Characterizing high-risk enrollment criteria and impact on clinical outcomes in a large randomized clinical trial: Insights from the TWILIGHT trial

BACKGROUND

The TWILIGHT trial showed that, among high-risk patients who underwent percutaneous coronary intervention (PCI) and were event-free at 3 months, ticagrelor monotherapy versus ticagrelor plus aspirin reduced bleeding without increasing ischemic events.

METHODS

This posthoc analysis describes the risk profiles and outcomes of patients enrolled in the TWILIGHT trial. The primary outcome was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding, and the key secondary outcome was a composite of death, myocardial infarction, or stroke within 1 year after randomization.

RESULTS

The proportion of patients (n = 7,119) fulfilling ≤ 3, 4, 5, or ≥ 6 risk factors was 21.5%, 32.7%, 27.4%, and 18.4%, respectively. Troponin-positive acute coronary syndrome (ACS) was the most prevalent clinical criterion (64.9%), and multivessel disease (MVD) was the most prevalent angiographic criterion (66.5%). The most frequent intersection of criteria was the combination of troponin-positive ACS, atherosclerotic vascular disease, MVD, left main or proximal anterior descending lesion, and stent length > 30 mm. A stepwise increase in ischemic but not in bleeding risk was noted with an increasing number of high-risk criteria. Compared with ticagrelor plus aspirin, ticagrelor monotherapy reduced bleeding regardless of the number of risk factors (≤ 3-RF: 3.5% vs 5.8%, HR 0.59, 95% CI [0.38-0.93]; 4-RF: 3.7% vs 6.4%, HR 0.57, 95% CI [0.37-0.86]; 5-RF: 3.8% vs 8.6%, HR 0.44, 95% CI [0.29-0.66]; ≥ 6-RF: 5.3% vs 7.9%, HR 0.65, 95% CI [0.44-0.96]; p-interaction = .56) without significantly increasing the ischemic risk (≤ 3-RF: 1.6% vs 2.1%, HR 0.75, 95% CI [0.38-1.50]; 4-RF: 3.5% vs 2.2%, HR 1.58, 95% CI [0.91-2.75]; 5-RF: 4.1% vs 5.0%, HR 0.80, 95% CI [0.51-1.24]; ≥ 6-RF: 6.7% vs 6.9%, HR 0.98, 95% CI [0.67-1.43]; p-interaction = .22).

CONCLUSIONS

In the TWILIGHT trial, the high-risk features correlated more strongly with ischemic than with bleeding risk. Nonetheless, the benefits of ticagrelor compared with ticagrelor plus aspirin were consistent, irrespective of the number of high-risk features. These findings are only applicable to patients who are event-free at 3 months after PCI.

CLINICAL TRIAL REGISTRATION

The trial was registered with ClinicalTrials.gov, NCT02270242.

Gender disparities in cangrelor usage for the treatment of patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Cangrelor is a rapid, potent intravenous P2Y12 inhibitor that reduces thrombotic and ischemic events in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). This study aimed to investigate gender disparities in Cangrelor usage, efficacy, and safety across gender in patients presenting with acute coronary syndrome (ACS) undergoing PCI.

METHODS

This is an observational retrospective analysis included patients presented with ACS who underwent PCI and received Cangrelor at MedStar Washington Hospital Center (2018-2023). Access to Cangrelor across gender was recorded. The primary safety outcome was in-hospital thrombolysis in myocardial infarction (TIMI) major bleeding, while the primary efficacy outcome was in-hospital major adverse cardiac events (MACE): defined as the composite of in-hospital cardiac death, MI, and stroke. A control group was investigated gender disparities in patients with ACS who did not receive Cangrelor.

RESULTS

A total of 2859 patients with ACS underwent PCI (991 women and 1868 men). Among these patients, women were less likely to receive Cangrelor during PCI compared to men (40.2 % vs. 48 %; P < 0.001). The Cangrelor cohort consisted of 1295 patients (398 women, 897 men), and among those, women had significantly higher rates of in-hospital TIMI major bleeding (3.5 % vs. 0.6 %; P < 0.001) and higher in-hospital MACE (5.0 % vs. 1.3 %; P < 0.001) compared to men. Multivariate modeling after adjusting for differences in baseline characteristics showed that women were associated with increased TIMI major bleeding (OR 4.02, 95 %CI 1.09-14.79; P 0.037), but not in-hospital MACE (OR 2.11, 95 %CI 0.88-5.07; P 0.096). In the non-Cangrelor cohort, there were no significant difference between women and men in TIMI major bleeding (0.8 % vs. 0.9 %, P = 0.865) and MACE (1.5 % vs. 1.6, P = 0.842).

CONCLUSION

In patients presenting with ACS, women who received cangrelor had higher rates of TIMI major bleeding, without an impact on MACE. This may partially explain why women with ACS undergoing PCI receive less cangrelor compared to men. Therefore, increased bleeding events in women receiving cangrelor warrant further investigation.

