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Improta R, Di Pietro G, Piccialuti A, De Filippo O, Birtolo LI, Severino P, Tocci M, Saade W, Cammertoni F, Vizza CD, Sardella G, D'Ascenzo F, Stefanini G, Mancone M. Invasive and conservative management of elderly patients presenting with acute coronary syndrome: A meta-analysis of randomized controlled trials and adjusted observational studies. Int J Cardiol 2024; 417:132523. [PMID: 39255918 DOI: 10.1016/j.ijcard.2024.132523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 08/12/2024] [Accepted: 09/04/2024] [Indexed: 09/12/2024]
Abstract
BACKGROUND Elderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, METHODS: The analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality. RESULTS Invasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54-0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52-0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55-0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39-1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77). CONCLUSION An initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies.
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Affiliation(s)
- Riccardo Improta
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Gianluca Di Pietro
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Alice Piccialuti
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Ovidio De Filippo
- Department of Medical Sciences, University of Turin, Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Marco Tocci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Wael Saade
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Federico Cammertoni
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Gennaro Sardella
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy
| | - Fabrizio D'Ascenzo
- Department of Medical Sciences, University of Turin, Division of Cardiology, Cardiovascular and Thoracic Department, "Citta della Salute e della Scienza" Hospital, Turin, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele - Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano - Milan, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Italy.
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Charles-Schoeman C, Choy E, McInnes IB, Mysler E, Nash P, Yamaoka K, Lippe R, Khan N, Shmagel AK, Palac H, Suboticki J, Curtis JR. MACE and VTE across upadacitinib clinical trial programmes in rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. RMD Open 2023; 9:e003392. [PMID: 37945286 PMCID: PMC10649869 DOI: 10.1136/rmdopen-2023-003392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVES To provide an integrated analysis of major adverse cardiovascular events (MACEs) and events of venous thromboembolism (VTE) and associated risk factors across rheumatoid arthritis (RA), psoriatic arthritis (PsA), and ankylosing spondylitis (AS) phase 2b/3 upadacitinib clinical programmes. METHODS Data were analysed and summarised from clinical trials of RA, PsA and AS treated with upadacitinib 15 mg once daily (QD) and 30 mg QD (as of 30 June 2021). Data from adalimumab (RA and PsA) and methotrexate (RA) arms were included as comparators. Adjudicated MACEs and VTE events were presented as exposure-adjusted rates per 100 patient-years (E/100 PY). Univariable Cox proportional hazard regression analyses assessed potential associations of risk factors for MACE and VTE. RESULTS In total, 4298 patients received upadacitinib 15 mg (RA n=3209, PsA n=907 and AS n=182) and 2125 patients received upadacitinib 30 mg (RA n=1204 and PsA n=921). In patients with RA and PsA, rates of MACE (0.3-0.6 E/100 PY) and VTE (0.2-0.4 E/100 PY) were similar across upadacitinib doses; in patients with AS, no MACEs and one VTE event occurred. Most patients experiencing MACEs or VTE events had two or more baseline cardiovascular risk factors. Across RA and PsA groups, rates of MACEs and VTE events were similar. CONCLUSIONS Rates of MACEs and VTE events with upadacitinib were consistent with previously reported data for patients receiving conventional synthetic and biologic disease-modifying anti-rheumatic drugs and comparable with active comparators adalimumab and methotrexate. Associated patient characteristics are known risk factors for MACEs and VTE events. TRIAL REGISTRATION NUMBERS RA (SELECT-NEXT: NCT02675426; SELECT-MONOTHERAPY: NCT02706951; SELECT-BEYOND: NCT02706847; SELECT-COMPARE: NCT02629159; SELECT-EARLY: NCT02706873, SELECT-CHOICE: NCT03086343), PsA (SELECT-PsA 2: NCT03104374; SELECT-PsA 1: NCT03104400), and AS (SELECT-AXIS 1: NCT03178487).
