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Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
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Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
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GAROT P, Morice MC, Angiolillo DJ, Cabau JR, Park DW, Van Mieghem NM, Collet JP, Leon MB, Sengottuvelu G, Neylon A, ten Berg JM, Mylotte D, Tchétché D, Krucoff MW, Reardon MJ, Piazza N, Mack MJ, Généreux P, Makkar R, Hayashida K, Ohno Y, Mochizuki S, Shirai Y, Matsumara R, Jin Y, Webb JG, Cutlip DE, Chen M, Spitzer E, Mehran R, Capodanno D. Defining high bleeding risk in patients undergoing transcatheter aortic valve implantation: a VARC-HBR consensus document. EUROINTERVENTION 2024; 20:536-550. [PMID: 38726720 PMCID: PMC11067726 DOI: 10.4244/eij-d-23-01020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 02/12/2024] [Indexed: 05/14/2024]
Abstract
The identification and management of patients at high bleeding risk (HBR) undergoing transcatheter aortic valve implantation (TAVI) are of major importance, but the lack of standardised definitions is challenging for trial design, data interpretation, and clinical decision-making. The Valve Academic Research Consortium for High Bleeding Risk (VARC-HBR) is a collaboration among leading research organisations, regulatory authorities, and physician-scientists from Europe, the USA, and Asia, with a major focus on TAVI-related bleeding. VARC-HBR is an initiative of the CERC (Cardiovascular European Research Center), aiming to develop a consensus definition of TAVI patients at HBR, based on a systematic review of the available evidence, to provide consistency for future clinical trials, clinical decision-making, and regulatory review. This document represents the first pragmatic approach to a consistent definition of HBR evaluating the safety and effectiveness of procedures, devices and drug regimens for patients undergoing TAVI..
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Affiliation(s)
- Philippe GAROT
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | - Marie-Claude Morice
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Josep Rodés- Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
- Clínic Barcelona, Barcelona, Spain
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital, Paris, France
| | - Martin B. Leon
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, NY, USA and Cardiovascular Research Foundation, New York, NY, USA
| | - Gunasekaran Sengottuvelu
- Department of Cardiology, Apollo Hospitals, Chennai, Tamil Nadu, India
- Department of Cardiology and Center for Platelet Function Research, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Antoinette Neylon
- Institut Cardiovasculaire Paris-Sud (ICPS), Hôpital privé Jacques Cartier, Ramsay-Santé, Massy, France
- Cardiovascular European Research Center (CERC), Massy, France
| | | | - Darren Mylotte
- Galway University Hospital and University of Galway, Galway, Ireland
| | - Didier Tchétché
- Groupe CardioVasculaire Interventionnel, Clinique Pasteur, Toulouse, France
| | - Mitchell W. Krucoff
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Michael J. Reardon
- Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, QC, Canada
| | | | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | | | | | | | - Yu Jin
- Notified body 1639, SGS, Antwerp, Belgium
| | - John G. Webb
- Department of Cardiology, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Donald E. Cutlip
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA and Baim Clinical Research Institute, Boston, MA, USA
| | - Mao Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center, and Cardialysis, Clinical Trial Management and Core Laboratories, Rotterdam, the Netherlands
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Capodanno
- Cardiovascular European Research Center (CERC), Massy, France
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy
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Goyal A, Abbasi FQ, Tariq MD, Kanagala SG, Changez MIK, Safi D, Basit J, Sulaiman SA, Marsool MDM, Daoud M, Sohail AH. Efficacy and outcomes of antiplatelet therapy versus oral anticoagulants in patients undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:2911-2925. [PMID: 38694361 PMCID: PMC11060210 DOI: 10.1097/ms9.0000000000001908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/24/2024] [Indexed: 05/04/2024] Open
Abstract
Background Recent guidelines suggest that antiplatelet therapy (APT) is the standard of care in the absence of long-term oral anticoagulation (OAC) indications in patients post-transcatheter aortic valve replacement (TAVR). The superiority of one method over the other remains controversial. Materials and methods Several databases, including MEDLINE, Google Scholar, and EMBASE, were electronically searched. The primary endpoint was the all-cause mortality (ACM) rate. Secondary endpoints included cardiovascular death, myocardial infarction (MI), stroke/TIA, haemorrhagic stroke, bleeding events, systemic embolism, and valve thrombosis in post-TAVR patients receiving APT and oral anticoagulants (OACs). Forest plots were generated using Review Manager version 5.4, with a p value less than 0.05 indicating statistical significance. Subgroup analysis was performed to explore potential sources of heterogeneity. Results Twelve studies were selected. No significant differences were observed in APT and OAC group for ACM [risk ratio (RR): 0.67; 95% CI:0.45-1.01; P=0.05], cardiovascular death [RR:0.91; 95% CI:0.73-1.14; P=0.42], MI [RR:1.69; 95% CI:0.43-6.72; P=0.46], Stroke/TIA [RR:0.79; 95% CI:0.58-1.06; P=0.12], ischaemic stroke [RR:0.83; 95% CI:0.50-1.37; P=0.47], haemorrhagic stroke [RR:1.08; 95% CI: 0.23-5.15; P=0.92], major bleeding [RR:0.79; 95% CI:0.51-1.21; P=0.28], minor bleeding [RR:1.09; 95% CI: 0.80-1.47; P=0.58], life-threatening bleeding [RR:0.85; 95% CI:0.55-1.30; P=0.45], any bleeding [RR:0.98; 95% CI:0.83-1.15; P=0.78], and systemic embolism [RR:0.87; 95% CI:0.44-1.70; P=0.68]. The risk of valve thrombosis was higher in patients receiving APT than in those receiving OAC [RR:2.61; 95% CI:1.56-4.36; P =0.0002]. Conclusions Although the risk of valve thrombosis increased in patients receiving APT, the risk of other endpoints was comparable between the two groups.
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Affiliation(s)
- Aman Goyal
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | | | | | | | | | - Darsh Safi
- Department of Internal Medicine, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Jawad Basit
- Department of Internal Medicine, Rawalpindi Medical University, Rawalpindi
| | - Samia Aziz Sulaiman
- Department of Internal Medicine, School of Medicine, University of Jordan, Amman, Jordan
| | | | - Mohamed Daoud
- Department of Internal Medicine, Bogomolets National Medical University, Kyiv, Ukraine
| | - Amir H. Sohail
- Department of Surgery, University of New Mexico Health Sciences, Albuqurque, NM
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Alperi A, Ptaszynski R, Pascual I, Del Valle R, Hernández-Vaquero D, Almendárez M, Antuna P, Ludeña R, Morís C, Avanzas P. Late bleeding events in TAVI patients receiving vitamin K antagonists or direct oral anticoagulants. Rev Esp Cardiol (Engl Ed) 2024:S1885-5857(24)00146-4. [PMID: 38701880 DOI: 10.1016/j.rec.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/14/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES The optimal chronic antithrombotic regimen for patients with atrial fibrillation undergoing transcatheter aortic valve implantation (TAVI) remains uncertain. Our aim was to compare the incidence of late bleeding events between patients on direct oral anticoagulants (DOACs) and those on vitamin-K antagonists (VKA). METHODS This single-center observational study included TAVI patients requiring oral anticoagulation at discharge between 2015 and 2021. The primary endpoint was any clinically significant bleeding event. Secondary endpoints were stroke, heart failure, and all-cause mortality. RESULTS A total of 702 TAVI procedures were performed, with 297 patients requiring oral anticoagulation at discharge. Among them, 206 (69.4%) received VKA and 91 (30.6%) received DOAC. Baseline clinical, procedural and in-hospital characteristics did not significantly differ between groups, except for better renal function among DOAC patients. The median length of follow-up was 2.8 years. The risk of bleeding events was higher in patients receiving DOACs than in those receiving VKA (HR, 2.27; 95%CI, 1.21-4.26; incidence of 9.7 and 4.2 events per 100 patient-years of follow-up for DOAC and VKA patients, respectively). There were no statistically significant differences in the rates of stroke (HR, 1.28; 95%CI, 0.4-4.3), heart failure hospitalization (HR, 0.92; 95%CI, 0.46-1.86), or all-cause mortality (HR, 1.02; 95%CI, 0.68-1.55). CONCLUSIONS In older patients undergoing TAVI and receiving anticoagulant therapy for atrial fibrillation, the use of DOAC was associated with a higher risk of late bleeding events than VKA.
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Affiliation(s)
- Alberto Alperi
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain
| | - Raul Ptaszynski
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Isaac Pascual
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Raquel Del Valle
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain
| | - Daniel Hernández-Vaquero
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Marcel Almendárez
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Paula Antuna
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Raul Ludeña
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - César Morís
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain
| | - Pablo Avanzas
- Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Asturias, Spain; Universidad de Oviedo, Oviedo, Asturias, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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Alkhezi OS, Buckley LF, Fanikos J. Trends in Oral Anticoagulant Use and Individual Expenditures Across the United States from 2014 to 2020. Am J Cardiovasc Drugs 2024; 24:433-444. [PMID: 38583107 DOI: 10.1007/s40256-024-00638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Landmark clinical trials have expended the indications for the direct oral anticoagulants (DOACs), but contemporary data on usage and expenditure patterns are lacking. OBJECTIVE This study aimed to assess annual trends in oral anticoagulant (OAC) utilization and expenditure across the United States (US) from 2014 to 2020. METHODS We utilized the Medical Expenditure Panel Survey (MEPS) to study the trends of use and expenditures of warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban between 2014 and 2020 in the US. Survey respondents reported OAC use within the past year, which was verified against pharmacy records. Payment information was obtained from the respondent's pharmacy and was categorized as third-party or self/out-of-pocket. Potential indications and medical conditions of interest for OAC therapy were identified from respondent-reported medical conditions. We estimated the national number of OAC users and total expenditures across age, sex, race, ethnicity, insurance, and medical condition subgroups. Trends of OAC users' characteristics, expenditure, and number of prescriptions were evaluated using the Mann-Kendall test for trends. RESULTS Between 2014 and 2020, the number of warfarin users decreased from 3.8 million (70% of all OAC users) to 2.2 million (p = 0.007) [29% of all OAC users], while the number of DOAC users increased from 1.6 million (30% of all OAC users) to 5.4 million (p = 0.003) [70% of all OAC users]. The total expenditure of OACs in the US increased from $3.4 billion in 2014 to $17.8 billion in 2020 (p = 0.003), which was driven by the increase in DOAC expenditures (p = 0.003). CONCLUSIONS DOACs have replaced warfarin as the preferred OAC in the US. The increased costs associated with DOAC use may decline when generic formulations are approved.
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Affiliation(s)
- Omar S Alkhezi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia.