Genotype-guided de-escalation and abbreviation of dual antiplatelet therapy in patients with myocardial infarction and high bleeding risk: Design and rationale of the investigator-initiated, multicenter, randomized, controlled trial, DAN-DAPT

RATIONALE

Approximately one-third of patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) are at high risk of bleeding side-effects when on dual antiplatelet therapy (DAPT). High bleeding risk is often accompanied by high ischemic risk, thus challenging the choice of P2Y12 inhibitor and duration of DAPT. The optimal DAPT strategy for these patients remains debated, and it is unknown whether genotype-guided DAPT de-escalation to clopidogrel and aspirin, with or without abbreviation of DAPT to 3 months, is noninferior in terms of net adverse clinical events (NACE) and superior in reducing bleeding side-effects compared with standard DAPT for 6 months.

DESIGN

The DAN-DAPT trial is an investigator-initiated, open-label, multicenter, multiarm, randomized controlled trial conducted at all Danish hospitals performing PCI. From 2022 to 2029, we planned to randomize 2,700 patients with MI and high bleeding risk in a 1:1:1 ratio to 1 of 3 groups: CYP2C19-genotyping and 6 months DAPT (experimental group 1), CYP2C19-genotyping and 3 months DAPT (experimental group 2), and 6 months DAPT with prasugrel (or ticagrelor) and aspirin (control group). The coprimary outcomes are NACE defined as the composite of all-cause mortality, recurrent MI, definite stent thrombosis, stroke, and BARC type 3-5 bleeding (Bleeding Academic Research Consortium), and major and minor bleedings defined as the composite of BARC type 2-5 bleedings at 1 year.

CONCLUSION

DAN-DAPT trial is an open-label, multicenter, randomized controlled trial comparing genotype-guided DAPT de-escalation to clopidogrel - with or without DAPT abbreviation to 3 months - and standard DAPT for 6 months after PCI in high bleeding risk patients with MI. As of March 2025, 36% of the planned 2,700 patients have been enrolled in the study.

TRIAL REGISTRATION

ClincialTrials.gov (NCT05262803) and EU number (2022-500125-32-00).

Long-term (12 months) vs. short-term (<12 months) dual antiplatelet therapy post-percutaneous coronary intervention with drug-eluting stents: a critical appraisal and systematic review

BACKGROUND

A growing body of evidence supports short-term DAPT as safe and efficacious following PCI with DES. However, methodological criticism of RCTs has led to caution when translating results into clinical practice. This study aimed to critically appraise the methodological rigour of included studies and consolidate the evidence on the safety and efficacy of short-term DAPT.

METHODS

Medline, Cochrane Library and Embase were searched from inception until August 2022. The primary outcome was the methodological quality of published primary studies. Risk of bias was assessed using RoB 2.0 and the CASP tool. Evidence was rated for quality using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) score approach. Other endpoints were all-cause mortality and major bleeding.

RESULTS

Eighteen RCTs were included. Based on GRADE score, there was a moderate level of certainty that the reported results for both outcomes are probably close to the true effect. A total of 78% (14/18) of RCTs had a low risk of bias when assessing all-cause mortality and 61% (11/18) when assessing major bleeding. The CASP tool confirmed methodological rigour; however, only 33% (6/18) of studies were applicable beyond the studied populations. Compared with 12 months of DAPT, short-term DAPT was associated with a reduced risk of major bleeding [relative risk (RR): 0.69, 95% CI: 0.54-0.88, P = 0.003, I2 = 45%] and trended towards a reduced risk in all-cause mortality (RR: 0.90, 95% CI: 0.79-1.01, P = 0.08, I2 = 0%).

CONCLUSION

With moderate certainty evidence, short-term DAPT appears safe and efficacious post-PCI with DES in the studied populations.

How does the addition of antiplatelet therapy to antithrombotic therapy in patients with atrial fibrillation and stable coronary artery disease affect outcomes? A meta-analysis of randomized controlled trials

Atrial fibrillation (AF) and stable coronary artery disease (CAD) often coexist, creating a significant burden. The efficacy of adding antiplatelet therapy to oral anticoagulant (OAC) therapy in treating these patients remains unclear, prompting this meta-analysis. A comprehensive search across databases was conducted for relevant studies. Outcomes of interest included net adverse clinical event (NACE), all-cause mortality, cardiovascular disease (CVD) mortality, major bleeding, any bleeding, hemorrhagic stroke, and ischemic stroke. A hazard ratio (HR) with 95% confidence intervals (CI) was pooled. Three randomized controlled trials (3945 patients) were analyzed. OAC monotherapy (MT) significantly reduced major bleeding (HR: 0.57; 95% CI: 0.40-0.83; P = 0.003) and any bleeding (HR: 0.55; 95% CI: 0.46-0.65; P < 0.0001) compared to combination therapy. No significant findings were observed for NACE, all-cause mortality, CVD mortality, hemorrhagic and ischemic strokes. Our meta-analysis revealed that OAC MT significantly reduced bleeding events while the number of stroke events and mortality remained similar compared to combination therapy in patients with AF and stable CAD.