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Affiliation(s)
| | - Ernest Choy
- Division of Infection and Immunity, CREATE Centre, Cardiff University, Cardiff, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Eduardo Mysler
- Department of Rheumatology, OMI (Medical Research Organization), Buenos Aires, Argentina
| | - Peter Nash
- Department of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Kunihiro Yamaoka
- Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Ralph Lippe
- AbbVie Deutschland GmbH & Co KG, Wiesbaden, Germany
| | | | | | | | | | - Jeffrey R Curtis
- Department of Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Agewall S. Treating patients with anticoagulants and antiplatelet drugs is always a balance between risk for thrombosis vs. risk for bleeding. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:645-647. [PMID: 36172980 DOI: 10.1093/ehjcvp/pvac048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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Córdoba-Soriano JG, Gutiérrez-Díez A, Del Blanco BG, Núñez J, Amat-Santos IJ, Oteo JF, Romaguera R, Gallardo-López A, Lozano Ruíz-Poveda F, Baello P, Aguar P, Jerez-Valero M, Jiménez-Díaz VA, Serra B, Cascon JD, Morales-Ponce FJ, Portero-Portaz JJ, Melehi El Assali D, Cerrato-García P, Jiménez-Mazuecos J. Bioactive or Drug Eluting Stents in 75 years or older patients: The BIODES-75 Registry. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 42:114-120. [DOI: 10.1016/j.carrev.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/03/2022] [Indexed: 11/27/2022]
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Agewall S. Treatment with dual antiplatelet therapy after an acute coronary event may often be tailor-made for the patient. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:1-3. [PMID: 34984441 DOI: 10.1093/ehjcvp/pvab078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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Schäfer A. Clopidogrel or ticagrelor in elderly patients with acute coronary syndromes – Nihil nocere! Int J Cardiol 2022; 352:19-20. [DOI: 10.1016/j.ijcard.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 11/05/2022]
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Schäfer A, Bauersachs J. P2Y12 inhibition in acute coronary syndromes treated with percutaneous intervention - Understanding the debate on Prasugrel or Ticagrelor. Pharmacol Ther 2021; 233:108029. [PMID: 34740747 DOI: 10.1016/j.pharmthera.2021.108029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 12/12/2022]
Abstract
After more than 10 years of routine clinical use, a debate about the preference of prasugrel over ticagrelor has been unveiled following publication of the ISAR-REACT 5 trial, an investigator-initiated trial directly comparing both substances as part of dual anti-platelet therapy following interventional treatment in patients with acute coronary syndromes (ACS). Both substances had been tested in trials, approved by authorities and subsequently recommended by guidelines according to the strategy applied in the respective approval trial. This resulted in prasugrel tested in TRITON only be given after diagnostic coronary angiography in the absence of ST-segment elevations (NSTE-ACS) and ticagrelor tested in PLATO being administered even before diagnostic coronary angiography in all forms of acute coronary syndromes. Whichever way was safest and most efficient, had never been clarified before. ISAR-REACT 5 showed superior efficacy of prasugrel over ticagrelor in general, and of deferred administration of prasugrel over pre-treatment with ticagrelor in NSTE-ACS patients undergoing percutaneous coronary interventions. Subsequently, in 2020 the European guidelines for NSTE-ACS adopted both positions in recommending the respective preference. Afterwards, a confrontational debate erupted between those favouring the ISAR-REACT 5 results and their implementation in guidelines and others still preferring the generalized interpretation of the overall study results from PLATO. In this review, we reflect the history leading to trial design of TRITON and PLATO and the way this subsequently impacted on clinical practice and guideline recommendations.
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Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Germany.
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Germany
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McFadyen JD, Peter K. Transcatheter Aortic Valve Implantation, Atrial Fibrillation, and Bleeding: A Surprisingly Fatal Attraction. Thromb Haemost 2020; 120:1479-1482. [PMID: 33070302 DOI: 10.1055/s-0040-1718533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- James D McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Clinical Hematology, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Cardiometabolic Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
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Abstract
Ischaemic stroke and systemic embolism are the major potentially preventable complications of atrial fibrillation (AF) leading to severe morbidity and mortality. Anticoagulation using vitamin K antagonists (VKA) or non-vitamin K oral anticoagulants (NOACs) is mandatory for stroke prevention in AF. Following approval of the four NOACs dabigatran, rivaroxaban, apixaban, and edoxaban, the use of VKA is declining steadily. Increasing age with thresholds of 65 and 75 years is a strong risk factor when determining annual stroke risk in AF patients. Current recommendations such as the "2016 Guidelines for the management of atrial fibrillation" of the European Society of Cardiology and the "2019 AHA/ACC/HRS Focused Update" by the American College of Cardiology, the American Heart Association, and the Heart Rhythm Society strengthen the importance of anticoagulation and detection of bleeding risks, of which older age is an important one. While patients aged ≥ 75 years are usually underrepresented in randomised clinical trials, they represent almost 40% of the trial populations in the large NOAC approval studies. Therefore, a sufficient amount of data is available to assess the efficacy and safety for this patient cohort in that specific indication. In this article, the evidence for stroke prevention in AF using either VKA or NOACs is summarised with a special focus on efficacy compared to bleeding risk in patients aged ≥ 75 years. Specifically, we used a model of increased weighing of intracranial bleeding to illustrate the potential benefit of NOACs over VKA in the elderly population. In brief, there are at least two tested strategies with apixaban and edoxaban which even confer an additional clinical net benefit compared with VKA. Furthermore, elderly subgroups of trials for combined antithrombotic treatment following percutaneous coronary interventions in anticoagulated patients are analysed.
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Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30659, Hannover, Germany.
| | - Ulrike Flierl
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30659, Hannover, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30659, Hannover, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, D-30659, Hannover, Germany
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Kotsiou OS, Xirogiannis IK. Antithrombotic therapy for elderly patients with acute coronary syndrome: reasons to be cautious. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:69. [PMID: 31504377 DOI: 10.1093/ehjcvp/pvz042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Ourania S Kotsiou
- Respiratory Medicine Department, Faculty of Medicine, University of Thessaly, BIOPOLIS, Larissa, Greece
| | - Ioannis K Xirogiannis
- Department of Cardiology, General Hospital of Lamia, Papasiopoulou, Lamia, Fthiotida, Greece
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Schäfer A, Flierl U, Bauersachs J. Response to: Antithrombotic therapy for elderly patients with acute coronary syndrome: reasons to be cautious. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:70. [PMID: 31498382 DOI: 10.1093/ehjcvp/pvz043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Andreas Schäfer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover D-30659, Germany
| | - Ulrike Flierl
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover D-30659, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover D-30659, Germany
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