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
| | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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6
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Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 38687179 DOI: 10.1111/pace.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
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7
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MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
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8
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Kleiman NS, Goel SS. The Shape of Things to Come? Is a Trial of Combined Interventional Procedures Necessary in Today's World? Circulation 2024; 149:744-746. [PMID: 38437486 DOI: 10.1161/circulationaha.123.067744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Neal S Kleiman
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
| | - Sachin S Goel
- Houston Methodist DeBakey Heart and Vascular Center, Houston, TX
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Kim M, Ahn JM, Kang DY, Kim MJ, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Wong YTA, Lam CCS, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Yu Ko T, Kim WJ, Kang SH, Lee SA, Ko E, Kim DH, Kang JW, Lee JH, Lee J, Park J, Kim H, Choi Y, Park SJ, Park DW. Low- or standard-dose edoxaban versus antiplatelet therapy for leaflet thrombus and cerebral thromboembolism after TAVR: A prespecified analysis of randomized ADAPT-TAVR trial. Am Heart J 2024; 269:167-178. [PMID: 38123045 DOI: 10.1016/j.ahj.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The risks of leaflet thrombosis and the associated cerebral thromboembolism are unknown according to different anticoagulation dosing after transcatheter aortic valve replacement (TAVR). The aim was to evaluate the incidence of leaflet thrombosis and cerebral thromboembolism between low-dose (30 mg) or standard-dose (60 mg) edoxaban and dual antiplatelet therapy (DAPT) after TAVR. METHODS In this prespecified subgroup analysis of the ADAPT-TAVR trial, the primary endpoint was the incidence of leaflet thrombosis on 4-dimensional computed tomography at 6-months. Key secondary endpoints were new cerebral lesions on brain magnetic resonance imaging and neurological and neurocognitive dysfunction. RESULTS Of 229 patients enrolled in this study, 118 patients were DAPT group and 111 were edoxaban group (43 [39.1%] 60 mg vs 68 [61.3%] 30 mg). There was a significantly lower incidence of leaflet thrombosis in the standard-dose edoxaban group than in the DAPT group (2.4% vs 18.3%; odds ratio [OR] 0.11; 95% confidence interval [CI], 0.01-0.55; P = .03). However, no significant difference was observed between low-dose edoxaban and DAPT (15.0% vs 18.3%; OR 0.79; 95% CI, 0.32-1.81; P = .58). Irrespective of different antithrombotic regiments, the percentages of patients with new cerebral lesions on brain MRI and worsening neurological or neurocognitive function were not significantly different. CONCLUSIONS In patients without an indication for anticoagulation after TAVR, the incidence of leaflet thrombosis was significantly lower with standard-dose edoxaban but not with low-dose edoxaban, as compared with DAPT. However, this differential effect of edoxaban on leaflet thrombosis was not associated with a reduction of new cerebral thromboembolism and neurological dysfunction.
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Affiliation(s)
- Mijin Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Ju Kim
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Republic of Korea
| | - Hyun Jung Koo
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Seung-Ah Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euihong Ko
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | - Dae-Hee Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Joon-Won Kang
- Department of Radiology Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jinsun Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hoyun Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeonwoo Choi
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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Kobari Y, Hayashida K. What is the current optimal antithrombotic therapy after transcatheter aortic valve implantation? Current evidence from Japan and the world. J Cardiol 2024; 83:141-148. [PMID: 37524301 DOI: 10.1016/j.jjcc.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
Aortic stenosis (AS) is a major valvular disease that can have a negative impact on patients' prognosis, and its prevalence is increasing due to an aging population worldwide. Transcatheter aortic valve implantation (TAVI) is a well-established therapy for symptomatic severe AS utilized across the entire surgical risk spectrum. Based on the recently published evidence of large, randomized controlled trials (RCTs), the number of patients undergoing TAVI is increasing worldwide. Ischemic and bleeding events are common after TAVI and can have serious consequences both immediately after the procedure and in the long-term. Antiplatelet therapy has been traditionally recommended to prevent thromboembolic events after TAVI. The situation regarding the optimal antithrombotic regimen following TAVI is rapidly changing because many game-changing RCTs have been published. This report provides an overview of the current status and remaining issues in the field of optimal antithrombotic therapy following TAVI, including its possible effect on leaflet thrombosis.
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11
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Ten Berg JM, Overduin DC, van Ginkel DJ. What Oral Anticoagulant Is Best After TAVR: Vitamin K Antagonists or Direct Oral Anticoagulants? JACC Cardiovasc Interv 2024; 17:419-421. [PMID: 38355270 DOI: 10.1016/j.jcin.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 12/19/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Daniël C Overduin
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Dirk-Jan van Ginkel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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Alaour B, Ferrari E, Heg D, Tueller D, Pilgrim T, Muller O, Noble S, Jeger R, Reuthebuch O, Toggweiler S, Templin C, Wenaweser P, Nietlispach F, Taramasso M, Huber C, Roffi M, Windecker S, Stortecky S. Non-Vitamin K Antagonist Versus Vitamin K Antagonist Oral Anticoagulant Agents After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2024; 17:405-418. [PMID: 38355269 DOI: 10.1016/j.jcin.2023.11.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Studies comparing long-term outcomes between non-vitamin K antagonist (VKA) oral anticoagulant agents (direct oral anticoagulant agents [DOACs]) and VKA anticoagulant agents after transcatheter aortic valve replacement (TAVR) are scarce, with conflicting results. OBJECTIVES The aim of this study was to examine the periprocedural, short-term, and long-term safety and effectiveness of DOACs vs VKAs in patients undergoing TAVR via femoral access with concomitant indications for oral anticoagulation. METHODS Consecutive patients undergoing transfemoral TAVR in the prospective national SwissTAVI Registry between February 2011 and June 2021 were analyzed. Net clinical benefit (a composite of all-cause mortality, myocardial infarction, stroke, and life-threatening or major bleeding) and the primary safety endpoint (a composite of life-threatening and major bleeding) were compared between the VKA and DOAC groups at 30 days, 1 year, and 5 years after TAVR. RESULTS After 1:1 propensity score matching, 1,454 patients were available for analysis in each group. There was no significant difference in the rate of the net clinical benefit and the safety endpoints between the groups as assessed at 30 days and 1 and 5 years post-TAVR between VKAs and DOACs. VKAs were associated with significantly higher rates of 1- year (HR: 1.28; 95% CI: 1.01-1.62) and 5-year (HR: 1.25; 95% CI: 1.11-1.40) all-cause mortality. Long-term risk for disabling stroke was significantly lower in the VKA group after excluding periprocedural events (HR: 0.64; 95% CI: 0.46-0.90). CONCLUSIONS At 5 years after TAVR, VKAs are associated with a higher risk for all-cause mortality, a lower risk for disabling stroke, and a similar rate of life-threatening or major bleeding compared with DOACs. (SwissTAVI Registry; NCT01368250).
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Affiliation(s)
- Bashir Alaour
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Enrico Ferrari
- Department of Cardiovascular Surgery, Cardiocentro Ticino Institute-EOC, Lugano, Switzerland
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - David Tueller
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Olivier Muller
- Department of Cardiology, Lausanne University Hospital-CHUV, Lausanne, Switzerland
| | - Stephane Noble
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, Zurich, Switzerland; University of Basel, Basel, Switzerland
| | - Oliver Reuthebuch
- University of Basel, Basel, Switzerland; Department of Cardiovascular Surgery, Basel University Hospital, University of Basel, Basel, Switzerland
| | | | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Peter Wenaweser
- Heart Clinic Hirslanden, Hirslanden Clinic Zurich, Zurich, Switzerland
| | | | | | - Christoph Huber
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Marco Roffi
- Division of Cardiology and Cardiovascular Surgery, University Hospital, Geneva, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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13
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Xu Q, Chen G, Ai S, Zheng K, Zhao B, Li X. Acute Kidney Injury in Different Anticoagulation Strategies: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07558-0. [PMID: 38319470 DOI: 10.1007/s10557-024-07558-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Acute kidney injury (AKI) following anticoagulant application has received growing attention as a significant emerging complication of anticoagulation. Nevertheless, there remains a lack of real-world studies to compare the incidence, clinical features, and prognosis of AKI across different anticoagulant regimens. METHODS Disproportionality analysis and Bayesian analysis were used to identify suspected AKI cases after different anticoagulant use within the Food and Drug Administration's Adverse Event Reporting System from January 2004 to March 2023. The time to onset, fatality, and hospitalization rates of anticoagulant-associated AKI were also investigated. RESULTS We identified 9313 anticoagulant-associated AKIs, which appeared to influence mostly patients over 65 years old (65.37%). Lepirudin displayed a stronger AKI association than others, based on the highest reporting odds ratio (ROR = 6.66, 95% CI = 3.97-11.18), proportional reporting ratio (PRR = 6.08, χ2 = 69.12), and empirical Bayes geometric mean (EBGM = 6.08, the lower 90% one-sided CI = 3.95). Warfarin showed the slightest association with AKI in oral anticoagulants, lower than any direct oral anticoagulants excluding apixaban. Edoxaban exhibited the highest potential renal risk among direct oral anticoagulants, with an ROR of 3.32 (95% CI = 2.95-3.72). The median time to AKI onset was 36 (IQR 7-205) days following the initiation of anticoagulation therapy, and most AKI cases occurred within the first month. CONCLUSION Particular attention should be directed toward monitoring renal function in individuals receiving anticoagulants, including warfarin and direct oral anticoagulants, as well as other anticoagulant agents. This diligence is particularly imperative within the first month after anticoagulant administration for individuals with a tendency for AKI.
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Affiliation(s)
- Qiuyu Xu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Sanxi Ai
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Bin Zhao
- Department of Pharmacy, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
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14
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Maznyczka A, Pilgrim T. Antithrombotic Treatment After Transcatheter Valve Interventions: Current Status and Future Directions. Clin Ther 2024; 46:122-133. [PMID: 37926630 DOI: 10.1016/j.clinthera.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/15/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE The optimal antithrombotic strategy after transcatheter valve interventions is a subject of ongoing debate. Although there is evidence from randomized trials in patients undergoing transcatheter aortic valve replacement (TAVR), current evidence on optimal antithrombotic management after transcatheter mitral or tricuspid valve interventions is sparse. This article appraises the current evidence on this topic. METHODS This narrative review presents key research findings and guideline recommendations, as well as highlights areas for future research. FINDINGS After TAVR, randomized trial evidence suggests that single antiplatelet therapy is reasonable for patients without pre-existing indications for oral anticoagulation (OAC). If there is a concurrent indication for OAC, the addition of antiplatelet therapy increases bleeding risk. Whether direct oral anticoagulants achieve better outcomes than vitamin K antagonists is uncertain in this setting. Although OAC has been shown to reduce subclinical leaflet thrombosis (which may progress to structural valve degeneration), bleeding events are unacceptably high. There is a lack of randomized trial data comparing antithrombotic strategies after transcatheter mitral or tricuspid valve replacement or after mitral or tricuspid transcatheter edge-to-edge repair. Single antiplatelet therapy after mitral or tricuspid transcatheter edge-to-edge repair may be appropriate, whereas at least 3 months of OAC is suggested after transcatheter mitral valve replacement or transcatheter tricuspid valve replacement. IMPLICATIONS Randomized studies are warranted to address the knowledge gaps in antithrombotic therapy after transcatheter valve interventions and to optimize outcomes.
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Affiliation(s)
- Annette Maznyczka
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, Bern, Switzerland.
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15
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Doni K, Bühn S, Weise A, Mann NK, Hess S, Sönnichsen A, Salem S, Pieper D, Thürmann P, Mathes T. Safety outcomes of direct oral anticoagulants in older adults with atrial fibrillation: a systematic review and meta-analysis of (subgroup analyses from) randomized controlled trials. GeroScience 2024; 46:923-944. [PMID: 37261677 PMCID: PMC10828375 DOI: 10.1007/s11357-023-00825-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023] Open
Abstract
Balancing stroke prevention and risk of bleeding in patients with atrial fibrillation (AF) is challenging. Direct oral anticoagulants (DOACs) are by now considered standard of care for treating patients with AF in international guidelines. Our objective was to assess the safety of long-term intake of DOACs in older adults with AF. We included RCTs in elderly (≥ 65 years) patients with AF. A systematic search in MEDLINE and EMBASE was performed on 19 April 2022. For determination of risk of bias, the RoB 2 tool was applied. We pooled outcomes using random-effects meta-analyses. The quality of evidence was assessed using GRADE. Eleven RCTs with a total of 63,374 patients were identified. Two RCTs compared apixaban with either warfarin or aspirin, four edoxaban with either placebo, aspirin, or vitamin K antagonists (VKAs), two dabigatran with warfarin and three rivaroxaban with warfarin. DOACs probably reduce mortality in elderly patients with AF (HR 0.89 95%CI 0.77 to 1.02). Low-dose DOACs likely reduce bleeding compared to VKAs (HR ranged from 0.47 to 1.01). For high-dose DOACS the risk of bleeding varied widely (HR ranged from 0.80 to 1.40). We found that low-dose DOACs probably decrease mortality in AF patients. Moreover, apixaban and probably edoxaban are associated with fewer major or clinically relevant bleeding (MCRB) events compared to VKAs. For dabigatran and rivaroxaban, the risk of MCRB varies depending on dose. Moreover, subgroup analyses indicate that in the very old (≥ 85) the risk for MCRB events might be increased when using DOACs.Registration: PROSPERO: CRD42020187876.