Tirofiban efficacy and safety for percutaneous coronary intervention in patients with acute coronary syndrome: protocol for a systematic review and meta-analysis

INTRODUCTION

Percutaneous coronary interventions (PCI) have become a cornerstone in the management of acute coronary syndromes (ACS), yet they carry risks of complications like stent thrombosis and reinfarction. Glycoprotein IIb/IIIa inhibitors, particularly tirofiban, have been employed as adjunctive therapies to reduce these risks. Despite its potential benefits, the use of tirofiban remains a subject of debate, with varying recommendations across major clinical guidelines.

METHODS AND ANALYSIS

We systematically searched five databases from 1 January 1992 to 1 April 2025, including Medline, Embase, Lilacs, Clinicaltrials.org and Cochrane Central Register of Controlled Trials (CENTRAL), in addition to three grey literature databases. Randomised controlled trials and cluster randomised trials investigating the use of intravenous or intracoronary tirofiban in patients with ACS, unstable angina or myocardial infarction were considered for inclusion. Only published studies in English, Portuguese, Spanish and French were included. Data selection and extraction will be performed independently by two researchers, with any inconsistencies resolved with consensus or by consulting a third senior researcher. The risk of bias will be assessed through the risk of bias measurement tool (Rob-2) for interventions and/or cluster trials by two researchers independently, and the overall certainty of evidence will be assessed by using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. A meta-analysis will be carried out if there is sufficient homogeneity between studies, with subgroup analysis being performed if significant heterogeneity is detected. Additionally, a metaregression model will be conducted if sufficient data are available.

ETHICS AND DISSEMINATION

As this study involves secondary analysis of published data, ethics approval is not required. The results will be disseminated through peer-reviewed publication, conference presentations and will be shared with relevant clinical guideline committees.

PROSPERO REGISTRATION NUMBER

CRD42024585252.

Impact of Post-PCI Lipid Core Burden Index on Angiographic and Clinical Outcomes: Insights From NIRS-IVUS

BACKGROUND

The impact of lipid core burden index (LCBI) after percutaneous coronary intervention (PCI) in the stented segment assessed by intracoronary near-infrared spectroscopy on the outcomes remains unclear.

METHODS

In this prospective observational study, we aimed to assess the impact of post-PCI LCBI on late luminal loss and clinical outcomes. Post-PCI intracoronary near-infrared spectroscopy imaging was performed in the stented segment after PCI. Patients were categorized into 2 groups based on the post-PCI maxLCBI4mm with a cut-off value of 200. Angiographic and clinical outcomes were compared at 12 months. The primary end point was angiographic late luminal loss. The secondary end point was target lesion failure (composite of cardiovascular death, target vessel myocardial infarction, and clinically driven target lesion revascularization) and major adverse cardiac and cerebrovascular events (composite of cardiac death, myocardial infarction, any repeat revascularization, and stroke).

RESULTS

A total of 228 patients with 278 target lesions were followed up for 1 year. One-year follow-up angiography was performed on 198 lesions in 163 patients. Follow-up quantitative coronary angiography revealed that stented segments with post-PCI maxLCBI4mm ≥200 had higher late luminal loss compared with those with a post-PCI maxLCBI4mm <200 (mean, 0.503±0.683 mm versus 0.115±0.326 mm; P<0.001; median, 0.250 mm versus 0.050 mm; P<0.001). Patients with post-PCI maxLCBI4mm ≥200 had a significantly higher 1-year cumulative incidence of both target lesion failure (6.9% versus 0.6%; P=0.002) and major adverse cardiac and cerebrovascular events (15.1% versus 2.2%; P<0.001).

CONCLUSIONS

Post-PCI LCBI assessed by intracoronary near-infrared spectroscopy-intravascular ultrasound was associated with late luminal loss as well as subsequent target lesion failure and major adverse cardiac and cerebrovascular events.

Association Between Time From Percutaneous Coronary Intervention to Cancer Surgery and Cardiovascular and Oncological Outcomes

BACKGROUND

Patients who undergo noncardiac surgery shortly after percutaneous coronary intervention (PCI) experience higher rates of perioperative ischemic events, but delaying surgery may affect disease staging and influence cancer recurrence. We aimed to evaluate the association between time from PCI to cancer surgery and cardiovascular and oncologic outcomes in patients with early-stage cancer.

