including cardiovascular and major adverse limb events. This, coupled with risks of bleeding, requires a patient-centered and holistic assessment of benefit-risk when selecting antithrombotic strategies for patients with PAD. A global multidisciplinary work group was convened to evaluate antithrombotic strategies in PAD and to summarize the current state of the art. Common clinical scenarios around antithrombotic decision making were provided. Finally, insights with regard to implementation future investigation were described.
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Affiliation(s)
- Marc P Bonaca
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien, Frankfurt, Germany, and the Center for Vascular Research, Munich, Germany
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Michael S Conte
- Vascular Surgery and Center for Limb Preservation, University of California-San Francisco, San Francisco, California, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Connie N Hess
- CPC Clinical Research, Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Maya Serhal
- Cardiovascular Division, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Department of Internal Medicine, Section of Cardiology, Yale University, New Haven, Connecticut, USA
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Joshua A Beckman
- Vascular Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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16
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Wang Z, Yang S, Tong L, Li X, Mao W, Yuan H, Chen Y, Zhang S, Zhang H, Chen R. eIF6 deficiency regulates gut microbiota, decreases systemic inflammation, and alleviates atherosclerosis. mSystems 2024:e0059524. [PMID: 39225466 DOI: 10.1128/msystems.00595-24] [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: 05/11/2024] [Accepted: 07/20/2024] [Indexed: 09/04/2024] Open
Abstract
Altered composition of the gut microbiota affects immunity and metabolism. This study previously found that eIF6 gene knockdown changes the composition of the intestinal flora in the eIF6 gene knockdown mouse model. Lactobacillus acidophilus is significantly increased in the model. This study was designed to investigate the role of L. acidophilus in the pathogenesis of atherosclerosis. Transcriptomic data from 117 patients with coronary artery disease (CAD) and 79 healthy individuals were obtained. ApoE-/- and ApoE-/-/eIF6+/- mice on normal chow diet or a high-fat diet were treated for 16 weeks; eIF6 deficiency was evaluated atherosclerosis. ApoE-/- mice on normal chow diet or a high-fat diet were treated with L. acidophilus by daily oral gavage for 16 weeks. Moreover, one group was treated with lipopolysaccharide at 12 weeks. The levels of eIF6, RNASE3, and RSAD2 were notably higher in the patients with CAD than in the healthy individuals. eIF6 deficiency altered the composition of gut microbiota. eIF6 deficiency reduced the atherosclerotic lesion formation in ApoE-/-/eIF6+/- mice compared with the ApoE-/- mice. The microbial sequencing and metabolomics analysis demonstrated some beneficial bacterial (L. acidophilus, Ileibacterium, and Bifidobacterium) and metabolic levels significantly had deference in ApoE-/-/eIF6+/- mice compared with the ApoE-/- mice. Correlational studies indicated that L. acidophilus had close correlations with low-density lipoprotein cholesterol, lesion area, and necrotic area. L. acidophilus inhibited high-fat diet-induced inflammation and atherosclerotic lesion, increasing the expression of tight junction proteins (ZO-1 and claudin-1) and reducing the gut permeability. However, lipopolysaccharide reversed the protective effect of L. acidophilus against atherosclerosis. eIF6 deficiency protected against atherosclerosis by regulating the composition of gut microbiota and metabolites. L. acidophilus attenuated atherosclerotic lesions by reducing inflammation and increasing gut permeability.IMPORTANCEeIF6 deficiency modulates the gut microbiota and multiple metabolites in atherosclerotic ApoE-/- mice. L. acidophilus was reduced in the gut of atherosclerotic ApoE-/- mice, but administration of Lactobacillus acidophilus reversed intestinal barrier dysfunction and vascular inflammation. Our findings suggest that targeting individual species is a beneficial therapeutic strategy to prevent inflammation and atherosclerosis.
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Affiliation(s)
- Zhenzhen Wang
- Cancer Institute, Xuzhou Medical University, Xuzhou, China
| | - Shuai Yang
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Linglin Tong
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Xin Li
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Weiyi Mao
- School of Basic Medical Sciences, Nanjing Medical University, Jiangsu, China
| | - Honghua Yuan
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yang Chen
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Shenyang Zhang
- Department of Neurology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - He Zhang
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Renjin Chen
- College of Life Sciences, Xuzhou Medical University, Xuzhou, Jiangsu, China
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17
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Kastrati L, Raeisi-Dehkordi H, Llanaj E, Quezada-Pinedo HG, Khatami F, Ahanchi NS, Llane A, Meçani R, Muka T, Ioannidis JPA. Agreement Between Mega-Trials and Smaller Trials: A Systematic Review and Meta-Research Analysis. JAMA Netw Open 2024; 7:e2432296. [PMID: 39240561 PMCID: PMC11380108 DOI: 10.1001/jamanetworkopen.2024.32296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Abstract
Importance Mega-trials can provide large-scale evidence on important questions. Objective To explore how the results of mega-trials compare with the meta-analysis results of trials with smaller sample sizes. Data Sources ClinicalTrials.gov was searched for mega-trials until January 2023. PubMed was searched until June 2023 for meta-analyses incorporating the results of the eligible mega-trials. Study Selection Mega-trials were eligible if they were noncluster nonvaccine randomized clinical trials, had a sample size over 10 000, and had a peer-reviewed meta-analysis publication presenting results for the primary outcome of the mega-trials and/or all-cause mortality. Data Extraction and Synthesis For each selected meta-analysis, we extracted results of smaller trials and mega-trials included in the summary effect estimate and combined them separately using random effects. These estimates were used to calculate the ratio of odds ratios (ROR) between mega-trials and smaller trials in each meta-analysis. Next, the RORs were combined using random effects. Risk of bias was extracted for each trial included in our analyses (or when not available, assessed only for mega-trials). Data analysis was conducted from January to June 2024. Main Outcomes and Measures The main outcomes were the summary ROR for the primary outcome and all-cause mortality between mega-trials and smaller trials. Sensitivity analyses were performed with respect to the year of publication, masking, weight, type of intervention, and specialty. Results Of 120 mega-trials identified, 41 showed a significant result for the primary outcome and 22 showed a significant result for all-cause mortality. In 35 comparisons of primary outcomes (including 85 point estimates from 69 unique mega-trials and 272 point estimates from smaller trials) and 26 comparisons of all-cause mortality (including 70 point estimates from 65 unique mega-trials and 267 point estimates from smaller trials), no difference existed between the outcomes of the mega-trials and smaller trials for primary outcome (ROR, 1.00; 95% CI, 0.97-1.04) nor for all-cause mortality (ROR, 1.00; 95% CI, 0.97-1.04). For the primary outcomes, smaller trials published before the mega-trials had more favorable results than the mega-trials (ROR, 1.05; 95% CI, 1.01-1.10) and subsequent smaller trials published after the mega-trials (ROR, 1.10; 95% CI, 1.04-1.18). Conclusions and Relevance In this meta-research analysis, meta-analyses of smaller studies showed overall comparable results with mega-trials, but smaller trials published before the mega-trials gave more favorable results than mega-trials. These findings suggest that mega-trials need to be performed more often given the relative low number of mega-trials found, their low significant rates, and the fact that smaller trials published prior to mega-trial report more beneficial results than mega-trials and subsequent smaller trials.
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Affiliation(s)
- Lum Kastrati
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Hamidreza Raeisi-Dehkordi
- Department of Global Public Health and Bioethics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Erand Llanaj
- Epistudia, Bern, Switzerland
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbrücke, Nuthetal, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hugo G Quezada-Pinedo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Farnaz Khatami
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Community Medicine Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Noushin Sadat Ahanchi
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | | | - Renald Meçani
- Epistudia, Bern, Switzerland
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Taulant Muka
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Epistudia, Bern, Switzerland
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California
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18
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Marè A, Cella A, Tereshko Y, Toraldo F, Gigli GL, Valente M, Merlino G. Milvexian, a novel factor XIa inhibitor for stroke prevention: pharmacokinetic and pharmacodynamic evaluation. Expert Opin Drug Metab Toxicol 2024:1-8. [PMID: 39215446 DOI: 10.1080/17425255.2024.2399721] [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: 06/13/2024] [Accepted: 08/29/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Antiplatelets and oral anticoagulants are commonly used to treat patients with various cardiovascular and cerebrovascular diseases. However, the primary concern for clinicians remains the risk of bleeding, thus necessitating the development of new therapies. Milvexian is a new anticoagulant that inhibits factor XIa, preventing the pathological formation of thrombi without increasing bleeding risk. AREAS COVERED This drug evaluation examines the pharmacokinetic properties of milvexian and provides information on its pharmacodynamics and clinical efficacy in treating some cerebrovascular conditions. EXPERT OPINION Milvexian shows a good pharmacokinetic profile with low renal elimination rates, justifying its use in patients with a high degree of renal impairment, and without relevant drug-drug interactions. In patients affected by acute non-cardioembolic ischemic stroke or high-risk transient ischemic stroke, milvexian, in addition to dual antiplatelet therapy, seems to have a positive efficacy profile without any safety concerns, especially in terms of intracranial hemorrhage. Two phase 3 trials are ongoing to investigate the efficacy and safety of milvexian for preventing cardioembolic and non-cardioembolic ischemic stroke.