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Affiliation(s)
- Katharina Doni
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
- Institute for Health Economics and Clinical Epidemiology of the University of Cologne, Gleueler Str. 176-178, 50935, Cologne, Germany
| | - Stefanie Bühn
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Alina Weise
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Nina-Kristin Mann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
| | - Simone Hess
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | | | - Susanna Salem
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Dawid Pieper
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany
| | - Petra Thürmann
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- Philipp Klee-Institute for Clinical Pharmacology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | - Tim Mathes
- Institute for Research in Operative Medicine, School of Medicine, Faculty of Health, Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Witten, Germany.
- Department of Clinical Pharmacology, School of Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany.
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.
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16
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Moreno R, Souza J, Smolnik R, Nombela-Franco L, Van Mieghem NM, Hengstenberg C, Valgimigli M, Jin J, Ohlmann P, Dangas G, Unverdorben M, Möllmann H. Outcomes after TAVI in patients with atrial fibrillation and a history of recent PCI: Results from the ENVISAGE-TAVI AF trial. Clin Res Cardiol 2024:10.1007/s00392-024-02379-5. [PMID: 38294497 DOI: 10.1007/s00392-024-02379-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/10/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and a recent (≤ 90 days) percutaneous coronary intervention (PCI) undergoing transcatheter aortic valve implantation (TAVI) are at high bleeding risk due to the addition of oral antiplatelet (OAP) agents on top of oral anticoagulants. Data on outcomes of these patients are needed to optimize antithrombotic treatment. METHODS This analysis compared annualized clinical event rates in patients with and without a recent PCI enrolled in ENVISAGE-TAVI AF, a prospective, randomized, open-label, adjudicator-masked trial comparing edoxaban and vitamin K antagonists in AF patients after TAVI. The primary efficacy and safety outcomes were net adverse clinical events (NACE) and major bleeding. RESULTS Overall, 132 (94.3%) patients with a recent PCI (n = 140) received OAP after TAVI, compared with 692 (55.9%) patients without a recent PCI (n = 1237). Among patients with a recent PCI on OAP agents, use of dual antiplatelet therapy decreased to 5.5%, and use of single antiplatelet therapy (SAPT) increased to 78.0% over 3 months post-randomization. Conversely, use of SAPT predominated at all time points in patients without a recent PCI history. There were no significant differences in the incidence of NACE or other outcomes assessed, except for major bleeding events, which were more frequent in patients with vs without a recent PCI history (hazard ratio [95% confidence interval]: 2.17 [1.27, 3.73]; P = 0.005). CONCLUSIONS Patients with AF undergoing TAVI with a recent PCI have a similar risk of ischemic events and mortality, but an increased risk of major bleeding compared with patients without a recent PCI.
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Affiliation(s)
- Raúl Moreno
- Interventional Cardiology, University Hospital La Paz, Paseo La Castellana, 261, 28046, Madrid, Spain.
| | | | | | | | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, the Netherlands
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University, Vienna, Austria
| | - Marco Valgimigli
- Division of Cardiology, Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università Della Svizzera Italiana (USI) and University of Berne, Berne, Switzerland
| | - James Jin
- Daiichi Sankyo, Inc, Basking Ridge, NJ, USA
| | - Patrick Ohlmann
- Division of Cardiovascular Medicine, University Hospital of Strasbourg, Strasbourg, France
| | - George Dangas
- Mount Sinai Hospital, Zena and Michael A. Wiener Cardiovascular Institute, New York, NY, USA
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Helge Möllmann
- Department of Internal Medicine, St. Johannes Hospital, Dortmund, Germany
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17
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Skogseid EL, Batra G, Westerbergh J, Held C, Christersson C. Thromboembolic and bleeding events after valvular intervention in patients with atrial fibrillation. Open Heart 2024; 11:e002602. [PMID: 38290732 PMCID: PMC10826562 DOI: 10.1136/openhrt-2024-002602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/16/2024] [Indexed: 02/01/2024] Open
Abstract
AIM To assess outcomes after cardiac surgery with biological valve replacement, valve repair or transcatheter aortic valve implantation (TAVI) in patients with atrial fibrillation (AF) in accordance with oral anticoagulant (OAC) treatment. METHODS All patients in Sweden undergoing valvular intervention with AF were included. Associations between OAC exposure and cardiovascular (CV) events (composite of CV death, ischaemic stroke or systemic embolism) and major bleeding were investigated using Cox regression analysis. The analysis was separated in time periods of 0-3 and 3-12 months after discharge. RESULTS 4730 patients were included in the first time period, 54.0% had received a surgical biological valve prosthesis, 23.8% valve repair and 22.2% TAVI. Exposure to warfarin (comparator) was 62.3%, to non-vitamin K antagonist oral anticoagulants (NOACs) 10.0% and to no OAC 27.7%. NOAC exposure was associated with similar risk of the composite CV outcome and major bleeding from 0 to 3 months. No OAC was associated with increased risk of the composite CV outcome (HR 1.71; 95% CI 1.26 to 2.32) and similar risk of major bleeding. Further analysis of the bioprosthetic valve replacement subgroup indicated increased risk of CV death when exposed to NOAC (HR 2.58; 95% CI 1.15 to 5.78) and no OAC (HR 2.82; 95% CI 1.65 to 4.82) compared with warfarin from 0 to 3 months. No differences were seen between 3 and 12 months. CONCLUSION In this registry-based cohort study of patients with AF with severe valvular heart disease undergoing various valvular interventions, NOAC appears to be comparable with warfarin regarding efficacy and safety. Patients not receiving OAC had higher risk of CV events. NOAC was associated with increased CV death compared with warfarin in the surgical bioprosthetic valve replacement subgroup, illustrating the importance of being cautious when extrapolating data from one patient group to another. Further studies comparing NOAC and warfarin in the early postoperative phase are warranted, especially following surgical bioprosthetic valve replacement.
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Affiliation(s)
| | - Gorav Batra
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Johan Westerbergh
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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18
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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19
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Ten Berg JM, Overduin DC, van Ginkel DJ. Best Oral Anticoagulant for Transcatheter Mitral Valve Replacement. J Am Coll Cardiol 2024; 83:347-349. [PMID: 38199712 DOI: 10.1016/j.jacc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 11/06/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Jurriën M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; Department of Cardiology, University Medical Center Maastricht, Maastricht University Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Daniël C Overduin
- Department of Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands
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20
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El Bèze N, Himbert D, Suc G, Brochet E, Ajzenberg N, Cailliau A, Kikoïne J, Delhomme C, Carrasco JL, Ou P, Iung B, Urena M. Comparison of Direct Oral Anticoagulants vs Vitamin K Antagonists After Transcatheter Mitral Valve Replacement. J Am Coll Cardiol 2024; 83:334-346. [PMID: 38199711 DOI: 10.1016/j.jacc.2023.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/13/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND There is currently no established recommendation for antithrombotic treatment following transcatheter mitral valve replacement (TMVR). However, based on the analogy with surgical mitral bioprosthesis, vitamin K antagonists (VKAs) are predominantly used. OBJECTIVES The purpose of this study was to compare bleeding and thrombotic events associated with direct oral anticoagulants (DOACs) or VKAs in a prospective cohort of TMVR patients. METHODS We enrolled consecutive patients who underwent transseptal TMVR using a SAPIEN family prosthesis at our center between 2011 and 2023. The primary outcome was the occurrence of bleeding. VKAs were administered to patients until October 2019, after which DOACs were prescribed. The median follow-up was 4.7 months (Q1-Q3: 2.6-6.7 months). RESULTS A total of 156 patients were included. The mean age was 65 ± 18.5 years, and 103 patients (66%) were women. The median EuroSCORE II was 7.48% (Q1-Q3: 3.80%-12.97%). Of the participants, 20.5% received DOACs and 79.5% were treated with VKAs. The primary outcome was observed in 50 (40%) patients in the VKA group and 3 (9%) patients in the DOAC group (adjusted HR: 0.21; 95% CI: 0.06-0.74; P = 0.02). Treatment with DOAC was associated with a shorter length of hospital stay. No significant differences were found in terms of thrombotic events, major vascular complications, stroke, or death. CONCLUSIONS The use of DOACs after TMVR, compared with VKAs, appears to reduce the risk of bleeding complications and decrease the length of hospital stay for patients, without a significant increase in the risk of thrombotic events.
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Affiliation(s)
- Nathan El Bèze
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Dominique Himbert
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France; INSERM UMRS1148, INSERM, Paris, France
| | - Gaspard Suc
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France; INSERM UMRS1148, INSERM, Paris, France
| | - Eric Brochet
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Nadine Ajzenberg
- INSERM UMRS1148, INSERM, Paris, France; Department of Hematology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Audrey Cailliau
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - John Kikoïne
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Clemence Delhomme
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Jose Luis Carrasco
- Department of Anesthesiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Phalla Ou
- Department of Radiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France
| | - Bernard Iung
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France; INSERM UMRS1148, INSERM, Paris, France
| | - Marina Urena
- Department of Cardiology, Bichat Claude Bernard Hospital-Paris City University, Paris, France; INSERM UMRS1148, INSERM, Paris, France.
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21
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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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22
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Kawashima H, Numasawa Y, Hayakawa N, Asano T, Tanaka S, Torii S, Ueshima D, Hishikari K, Hioki H, Watanabe Y, Mizutani K, Matsuo Y, Hayashida K, Jujo K, Nakazawa G. Review of Bleeding and Thrombotic Risks Associated With Antithrombotic Therapy After Transcatheter Structural Heart Interventions. JACC Asia 2024; 4:1-9. [PMID: 38222261 PMCID: PMC10782401 DOI: 10.1016/j.jacasi.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 01/16/2024]
Abstract
Transcatheter structural heart interventions have drastically evolved over the past 2 decades. However, most catheterization procedures require the deployment of devices in the body; therefore, the adhesion of thrombi to those devices is a major problem, resulting in the requirement of a period of postprocedural antithrombotic regimen. However, in recent years, bleeding associated with these antithrombotic therapies has also become a major concern, attracting the attention of investigators. This is complicated by the fact that patients at high thrombotic risk are also at high bleeding risk, making the issue of administrating antithrombotic therapy challenging. The objective of this review was to identify the important issues and summarize the current status of postoperative antithrombotic therapy and assessment of the bleeding risk following transcatheter structural heart interventions such as transcatheter aortic valve replacement, transcatheter edge-to-edge repair, and transcatheter left atrial appendage occlusion.