METHODS AND RESULTS

We included patients with early-stage cancer with a history of PCI who underwent cancer surgery (N=3621). The patients were divided into 2 groups based on the time between the dates of PCI and cancer surgery (<12 and ≥12 months). We also grouped patients who underwent early surgery and late surgery, defined as patients who underwent surgery ≥1 and <1 month after cancer diagnosis. Outcomes included bleeding, spontaneous myocardial infarction, repeat revascularization, cancer recurrence, and death. The time from PCI to cancer surgery <12 months group had higher bleeding (hazard ratio [HR], 1.30 [95% CI, 1.18-1.32]), spontaneous myocardial infarction (HR,1.96 [95% CI, 1.32-2.92]), cancer recurrence (HR, 1.26 [95% CI, 1.01-1.56]), and mortality (HR, 1.23 [95% CI, 1.04-1.44]) compared with the ≥12 months group. Among the time from PCI to cancer surgery <12 months group, the early-surgery group had lower cancer recurrence risk than those who underwent late surgery (HR, 0.70 [95% CI, 0.49-0.99]) without differences in bleeding and cardiac outcome.

CONCLUSIONS

Although patients who undergo surgery within 12 months of PCI have higher risks of bleeding and cardiovascular events, delaying surgery may increase the risk of cancer recurrence. Therefore, the timing of surgery should be a personalized decision, weighing the risks of cardiovascular complications against the potential oncologic outcomes.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06357000.

Management of patients with congenital bleeding disorders and cardiac indications for antithrombotic therapy

AIMS

Cardiologists have only had rare exposure to haemophilia patients and patients with other congenital bleeding disorders during the last decades, as these patients had a reduced life expectancy and were partly protected against thrombosis due to the bleeding disorder. With the availability of effective and safe replacement therapies of clotting factors, the average life expectancy in these populations of patients has significantly increased, and thrombotic complications may occur.

METHODS AND RESULTS

The European Society of Cardiology Working Group on Thrombosis has taken the initiative to broaden the spectrum of these haematological conditions to include patients with a larger variety of congenital bleeding disorders with concomitant cardiac conditions as compared to a recent position paper by the European Haematology Association in collaboration with other societies (ISTH, European Association for Haemophilia and Allied Disorders, and ESO). Management of antithrombotic therapy or thromboprophylaxis in these individuals is challenging due to the wide phenotypes encompassed by congenital bleeding disorders. These include abnormalities in both primary haemostasis (involving von Willebrand factor and platelet function) and secondary haemostasis (related to coagulation factors and fibrinogen). Bleeding disorders range from mild to very severe. Based on existing literature, we provide clinical consensus statements on optimizing antithrombotic treatment strategies for patients with congenital bleeding disorders and highlight the current gaps in knowledge in these complex clinical settings.

CONCLUSION

Of importance, an individualized approach to antithrombotic therapy is warranted to properly balance the two risks of thrombosis and bleeding. Adoption of the safest interventional techniques, reduction of the intensity and/or duration of antithrombotic therapies, and attention to the safe levels of clotting factors is generally advised.

Prasugrel Intermediate Metabolite Modulates Platelet Inhibition by Negatively Interfering With an Active Metabolite: An Ex Vivo, In Vitro, and In Silico Study

BACKGROUND

Prasugrel is converted into prasugrel active metabolite (PAM; R-138727) through the cytochrome P450-mediated conversion of an intermediate metabolite (PIM; R-95913). It is unknown whether PIM exerts any biological function. The FABOLUS-FASTER trial (Facilitation Through Aggrastat or Cangrelor Bolus and Infusion Over Prasugrel: A Multicenter Randomized Open-Label Trial in Patients With ST-Elevation Myocardial Infarction Referred for Primary Percutaneous Intervention) showed that chewed prasugrel does not improve bioactivity, in spite of accelerated PAM kinetics.

METHODS

PIM and PAM pharmacokinetics were assessed by mass spectrometry in blood samples collected from ST-segment-elevation myocardial infarction patients randomized to chewed (n=17) or integral (n=15) 60 mg prasugrel. The ex vivo and in vitro effects of PAM and PIM were assessed on ADP-induced platelet activation. The binding sites of PIM and PAM were investigated by molecular dynamics simulation.

RESULTS

Chewed prasugrel was associated with higher PIM levels compared with integral prasugrel: PIM median area under the curve (25-75 p): 73 (41.5-92.0) versus 33 (0.0-50.0) ng·h/mL (P<0.05). PIM plasma concentrations negatively correlated with inhibition of ADP-induced platelet aggregation, which strongly correlated to the PAM/PIM ratio (ρ=0.782; P<0.001; n=30) than PAM, suggesting an antagonistic role of PIM on PAM-induced P2Y12 inhibition. Subsequent in vitro tests confirmed the dose-dependent, reversible antagonistic effect of PIM on PAM inhibition of aggregation (maximum effect, -49.5% [95% CI, -54.4% to -44.6%]; P<0.001), confirmed by P-selectin expression and vasodilator-stimulated phosphoprotein phosphorylation as readouts at the signaling level. At molecular dynamics simulations of the drug-receptor systems, PIM accommodates through noncovalent reversible binding in the same PAM-binding site, distinct from that of 2-methylthio-adenosine-5'-diphosphate.