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Affiliation(s)
- Alessandro Marè
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Arianna Cella
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Toraldo
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | | | - Mariarosaria Valente
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- DMED, University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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19
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Sehgal K, Shung DL. Editorial: Incidence and predictors of major gastrointestinal bleeding in patients on aspirin, low-dose rivaroxaban or the combination: Secondary analysis of the COMPASS randomised controlled trial. Aliment Pharmacol Ther 2024. [PMID: 39219413 DOI: 10.1111/apt.18195] [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: 09/04/2024]
Abstract
LINKED CONTENTThis article is linked to Forbes et al paper. To view this article, visit https://doi.org/10.1111/apt.18139
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Affiliation(s)
- Kanika Sehgal
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Dennis L Shung
- Department of Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut, USA
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20
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Hernandez-Sómerson MA, Montoya-Agudelo F, Huertas-Rodriguez G. Efficacy and safety of drugs in residual cardiovascular risk: A systematic review of the literature. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2024; 22:200298. [PMID: 38983606 PMCID: PMC11231711 DOI: 10.1016/j.ijcrp.2024.200298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 06/04/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
Background The objective of this research is to evaluate the efficacy and safety of drugs in the residual risk in any of its three components: lipid, inflammatory and thrombotic risk. Methods A systematic review was conducted of randomized clinical trials that included as a primary outcome, at least one of the conditions related to atherosclerotic cardiovascular disease. The databases used were PUBMED/MEDLINE, Scopus and ClinicalTrials.gov. The risk of bias of the studies was assessed using the Risk of Bias 2 tool. Results and discussion: 18 studies were included in the analysis. Half of the studies had low risk of bias or some concerns. Several drugs were effective in reducing the primary outcome: ethyl eicosapentaenoeic acid (17.2 % E-EPA versus 22 % placebo HR: 0.75; 95 % CI 0.68-0.83; p < 0.001), colchicine in stable coronary artery disease (6.8 % vs placebo 9.6 %, HR 0.59, 95 % CI 0.57-0.83; p < 0.001), Canakinumab (150 mg vs placebo ARR 15 %, HR 0.85, 95 % CI 0.74-0.98; p = 0.021) and Rivaroxaban with Aspirin in stable atherosclerotic disease (4.1 % versus aspirin 5.4 %, HR 0.76, 95 % CI 0.66-0.86, P < 0.001). Serious adverse events did not differ between study groups, except for a higher rate of bleeding with the use of combination antithrombotic therapy. Conclusion The residual risk can be reduced through the use of different drugs that act by modifying atherogenic lipid levels, modulating inflammatory pathways and the risk of thrombosis, with an acceptable safety profile in most studies.
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Affiliation(s)
- Mario Andres Hernandez-Sómerson
- Department of Medical Clinics, Hospital Universitario Mayor - MEDERI, 111411, Bogotá, Colombia
- Universidad del Rosario, 111411, Bogotá, Colombia
- Internal Medicine Service, Clínica de la Mujer, 110221, Bogotá, Colombia
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21
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Cohen M, Jones C. Patient and Physician Perspectives on the Benefits and Risks of Antiplatelet Therapy for Acute Coronary Syndrome. Cardiol Ther 2024; 13:631-643. [PMID: 38907182 PMCID: PMC11333664 DOI: 10.1007/s40119-024-00372-7] [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: 04/12/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024] Open
Abstract
This article is co-authored by a patient with acute coronary syndrome (ACS) who is receiving long-term antiplatelet therapy in the USA and a cardiologist who routinely treats patients with ACS. The patient describes his experience from diagnosis to the present day and discusses his concerns regarding treatment and management of the condition, including the balance between the benefits and risks of antiplatelet therapy. The patient also describes his work as an advocate for cardiac health. The physician perspective on treating and managing patients with ACS is provided by a cardiologist based in the USA who is and was not involved in this patient's care. The physician reviews the benefits and risks of antiplatelet therapies for the treatment of patients with ACS and discusses his own clinical experience of managing these patients, including how issues such as treatment adherence, as well as the potential inertia to prescribing certain medications that may be seen among physicians, could be overcome.
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Affiliation(s)
- Marc Cohen
- Newark Beth Israel Medical Center, 201 Lyons Avenue at Osborne Terrace, Newark, NJ, USA.
- Rutgers New Jersey Medical School, Medical Science Building, 185 South Orange Avenue, Newark, NJ, USA.
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22
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Porras CP, de Boer AR, Koop Y, Vaartjes I, Teraa M, Hazenberg CEVB, Verhaar MC, Vernooij RWM. Sex Differences in Mortality Risk after the First Hospitalisation with Lower Extremity Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2024; 68:378-384. [PMID: 38697256 DOI: 10.1016/j.ejvs.2024.04.039] [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: 07/04/2023] [Revised: 03/22/2024] [Accepted: 04/25/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE Lower extremity peripheral arterial disease (PAD) is a severe condition that increases the risk of major adverse cardiovascular events, major adverse limb events, and all cause mortality. This study aimed to investigate the mortality risk among females and males hospitalised for the first time with lower extremity PAD. METHODS Three cohorts of patients who were admitted for the first time with lower extremity PAD in 2007 - 2010, 2011 - 2014, and 2015 - 2018 were constructed. For the 2007 - 2010 and 2011 - 2014 cohorts, the 28 day, one year, and five year mortality rates were calculated, assessing survival time from date of hospital admission until date of death, end of study period, or censoring. For the 2015 - 2018 cohort, only 28 day and one year mortality were investigated due to lack of follow up data. Mortality rates of these cohorts were compared with the general population using standardised mortality rates (SMRs), and the risk of death between sexes was evaluated using Cox proportional hazards models. Cox models were adjusted for age, cardiovascular disease, and diabetes mellitus to account for potential confounding factors. RESULTS In total, 7 950, 9 670, and 13 522 patients were included in the 2007 - 2010, 2011 - 2014, and 2015 - 2018 cohorts, respectively. Over 60% of individuals in each cohort were males. Mortality rates at 28 day and one year remained stable across all cohorts, while the five year mortality rate increased for both males and females in the 2011 - 2014 cohort. The SMRs both of females and males with PAD were significantly higher than in the general population. Multivariable regression analyses found no significant differences in mortality risk between sexes at 28 day and one year. However, the five year mortality risk was lower in females, with a hazard ratio of 0.89 (95% confidence interval [CI] 0.83 - 0.97) in the 2007 - 2010 cohort and 0.88 (95% CI 0.82 - 0.94) in the 2011 - 2014 cohort. CONCLUSION The five year mortality risk has increased, and females face a lower mortality risk than males. Lower extremity PAD still carries unfavourable long term consequences compared with the general population.
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Affiliation(s)
- Cindy P Porras
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Annemarijn R de Boer
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Yvonne Koop
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ilonca Vaartjes
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Robin W M Vernooij
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, the Netherlands; Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands.
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23
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Ramacciotti E, Volpiani GG, Britto KF, Agati LB, Ribeiro CM, Aguiar VCR, Paganotti A, Pereira FM, Caffaro RA, Krakauer R, Rached HRS, Fareed J, Wolosker N, Anand SS, Eikelboom JW, Chang C, Lopes RD. Rivaroxaban for Patients with Intermittent Claudication. NEJM EVIDENCE 2024; 3:EVIDoa2400021. [PMID: 39185955 DOI: 10.1056/evidoa2400021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
BACKGROUND The combination of rivaroxaban plus aspirin compared with aspirin alone reduces the risk of major adverse cardiovascular and limb events for high-risk patients with peripheral artery disease. It is unknown whether rivaroxaban plus aspirin improves intermittent claudication for adults with lower-risk peripheral arterial disease. METHODS In this randomized, open-label, multicenter, 24-week clinical trial, we randomly assigned patients with peripheral artery disease and intermittent claudication to receive either 2.5 mg of rivaroxaban twice daily plus 100 mg of aspirin once daily or 100 mg of aspirin once daily. The primary outcome was a 24-week change in total walking distance, measured by the 6-minute walking test. The primary safety outcome was the incidence of major bleeding or clinically relevant nonmajor bleeding. RESULTS Eighty-eight patients were randomly assigned to either rivaroxaban plus aspirin (n=46) or aspirin alone (n=42). The mean age was 67 years, and 54% were female. The total walking distance measured by 6-minute walk test improved by 89 ± 18 m (mean±standard error) in the rivaroxaban-plus-aspirin group versus 21 ± 16 m in the aspirin-alone group. This corresponded to an absolute difference of 68 ± 24 m (95% confidence interval [CI], 19 to 116 m; P=0.007) and a relative improvement over the aspirin-alone group of 327% (95% CI, 94 to 560%). No major bleeding events were observed in either group. CONCLUSIONS In patients with peripheral artery disease and intermittent claudication, 2.5 mg of rivaroxaban twice daily plus 100 mg of aspirin daily improved the total walking distance by a 6-minute walking test compared with 100 mg of aspirin daily alone. (Funded by Bayer S.A.; Clinicaltrials.gov number, NCT04853719.).