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Affiliation(s)
- Hideyuki Kawashima
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Naoki Hayakawa
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
| | - Taku Asano
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, St. Luke's International University, Tokyo, Japan
| | - Shigemitsu Tanaka
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Sho Torii
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
| | - Daisuke Ueshima
- Department of Cardiology, Kameda Medical Center, Kamogawa, Japan
| | - Keiichi Hishikari
- Department of Cardiology, Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
| | - Hirofumi Hioki
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Kazuki Mizutani
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yae Matsuo
- Department of Cardiovascular Medicine, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shibukawa, Gunma, Japan
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Jujo
- Department of Cardiology, Saitama Medical University/Saitama Medical Center, Saitama, Japan
| | - Gaku Nakazawa
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - SUNRISE Lab Investigators
- Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
- Department of Cardiovascular Medicine, St. Luke’s International Hospital, St. Luke's International University, Tokyo, Japan
- Department of Cardiology, Tokai University School of Medicine, Isehara, Japan
- Department of Cardiology, Kameda Medical Center, Kamogawa, Japan
- Department of Cardiology, Cardiovascular Center, Yokosuka Kyosai Hospital, Yokosuka, Japan
- Department of Cardiology, Kindai University Faculty of Medicine, Osaka, Japan
- Department of Cardiovascular Medicine, Cardiovascular Hospital of Central Japan (Kitakanto Cardiovascular Hospital), Shibukawa, Gunma, Japan
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Department of Cardiology, Saitama Medical University/Saitama Medical Center, Saitama, Japan
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23
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Choi Y, Ahn JM, Kang DY, Kim HJ, Kim H, Lee J, Kim M, Park J, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Anthony Wong YT, Simon Lam CC, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Lee SA, Kim DH, Lee JH, Park SJ, Park DW. Frequency, Predictors, and Clinical Impact of Valvular and Perivalvular Thrombus After Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2023; 16:2967-2981. [PMID: 38151311 DOI: 10.1016/j.jcin.2023.10.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Subclinical aortic valve complex (valvular and perivalvular) thrombus is not rare after transcatheter aortic valve replacement (TAVR). The risk factors and clinical implications of these findings remain uncertain. OBJECTIVES This study sought to evaluate the frequency, predictors, and clinical outcome of aortic valve complex thrombus after TAVR. METHODS In the ADAPT-TAVR (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement) trial comparing edoxaban vs dual antiplatelet therapy in TAVR patients without an indication for chronic anticoagulation, the frequency of valvular (subclinical leaflet thrombus) and perivalvular (supravalvular, subvalvular, and sinus of Valsalva) thrombus was evaluated by 4-dimensional computed tomography at 6 months. The association of these phenomena with new cerebral thromboembolism on brain magnetic resonance imaging, neurologic and neurocognitive dysfunction, and clinical outcomes was assessed. RESULTS Among 211 patients with 6-month computed tomography evaluations, 91 patients (43.1%) had thrombus at any aortic valve complex, 30 (14.2%) patients had leaflet thrombus, and 78 (37.0%) patients had perivalvular thrombus. A small maximum diameter of the stent at the valve level and low body surface area were independent predictors of aortic valve complex and perivalvular thrombus, and decreased renal function was an independent predictor of leaflet thrombus. No significant differences were observed in new cerebral lesions, neurologic or neurocognitive functions, or clinical outcomes among patients with or without valvular or perivalvular thrombus. CONCLUSIONS Subclinical aortic valve complex (valvular and perivalvular) thrombus was common in patients who had undergone successful TAVR. However, these imaging phenomena were not associated with new cerebral thromboembolism, neurologic or neurocognitive dysfunction, or adverse clinical outcomes. (Anticoagulation Versus Dual Antiplatelet Therapy for Prevention of Leaflet Thrombosis and Cerebral Embolization After Transcatheter Aortic Valve Replacement [ADAPT-TAVR]; NCT03284827).
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Affiliation(s)
- Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwa Jung Kim
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mijin Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinsun Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, Seoul, Korea
| | - Hyun Jung Koo
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Hyun Yang
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Chai Jung
- Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Medical Center, Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Medical Center, Korea
| | - Seung-Ah Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hee Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hong Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Hengstenberg C, Van Mieghem NM, Wang R, Ye X, Shi L, Guo S, Chen C, Jin J, Ye X, Dangas G, Unverdorben M. Treatment Satisfaction and Convenience for Patients With Atrial Fibrillation on Edoxaban or Vitamin K Antagonists After Transcatheter Aortic Valve Replacement: A Post Hoc Analysis from the ENVISAGE-TAVI AF Trial. Am J Cardiol 2023; 209:212-219. [PMID: 37848174 DOI: 10.1016/j.amjcard.2023.09.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/14/2023] [Accepted: 09/24/2023] [Indexed: 10/19/2023]
Abstract
ENVISAGE-TAVI AF (Edoxaban versus Standard of Care and Their Effects on Clinical Outcomes in Patients Having Undergone Transcatheter Aortic Valve Implantation-Atrial Fibrillation; NCT02943785) was a prospective, randomized, open-label trial comparing non-vitamin K oral anticoagulant (NOAC) edoxaban with vitamin K antagonists (VKAs) in patients with atrial fibrillation after successful transcatheter aortic valve replacement (TAVR). The effect of edoxaban- or VKA-based therapy on patient-reported outcomes remains unknown, as most studies focus on efficacy and safety. Pre-TAVR patient-reported expectations and post-TAVR Treatment Satisfaction and Convenience with edoxaban or VKA treatment (at months 3 and 12) were analyzed using the Perception of Anticoagulation Treatment Questionnaire (PACT-Q). This analysis included randomized and dosed patients with an evaluable PACT-Q1 assessment at baseline and ≥1 postbaseline assessment (PACT-Q2). Subanalyses included patients stratified by pre-TAVR anticoagulant (NOAC, VKA, no NOAC/VKA). Edoxaban- (n = 585) and VKA-treated (n = 522) patients had similar baseline characteristics and treatment expectations. Pre-TAVR anticoagulant use did not affect treatment expectations. After TAVR, edoxaban-treated patients had significantly higher Treatment Satisfaction and Convenience scores compared with VKA-treated patients at all time points (p <0.001 for all). Among edoxaban-treated patients, those who received VKAs pre-TAVR were significantly more satisfied with treatment than those who received NOACs (p <0.001) or no NOACs/VKAs (p = 0.003); however, there was no significant difference in the perception of convenience (p = 0.927 and p = 0.092, respectively). Conversely, among VKA-treated patients, the type of anticoagulant used pre-TAVR did not affect Treatment Satisfaction or Convenience scores post-TAVR. In conclusion, patients with atrial fibrillation who received edoxaban post-TAVR reported significantly higher Treatment Satisfaction and Convenience scores compared with those who received VKAs, resulting in a clinically meaningful difference between treatment groups.
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Affiliation(s)
- Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University, Vienna, Austria.
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Centre, Thoraxcenter, Rotterdam, The Netherlands
| | - Rosa Wang
- Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Xiaomei Ye
- Clinical Outcomes Analytics, Evidera PPD, LLC, Bethesda, Maryland
| | - Ling Shi
- Clinical Outcomes Analytics, Evidera PPD, LLC, Bethesda, Maryland
| | - Shien Guo
- Clinical Outcomes Analytics, Evidera PPD, LLC, Bethesda, Maryland
| | - Cathy Chen
- Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - James Jin
- Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Xin Ye
- Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York; School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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25
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Ya’Qoub L, Arnautovic J, Sharkawi M, AlAasnag M, Jneid H, Elgendy IY. Antithrombotic Management for Transcatheter Aortic Valve Implantation. J Clin Med 2023; 12:7632. [PMID: 38137701 PMCID: PMC10743716 DOI: 10.3390/jcm12247632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND There have been significant changes in the optimal antithrombotic regimen post transcatheter aortic valve implantation (TAVI) after the results of major clinical trials in the past few years. Given the clinical importance of the optimal antithrombotic therapy post TAVI, we performed a narrative description of the major clinical trials behind the scientific evidence supporting these changes, as well the current guideline recommendations and knowledge gaps. METHODS We performed a narrative description of the major clinical trials behind the scientific evidence supporting these changes. We used PubMed as a major source to collect the major clinical trials including the following key words: "transcatheter aortic valve replacement", "transcatheter aortic valve implantation", "antithrombotic", "antiplatelet" and "anticoagulation". We selected the major clinical trials on this topic. This is not a systematic review or meta-analysis. RESULTS We describe the results of the major clinical trials on antithrombotic therapy post TAVI: POPULAR-TAVI A, POPULAR-TAVI B, ENVISAGE-TAVI AF, GALILEO, ATLANTIS and ADAPT-TAVR trials. Based on the results of these trials, single antiplatelet therapy is recommended post TAVI in patients without concomitant indication for oral anticoagulation or dual antiplatelet therapy, especially in elderly patients. In younger patients, it is advised to evaluate the patient's bleeding and thrombotic risk, and dual antiplatelet therapy may be reasonable in patients with a high thrombotic risk and low bleeding risk. In patients with a concurrent indication for oral anticoagulation or dual antiplatelet therapy, it is recommended to continue oral anticoagulation or dual antiplatelet therapy post TAVI. CONCLUSION In most patients without concomitant indication for oral anticoagulation, single antiplatelet therapy is recommended post TAVI.
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Affiliation(s)
- Lina Ya’Qoub
- Division of Structural Heart Disease, University of California (San Francisco), San Francisco, CA 93106, USA
| | - Jelena Arnautovic
- Division of Interventional Cardiology, Henry Ford Macomb Hospital, Clinton Twp, MI 48038, USA;
| | - Musa Sharkawi
- Division of Structural Heart Disease, Medical College of Georgia, Augusta, GA 30912, USA;
| | - Mirvat AlAasnag
- Department of Cardiology, King Fahd Medical Center, Jeddah 21589, Saudi Arabia;
| | - Hani Jneid
- Department of Cardiology, Saint Luke’s Baylor Medical Center, Houston, TX 77030, USA;
| | - Islam Y. Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY 40506, USA
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26
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Lin DS, Lo H, Huang K, Lin T, Lee J. Efficacy and Safety of Direct Oral Anticoagulants for Stroke Prevention in Older Patients With Atrial Fibrillation: A Network Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc 2023; 12:e030380. [PMID: 38014696 PMCID: PMC10727327 DOI: 10.1161/jaha.123.030380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Although older patients with atrial fibrillation are at heightened risk of thromboembolic and bleeding events, their optimal treatment choice remains uncertain. METHODS AND RESULTS This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the PubMed, EMBASE, and Cochrane databases for randomized controlled trials that compared thromboembolic or bleeding outcomes between a direct oral anticoagulant (DOAC) and a vitamin K antagonist (VKA) and reported outcomes for patients aged ≥75 years with atrial fibrillation. The efficacy outcome was the composite of stroke and systemic embolism. Safety outcomes included major bleeding, any clinically relevant bleeding, and intracranial hemorrhage. Each DOAC and VKA was compared pairwise in a network meta-analysis. High- and low-dose regimens and factor IIa and Xa inhibitors were also compared. Seven randomized controlled trials were included in the analysis. Stroke and systemic embolism risks did not differ significantly among DOACs. There were no significant differences in major bleeding between each DOAC and VKA. Intracranial hemorrhage risk was significantly lower with dabigatran, apixaban, and edoxaban than with VKA and rivaroxaban, which had similar risks. High-dose regimens led to lower risks of stroke or systemic embolism compared with VKA and low-dose regimens, with both doses having similar bleeding risks. CONCLUSIONS In patients aged ≥75 years with atrial fibrillation, DOACs were associated with fewer thromboembolic events compared with VKA, whereas dabigatran, apixaban, and edoxaban were associated with lower risks of intracranial hemorrhage compared with VKA and rivaroxaban. REGISTRATION URL: www.crd.york.ac.uk/prospero/. Unique identifier: CRD42022329557.