CONCLUSIONS

PIM negatively interferes with PAM, thereby reducing its inhibitory activity, likely competing at the P2Y12 receptor-binding site.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02978040. URL: https://www.clinicaltrialsregister.eu; Unique identifier: EudraCT 2017-001065-24.

Proton Pump Inhibitor Use Exceeding the U.S. Food and Drug Administration Approved Treatment Duration for Patients With Peptic Ulcer Disease: A Retrospective Cohort Study

BACKGROUND

Proton-pump inhibitors (PPIs) are effective in treating peptic ulcer disease (PUD), but they are often prescribed beyond the approved duration. Because PPIs are associated with adverse effects, there is a need for effective stewardship.

OBJECTIVE

To identify the frequency of and healthcare factors associated with PPI prescriptions exceeding the approved eight-week treatment duration for PUD.

METHODS

We conducted a retrospective cohort study of patients diagnosed with acute PUD without other indications for PPI use using data from the Veterans Health Administration in the United States. Exposures were patient, provider, and facility factors that could influence PPI prescribing. The outcome was time to a filled PPI prescription exceeding the approved treatment duration for PUD. Associations were assessed using a multivariable time-to-recurrent-event model to calculate adjusted hazard ratios (aHR) and population-attributable fractions. Patients who developed indications for long-term PPI use were censored.

RESULTS

We identified 7708 patients with PUD who met eligibility criteria and received PUD treatment (median age 79 [IQR 71-85], 7% female). Thirty-five percent had PPI prescriptions exceeding the approved duration for a median of 346 days (IQR 165-643) of overuse. On the patient level, inpatient PUD diagnosis (aHR 1.32, 95% CI 1.25-1.39), use of nonsteroidal anti-inflammatory drugs (NSAIDs) (aHR 1.26, 95% CI 1.18-1.34), use of anticoagulants (aHR 1.25, 95% CI 1.13-1.38), and moderate frailty (1.15, 95% CI 1.06-1.26) had the strongest associations with filled PPI prescriptions exceeding the approved duration. On the health-system level, inpatient PUD diagnosis had the highest peak population attributable fraction at 0.26, followed by NSAIDs and anticoagulants at 0.18.

CONCLUSIONS

Markers of patient complexity and medication use not meeting gastroprotection guidelines are associated with inappropriate PPI persistence among patients with PUD. These data may inform future targeted PPI deprescribing programs.

Post-discharge pharmacotherapy in people with atrial fibrillation hospitalized for acute myocardial infarction: an Australian cohort study 2018-22

BACKGROUND

Dual antiplatelet therapy with P2Y12 inhibitors (P2Y12i) and aspirin following acute myocardial infarction (AMI) prevents future ischaemic events. People with atrial fibrillation (AF) also require oral anticoagulants (OAC), increasing bleeding risk. Guidelines recommend post-discharge prescribing of direct OAC with clopidogrel and discontinuation of P2Y12i after 12 months, but little is known about use in clinical practice.

AIM

To describe post-discharge use of OACs and P2Y12i in people with AF and a history of OAC use hospitalized for AMI.

METHODS AND RESULTS

We identified 1330 people hospitalized for AMI with a diagnosis of AF and history of OAC use in New South Wales, Australia, July 2018-June 2020. We identified three aspects of post-discharge antithrombotic medicine use with possible safety implications: (1) not being dispensed OACs; (2) dispensing OAC and P2Y12i combinations associated with increased bleeding (involving warfarin, ticagrelor, or prasugrel); and (3) P2Y12i use longer than 12 months.After discharge, 74.3% of people were dispensed an OAC, 45.4% were dispensed a P2Y12i, and 35.8% were dispensed both. People with comorbid heart failure or cancer were less likely to receive OACs. Only 11.2% of people who dispensed both an OAC and P2Y12i received combinations associated with increased bleeding; this was more common among people with chronic kidney disease or prior warfarin or statin use. A total of 44.6% of people dispensed both medicines continued P2Y12i for over 12 months; this was more common in people who received a revascularization or lived in areas of social disadvantage.

CONCLUSION

We identified potential gaps in pharmacotherapy, including underuse of recommended therapies at discharge, use of combinations associated with increased bleeding, and P2Y12i use beyond 12 months. Prescribing vigilance across both hospital and community care is required.

Adherence to periprocedural antithrombotic treatment recommendations and its prognostic impact in patients with high ischemic and hemorrhagic risk

INTRODUCTION AND OBJECTIVES

To analyze the clinical impact of the inappropriate use of antithrombotic treatment in patients with high ischemic or hemorrhagic risk during the periprocedural/perisurgical period in Spain.

METHODS

Prospective multicenter observational registry of patients receiving antiplatelet and/or anticoagulant therapy who required an intervention. The incidence of 30-day events was compared based on the peri-intervention management of antithrombotic treatment and the patients' risk classification (high vs. moderate-to-low risk). The primary endpoint was a composite of death, cardiovascular ischemic events, or bleeding events classified as BARC 2 or higher.