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Affiliation(s)
- Eduardo Ramacciotti
- Science Valley Research Institute, São Paulo
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
- Hemostasis & Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, IL
| | - Giuliano Giova Volpiani
- Science Valley Research Institute, São Paulo
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
- Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo
| | | | | | | | | | | | | | | | - Rogério Krakauer
- Hospital e Maternidade Christóvão da Gama, Grupo DASA, São Paulo
| | | | - Jawed Fareed
- Hemostasis & Thrombosis Research Laboratories, Loyola University Medical Center, Maywood, IL
| | | | - Sonia S Anand
- Department of Medicine, Population Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Department of Medicine, Population Health Research Institute, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Chiann Chang
- Department of Statistics, Institute of Mathematics and Statistics, University of São Paulo, São Paulo
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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24
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Adeniji O, Olowoyo P, Akinyemi R, Fisher M, Owolabi M. Advances in Primordial, Primary, and Secondary Prevention of Stroke in Diverse Populations. Stroke 2024; 55:2359-2365. [PMID: 38445485 DOI: 10.1161/strokeaha.123.044231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/22/2024] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Olaleye Adeniji
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
| | - Paul Olowoyo
- Neurology Unit, Department of Medicine, Afe Babalola University Ado Ekiti, Nigeria (P.O.)
| | - Rufus Akinyemi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
| | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Mayowa Owolabi
- Department of Neurology, University College Hospital, Ibadan, Nigeria (O.A., R.A., M.O.)
- Center for Genomic and Precision Medicine, University of Ibadan, Nigeria (R.A., M.O.)
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25
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Lip GYH. Atrial Fibrillation and Stable Coronary Artery Disease. N Engl J Med 2024. [PMID: 39225269 DOI: 10.1056/nejme2409696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Gregory Y H Lip
- From the Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, and Liverpool Heart and Chest Hospital - all in Liverpool, United Kingdom
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26
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Forbes N, Yi Q, Moayyedi P, Bosch J, Bhatt DL, Fox KAA, Eikelboom JW. Incidence and predictors of major gastrointestinal bleeding in patients on aspirin, low-dose rivaroxaban, or the combination: Secondary analysis of the COMPASS randomised controlled trial. Aliment Pharmacol Ther 2024; 60:737-748. [PMID: 38952045 DOI: 10.1111/apt.18139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/02/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
BACKGROUND The incidence of major gastrointestinal bleeding (GIB) in patients on low-dose direct-acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking. AIMS To assess GIB incidence and predictors from RCT data of patients on aspirin, low-dose rivaroxaban, or both. METHODS This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures. RESULTS Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53-6.82 for ≥75 vs. 55-64), peptic ulcer disease (PUD, OR 1.57, 1.01-2.44), liver disease (OR 2.09, 1.01-4.33), hypertension (OR 1.42, 1.04-1.94), and smoking (OR 1.85, 1.26-2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12-2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88-7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64-4.84) than upper GIB (OR 1.86, 1.18-2.92). CONCLUSIONS We established incidences and identified risk factors for GIB in users of low-dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors.
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Affiliation(s)
- Nauzer Forbes
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Paul Moayyedi
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Gastroenterology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Keith A A Fox
- Division of Cardiology, University of Edinburgh, Edinburgh, UK
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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27
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Muthalaly RG, Abrahams TB, Nerlekar N, Nelson AJ, Tan S, Chan J, Phan T, Ma H, Nicholls SJ. Asymptomatic coronary artery disease in ischaemic stroke survivors: A systematic review and meta-analysis. Eur Stroke J 2024; 9:540-554. [PMID: 38357886 DOI: 10.1177/23969873241231702] [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] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Ischaemic stroke and coronary artery disease share risk factors and stroke survivors experience a high rate of cardiac events. Recent work suggests a high burden of asymptomatic coronary artery disease (CAD) in ischaemic stroke survivors. Thus, we performed this systematic review and meta-analysis to A) estimate the prevalence of CAD in ischaemic stroke survivors without known CAD and B) evaluate the association between coronary atherosclerosis and future major adverse cardiovascular events (MACE) in stroke survivors. PATIENTS AND METHODS We conducted a systematic review and meta-analysis according to the PRISMA statement. We included studies investigating acute ischaemic stroke or transient ischaemic attack where participants underwent anatomical assessment of all coronary arteries. For objective B) we included studies that reported an association between coronary atherosclerosis and MACE. Two reviewers used the Newcastle-Ottawa Scale to assess risk of bias. We used random-effects modelling for our analyses. RESULTS We identified 2983 studies of which 17 were included. These studies had a total of 6862 participants between 2008 and 2022. The pooled prevalence of any coronary atherosclerosis was 66.8% (95% CI 57.2%-75.1%) with substantial heterogeneity (I2 = 95.2%). The pooled prevalence of obstructive (>50%) stenosis was 29.3% with substantial heterogeneity (I2 = 91%). High-risk coronary anatomy (triple vessel disease or left main stenosis) was found in 7.0% (95% CI 4%-12%) with high heterogeneity I2 = 72%. One study examined high-risk plaques and found a prevalence of 5.9%. Five studies reported the association of coronary atherosclerosis with future MACE. The presence of obstructive CAD confers a HR of 8.0 (95% CI 1.7-37.1, p = 0.007) for future MACE. DISCUSSION AND CONCLUSIONS Asymptomatic CAD is common in ischaemic stroke survivors. The presence and severity of asymptomatic CAD strongly associates with the risk of future MACE. Further evaluation of the benefits of routine coronary assessment in ischaemic stroke is warranted.
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Affiliation(s)
- Rahul G Muthalaly
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | | | - Nitesh Nerlekar
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Adam J Nelson
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Sean Tan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Jasmine Chan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Thanh Phan
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
| | - Henry Ma
- Victorian Heart Institute, Monash University, Clayton, VIC, Australia
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Valeriani E, Bartimoccia S, Pignatelli P, Pastori D. Aging and Antithrombotic Treatment. Antioxid Redox Signal 2024; 41:542-556. [PMID: 37742116 DOI: 10.1089/ars.2023.0373] [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] [Indexed: 09/25/2023]
Abstract
Significance: Several aging-related pathophysiological mechanisms have been described to contribute to increased thrombotic risk in the elderly, including oxidative stress, endothelial dysfunction, and platelet and coagulation cascade activation. Antithrombotic treatment in the elderly should be individualized. Recent Advances: Recent studies have clarified some pathophysiological mechanisms of enhanced oxidative stress and thrombotic alterations in older adults. In the last decade, randomized trials have evaluated different antithrombotic strategies to reduce the risk of cardiovascular events in these patients. Critical Issues: The proportion of elderly patients included in clinical trials is generally low, thus not reflecting the daily clinical practice. There is no consensus on the most appropriate antithrombotic treatment in the elderly, also considering that bleeding risk management may be challenging in this high-risk subgroup of patients. Routine antiplatelet treatment is not a valid strategy for the primary prevention of cardiovascular events given the associated high risk of bleeding. In elderly patients with acute coronary syndrome, low-dose prasugrel or clopidogrel, shorter dual antiplatelet therapy, and no pretreatment before stent placement should be considered. Advanced age should not be the only reason for the underuse of oral anticoagulation in patients with atrial fibrillation, with direct oral anticoagulants preferred over warfarin for stroke prevention. Instead, a case-by-case clinical evaluation is warranted based on patient's bleeding risk also. Future Directions: There is a need for a structured tailored approach to manage thrombotic risk in elderly patients. The choice of the most appropriate antithrombotic treatment should balance efficacy and safety to reduce the risk of bleeding.