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Affiliation(s)
- Donna Shu‐Han Lin
- Division of CardiologyDepartment of Internal MedicineShin Kong Wu Ho‐Su Memorial HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
| | - Hao‐Yun Lo
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalHsin‐Chu BranchHsinchuTaiwan
| | - Kuan‐Chih Huang
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalHsin‐Chu BranchHsinchuTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
| | - Ting‐Tse Lin
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
| | - Jen‐Kuang Lee
- Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalTaipeiTaiwan
- Department of Internal MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Department of Laboratory MedicineNational Taiwan University College of MedicineTaipeiTaiwan
- Cardiovascular CenterNational Taiwan University HospitalTaipeiTaiwan
- Telehealth CenterNational Taiwan University HospitalTaipeiTaiwan
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27
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Yamamoto M, Hayashida K, Hengstenberg C, Watanabe Y, Van Mieghem NM, Jin J, Saito S, Valgimigli M, Nicolas J, Mehran R, Moreno R, Kimura T, Chen C, Unverdorben M, Dangas GD. Predictors of All-Cause Mortality After Successful Transcatheter Aortic Valve Implantation in Patients With Atrial Fibrillation. Am J Cardiol 2023; 207:150-158. [PMID: 37741105 DOI: 10.1016/j.amjcard.2023.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/13/2023] [Indexed: 09/25/2023]
Abstract
Prevalent and incident atrial fibrillation are common in patients who undergo transcatheter aortic valve implantation and are associated with impaired postprocedural outcomes, including mortality. We determined predictors of long-term mortality in patients with atrial fibrillation after successful transcatheter aortic valve implantation. The EdoxabaN Versus standard of care and theIr effectS on clinical outcomes in pAtients havinG undergonE Transcatheter Aortic Valve Implantation-Atrial Fibrillation (ENVISAGE-TAVI AF) trial (NCT02943785) was a multicenter, prospective, randomized controlled trial in patients with prevalent or incident atrial fibrillation after successful transcatheter aortic valve implantation who received edoxaban or vitamin K antagonists. A Cox proportional hazard model was performed to identify predictors of all-cause mortality using a stepwise approach for multiple regression analysis. In addition, we assessed the performance of different risk scores and prediction models using ENVISAGE-TAVI AF data. Of 1,426 patients in ENVISAGE-TAVI AF, 178 (12.5%) died during the follow-up period (median 548 days). Our stepwise approach identified greater risk of mortality with older age, impaired renal function, nonparoxysmal atrial fibrillation, excessive alcohol use, New York Heart Association heart failure class III/IV, peripheral artery disease, and history of major bleeding or predisposition to bleeding. The present model (concordance statistic [c-statistic] 0.67) was a better discriminator than were other frequently used risk scores, such as the Society of Thoracic Surgeons score (c-statistic 0.56); Congestive heart failure, Hypertension, Age ≥75, Diabetes, Stroke, Vascular disease, Age 65 to 74 years, and Sex category (CHA2DS2-VASc) score (c-statistic 0.54); or Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly, and Drugs/alcohol concomitantly (HAS-BLED) score (c-statistic 0.58). In ENVISAGE-TAVI AF, several modifiable and nonmodifiable clinical characteristics were significantly associated with greater long-term all-cause mortality. Improved risk stratification to estimate the probability of mortality after successful transcatheter aortic valve implantation in patients with atrial fibrillation may improve long-term patient prognosis.
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Affiliation(s)
| | - Kentaro Hayashida
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University, Vienna, Austria
| | - Yusuke Watanabe
- Division of Cardiology, Teikyo University Hospital, Tokyo, Japan
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Thoraxcenter, Rotterdam, The Netherlands
| | - James Jin
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Shigeru Saito
- Division of Cardiology & Catheterization Laboratories, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Marco Valgimigli
- Division of Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), Lugano, Switzerland; Department of Cardiology, University of Bern, Bern, Switzerland
| | - Johny Nicolas
- Icahn School of Medicine, Mount Sinai Hospital, New York, NY, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York
| | - Raul Moreno
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Cathy Chen
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - Martin Unverdorben
- Global Specialty Medical Affairs, Daiichi Sankyo, Inc., Basking Ridge, New Jersey
| | - George D Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York.
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28
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Aikawa T, Kuno T, Malik AH, Briasoulis A, Kolte D, Kampaktsis PN, Latib A. Transcatheter Aortic Valve Replacement in Patients With or Without Active Cancer. J Am Heart Assoc 2023; 12:e030072. [PMID: 37889175 PMCID: PMC10727376 DOI: 10.1161/jaha.123.030072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
Background Data on clinical outcomes after transcatheter aortic valve replacement (TAVR) in specific cancer types or the presence of metastatic disease remain sparse. This study aimed to investigate the impact of active cancer on short-term mortality, complications, and readmission rates after TAVR across different cancer types. Methods and Results The authors assessed the Nationwide Readmissions Database for TAVR cases from 2012 to 2019. Patients were stratified by specific cancer types. Primary outcome was in-hospital mortality. Secondary outcomes included bleeding requiring blood transfusion and readmissions at 30, 90, and 180 days after TAVR. Overall, 122 573 patients undergoing TAVR were included in the analysis, of whom 8013 (6.5%) had active cancer. After adjusting for potential confounders, the presence of active cancer was not associated with increased in-hospital mortality (adjusted odds ratio [aOR], 1.06 [95% CI, 0.89-1.27]; P=0.523). However, active cancer was associated with an increased risk of readmission at 30, 90, and 180 days after TAVR and increased risk of bleeding requiring transfusion at 30 days. Active colon and any type of metastatic cancer were individually associated with readmissions at 30, 90, and 180 days after TAVR. At 30 days after TAVR, colon (aOR, 2.51 [95% CI, 1.68-3.76]; P<0.001), prostate (aOR, 1.40 [95% CI, 1.05-1.86]; P=0.021), and any type of metastatic cancer (aOR, 1.65 [95% CI, 1.23-2.22]; P=0.001) were individually associated with an increased risk of bleeding requiring transfusion. Conclusions Patients with active cancer had similar in-hospital mortality after TAVR but higher risk of readmission and bleeding requiring transfusion, the latter depending on certain types of cancer.
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Affiliation(s)
- Tadao Aikawa
- Department of CardiologyJuntendo University Urayasu HospitalUrayasuJapan
- Department of RadiologyJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
- Division of Cardiology, Jacobi Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
| | - Aaqib H. Malik
- Department of CardiologyWestchester Medical CenterValhallaNYUSA
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and TransplantationUniversity of IowaIowa CityIAUSA
| | - Dhaval Kolte
- Division of CardiologyMassachusetts General Hospital and Harvard Medical SchoolBostonMAUSA
| | | | - Azeem Latib
- Division of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNYUSA
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29
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Suppah M, Kamal A, Saadoun R, Baradeiya AMA, Abraham B, Alsidawi S, Sorajja D, Fortuin FD, Arsanjani R. An Evidence-Based Approach to Anticoagulation Therapy Comparing Direct Oral Anticoagulants and Vitamin K Antagonists in Patients With Atrial Fibrillation and Bioprosthetic Valves: A Systematic Review, Meta-Analysis, and Network Meta-Analysis. Am J Cardiol 2023; 206:132-150. [PMID: 37703679 DOI: 10.1016/j.amjcard.2023.07.141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/21/2023] [Accepted: 07/30/2023] [Indexed: 09/15/2023]
Abstract
Direct oral anticoagulants (DOACs) are a newer class of anticoagulants that inhibit factor Xa or factor IIa and include drugs such as rivaroxaban, apixaban, edoxaban, betrixaban, and dabigatran. Although vitamin K antagonists (VKAs) have been traditionally used to prevent thromboembolic events, DOACs have gained popularity because of their faster onset and offset of action and reduced need for monitoring. This study aimed to provide more data for anticoagulants in patients with atrial fibrillation with bioprosthetic heart valves by incorporating all available trials to date. A search was performed across 5 electronic databases to identify relevant studies. We analyzed the data using a pooled risk ratio for categorical outcomes and used the I2 test to determine heterogeneity. The quality of randomized controlled trials was assessed using the Cochrane risk of bias assessment tool, and the National Institutes of Health tool was used for observational studies. Our study included a frequentist network meta-analysis (MA) of the aggregate data to obtain the network estimates for the outcomes of interest. We retrieved 28 studies with a total of 74,660 patients with bioprosthetic heart valves. Our MA significantly showed that DOACs decrease the risk of all-cause bleeding (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.75 to 0.85, p >0.00001), stroke and systemic embolization (RR 0.89, 95% CI 0.80 to 0.99, p = 0.03), and intracranial bleeding outcomes (RR 0.62, 95% CI 0.45 to 0.86, p = 0.004) compared with VKA. In contrast, there was no significant difference between the compared groups in major bleeding (RR = 0.92, 95% CI 0.84 to 1.02, p = 0.10) and all-cause mortality outcomes (RR = 0.96, 95% CI 0.85 to 1.07, p = 0.43), respectively. In addition, the network MA results did not favor any of the studied interventions over each other (p <0.05) regarding all-cause bleeding, mortality, stroke and systemic embolization, and major bleeding outcomes. In conclusion, our study found that DOACs are more effective in reducing the risk of bleeding, stroke, systemic embolism, and intracranial bleeding than VKAs. However, no significant difference was observed in the incidence of gastrointestinal bleeding, major bleeding, thromboembolic events, and all-cause mortality. In addition, our network MA did not identify any specific DOAC treatment as more favorable than others.
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Affiliation(s)
- Mustafa Suppah
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Abdallah Kamal
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Rakan Saadoun
- Department of Cardiology, University of Pittsburgh Medical Center, Hillman Cancer Center, Pittsburgh, Pennsylvania
| | | | - Bishoy Abraham
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Said Alsidawi
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Dan Sorajja
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - F David Fortuin
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Reza Arsanjani
- Department of Cardiology, Mayo Clinic Arizona, Phoenix, Arizona
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30
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Orban M. Atrial Fibrillation and Bioprosthetic Valves: An Evidence-Based Approach to Anticoagulation Therapy With Direct Oral Anticoagulants and Vitamin K Antagonists: A Systematic Review, Meta-Analysis, and Network Meta-Analysis. Am J Cardiol 2023; 206:339-340. [PMID: 37752022 DOI: 10.1016/j.amjcard.2023.08.173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 08/26/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Marek Orban
- Nemocnicna a.s., Cardiology Clinic, Malacky, Slovakia.
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31
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Dodgson CS, Beitnes JO, Kløve SF, Herstad J, Opdahl A, Undseth R, Eek CH, Broch K, Gullestad L, Aaberge L, Lunde K, Bendz B, Lie ØH. An investigator-sponsored pragmatic randomized controlled trial of AntiCoagulation vs AcetylSalicylic Acid after Transcatheter Aortic Valve Implantation: Rationale and design of ACASA-TAVI. Am Heart J 2023; 265:225-232. [PMID: 37634655 DOI: 10.1016/j.ahj.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unknown. Bioprosthetic valve dysfunction (BVD) is associated with adverse outcomes and may be prevented by anticoagulation therapy. A dedicated randomized trial comparing monotherapy NOAC to single antiplatelet therapy has not been performed previously. We hypothesize that therapy with any anti-factor Xa NOAC will reduce BVD compared to antiplatelet therapy, without compromising safety. METHODS ACASA-TAVI is a multicenter, prospective, randomized, open-label, blinded endpoint, all-comers trial comparing a monotherapy anti-factor Xa NOAC strategy (intervention arm) with a single antiplatelet therapy strategy (control arm) after successful TAVI. Three-hundred and sixty patients without indication for oral anticoagulation will be randomized in a 1:1 ratio to either apixaban 5 mg twice per day, edoxaban 60 mg daily, or rivaroxaban 20 mg daily for 12 months followed by acetylsalicylic acid 75 mg daily indefinitely, or to acetylsalicylic acid 75 mg daily indefinitely. The 2 co-primary outcomes are (1) incidence of Hypo-Attenuated Leaflet Thickening (HALT) on 4-dimensional cardiac CT at 12 months, and (2) a Safety Composite of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause, at 12 months. RESULTS The first 100 patients had a mean age of 74 ± 3.6 years, 33% were female, the average body-mass index was 27.9 ± 4.4 kg/m2, and 15% were smokers. A balloon-expanded valve was used in 82% and a self-expandable valve in 18%. CONCLUSIONS The trial is planned, initiated, funded, and conducted without industry involvement. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05035277.