RESULTS

A total of 1152 patients were analyzed. Of these, 1.9% had both high ischemic and hemorrhagic risks (A);10.8% had high ischemic risk and low-to-moderate hemorrhagic risk (B); 12% had high hemorrhagic risk and low-to-moderate ischemic risk (C); and 75.3% had both low-to-moderate risks (D). The prevalence of inappropriate treatment was higher in the subgroup with high hemorrhagic risk and low-to-moderate ischemic risk (C) (62.6% vs 40.9% in subgroup A; P<.05; 40.3% in subgroup B; P<.001; and 39.8% in subgroup D; P<.05). The incidence of the composite endpoint was higher in the subgroups with high ischemic and hemorrhagic risks (22.7%) and high ischemic and low-to-moderate hemorrhagic risks (20.9%), compared with 3.6% in subgroup C (P<.05) and 5.7% in subgroup D (P<.001). Among patients with inappropriate treatment, the incidence of the composite endpoint was significantly higher in subgroups with high ischemic and hemorrhagic risks (44.4% vs 7.7%; P=.043) and high ischemic and low-to-moderate hemorrhagic risks (30% vs 14.8%; P=.042).

CONCLUSIONS

The prevalence of inappropriate periprocedural/perisurgical treatment was higher in patients with high hemorrhagic risk and low-to-moderate ischemic risk. The incidence of events was higher in patients with high ischemic risk, with inadequate antithrombotic management being associated with a higher event rate in these groups.

Role of Proton Pump Inhibitors in Prevention of Upper Gastrointestinal Bleeding in Patients on Dual Antiplatelet Therapy: Systematic Review and Meta-Analysis

BACKGROUND

Dual antiplatelet therapy (DAPT) with oral P2Y12 inhibitors and aspirin is crucial for patients with acute coronary syndrome (ACS) and postpercutaneous coronary interventions (PCI). Concomitant proton pump inhibitor (PPI) therapy with DAPT can potentially reduce the risk of upper gastrointestinal bleeding (UGIB).

AIM

We conducted a meta-analysis of randomized controlled trials to evaluate the prevention of UGIB with concomitant use of PPI with DAPT.

METHODS

We reviewed several databases to identify randomized controlled trials comparing the risk of UGIB in patients using DAPT + PPI vs . DAPT with no PPI or DAPT + Histamine 2 receptor antagonists. Our outcomes of interest were UGIB, major cardiovascular adverse events (MACE), myocardial infarction, and all-cause mortality. We calculated pooled risk ratio (RR) with 95% confidence intervals (CI) for all of the outcomes and analyzed data using random effect model. Heterogeneity was assessed using I 2 statistic.

RESULTS

Seven randomized controlled trials comprising 6708 patients were included. Rate of UGIB was significantly lower in the PPI + DAPT group, RR (95% CI): 0.39 (0.25-0.60). There was no significant difference in the rate of MACE between groups, RR (95% CI): 0.87 (0.69-1.10). Rate of MI was also not significantly different between groups, RR (95% CI): 0.93 (0.75-1.14). Rate of mortality was significantly lower in the PPI + DAPT group, RR (95% CI) 0.46 (0.27-0.80).

CONCLUSIONS

Our meta-analysis demonstrates that adding PPI therapy to DAPT significantly lowers the risk of UGIB and all-cause mortality, without adversely affecting major cardiovascular outcomes.

Clinical impact of visceral adiposity on long-term mortality in patients undergoing coronary artery bypass grafting

INTRODUCTION AND OBJECTIVES

Although visceral adiposity increases cardiovascular risk in the general population, the obesity paradox has been reported in critically ill patients. However, evidence for its prognostic role in patients undergoing coronary artery bypass grafting (CABG) is limited. This study evaluated the prognostic implications of visceral adiposity in patients who underwent CABG using computed tomography-based measurement of visceral fat.

METHODS

A total of 2810 patients who underwent CABG from 2007 to 2017 were analyzed. The study population was classified into 3 groups according to visceral fat area index (VFAI) tertiles. VFAI was calculated as visceral fat area (cm2)/height2 (m2) at the L3 level. The primary outcome was all-cause mortality during follow-up.

RESULTS

Patients in the low VFAI group (lowest tertile) were younger and had a lower body mass index and less subcutaneous fat than those in the high VFAI group (highest tertile). During a median 8.7-year follow-up, VFAI was significantly associated with the risk of mortality in restricted cubic spline curve analysis (HR, 0.94 per 10 increases; 95%CI, 0.91-0.97; P<.001). Patients in the low VFAI group had a higher incidence of long-term mortality than those in the intermediate and high VFAI groups (T1 36.1%, T2 27.2%, and T3 29.1%; T1 vs T2; adjusted HR, 1.36; 95%CI, 1.15-1.61; P<.001; T1 vs T3; adjusted HR, 1.37; 95%CI, 1.16-1.62; P<.001). Similar results were obtained after inverse probability treatment-weighting analysis.