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Affiliation(s)
- Emanuele Valeriani
- Department of General Surgery, Surgical Specialties and Organ Transplantation "Paride Stefanini", Sapienza University of Rome, Rome, Italy
- Infectious Disease Department, Umberto I Hospital of Rome, Rome, Italy
| | - Simona Bartimoccia
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Boden WE, De Caterina R, Kaski JC, Merz NB, Berry C, Marzilli M, Pepine CJ, Barbato E, Stefanini G, Prescott E, Steg PG, Bhatt DL, Hill JA, Crea F. Myocardial ischaemic syndromes: a new nomenclature to harmonize evolving international clinical practice guidelines. Eur Heart J 2024:ehae278. [PMID: 39211956 DOI: 10.1093/eurheartj/ehae278] [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: 04/15/2024] [Accepted: 04/22/2024] [Indexed: 09/04/2024] Open
Abstract
Since the 1960s, cardiologists have adopted several binary classification systems for acute myocardial infarction (MI) that facilitated improved patient management. Conversely, for chronic stable manifestations of myocardial ischaemia, various classifications have emerged over time, often with conflicting terminology-e.g. 'stable coronary artery disease' (CAD), 'stable ischaemic heart disease', and 'chronic coronary syndromes' (CCS). While the 2019 European guidelines introduced CCS to impart symmetry with 'acute coronary syndromes' (ACS), the 2023 American guidelines endorsed the alternative term 'chronic coronary disease'. An unintended consequence of these competing classifications is perpetuation of the restrictive terms 'coronary' and 'disease', often connoting only a singular obstructive CAD mechanism. It is now important to advance a more broadly inclusive terminology for both obstructive and non-obstructive causes of angina and myocardial ischaemia that fosters conceptual clarity and unifies dyssynchronous nomenclatures across guidelines. We, therefore, propose a new binary classification of 'acute myocardial ischaemic syndromes' and 'non-acute myocardial ischaemic syndromes', which comprises both obstructive epicardial and non-obstructive pathogenetic mechanisms, including microvascular dysfunction, vasospastic disorders, and non-coronary causes. We herein retain accepted categories of ACS, ST-segment elevation MI, and non-ST-segment elevation MI, as important subsets for which revascularization is of proven clinical benefit, as well as new terms like ischaemia and MI with non-obstructive coronary arteries. Overall, such a more encompassing nomenclature better aligns, unifies, and harmonizes different pathophysiologic causes of myocardial ischaemia and should result in more refined diagnostic and therapeutic approaches targeted to the multiple pathobiological precipitants of angina pectoris, ischaemia and infarction.
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Affiliation(s)
- William E Boden
- VA Boston Healthcare System, Boston University School of Medicine, 150 S. Huntington Avenue, Boston, MA 02130, USA
| | - Raffaele De Caterina
- Division of Cardiology, University of Pisa and Pisa University Hospital, Pisa, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Colin Berry
- British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mario Marzilli
- Division of Cardiology, University of Pisa and Pisa University Hospital, Pisa, Italy
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida School of Medicine, Gainesville, FL, USA
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Humanitas Research Hospital IRCCS, Milan, Italy
| | - Eva Prescott
- Centre for Cardiovascular Research, Bispebjerg Frederiksberg University Hospital, Copenhagen, Denmark
| | - Philippe Gabriel Steg
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, FACT and INSERM U1148, Paris, France
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York City, NY, USA
| | - Joseph A Hill
- Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Filippo Crea
- Department of Cardiovascular Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024:ehae177. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [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: 09/04/2024] Open
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31
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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [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: 09/04/2024] Open
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Khalife R, Burnett AE, Tritschler T, Waldron B, Xu Y. Practical Prescribing: Direct oral anticoagulants. BMJ 2024; 386:e079520. [PMID: 39214564 DOI: 10.1136/bmj-2024-079520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Affiliation(s)
- Roy Khalife
- Department of Medicine (Hematology), The Ottawa Hospital, University of Ottawa, Ottawa, Canada
| | - Allison E Burnett
- University of New Mexico Hospital, UNM College of Pharmacy, Albuquerque, NM, USA
| | | | | | - Yan Xu
- Department of Medicine (Hematology), The Ottawa Hospital, University of Ottawa, Ottawa, Canada
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Li B, Nassereldine R, Shaikh F, Younes H, AbuHalimeh B, Zamzam A, Abdin R, Qadura M. Inflammatory Protein Panel: Exploring Diagnostic Insights for Peripheral Artery Disease Diagnosis in a Cross-Sectional Study. Diagnostics (Basel) 2024; 14:1847. [PMID: 39272633 PMCID: PMC11394143 DOI: 10.3390/diagnostics14171847] [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: 07/02/2024] [Revised: 08/14/2024] [Accepted: 08/22/2024] [Indexed: 09/15/2024] Open
Abstract
Cytokine-induced neutrophil chemoattractant 1 (CINC-1), a cluster of differentiation 95 (CD95), fractalkine, and T-cell immunoglobulin and mucin domain 1 (TIM-1) are circulating proteins known to be involved in inflammation. While their roles have been studied in neurological conditions and cardiovascular diseases, their potential as peripheral artery disease (PAD) biomarkers remain unexplored. We conducted a cross-sectional diagnostic study using data from 476 recruited patients (164 without PAD and 312 with PAD). Plasma levels of CINC-1, CD95, fractalkine, and TIM-1 were measured at baseline. A PAD diagnosis was established at recruitment based on clinical exams and investigations, defined as an ankle-brachial index < 0.9 or toe-brachial index < 0.67 with absent/diminished pedal pulses. Using 10-fold cross-validation, we trained a random forest algorithm, incorporating clinical characteristics and biomarkers that showed differential expression in PAD versus non-PAD patients to predict a PAD diagnosis. Among the proteins tested, CINC-1, CD95, and fractalkine were elevated in PAD vs. non-PAD patients, forming a 3-biomarker panel. Our predictive model achieved an AUROC of 0.85 for a PAD diagnosis using clinical features and this 3-biomarker panel. By combining the clinical characteristics with these biomarkers, we developed an accurate predictive model for a PAD diagnosis. This algorithm can assist in PAD screening, risk stratification, and guiding clinical decisions regarding further vascular assessment, referrals, and medical/surgical management to potentially improve patient outcomes.
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Affiliation(s)
- Ben Li
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, ON M5S 1A1, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Rakan Nassereldine
- Division of Vascular Surgery, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon
| | - Farah Shaikh
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
| | - Houssam Younes
- Heart, Vascular, & Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Batool AbuHalimeh
- Heart, Vascular, & Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Mohammad Qadura
- Division of Vascular Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON M5S 1A1, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
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Gao J, Guo H, Li J, Zhan M, You Y, Xin G, Liu Z, Fan X, Gao Q, Liu J, Zhang Y, Fu J. Buyang Huanwu decoction ameliorates myocardial injury and attenuates platelet activation by regulating the PI3 kinase/Rap1/integrin α(IIb)β(3) pathway. Chin Med 2024; 19:109. [PMID: 39160598 PMCID: PMC11331649 DOI: 10.1186/s13020-024-00976-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 07/31/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Buyang Huanwu Decoction (BYHWD) is a traditional Chinese medicine to treat the syndrome of qi deficiency and blood stasis. Platelets play an important role in regulating thrombus and inflammation after ischemic injury, studies have shown that BYHWD regulate myocardial fibrosis and exert anti-inflammatory effects through IL-17 and TLR4 pathways, but the mechanism of platelet activation by BYHWD in stable coronary heart disease is still unknown. In the present study, model of left anterior descending coronary artery ligation was applied to investigate the mechanisms of BYHWD on modulating platelets hyperreactivity and heart function after fibrosis of ischemic myocardial infarction (MI). METHODS Myocardial infarction model was constructed by ligation of the left anterior descending coronary artery. The rats were randomly divided into five groups: sham, model, MI with aspirin (positive), MI with a low dosage of BYHWD (BYHWD-ld) and MI with a high dosage of BYHWD (BYHWD-hd) for 28 days. RESULTS Coronary artery ligation prominently induced left ventricle dysfunction, increased cardiomyocyte fibrosis, which was accompanied by platelets with hyperreactivity, and high levels of inflammatory factors. BYHWD obviously reversed cardiac dysfunction and fibrosis, increased the thickness of the left ventricular wall, and inhibited aggregation ratio and CD62p expression. BYHWD restored the mitochondrial respiration of platelets after MI, concomitant with an increased telomere expression and decreased inflammation. According to the result of transcriptome sequencing, we found that 106 differentially expressed genes compared model with BYHWD treatment. Enrichment analysis screened out the Ras-related protein Rap-1 (Rap1) signaling pathway and platelet activation biological function. Quantitative real-time PCR and Western blotting were applied to found that BYHWD reduced the expression of Rap1/PI3K-Akt/Src-CDC42 genes and attenuated the overactivity of PI3 kinase/Rap1/integrin α(IIb)β(3) pathway. CONCLUSION BYHWD reduced inflammation and platelet activation via the PI3 kinase/Rap1/integrin α(IIb)β(3) pathway and improved heart function after MI.