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Affiliation(s)
- Christopher S Dodgson
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jan Otto Beitnes
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Sophie F Kløve
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Jon Herstad
- Department of Cardiology, Haukeland University Hospital, Bergen, Norway
| | - Anders Opdahl
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway
| | | | - Christian H Eek
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Kaspar Broch
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Gullestad
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway; K. G. Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Lars Aaberge
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ketil Lunde
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Øyvind H Lie
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway.
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32
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Hohmann C, Pfister R, Frerker C, Beckmann A, Walther T, Bleiziffer S, Ensminger S, Bekeredjian R, Seiffert M, Sinning JM, Möllmann H, Beyersdorf F, Baldus S, Böning A, Herrmann E, Balaban Ü, Kuhn E. Direct oral anticoagulants versus vitamin K antagonist after transcatheter aortic valve implantation. Heart 2023; 109:1706-1713. [PMID: 37407220 DOI: 10.1136/heartjnl-2023-322548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/08/2023] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVE After transcatheter aortic valve implantation (TAVI), the optimal regimen of anticoagulant therapy in patients with an additional indication for oral anticoagulation remains a matter of debate. This study investigates the efficacy of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) in patients after TAVI in a real-world population. METHODS The German Aortic Valve RegistrY (GARY) is a prospective, multicentre registry enrolling patients undergoing invasive treatment for aortic valve disease. From January 2011 to December 2019, 1 41 790 patients from 92 hospitals in Germany were enrolled. Anticoagulatory treatment regimens were assessed at hospital discharge for patients after TAVI procedures. All-cause mortality and the combined endpoint 'cardiac and cerebrovascular events' containing myocardial infarction, stroke, transient ischaemic attack, aortic prosthesis reintervention and all-cause mortality in the first year after TAVI were examined by treatment regimen. RESULTS Of 45 598 patients (mean age 80.7±5.7 years, 49.3% males) undergoing TAVI, 16 974 patients (37.2%) received an anticoagulant regimen that included VKA or DOAC. Hereof, the majority of patients were prescribed VKA (n=11 333, 66.8%) compared with DOAC (n=5641, 33.2%) with an increase of DOAC use from 9.4% in 2011 to 69.9% in 2019. During the 1-year follow-up, the absolute event rates per 100 person-years for all-cause mortality and the combined endpoint cardiac and cerebrovascular events were 1.9 and 1.3 for VKA-treated and 1.7 and 1.2 for DOAC-treated patients, respectively. After adjustment for baseline confounders, all-cause mortality (HR 0.95, 95% CI 0.88 to 1.01, p=0.114) and cardiac and cerebrovascular event-free survival (HR 0.93, 95% CI 0.86 to 1.01, p=0.071) did not differ significantly between VKA and DOAC groups. CONCLUSIONS This study supports evidence of the efficacy of DOAC use after TAVI in patients with an indication for oral anticoagulation.
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Affiliation(s)
- Christopher Hohmann
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Roman Pfister
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Christian Frerker
- Department of Cardiology, Vascular Medicine and Intensive Care, University Hospital Schleswig-Holstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Andreas Beckmann
- Department of Cardiac Surgery, Heart Centre Duisburg, Evangelisches Krankenhaus Niederrhein, Heinrich-Heine-Universität Düsseldorf, Dusseldorf, Germany
| | - Thomas Walther
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Department of Cardiothoracic Surgery, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Sabine Bleiziffer
- Department of Cardiothoracic Surgery, Heart and Diabetes Center NRW, University Hospital of the Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital SchleswigHolstein, Lübeck, Germany
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | | | - Moritz Seiffert
- German Center for Cardiovascular Research DZHK, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jan-Malte Sinning
- Department of Cardiology, St. Vinzenz-Hospital Cologne, Cologne, Germany
| | - Helge Möllmann
- Department of Cardiology, St. Johannes Hospital, Dortmund, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, University Hospital Freiburg, Freiburg, Germany
- Medical Faculty of the Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Stephan Baldus
- Department III of Internal Medicine, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
| | - Andreas Böning
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
| | - Eva Herrmann
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Ümniye Balaban
- German Center for Cardiovascular Research, DZHK, Partner Site Rhine-Main, Rhine-Main, Germany
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt am Main, Frankfurt am Main, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital Giessen, Giessen, Germany
- Department of Cardiothoracic Surgery, Heart Center, Faculty of Medicine and University Hospital of Cologne, Cologne, Germany
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33
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Dobesh PP, Goldsweig AM. Antithrombotic therapy with Transcatheter aortic valve replacement. Pharmacotherapy 2023; 43:1064-1083. [PMID: 37464970 DOI: 10.1002/phar.2847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/25/2023] [Accepted: 05/29/2023] [Indexed: 07/20/2023]
Abstract
Aortic valve replacement is a necessary management strategy for patients with severe aortic stenosis. The use of transaortic valve replacement (TAVR) has increased significantly over the last decade and now exceeds traditional surgical aortic valve replacement. Since the valve systems used in TAVR consist of bioprosthetic valve tissue encased in a metal stent frame, antithrombotic therapy recommendations cannot be extrapolated from prior data with differently constructed surgical bioprosthetic or mechanical valves. Data on the use of antithrombotic therapy with TAVR are a rapidly developing area of medicine. Choice of agents depends on several patient factors. Patients undergoing TAVR also have a relatively high incidence of subclinical valve thrombosis. The clinical impact of this phenomenon and the implications for antithrombotic therapy continue to evolve. It is critical for clinicians who treat patients undergoing TAVR to have a firm understanding of practice guidelines, the evolving evidence, and its implications for the use of antithrombotic therapy in these patients.
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Affiliation(s)
- Paul P Dobesh
- Pharmacy Practice and Science, College of Pharmacy, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Andrew M Goldsweig
- Cardiac Catheterization Laboratory, Cardiovascular Clinical Research, Baystate Medical Center, Springfield, Massachusetts, USA
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34
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Sharma H, Afzal S, Leick J, Werner N, Doshi SN, Nadir MA. Antithrombotic therapy following transcatheter aortic valve intervention. Pharmacol Ther 2023; 250:108509. [PMID: 37572882 DOI: 10.1016/j.pharmthera.2023.108509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is increasingly being performed to treat symptomatic patients with aortic stenosis and annual procedure volume has overtaken surgical aortic valve replacement in the United States. However, current international guidelines were written prior to the publication of several important recent studies. Furthermore, European and American guidelines differ in their recommendations of antithrombotic therapy following TAVR. Consequently, there is a need to examine the literature to provide clinicians guidance on the optimum antithrombotic strategy, particularly as different patient populations exist. In this review, we examine the data for antiplatelet and anticoagulation therapy post-TAVR.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shazia Afzal
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Jürgen Leick
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Nikos Werner
- Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - M Adnan Nadir
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK; Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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Fisher B, Chu D. Quest for the Perfect Anticoagulant. Am J Cardiol 2023; 203:505-506. [PMID: 37516551 DOI: 10.1016/j.amjcard.2023.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 07/31/2023]
Affiliation(s)
- Bryant Fisher
- University of Pittsburgh Medical Center Heart & Vascular Institute, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Danny Chu
- University of Pittsburgh Medical Center Heart & Vascular Institute, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania..
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Lee JH, Ahn JM, Kang DY, Kim KW, Koo HJ, Yang DH, Jung SC, Kim B, Wong YTA, Lam CCS, Yin WH, Wei J, Lee YT, Kao HL, Lin MS, Ko TY, Kim WJ, Kang SH, Yun SC, Ko E, Park H, Lee SA, Kim DH, Park SJ, Park DW. Effect of Edoxaban Versus Antiplatelet Therapy on Leaflet Thrombosis and Cerebral Thromboembolism After TAVI According to Major Clinical and Anatomic Factors in Prespecified Subgroup Analysis from the ADAPT-TAVR Trial. Am J Cardiol 2023; 203:352-361. [PMID: 37517131 DOI: 10.1016/j.amjcard.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/06/2023] [Indexed: 08/01/2023]
Abstract
It is unknown whether edoxaban versus dual antiplatelet therapy (DAPT) has differential treatment effects on leaflet thrombosis, cerebral thromboembolism, and neurologic or neurocognitive dysfunction according to clinical and anatomic factors after transcatheter aortic valve implantation. To investigate the relative effects of edoxaban and DAPT on leaflet and cerebral thromboembolism in patients with major risk factors. The primary end point of this study was the incidence of leaflet thrombosis on computed tomography at 6 months. The secondary end points were new cerebral lesions on brain magnetic resonance imaging and neurologic and neurocognitive dysfunction between baseline and 6-month follow-up. Cox regression models assessed the consistency of the treatment effects in the prespecified subgroups. The favorable effect of edoxaban versus DAPT on the leaflet thrombosis was consistent across multiple clinical or anatomic subgroups, without significant interaction between the drug effect and each subgroup (p for interaction for age = 0.597, gender = 0.557, body mass index = 0.866, Society of Thoracic Surgeons score = 0.307, valve type = 0.702, edoxaban reduction criteria = 0.604, and valve morphology = 0.688). However, the incidence of new cerebral lesions on brain magnetic resonance imaging and worsening of neurologic and neurocognitive function were not significantly different between the groups among the various key subgroups. The relative effects of edoxaban and DAPT on the risk of leaflet thrombosis, cerebral thromboembolism, and neurologic dysfunction were consistent across a diverse spectrum of clinical or anatomical factors. Further studies are required to define tailored antithrombotic therapy for high-risk groups with specific clinical or anatomic characteristics.
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Affiliation(s)
| | | | | | - Kyung Won Kim
- Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences
| | - Hyun Jung Koo
- Department of Radiology Research Institute of Radiology, and
| | - Dong Hyun Yang
- Department of Radiology Research Institute of Radiology, and
| | - Seung Chai Jung
- Department of Radiology Research Institute of Radiology, and
| | - Byungjun Kim
- Department of Radiology, Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Yiu Tung Anthony Wong
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Cheung Chi Simon Lam
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Wei-Hsian Yin
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Jeng Wei
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yung-Tsai Lee
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsung-Yu Ko
- Division of Cardiology, Department of Internal Medicine, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Won-Jang Kim
- Department of Cardiology, CHA Ilsan Medical Center, Goyang, Korea
| | - Se Hun Kang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Korea
| | - Sung-Cheol Yun
- Division of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Euihong Ko
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu-city, Fukuoka, Japan
| | - Hanbit Park
- Department of Cardiology, GangNeung Asan Hospital, GangNeung, Korea
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Khodadadiyan A, Jazi K, Bazrafshan Drissi H, Bazroodi H, Mashayekh M, Sadeghi E, Gholamabbas G, Bazrafshan M, Rahmanian M. Direct oral anticoagulants versus vitamin K antagonists: Which one is more effective in atrial fibrillation. Perfusion 2023:2676591231202383. [PMID: 37697799 DOI: 10.1177/02676591231202383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
BACKGROUND The optimal approach for anticoagulation in patients with bioprosthetic valves and atrial fibrillation (AF) remains a subject of debate. A meta-analysis using updated evidence to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) compared to vitamin K antagonists (VKAs) in patients with AF and bioprosthetic valves to address this controversy. METHODS A comprehensive search was conducted in multiple databases, including PubMed, Scopus, Web of Science, ProQuest, and the Cochrane Central Register of Controlled Trials, up until March 2023. The search aimed to identify relevant randomized controlled trials (RCTs) that examined the efficacy and safety outcomes of both direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) in patients with bioprosthetic valves and atrial fibrillation. The primary outcomes of interest were major bleeding and all-cause mortality. RESULTS Our study demonstrated that despite the difference was not significant, the hazard of all-cause mortality was 2.5% higher in the DOAC group (HR = 1.03, 95% CI = [0.88, 1.19], p-value = .75). Similarly, the hazard of stroke (HR = 1.03, 95% CI = [0.87, 1.32], p-value = .71) and major bleeding (HR = 1.11, 95% CI = [0.89, 1.38], p-value = .36) were found to be respectively 3.2 and 10.7% higher in the DOAC group, although the difference was not significant. However, the hazard of intracranial hemorrhage was found to be 28.8 lower in the DOAC treatment group (HR = 0.71, 95% CI = [0.39, 1.31], p-value = .27), which again was not statistically significant. CONCLUSIONS Our meta-analysis demonstrates that in patients undergoing bioprosthetic valve surgery and presenting with AF afterward, DOAC and VKA are similar regarding life-threatening and all-cause mortality outcomes, including major bleeding, stroke, and intracranial hemorrhage.