CONCLUSIONS

Low visceral adiposity was associated with an increased risk of long-term mortality in patients who underwent CABG.

Evolving trends in acid suppression therapy among patients undergoing dual antiplatelet therapy: A Nationwide study in South Korea from 2018 to 2022

AIMS

We aimed to examine the recent trends in the use of acid suppression therapies, including proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs) and potassium-competitive acid blockers (P-CABs), in patients undergoing dual antiplatelet therapy (DAPT) as aspirin-clopidogrel following coronary stent implantation in South Korea between 2018 and 2022.

METHODS

This observational study analysed data from the Health Insurance Review and Assessment Service (HIRA) on patients who underwent coronary stent implantation and received aspirin-clopidogrel DAPT. Patients who received acid suppression therapy for >60 days during DAPT were included in the analysis. Trends in the use of PPIs, H2RAs and P-CABs were assessed at 6-month intervals using the Cochran-Armitage trend test.

RESULTS

Of the 128 121 patients studied who received DAPT, 61 731 (48.2%) were prescribed acid suppression therapy. The proportion of patients receiving concomitant acid suppressants with DAPT increased from 42.8% in 2018 to 53.8% in 2022. PPIs were the most commonly used therapies (78.9%), followed by H2RAs (14.6%) and P-CABs (6.5%). PPI use peaked in 2020 and declined thereafter, whereas P-CAB use steadily increased, surpassing that of H2RA by 2021.

CONCLUSIONS

The landscape of acid suppression therapy for patients undergoing DAPT has evolved with a growing preference for P-CABs. This shift highlights the need for further research comparing the efficacy and safety of acid suppressants to guide clinical decision making.

Percutaneous coronary intervention in patients with acute coronary syndromes and increased platelet count

BACKGROUND

In patients with acute coronary syndromes (ACS) requiring percutaneous coronary intervention (PCI), abnormally elevated platelet counts are often associated with an increased risk of stent thrombosis and bleeding.

AIMS

To explore the associations between clinical benefits and PCI in patients with ACS and elevated platelet counts.

METHODS

Between July 2017 and December 2019, 50,009 patients with ACS were enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project. This study included patients with platelet count≥300×109/L. The primary outcome was net adverse clinical events (NACE), including major adverse cardiovascular or cerebrovascular events (MACCE; all-cause death, myocardial infarction, ischaemic stroke and stent thrombosis) and major bleeding during the index hospitalization. The difference in the risk of NACE between PCI and non-PCI groups was analysed using multivariable analysis and inverse probability of treatment weighting.

RESULTS

Among 4501 patients, PCI rates decreased as platelet count increased, with 3029 patients ultimately undergoing PCI. These patients exhibited a lower rate of NACE (adjusted odds ratio [OR]: 0.53, 95% confidence interval [95% CI]: 0.37-0.77; P=0.001) and a reduced risk of MACCE (OR: 0.44, 95% CI: 0.29-0.67; P<0.001). No significant differences in major bleeding were observed (adjusted OR: 1.40, 95% CI: 0.62-3.16; P=0.417). Inverse probability of treatment weighting confirmed these findings.

CONCLUSION

In patients with ACS and increased platelet counts who have more complex thrombohaemorrhagic profiles, PCI can effectively reduce the risk of ischaemic events without increasing the risk of bleeding.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/study/NCT02306616.

Abbreviated dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is a standard post-percutaneous coronary intervention (PCI) treatment to reduce thrombosis and ischemic events. However, the optimal DAPT duration remains unclear, with concerns about bleeding risks associated with long-term potent P2Y12 inhibitors. This systematic review and meta-analysis investigates the safety and efficacy of shortened DAPT regimens.

METHODS

A comprehensive search of PubMed, Scopus, and EMBASE identified randomized controlled trials (RCTs) comparing conventional DAPT (≥ 12 months) and abbreviated DAPT (≤ 3 months) post-PCI. Primary outcomes were 1-year all-cause mortality and bleeding, assessed using the Bleeding Academic Research Consortium (BARC) classification. Secondary outcomes included cardiovascular mortality, non-fatal myocardial infarction (MI), stroke, and major adverse cardiovascular events (MACE). Risk of bias was assessed with the Cochrane tool, and meta-analyses used random-effects models.

RESULTS

Forty studies involving 54,233 participants were included. Abbreviated DAPT significantly reduced all-cause mortality (RR: 0.90, 95%CI: 0.82-0.98) and bleeding (BARC 3 or 5: RR: 0.77, 95%CI: 0.60-0.97). No significant differences were observed in cardiovascular mortality, stroke, non-fatal MI, revascularization, or in-stent thrombosis. Subgroup analyses showed lower mortality with 1-month DAPT and reduced bleeding in patients with high bleeding risk, acute coronary syndrome (ACS), and complex PCI.