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Affiliation(s)
- Jiaming Gao
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Hao Guo
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Junmei Li
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Min Zhan
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Yue You
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Gaojie Xin
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Zixin Liu
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Xiaodi Fan
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Qinghe Gao
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China
| | - Jianxun Liu
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China.
| | - Yehao Zhang
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China.
| | - Jianhua Fu
- Institute of Basic Medical Sciences of Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing Key Laboratory of Pharmacology of Chinese Materia, Courtyard No. 1, Xiyuan Playground, Haidian District, Beijing, China.
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Robichaux T, Edwards K, Carter A, Washington A, Brooks S. Analysis of appropriateness and safety when discharging patients on triple-antithrombotic therapies. Am J Health Syst Pharm 2024; 81:S144-S151. [PMID: 38487864 DOI: 10.1093/ajhp/zxae068] [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] [Indexed: 08/20/2024] Open
Abstract
PURPOSE To analyze the appropriateness of triple-antithrombotic therapy based on the 2020 American College of Cardiology (ACC) consensus statement while evaluating safety outcomes for patients with respect to adverse events. METHODS A single-center, retrospective chart review was conducted using electronic medical records from December 18, 2020, to August 31, 2022. The primary endpoint was the rate of appropriateness for triple-antithrombotic therapy in patients discharged from Ochsner LSU Health Shreveport. Appropriateness was a composite endpoint extrapolated from the 2020 ACC consensus statement. For therapy to be defined as appropriate, patients had to have had the correct therapy indication, medications, dosing, and 30-day duration. Secondary safety endpoints included the percentage of patients rehospitalized at 14 and 30 days, the rate of major bleeding events, and the percentage of patients on gastrointestinal prophylaxis while on triple-antithrombotic therapy. RESULTS A total of 93 patients were included in the study, of whom 31 (33%) received appropriate triple-antithrombotic therapy. Prolonged duration of triple-antithrombotic therapy was the most common reason that therapy did not meet the primary endpoint. The readmission rate due to bleeding was 2.2% at 14 days and 6.5% at 30 days. Within 30 days of initiation of triple therapy, 4.3% of patients endured major bleeding as defined by the International Society on Thrombosis and Hemostasis and 2 patients died. CONCLUSION In this single-center study, triple-antithrombotic therapy appropriately adhered to the 2020 ACC consensus statement for one-third of patients discharged on this therapy.
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Affiliation(s)
- Taylor Robichaux
- Ochsner LSU Health Shreveport-Academic Medical Center, Shreveport, LA, USA
| | - Kristyn Edwards
- Ochsner LSU Health Shreveport-Academic Medical Center, Shreveport, LA, USA
| | - Ashley Carter
- The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Andrea Washington
- Ochsner LSU Health Shreveport-Academic Medical Center, Shreveport, LA, USA
| | - Shelby Brooks
- Ochsner LSU Health Shreveport-Academic Medical Center, Shreveport, LA
- University of Louisiana at Monroe College of Pharmacy, Monroe, LA, USA
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Nelson MR, Black JA. Aspirin: latest evidence and developments. Heart 2024; 110:1069-1073. [PMID: 39074973 DOI: 10.1136/heartjnl-2024-323948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 07/03/2024] [Indexed: 07/31/2024] Open
Abstract
Aspirin is a foundation drug of the pharmaceutical industry originally derived as an analgesic/anti-inflammatory agent but serendipitously discovered to have use as a prophylactic drug for major adverse cardiovascular events (MACE). Its modern-day utility in this latter role relies on its efficacy/safety balance in a contemporary population where, at least in high-income countries, age-standardised incident rates for MACE are falling, and where there are now competing therapeutic agents. Its future may be determined by its potential role as a chemoprophylactic or adjunct agent for cancer or other disease states. It therefore will continue to be the subject of further clinical research.
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Affiliation(s)
- Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - J Andrew Black
- Cardiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
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Bashir B, Schofield J, Downie P, France M, Ashcroft DM, Wright AK, Romeo S, Gouni-Berthold I, Maan A, Durrington PN, Soran H. Beyond LDL-C: unravelling the residual atherosclerotic cardiovascular disease risk landscape-focus on hypertriglyceridaemia. Front Cardiovasc Med 2024; 11:1389106. [PMID: 39171323 PMCID: PMC11335737 DOI: 10.3389/fcvm.2024.1389106] [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: 02/20/2024] [Accepted: 07/08/2024] [Indexed: 08/23/2024] Open
Abstract
Aims Historically, atherosclerotic cardiovascular disease (ASCVD) risk profile mitigation has had a predominant focus on low density lipoprotein cholesterol (LDL-C). In this narrative review we explore the residual ASCVD risk profile beyond LDL-C with a focus on hypertriglyceridaemia, recent clinical trials of therapeutics targeting hypertriglyceridaemia and novel modalities addressing other residual ASCVD risk factors. Findings Hypertriglyceridaemia remains a significant ASCVD risk despite low LDL-C in statin or proprotein convertase subtilisin/kexin type 9 inhibitor-treated patients. Large population-based observational studies have consistently demonstrated an association between hypertriglyceridaemia with ASCVD. This relationship is complicated by the co-existence of low high-density lipoprotein cholesterol. Despite significantly improving atherogenic dyslipidaemia, the most recent clinical trial outcome has cast doubt on the utility of pharmacologically lowering triglyceride concentrations using fibrates. On the other hand, purified eicosapentaenoic acid (EPA), but not in combination with docosahexaenoic acid (DHA), has produced favourable ASCVD outcomes. The outcome of these trials suggests alternate pathways involved in ASCVD risk modulation. Several other pharmacotherapies have been proposed to address other ASCVD risk factors targeting inflammation, thrombotic and metabolic factors. Implications Hypertriglyceridaemia poses a significant residual ASCVD risk in patients already on LDL-C lowering therapy. Results from pharmacologically lowering triglyceride are conflicting. The role of fibrates and combination of EPA and DHA is under question but there is now convincing evidence of ASCVD risk reduction with pure EPA in a subgroup of patients with hypertriglyceridaemia. Clinical guidelines should be updated in line with recent clinical trials evidence. Novel agents targeting non-conventional ASCVD risks need further evaluation.
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Affiliation(s)
- Bilal Bashir
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- NIHR/Wellcome Trust Clinical Research Facility, Manchester, United Kingdom
| | - Jonathan Schofield
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Paul Downie
- Department of Clinical Biochemistry, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Michael France
- Department of Clinical Biochemistry, Central Manchester University Hospitals, NHS Foundation Trust, Manchester, United Kingdom
| | - Darren M. Ashcroft
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Alison K. Wright
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Stefano Romeo
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Clinical Nutrition Unit, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
- Cardiology Department, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ioanna Gouni-Berthold
- Centre for Endocrinology, Diabetes and Preventive Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Akhlaq Maan
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Paul N. Durrington
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Handrean Soran
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
- Department of Endocrinology, Diabetes & Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- NIHR/Wellcome Trust Clinical Research Facility, Manchester, United Kingdom
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Muric M, Nikolic M, Todorovic A, Jakovljevic V, Vucicevic K. Comparative Cardioprotective Effectiveness: NOACs vs. Nattokinase-Bridging Basic Research to Clinical Findings. Biomolecules 2024; 14:956. [PMID: 39199344 PMCID: PMC11352257 DOI: 10.3390/biom14080956] [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: 06/12/2024] [Revised: 07/18/2024] [Accepted: 07/19/2024] [Indexed: 09/01/2024] Open
Abstract
The use of non-vitamin K antagonist oral anticoagulants (NOACs) has brought a significant progress in the management of cardiovascular diseases, considered clinically superior to vitamin K antagonists (VKAs) particularly in the prevention and treatment of thromboembolic events. In addition, numerous advantages such as fixed dosing, lack of laboratory monitoring, and fewer food and drug-to-drug interactions make the use of NOACs superior to VKAs. While NOACs are synthetic drugs prescribed for specific conditions, nattokinase (NK) is a natural enzyme derived from food that has potential health benefits. Various experimental and clinical studies reported the positive effects of NK on the circulatory system, including the thinning of blood and the dissolution of blood clots. This enzyme showed not only fibrinolytic activity due to its ability to degrade fibrin, but also an affinity as a substrate for plasmin. Recent studies have shown that NK has additional cardioprotective effects, such as antihypertensive and anti-atherosclerotic effects. In this narrative review, we presented the cardioprotective properties of two different approaches that go beyond anticoagulation: NOACs and NK. By combining evidence from basic research with clinical findings, we aim to elucidate the comparative cardioprotective efficacy of these interventions and highlight their respective roles in modern cardiovascular care.