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Affiliation(s)
| | - Kimia Jazi
- Student Research Committee, Faculty of Medicine, Medical University of Qom, Qom, Iran
| | | | - Helia Bazroodi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mina Mashayekh
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Erfan Sadeghi
- Research Consultation Center (RCC), Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ghazal Gholamabbas
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Bazrafshan
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahdi Rahmanian
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Guardia Martínez P, Avilés Toscano AL, Martínez Mayoral MA, Moltó Miralles J. DOAC versus VKA in patients with atrial fibrillation and bioprosthetic valves: a systematic review and meta-analysis. Rev Esp Cardiol (Engl Ed) 2023; 76:690-699. [PMID: 36804556 DOI: 10.1016/j.rec.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023]
Abstract
INTRODUCTION AND OBJECTIVES Direct oral anticoagulant (DOAC) therapy has been shown to be safe and effective in patients with atrial fibrillation (AF). However, outcomes in AF patients with bioprosthetic valves are unclear, as this population has been underrepresented in clinical trials. The aim of this study was to assess the safety and efficacy of DOACs in this population based on the existing published literature. METHODS A systematic search and review were conducted to identify randomized clinical trials and comparative observational studies published from 2017 to January 2022 that compared DOACs and vitamin K antagonists (VKAs) in AF patients with bioprosthetic valves. Hazard ratios (HR) were collected to compare the 2 treatments in terms of cardiovascular and all-cause mortality, stroke/systemic embolism, and major bleeding. A meta-analysis combining the results was performed. RESULTS We included 12 studies (30 283 patients). DOACs and VKAs were compared based on HRs at the 95% confidence interval. DOAC therapy was associated with a significant 9% reduction in all-cause mortality (HR, 0.91; 95%CI, 0.85-0.97; P=.0068; I2=8%), with no significant differences in the risk of stroke/systemic embolism (HR, 0.87; 95%CI, 0.67-1.14; P=.29; I2=45%) or major bleeding (HR, 0.82; 95%CI, 0.67-1.00; P=.054; I2=48.7%). CONCLUSIONS DOAC therapy in AF patients with bioprosthetic valves may be associated with a significant reduction in all-cause mortality, with no reduction in the efficacy of stroke/systemic embolism prevention or increase in major bleeding risk.
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Affiliation(s)
| | | | | | - Josep Moltó Miralles
- Departamento de Estadística, Matemáticas e Informática, Universidad Miguel Hernández, Elche, Alicante, Spain
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Wang L, Sang W, Jian Y, Zhang X, Han Y, Wang F, Wang L, Yang S, Wubulikasimu S, Yang L, Sun H, Li Y. Post-TAVR patients with atrial fibrillation: are NOACs better than VKAs?-A meta-analysis. Front Cardiovasc Med 2023; 10:1175215. [PMID: 37719975 PMCID: PMC10501834 DOI: 10.3389/fcvm.2023.1175215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023] Open
Abstract
Objective This study aimed to compare the efficacy of novel oral anticoagulants (NOACs) with traditional anticoagulants vitamin K antagonists (VKAs) in patients with atrial fibrillation (AF) post transcatheter aortic valve replacement (TAVR). Methods Studies comparing the usage of NOACs and VKAs in AF patients with oral anticoagulant indication post-TAVR were retrieved from PubMed, EMBASE, Medline, and Cochrane databases from their building-up to Jan. 2023. The literature was screened in line of inclusion and exclusion criteria. Risk ratio (RR) or odds ratio (OR),95% confidence interval (CI) and number needed to treat (NNT) were calculated for four main indexes that composite endpoints composed mainly of any clinically relevant risk events, stroke, major bleeding, and all-cause mortality. Subsequently, a meta-analysis was performed using the RevMan5.3 and Stata 16.0 software. Results In the aggregate of thirteen studies, contained 30388 post-TAVR patients with AF, were included in this meta-analysis. Our results indicated that there was no significant difference in stroke between the NOACs group and the VKAs group, and the NOACs group had a numerically but non-significantly higher number of composite endpoint events compared with the other group. Nevertheless, the incidence of major bleeding [11.29% vs. 13.89%, RR 0.82, 95%CI (0.77,0.88), P < 0.00001, I² = 69%, NNT = 38] and all-cause mortality [14.18% vs. 17.61%, RR 0.83, 95%CI (0.79,0.88), p < 0.00001, I² = 82%, NNT = 29] were significantly lower in the NOACs group than another group. Conclusion Taken together, our data indicated that the usage of NOACs reduced the incidence of major bleeding and all-cause mortality compared to VKAs in post-TAVR patients with AF.
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Affiliation(s)
- Lu Wang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Wanyue Sang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yi Jian
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaoxue Zhang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yafan Han
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Feifei Wang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Liang Wang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Suxia Yang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Subinuer Wubulikasimu
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li Yang
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Huaxin Sun
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yaodong Li
- Cardiac Pacing and Electrophysiology Department, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
- Xinjiang Key Laboratory of Cardiac Electrophysiology and Cardiac Remodeling, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Geers J, Bing R. Computed tomographic imaging of patients with native and prosthetic aortic valve stenosis. Heart 2023; 109:1327-1337. [PMID: 36948573 DOI: 10.1136/heartjnl-2022-321660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
Affiliation(s)
- Jolien Geers
- Department of Cardiology, CHVZ (Centrum voor Hart- en Vaatziekten), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rong Bing
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
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Gerontas A, Avgerinos D, Charitakis K, Maragou H, Drosatos K. 1821-2021: Contributions of physicians and researchers of Greek descent in the advancement of clinical and experimental cardiology and cardiac surgery. Front Cardiovasc Med 2023; 10:1231762. [PMID: 37600045 PMCID: PMC10436502 DOI: 10.3389/fcvm.2023.1231762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
While the role of Greeks in the development of early western medicine is well-known and appreciated, the contributions of modern Greek medical practitioners are less known and often overlooked. On the occasion of the 200-year anniversary of the Greek War of Independence, this review article sheds light onto the achievements of modern scientists of Greek descent in the development of cardiology, cardiac surgery, and cardiovascular research, through a short history of the development of these fields and of the related institutions in Greece. In the last decades, the Greek cardiology and Cardiac Surgery communities have been active inside and outside Greece and have a remarkable presence internationally, particularly in the United States. This article highlights the ways in which Greek cardiology and cardiovascular research has been enriched by absorbing knowledge produced in international medical centers, academic institutes and pharmaceutical industries in which generations of Greek doctors and researchers trained prior to their return to the homeland; it also highlights the achievements of medical practitioners and researchers of Greek descent who excelled abroad, producing ground-breaking work that has left a permanent imprint on global medicine.
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Affiliation(s)
- Apostolos Gerontas
- School of Applied Natural Sciences, Coburg University, Coburg, Germany
- School of Liberal Arts and Sciences, The American College of Greece, Athens, Greece
| | - Dimitrios Avgerinos
- Department of Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
- ARISTEiA-Institute for the Advancement of Research and Education in Arts, Sciences and Technology, McLean, VA, United States
| | - Konstantinos Charitakis
- Department of Internal Medicine, Division of Cardiology, University of Texas Health Science Center, Houston, TX, United States
| | - Helena Maragou
- School of Liberal Arts and Sciences, The American College of Greece, Athens, Greece
| | - Konstantinos Drosatos
- ARISTEiA-Institute for the Advancement of Research and Education in Arts, Sciences and Technology, McLean, VA, United States
- Metabolic Biology Laboratory, Cardiovascular Center, Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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Lip GYH, Proietti M, Potpara T, Mansour M, Savelieva I, Tse HF, Goette A, Camm AJ, Blomstrom-Lundqvist C, Gupta D, Boriani G. Atrial fibrillation and stroke prevention: 25 years of research at EP Europace journal. Europace 2023; 25:euad226. [PMID: 37622590 PMCID: PMC10451006 DOI: 10.1093/europace/euad226] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/17/2023] [Indexed: 08/26/2023] Open
Abstract
Stroke prevention in patients with atrial fibrillation (AF) is one pillar of the management of this common arrhythmia. Substantial advances in the epidemiology and associated pathophysiology underlying AF-related stroke and thrombo-embolism are evident. Furthermore, the introduction of the non-vitamin K antagonist oral anticoagulants (also called direct oral anticoagulants) has clearly changed our approach to stroke prevention in AF, such that the default should be to offer oral anticoagulation for stroke prevention, unless the patient is at low risk. A strategy of early rhythm control is also beneficial in reducing strokes in selected patients with recent onset AF, when compared to rate control. Cardiovascular risk factor management, with optimization of comorbidities and attention to lifestyle factors, and the patient's psychological morbidity are also essential. Finally, in selected patients with absolute contraindications to long-term oral anticoagulation, left atrial appendage occlusion or exclusion may be considered. The aim of this state-of-the-art review article is to provide an overview of the current status of AF-related stroke and prevention strategies. A holistic or integrated care approach to AF management is recommended to minimize the risk of stroke in patients with AF, based on the evidence-based Atrial fibrillation Better Care (ABC) pathway, as follows: A: Avoid stroke with Anticoagulation; B: Better patient-centred, symptom-directed decisions on rate or rhythm control; C: Cardiovascular risk factor and comorbidity optimization, including lifestyle changes.
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Affiliation(s)
- Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Irina Savelieva
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, School of Clinical Medicine, LKS Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098 Paderborn, Germany
| | - A John Camm
- Clinical Academic Group, Molecular and Clinical Sciences Institute, St. George’s University of London, Cranmer Terrace London SW17 0RE, UK
| | - Carina Blomstrom-Lundqvist
- Department of Cardiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 71, 41125 Modena, Italy
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Banga S, Abela GS, Saltiel F, Fischell T, Kalavakunta JK, Sood A, Jolly G, Najib K, Al-Ali H, Qintar M, Bazil J, Singh Y, Gupta V. Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 200:171-177. [PMID: 37329837 DOI: 10.1016/j.amjcard.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 05/01/2023] [Accepted: 05/16/2023] [Indexed: 06/19/2023]
Abstract
Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.
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Affiliation(s)
- Sandeep Banga
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan.
| | - George S Abela
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Frank Saltiel
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Tim Fischell
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Jagadeesh K Kalavakunta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Abhinav Sood
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - George Jolly
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Khalid Najib
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
| | - Haya Al-Ali
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Mohammed Qintar
- Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Jason Bazil
- Department of Physiology, Michigan State University, Lansing, Michigan
| | - Yashbir Singh
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Vishal Gupta
- Department of Cardiology, Ascension Borgess Hospital, Western Michigan University, Homer Stryker M.D. School of Medicine, Michigan State University, Kalamazoo, Michigan
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Renda G. Direct oral anticoagulants in patients with bioprosthetic heart valves. Intern Emerg Med 2023; 18:1269-1272. [PMID: 37243834 DOI: 10.1007/s11739-023-03288-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/22/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Giulia Renda
- Institute of Cardiology, Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University Chieti-Pescara, Via L. Polacchi 11, 66100, Chieti, Italy.