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Affiliation(s)
- Maja Muric
- Department of Physiology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia; (M.M.); (V.J.)
- Center of Excellence for Redox Balance Research in Cardiovascular and Metabolic Disorders, 34000 Kragujevac, Serbia;
| | - Marina Nikolic
- Department of Physiology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia; (M.M.); (V.J.)
- Center of Excellence for Redox Balance Research in Cardiovascular and Metabolic Disorders, 34000 Kragujevac, Serbia;
| | - Andreja Todorovic
- Department of Cardiology, General Hospital Ćuprija, 35230 Ćuprija, Serbia;
| | - Vladimir Jakovljevic
- Department of Physiology, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia; (M.M.); (V.J.)
- Center of Excellence for Redox Balance Research in Cardiovascular and Metabolic Disorders, 34000 Kragujevac, Serbia;
- Department of Human Pathology, First Moscow State Medical, University IM Sechenov, 119991 Moscow, Russia
| | - Ksenija Vucicevic
- Center of Excellence for Redox Balance Research in Cardiovascular and Metabolic Disorders, 34000 Kragujevac, Serbia;
- Department of Pharmacy, Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
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Moruzzi S, Castagna A, Spizzo M, Udali S, Pattini P, Pizzolo F, Friso S, Martinelli N. Activated Factor VII-Antithrombin Complex, a Biomarker of Tissue Factor-Related Pathways in Different Clinical Settings: A Narrative Review from Cardiovascular Diseases to Cancer. Diagnostics (Basel) 2024; 14:1711. [PMID: 39202199 PMCID: PMC11354109 DOI: 10.3390/diagnostics14161711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/02/2024] [Accepted: 08/03/2024] [Indexed: 09/03/2024] Open
Abstract
Tissue factor (TF) is a transmembrane glycoprotein that represents the fundamental physiological initiator of the coagulation cascade through its interaction with factor VII. TF belongs to the cytokine receptor protein superfamily and contributes to the transduction of cellular signaling. Therefore, TF-related pathways are involved in multiple pathophysiological processes, not only in coagulation/thrombosis but in a wider mechanisms' panorama, ranging from infective to neoplastic diseases. Consistently, the measurement of TF activity could have a diagnostic and/or prognostic meaning in different clinical conditions. However, the transmembrane localization, the expression on different cellular types and circulating extracellular vesicles, and the different conformations (encrypted and decrypted) and variants (such as the soluble alternatively spliced TF) hamper TF assessment in clinical practice. The activated factor VII-antithrombin (FVIIa-AT) complex is proposed as an indirect biomarker of the TF-FVIIa interaction and, consequently, of the functionally active TF expression. In this narrative review, we evaluate the clinical studies investigating the role of plasma concentration of FVIIa-AT in health and disease. Although without conclusive data, high FVIIa-AT concentrations predict the worst clinical outcomes in different pathologic conditions, such as cardiovascular disease and cancer, thereby suggesting that overactivation of TF-related pathways may play an unfavorable role in various clinical settings.
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Affiliation(s)
| | | | | | | | | | | | | | - Nicola Martinelli
- Department of Medicine, University of Verona, 37134 Verona, Italy; (S.M.); (A.C.); (M.S.); (S.U.); (P.P.); (F.P.); (S.F.)
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Romeo FJ. Dual Pathway Inhibition in Stable Cardiovascular Disease: It Takes Two to Tango! J Cardiovasc Pharmacol 2024; 84:152-154. [PMID: 38922582 DOI: 10.1097/fjc.0000000000001599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2024]
Affiliation(s)
- Francisco José Romeo
- Division of Cardiology, University of Miami/Jackson Memorial Hospital, Miami, FL
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Meschia JF. William M. Feinberg Lecture: Asymptomatic Carotid Stenosis: Current and Future Considerations. Stroke 2024; 55:2184-2192. [PMID: 38920049 PMCID: PMC11331494 DOI: 10.1161/strokeaha.124.046956] [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: 04/26/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024]
Abstract
Asymptomatic high-grade carotid stenosis is an important therapeutic target for stroke prevention. For decades, the ACAS (Asymptomatic Carotid Atherosclerosis Study) and ACST (Asymptomatic Carotid Surgery Trial) trials provided most of the evidence supporting endarterectomy for patients with asymptomatic high-grade stenosis who were otherwise good candidates for surgery. Since then, transfemoral/transradial carotid stenting and transcarotid artery revascularization have emerged as alternatives to endarterectomy for revascularization. Advances in treatments against atherosclerosis have driven down the rates of stroke in patients managed without revascularization. SPACE-2 (Stent-Protected Angioplasty Versus Carotid Endarterectomy-2), a trial that included endarterectomy, stenting, and medical arms, failed to detect significant differences in stroke rates among treatment groups, but the study was stopped well short of its recruitment goal. CREST-2 (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial) will be able to clarify whether revascularization by stenting or endarterectomy remains efficacious under conditions of intensive medical management. Transcarotid artery revascularization has a favorable periprocedural risk profile, but randomized trials comparing it to intensive medical management are lacking. Features like intraplaque hemorrhage on MRI and echolucency on B-mode ultrasonography can identify patients at higher risk of stroke with asymptomatic stenosis. High-grade stenosis with poor collaterals can cause hemispheric hypoperfusion, and unstable plaque can cause microemboli, both of which may be treatable risk factors for cognitive impairment. Evidence that there are patients with carotid stenosis who benefit cognitively from revascularization is presently lacking. New risk factors are emerging, like exposure to microplastics and nanoplastics. Strategies to limit exposure will be important without specific medical therapies.
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Affiliation(s)
- James F Meschia
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL
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42
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Lenard A, Hermann SA, Stoll F, Burhenne J, Foerster KI, Mikus G, Meid AD, Haefeli WE, Blank A. Effect of Clarithromycin, a Strong CYP3A and P-glycoprotein Inhibitor, on the Pharmacokinetics of Edoxaban in Healthy Volunteers and the Evaluation of the Drug Interaction with Other Oral Factor Xa Inhibitors by a Microdose Cocktail Approach. Cardiovasc Drugs Ther 2024; 38:747-756. [PMID: 36870039 PMCID: PMC11266212 DOI: 10.1007/s10557-023-07443-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/05/2023]
Abstract
PURPOSE We assessed the differential effect of clarithromycin, a strong inhibitor of cytochrome P450 (CYP) 3A4 and P-glycoprotein, on the pharmacokinetics of a regular dose of edoxaban and on a microdose cocktail of factor Xa inhibitors (FXaI). Concurrently, CYP3A activity was determined with a midazolam microdose. METHODS In an open-label fixed-sequence trial in 12 healthy volunteers, the pharmacokinetics of a microdosed FXaI cocktail (μ-FXaI; 25 μg apixaban, 50 μg edoxaban, and 25 μg rivaroxaban) and of 60 mg edoxaban before and during clarithromycin (2 x 500 mg/d) dosed to steady-state was evaluated. Plasma concentrations of study drugs were quantified using validated ultra-performance liquid chromatography-tandem mass spectrometry methods. RESULTS Therapeutic clarithromycin doses increased the exposure of a therapeutic 60 mg dose of edoxaban with a geometric mean ratio (GMR) of the area under the plasma concentration-time curve (AUC) of 1.53 (90 % CI: 1.37-1.70; p < 0.0001). Clarithromycin also increased the GMR (90% CI) of the exposure of microdosed FXaI apixaban to 1.38 (1.26-1.51), edoxaban to 2.03 (1.84-2.24), and rivaroxaban to 1.44 (1.27-1.63). AUC changes observed for the therapeutic edoxaban dose were significantly smaller than those observed with the microdose (p < 0.001). CONCLUSION Clarithromycin increases FXaI exposure. However, the magnitude of this drug interaction is not expected to be clinically relevant. The edoxaban microdose overestimates the extent of the drug interaction with the therapeutic dose, whereas AUC ratios for apixaban and rivaroxaban were comparable to the interaction with therapeutic doses as reported in the literature. TRIAL REGISTRATION EudraCT Number: 2018-002490-22.
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Affiliation(s)
- Alexander Lenard
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Simon A Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Felicitas Stoll
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Juergen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany
| | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Partner Site Heidelberg, German Center for Infection Research, Heidelberg, Germany.
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Kim TI, DeWan A, Murray M, Wang H, Mani A, Mena-Hurtado C, Guzman RJ, Ochoa Chaar CI. Anticoagulation in Patients with Premature Peripheral Artery Disease Undergoing Lower Extremity Revascularization. Ann Vasc Surg 2024; 105:150-157. [PMID: 38593922 DOI: 10.1016/j.avsg.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/11/2024] [Accepted: 02/13/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Premature peripheral artery disease (PAD), defined by lower extremity revascularization (LER) at age ≤ 50 years, is associated with poor major adverse limb events. The early onset of disease is thought to be influenced by genetic factors that regulate homeostasis of the vascular wall and coagulation. The aim of this study is to investigate the effect of anticoagulation as an adjunct to antiplatelet therapy on the outcomes of LER in patients with premature PAD. METHODS There were 8,804 patients with premature PAD on preoperative and postoperative antiplatelet therapy only and 1,236 patients on preoperative and postoperative anticoagulation plus antiplatelet therapy in the Vascular Quality Initiative peripheral vascular intervention, infrainguinal, and suprainguinal files. Propensity score matching (2:1) was performed between patients with premature PAD who were on antiplatelet therapy and those on anticoagulation plus antiplatelet therapy. Perioperative and 1-year outcomes were analyzed including reintervention, major amputation, and mortality. RESULTS Patients on anticoagulation were more likely to have coronary artery disease (48.7% vs. 41.2%, P < 0.001), congestive heart failure (20.2% vs. 13.1%, P < 0.001), and have undergone prior LER (73.9% vs. 49.2%, P < 0.001) compared to patients on antiplatelet therapy only. They were also less likely to be independently ambulatory (74.2% vs. 81.8%, P < 0.001) and be on a statin medication (66.8% vs. 74.3%, P < 0.001) compared to patients on antiplatelet therapy only. Patients on anticoagulation were also less likely to be treated for claudication (38.1% vs. 48.6%, P < 0.001), and less likely to be treated with an endovascular procedure (64.8% vs. 73.8%, P < 0.001). After matching for baseline characteristics, there were 1,256 patients on antiplatelet therapy only and 628 patients on anticoagulation. Patients on anticoagulation were more likely to require a return to the operating room (3.7% vs. 1.6%, P < 0.001) and had higher perioperative mortality (1.1% vs. 0.3%, P = 0.032), but major amputation was not significantly different (1.8% vs. 1.6%, P = 0.798) compared to patients on antiplatelet therapy alone. At 1 year, amputation-free survival was higher in patients on antiplatelets only compared to patients on anticoagulation and antiplatelet medications (87.5% vs. 80.9%, log-rank P = 0.001). CONCLUSIONS Anticoagulation in addition to antiplatelet therapy in patients with premature PAD undergoing LER is associated with increased reintervention and mortality at 1 year.
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Affiliation(s)
- Tanner I Kim
- Queen's Health System, Honolulu, HI; Department of Surgery, John A Burns School of Medicine, University of Hawaii, Honolulu, HI.
| | | | - Michael Murray
- Department of Genetics, Yale School of Medicine, New Haven, CT
| | - He Wang
- Department of Pathology, Yale University School of Medicine, New Haven, CT
| | - Arya Mani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
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Donato F, Donati T, Minelli F, Borghetti A, Minucci M, Luparelli A, Tinelli G, Tshomba Y. Treatment of Aorto-iliac and Infrainguinal Vascular Infections with a Prefabricated Bovine Pericardial Graft. Ann Vasc Surg 2024; 105:177-188. [PMID: 38599483 DOI: 10.1016/j.avsg.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infrainguinal infection. METHODS We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infrainguinal infection who underwent in situ reconstruction (ISR) with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics. RESULTS The indication for surgery was: mycotic aortic aneurysm in 4 patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in 5 patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and ISR were performed in all patients. Hospital mortality rate was 5% (n = 1) and graft-related mortality of 0%. During follow-up (median 13 months, range 6-34 months), reinfection was 5.2% and primary graft patency 94.7%. CONCLUSIONS The use of prefabricated bovine pericardial grafts represents a promising option for the treatment of native and prosthetic aorto-iliac and infrainguinal infections. The application of this biological graft with a standardized postoperative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.
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Affiliation(s)
- Federica Donato
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Tommaso Donati
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabrizio Minelli
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alberto Borghetti
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Infectious Diseases, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marta Minucci
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Luparelli
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Tinelli
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yamume Tshomba
- Dipartimento Cardiovascolare, Università Cattolica del Sacro Cuore, Rome, Italy; Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
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Douketis JD, Yi Q, Bhatt DL, Muehlhofer E, Wang MK, Connolly S, Yusuf S, Maggioni AP, Eikelboom JW. Perioperative management and outcomes in patients receiving low-dose rivaroxaban and/or aspirin: a subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial. J Thromb Haemost 2024; 22:2227-2233. [PMID: 38729576 DOI: 10.1016/j.jtha.2024.03.030] [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: 01/08/2024] [Revised: 03/11/2024] [Accepted: 03/27/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND No study has investigated the perioperative management and clinical outcomes in patients who are receiving rivaroxaban 2.5 mg twice a day and acetylsalicylic acid (ASA) 81 to 100 mg daily. OBJECTIVE To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. To assess perioperative management and outcomes in patients who are receiving low-dose rivaroxaban, 2.5 mg twice-daily, and low-dose ASA, 81 to 100 mg daily. METHODS Subanalysis of the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial was performed to assess perioperative management and clinical outcomes in patients with stable coronary or peripheral artery disease who were randomized to receive rivaroxaban 2.5 mg twice a day plus ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA 100 mg daily. Patients studied required a surgery/procedure during the trial. The study outcomes, which included myocardial infarction, angina, stroke, acute limb ischemia, bleeding, and death, were assessed according to treatment allocation. RESULTS There were 2632 patients studied (mean age, 68 years; 80% male) who had a surgery/procedure, comprising percutaneous coronary interventions (∼43%), carotid or other arterial angioplasty (∼15%), pacemaker or internal cardiac defibrillator implantation (∼9%), and coronary artery bypass graft surgery (∼7%). Perioperative study drug management varied, with about one-third of patients not interrupting study drug and the remainder interrupting it between 1 and ≥10 days preprocedure. The incidences of adverse outcomes across treatment groups were 12.7% to 15.3% for myocardial ischemia, 0.8% to 1.2% for stroke, 0.1% to 0.2% for venous thromboembolism, and 3.1% to 4.2% for any bleeding. There was no statistically significant difference in outcome rates across treatment groups. CONCLUSION In patients in the COMPASS trial who required a surgery/procedure, there was no significant difference in perioperative adverse outcomes whether patients were receiving rivaroxaban 2.5 mg twice a day and ASA 100 mg daily, rivaroxaban 5 mg twice a day, or ASA alone.
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Affiliation(s)
- James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
| | - Qilong Yi
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | | | - Michael K Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Stuart Connolly
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Salim Yusuf
- Mt. Sinai Fuster Heart Hospital, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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Krivosheeva EN, Komarov AL, Panchenko EP, Khakimova MB, Kropacheva ES, Pogorelova OA, Balakhonova TV, Titaeva EV, Dobrovolsky AB, Galyautdinov DM, Vlasova EE. [GDF-15 and the risk of bleeding in patients with stable CAD receiving multicomponent antithrombotic therapy: the results of the prospective REGATA register]. TERAPEVT ARKH 2024; 96:683-689. [PMID: 39106511 DOI: 10.26442/00403660.2024.07.202783] [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: 12/25/2023] [Accepted: 03/28/2024] [Indexed: 08/09/2024]
Abstract
AIM To evaluate the prognostic value of GDF-15 in relation the development of bleeding and events in stable CAD patients, receiving combined antithrombotic therapy. MATERIALS AND METHODS The data was obtained from the prospective registry REGATA, 343 CAD patients (249 males), median age 68 [IQR 62; 75] years) were enrolled. Patients with sinus rhythm and concomitant PAD received acetylsalicylic acid in combination with rivaroxaban 2.5 mg bid (31.8%) or clopidogrel (24.8%). Other 43.4% with concomitant atrial fibrillation (AF) received direct oral anticoagulants in combination with antiplatelet therapy after elective percutaneous coronary interventions. Median follow-up was 12 months [IQR 9.0; 18.0]. The safety end point was major and clinically relevant bleedings (type 2-5) according to the BARC classification. Plasma samples for GDF-15 identification were taken at the inclusion and analyzed using ELISA assay. RESULTS Frequency of BARC 2-5 bleedings was 16% (BARC 2 - 46; BARC 3 - 9; BARC 4-5 - 0), median GDF-15 level was 1185.0 pg/ml [850.0; 1680.0]. In patients with AF and concomitant MFA, the level of GDF-15 was significantly higher than in the subgroups of patients with only AF or MFA (p=0.0022). According to the quintile analysis, GDF-15 values in the top three quintiles of distribution (cut-off value >943 pg/ml) were associated with higher frequency of bleeding events: 23.2% versus 5.1%; p=0.0001. The multivariable logistic regression model demonstrated that bleeding events were independently associated with GDF-15 level>943 pg/ml (OR 2.65, 95% CI 1.11-6.30; p=0.0275), AF (OR 2.61, 95% CI 1.41-4.83; p=0.0023) and chronic kidney disease (OR 1.92, 95% CI 1.03-3.60; p=0.0401). Clinical factors determining the risk of bleeding events also determined a GDF-15 elevation. CONCLUSION Assessment of GDF-15 level may improve bleeding risk stratification in CAD patients with concomitant AF and/or PAD receiving combined antithrombotic therapy.