- Cardiology Unit - SS. Annunziata Hospital, Via Dei Vestini 31, 66100, Chieti, Italy.
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Arockiam S, Staniforth B, Kepreotis S, Maznyczka A, Bulluck H. A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice. Int J Mol Sci 2023; 24:11132. [PMID: 37446310 DOI: 10.3390/ijms241311132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient's thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
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Affiliation(s)
- Sacchin Arockiam
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Brittany Staniforth
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Sacha Kepreotis
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Annette Maznyczka
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
| | - Heerajnarain Bulluck
- Yorkshire Heart Centre, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds LS2 3AX, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK
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Selvaraj V, Khan MS, Mufarrih SH, Kazimuddin M, Waheed MA, Tripathi A, Bavishi C, Hyder ON, Aronow HD, Saad M, Abbott JD. Meta-Analysis Assessing Efficacy and Safety of Vitamin K Antagonists Versus Direct Oral Anticoagulants for Atrial Fibrillation After Transcatheter Aortic Valve Implantation. Am J Cardiol 2023; 201:260-267. [PMID: 37393728 DOI: 10.1016/j.amjcard.2023.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/26/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023]
Abstract
Patients who underwent transcatheter aortic valve implantation (TAVI) with concomitant atrial fibrillation (AF) are at a higher risk for thromboembolic and bleeding events. The optimal antithrombotic strategy for patients with AF after TAVI remains unclear. We sought to determine the comparative efficacy and safety of direct oral anticoagulants (DOAC) versus oral vitamin K antagonists (VKAs) in these patients. Electronic databases such as PubMed, Cochrane, and Embase databases were searched till January 31, 2023, for relevant studies evaluating clinical outcomes of VKA versus DOAC in patients with AF after TAVI. Outcomes assessed were (1) all-cause mortality, (2) stroke, (3) major/life-threatening bleeding, and (4) any bleeding. Hazard ratios (HRs) were pooled in meta-analysis using random effect model. Nine studies (2 randomized and 7 observational) were included in systematic review, and 8 studies with 25,769 patients were eligible to be included in the meta-analysis. The mean age of the patients was 82.1 years, and 48.3% were male. Pooled analysis using random-effects model showed no statistically significant difference in all-cause mortality (HR 0.91, 95% confidence interval [CI] 0.76 to 1.10, p = 0.33), stroke (HR 0.96, 95% CI 0.80 to 1.16, p = 0.70), and major/life-threatening bleeding (HR 1.05, 95% CI 0.82 to 1.35, p = 0.70) in patients that received DOAC compared with oral VKA. Risk of any bleeding was lower in the DOAC group compared with oral VKA (HR 0.83, 95% CI 0.76 to 0.91, p = 0.0001). In patients with AF, DOACs appear to be a safe alternative oral anticoagulation strategy to oral VKA after TAVI. Further randomized studies are required to confirm the role of DOACs in those patients.
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Affiliation(s)
- Vijairam Selvaraj
- Department of Medicine, The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Mohammad Saud Khan
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Syed Hamzah Mufarrih
- Department of Internal Medicine, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Mohammed Kazimuddin
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Mohammad Abdul Waheed
- Division of Cardiology, University of Kentucky College of Medicine - Bowling Green Campus, Bowling Green, Kentucky
| | - Avnish Tripathi
- Division of Cardiology, CHI St. Vincent Heart Clinic Arkansas, Searcy, Arkansas
| | - Chirag Bavishi
- Division of Cardiology, University of Missouri School of Medicine, Columbia, Missouri
| | - Omar N Hyder
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Marwan Saad
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - J Dawn Abbott
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, Rhode Island.
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Huang B, Yan H, Li Y, Zhou Q, Abudoureyimu A, Cao G, Jiang H. Transcatheter Aortic Valve Replacement in Elderly Patients: Opportunities and Challenges. J Cardiovasc Dev Dis 2023; 10:279. [PMID: 37504535 PMCID: PMC10380827 DOI: 10.3390/jcdd10070279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/18/2023] [Accepted: 06/27/2023] [Indexed: 07/29/2023] Open
Abstract
Over the past two decades, the rapid evolution of transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis (AS) in the elderly. The prevalence of comorbidities in elderly AS patients presents a considerable challenge to the effectiveness and prognosis of patients after TAVR. In this article, we aim to summarize some of the clinical aspects of the current use of TAVR in elderly patients and attempt to highlight the challenges and issues that need further consideration.
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Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Hui Yan
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Yunyao Li
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
| | - Qiping Zhou
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Ayipali Abudoureyimu
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Guiqiu Cao
- Department of Cardiology, Fifth Affiliated Hospital of Xinjiang Medical University, Urumqi 830000, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
- Cardiovascular Research Institute, Wuhan University, Wuhan 430060, China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, China
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Goette A, Mollenhauer M, Rudolph V, Lamparter M, Meier M, Böhm M. Pleiotropic effects of NOACs with focus on edoxaban: scientific findings and potential clinical implications. Herzschrittmacherther Elektrophysiol 2023; 34:142-152. [PMID: 37140824 DOI: 10.1007/s00399-023-00944-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/05/2023]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are well-established as inhibitors of factor Xa (FXa) and thrombin in the treatment and prevention of thrombosis. However, there is growing evidence that beneficial outcomes might be based on additional pleiotropic effects beyond anticoagulation. FXa and thrombin are also known to activate protease-activated receptors (PARs), which can mediate pro-inflammatory and pro-fibrotic effects. Since PAR‑1 and PAR‑2 play an important role in the development of atherosclerosis, the inhibition of this pathway represents an interesting potential target for preventing the progression of atherosclerosis and fibrosis. This review focuses on potential pleiotropic effects of FXa inhibition with edoxaban seen in a variety of studies in different in vitro and in vivo test systems. As common findings from these experiments, edoxaban was able to attenuate FXa- and thrombin-induced pro-inflammatory and pro-fibrotic effects and decrease pro-inflammatory cytokine expression. In some, but not all experiments edoxaban was also shown to decrease the levels of PAR‑1 and PAR‑2 expression. Further studies are required to clarify the clinical implications of the pleiotropic effects mediated by NOACs.
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Affiliation(s)
- Andreas Goette
- Medizinische Klinik II: Kardiologie und Intensivmedizin, St. Vincenz-Krankenhaus Paderborn, Am Busdorf 2, 33098, Paderborn, Germany.
| | - Martin Mollenhauer
- Department of Cardiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Volker Rudolph
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | | | - Martin Meier
- Daiichi Sankyo Deutschland GmbH, Munich, Germany
| | - Michael Böhm
- Innere Medizin III-Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
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Zaman A, Prendergast B, Hildick-Smith D, Blackman D, Anderson R, Spence MS, Mylotte D, Smith D, Wilding B, Chapman C, Atkins K, Pollock KG, Qureshi AC, Banning A. An Update on Anti-thrombotic Therapy Following Transcatheter Aortic Valve Implantation: Expert Cardiologist Opinion from a UK and Ireland Delphi Group. Interv Cardiol 2023; 18:e13. [PMID: 37398870 PMCID: PMC10311398 DOI: 10.15420/icr.2022.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 10/11/2022] [Indexed: 07/04/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) is an effective and established treatment for symptomatic aortic stenosis. However, there is a lack of consensus concerning the need for peri- and post-procedural anti-thrombotic medication. Contemporary guidelines recommend that anti-thrombotic therapy is balanced against a patient's bleeding risk following TAVI, but do not fully consider the evolving evidence base. The purpose of the Delphi panel recommendations presented here is to provide a consensus elicited from a panel of experts who regularly prescribe anti-thrombotic therapy post-TAVI. The goal was to address evidence gaps across four key topics: anti-thrombotic therapy (anti-platelet and/or anti-coagulant) in TAVI patients in sinus rhythm; anti-thrombotic therapy in TAVI patients with AF; direct oral anti-coagulants versus vitamin K antagonists; and the need for UK/Ireland specific guidance. This consensus statement aims to inform clinical decision-making by providing a concise, evidence-based summary of best practice for prescribing anti-thrombotic therapies following TAVI and highlights areas where further research is needed.
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Affiliation(s)
- Azfar Zaman
- Department of Cardiology, Freeman HospitalNewcastle upon Tyne, UK
- Newcastle UniversityNewcastle upon Tyne, UK
| | - Bernard Prendergast
- Department of Cardiology, St Thomas’ HospitalLondon, UK
- Cleveland ClinicLondon, UK
| | - David Hildick-Smith
- Sussex Cardiac Centre, Regional Specialist Unit, Brighton and Sussex University HospitalsBrighton, UK
| | - Daniel Blackman
- Department of Cardiology, Leeds Teaching Hospitals NHS TrustLeeds, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of WalesCardiff, UK
- Cardiff Metropolitan UniversityCardiff, UK
| | - Mark S Spence
- Department of Cardiology Mater Private HospitalDublin, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospitals GalwayGalway, Ireland
- National University of GalwayGalway, Ireland
| | - David Smith
- Department of Cardiology, Morriston HospitalSwansea, UK
- University of SwanseaSwansea, UK
| | - Ben Wilding
- Health Economics and Outcomes ResearchCardiff, UK
| | - Chris Chapman
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | - Kirsty Atkins
- Bristol Myers Squibb PharmaceuticalsUxbridge, Middlesex, UK
| | | | | | - Adrian Banning
- Department of Cardiology, John Radcliffe HospitalOxford, UK
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Li D, Chang P, Zhang H, Bai F, Wu Q. The efficacy and safety of direct oral anticoagulants versus vitamin K antagonists in patients with left-sided bioprosthetic heart valves and atrial fibrillation: a systematic review and meta-analysis. Eur J Clin Pharmacol 2023; 79:461-471. [PMID: 36795127 DOI: 10.1007/s00228-023-03463-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/26/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND The efficacy and safety of direct oral anticoagulants (DOACs) versus vitamin K antagonists (VKAs) for the treatment of patients with left-sided bioprosthetic heart valves (BHV) and atrial fibrillation (AF) remain controversial. This study aims to perform a meta-analysis to evaluate the efficacy and safety of DOACs versus VKAs in this region. METHODS We retrieved all relevant randomized controlled studies and observational cohort studies, which critically assessed the efficacy and safety of DOACs versus VKAs among patients with left-sided BHV and AF in databases of PubMed, Cochrane, ISI Web of Sciences, and Embase. The efficacy outcomes of this meta-analysis were stroke events and all-cause death when the safety outcomes included major and any bleeding. RESULTS The analysis integrated 13 studies while enrolling 27,793 patients with AF and left-sided BHV. DOACs reduced the rate of stroke by 33% compared with VKAs (risk ratio [RR] 0.67; 95% CI 0.50-0.91), with no increased incidence of all-cause death (RR 0.96; 95% CI 0.82-1.12). For safety outcomes, major bleeding was reduced by 28% using DOACs rather than VKAs (RR 0.72; 95% CI 0.52-0.99), while there was no difference in the events of any bleeding (RR 0.84; 95% CI 0.68-1.03). In addition, in patients younger than 75 years old, the stroke rate was reduced by 45% in the population using DOACs (RR 0.55; 95% CI 0.37-0.84). CONCLUSION Our meta-analysis demonstrated that in patients with AF and BHV, compared with VKAs, using DOACs was associated with reduced stroke and major bleeding events without an increase of all-cause mortality and any bleeding. In the population younger than 75 years old, DOAC might be more effective in preventing cardiogenic stroke.
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Affiliation(s)
- Dong Li
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Peng Chang
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Hongliang Zhang
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Feng Bai
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China
| | - Qiang Wu
- Department of Cardiovascular Medicine, Second Hospital of Lanzhou University, Lanzhou, China.
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