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Affiliation(s)
| | - A L Komarov
- Chazov National Medical Research Center of Cardiology
| | - E P Panchenko
- Chazov National Medical Research Center of Cardiology
| | - M B Khakimova
- Chazov National Medical Research Center of Cardiology
| | | | | | | | - E V Titaeva
- Chazov National Medical Research Center of Cardiology
| | | | | | - E E Vlasova
- Chazov National Medical Research Center of Cardiology
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Tan MC, Dinh D, Gayed D, Liang D, Brennan A, Duffy SJ, Clark D, Ajani A, Oqueli E, Roberts L, Reid C, Freeman M, Chandrasekhar J. Associations Between Dual Antiplatelet Therapy Score and Long-Term Mortality After Percutaneous Coronary Intervention: Analysis of More Than 27,000 Patients. Can J Cardiol 2024:S0828-282X(24)00582-8. [PMID: 39084254 DOI: 10.1016/j.cjca.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 06/12/2024] [Accepted: 06/30/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND The dual antiplatelet therapy (DAPT) score was developed to identify patients undergoing percutaneous coronary intervention (PCI) who are likely to derive benefit (score ≥ 2) or harm (score < 2) from extended DAPT beyond 1 year after PCI in terms of ischemic and bleeding outcomes. We examined the associations between DAPT score at index PCI and long-term mortality from an all-comers PCI registry in patients receiving DAPT according to the standard of care. METHODS We retrospectively examined prospectively collected data from the Melbourne Interventional Group PCI database (2005-2018) and grouped patients as having DAPT score ≥ 2 or < 2. Long-term mortality was assessed from the Australian National Death Index linkage. The primary end point was long-term mortality as determined using survival analysis. Secondary end points included in-hospital events and 30-day major adverse cardiac events (MACE), a composite of death, myocardial infarction, or target vessel revascularisation. RESULTS Of 27,740 study patients, 9402 (33.9%) had DAPT score ≥ 2. Patients with DAPT score ≥ 2 were younger, included more women, and had a higher prevalence of cardiovascular risk factors. Patients with DAPT score ≥ 2 had higher in-hospital mortality (3.0% vs 1.0%), major bleeding (2.3% vs 1.6%), 30-day MACE (7.1% vs 3.1%), and long-term mortality at a median follow-up of 5.17 years (21.9% vs 16.5%) P < 0.001 for all. CONCLUSIONS One-third of all-comer patients undergoing PCI had a DAPT score ≥ 2 with greater short-term ischemic and bleeding risk, and higher long-term mortality. Risk assessment with the DAPT score may guide the duration and intensity of DAPT beyond the early post-PCI period.
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Affiliation(s)
- Mae Chyi Tan
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Daniel Gayed
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Danlu Liang
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | | | - David Clark
- University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Andrew Ajani
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Grampians Health Ballarat, Ballarat, Victoria, Australia
| | - Louise Roberts
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia
| | - Christopher Reid
- University of Melbourne, Melbourne, Victoria, Australia; Curtin University, Perth, Western Australia, Australia
| | - Melanie Freeman
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia
| | - Jaya Chandrasekhar
- Department of Cardiology, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Clayton, Victoria, Australia.
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Bailey E, Lopes RD, Gibson CM, Eikelboom JW, Rao SV. Factor XIa inhibition as a therapeutic strategy for atherothrombosis. J Thromb Thrombolysis 2024:10.1007/s11239-024-03023-9. [PMID: 39078536 DOI: 10.1007/s11239-024-03023-9] [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: 07/09/2024] [Indexed: 07/31/2024]
Abstract
When selecting an anticoagulant, clinicians consider individual patient characteristic, the treatment indication, drug pharmacology, and safety and efficacy as demonstrated in randomized trials. An ideal anticoagulant prevents thrombosis with little or no increase in bleeding. Direct oral anticoagulants represent a major advance over traditional anticoagulants (e.g., unfractionated heparin, warfarin) but still cause bleeding, particularly from the gastrointestinal tract which can limit their use. Epidemiological studies indicate that patients with congenital factor XI (FXI) deficiency have a lower risk of venous thromboembolism (VTE) and ischemic stroke (IS) than non-deficient individuals, and do not have an increased risk of spontaneous bleeding, even with severe deficiency. These observations provide the rationale for targeting FXI as a new class of anticoagulant. Multiple FXI inhibitors have been introduced and several are being evaluated in Phase III trials. In this review, we explain why drugs that target FXI may be associated with a lower risk of bleeding than currently available anticoagulants and summarize the completed and ongoing trials.
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Affiliation(s)
- Eric Bailey
- New York University Langone Health System, New York, NY, USA.
| | - Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Sunil V Rao
- New York University Langone Health System, New York, NY, USA
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Grubic N, Ezekowitz JA. Rethinking Composite Endpoints With the Win Ratio: A Breakthrough or Business as Usual? Can J Cardiol 2024:S0828-282X(24)00580-4. [PMID: 39069071 DOI: 10.1016/j.cjca.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 07/30/2024] Open
Affiliation(s)
- Nicholas Grubic
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
| | - Justin A Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada
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50
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Li B, Shaikh F, Zamzam A, Raphael R, Syed MH, Younes HK, Abdin R, Qadura M. Prediction of Peripheral Artery Disease Prognosis Using Clinical and Inflammatory Biomarker Data. J Inflamm Res 2024; 17:4865-4879. [PMID: 39070129 PMCID: PMC11278072 DOI: 10.2147/jir.s471150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 07/09/2024] [Indexed: 07/30/2024] Open
Abstract
Purpose Inflammatory biomarkers associated with peripheral artery disease (PAD) have been examined separately; however, an algorithm that includes a panel of inflammatory proteins to inform prognosis of PAD could improve predictive accuracy. We developed predictive models for 2-year PAD-related major adverse limb events (MALE) using clinical/inflammatory biomarker data. Methods We conducted a prognostic study using 2 phases (discovery/validation models). The discovery cohort included 100 PAD patients that were propensity-score matched to 100 non-PAD patients. The validation cohort included 365 patients with PAD and 144 patients without PAD (non-matched). Plasma concentrations of 29 inflammatory proteins were determined at recruitment and the cohorts were followed for 2 years. The outcome of interest was 2-year MALE (composite of major amputation, vascular intervention, or acute limb ischemia). A random forest model was trained with 10-fold cross-validation to predict 2-year MALE using the following input features: 1) clinical characteristics, 2) inflammatory biomarkers that were expressed differentially in PAD vs non-PAD patients, and 3) clinical characteristics and inflammatory biomarkers. Results The model discovery cohort was well-matched on age, sex, and comorbidities. Of the 29 proteins tested, 5 were elevated in PAD vs non-PAD patients (MMP-7, MMP-10, IL-6, CCL2/MCP-1, and TFPI). For prognosis of 2-year MALE on the validation cohort, our model achieved AUROC 0.63 using clinical features alone and adding inflammatory biomarker levels improved performance to AUROC 0.84. Conclusion Using clinical characteristics and inflammatory biomarker data, we developed an accurate predictive model for PAD prognosis.
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Affiliation(s)
- Ben Li
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM), University of Toronto, Toronto, Ontario, Canada
| | - Farah Shaikh
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Abdelrahman Zamzam
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Ravel Raphael
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Muzammil H Syed
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Houssam K Younes
- Heart, Vascular, & Thoracic Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Rawand Abdin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Qadura
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
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