CONCLUSIONS

Abbreviated DAPT post-PCI is associated with lower all-cause mortality and bleeding without compromising ischemic protection, supporting its use in specific patient populations. Individualized DAPT durations should be considered to balance bleeding and ischemic risks.

Effect of Potassium-Competitive Acid Blockers on Upper Gastrointestinal Bleeding in Patients on Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Nationwide Cohort Study

BACKGROUND AND AIM

Proton pump inhibitors (PPIs) are the drug of choice to prevent upper gastrointestinal (UGI) bleeding in patients receiving dual antiplatelet therapy (DAPT); however, unmet needs remain. Potassium-competitive acid blockers (P-CABs) are novel acid-suppressive drugs that have emerged as potential alternatives. We evaluated the effectiveness of P-CAB in reducing the risk of UGI bleeding in patients receiving DAPT after percutaneous coronary intervention (PCI).

METHODS

This retrospective cohort study included patients with PCI on DAPT between January 2019 and January 2023 using the Korean nationwide health claims database. The primary outcome was admission for UGI bleeding within 6 months of PCI. A multivariate Cox regression model was used to evaluate UGI bleeding risk based on PPIs and P-CAB use.

RESULTS

Of the 210 447 patients who underwent PCI on DAPT (mean age, 65.5 years; 74.7% men), 4.6% and 47.5% patients were prescribed P-CABs and PPIs, respectively. Overall, 0.3% of patients experienced UGI bleeding within 6 months of PCI. P-CAB users had a reduced risk of UGI bleeding (adjusted hazard ratio, 0.59; 95% confidence interval, 0.38-0.92; p = 0.019) compared with patients not receiving P-CAB or PPI. No significant difference was observed between the P-CAB and PPI users (p > 0.05).

CONCLUSIONS

Among Korean patients undergoing PCI with DAPT, P-CABs reduced UGI bleeding comparably to PPIs. These findings suggest that P-CABs are potential alternatives to PPIs for preventing UGI bleeding.

A Novel Approach to Gastrointestinal Bleeding Risk Stratification and Proton Pump Inhibitor Effectiveness in Patients with Acute Coronary Syndrome on Dual Antiplatelet Therapy: A Nationwide Retrospective Cohort Study

PURPOSE

Proton pump inhibitors (PPIs) are effective in preventing gastrointestinal (GI) bleeding in high-risk patients on dual antiplatelet therapy (DAPT). Existing criteria for high GI bleeding risk, such as those from the American Heart Association (AHA), may not fully reflect East Asian patient profiles. This study aimed to evaluate the effectiveness of PPIs in preventing GI bleeding across DAPT combinations, stratified by GI bleeding risk using the Academic Research Consortium High Bleeding Risk (ARC-HBR) criteria in patients with acute coronary syndrome (ACS).

METHODS

A retrospective cohort of 93,153 patients with ACS initiating DAPT (2018-2020) was analyzed using the Korean National Health Insurance database. Modified ARC-HBR (mARC-HBR) criteria tailored to claims data were compared with AHA criteria in terms of concordance and performance. PPI effects on GI bleeding were analyzed by mARC-HBR risk groups over a 3-year observation period.

RESULTS

The mARC-HBR criteria identified three times more high-risk patients than the AHA criteria, demonstrating higher sensitivity (38.9% vs. 11.1%, p < 0.001) while maintaining a relatively high specificity (both > 70%). While PPI use offered no benefit for low-risk patients, it was associated with a 25.8% lower GI bleeding risk in high-risk patients, with the most pronounced effect observed in those on the aspirin/ticagrelor combination.

CONCLUSION

The mARC-HBR criteria enhance the identification of high GI bleeding risk patients with ACS and may inform targeted PPI use, given the observed associations suggesting potential benefit in high-risk ticagrelor users and limited effect in low-risk groups.

Long-term Antithrombotic Therapy in Patients With Chronic Coronary Syndrome: An Updated Review of Current Evidence

PURPOSE

Despite improvements in the secondary prevention of atherothrombosis in patients with coronary artery disease during the past decade, it is estimated that approximately 19 million people annually die from cardiovascular diseases worldwide. Atherothrombosis remains the core pathobiology of acute complications including myocardial infarction (MI), and therefore, antithrombotic therapy plays a pivotal role in the strategies for major adverse cardiovascular event (MACE) prevention. Unlike early antithrombotic management after acute coronary syndrome, less evidence is available on long-term antithrombotic therapy in patients with chronic coronary syndrome (CCS). In addition, greater recognition of the impact of bleeding complications of such therapies has led to a more complex and personalized approach to their application. The purpose of this article is to review the available evidence on long-term antithrombotic therapy in patients with CCS including those with high-risk characteristics such as prior MI or polyvascular disease.

METHODS

A comprehensive literature review was performed in major databases including PubMed, Embase, and the Cochrane Library. The main focus of this narrative review was on available data from guidelines, meta-analysis, randomized controlled trials, and observational studies that assessed the efficacy and safety profile of long-term antithrombotic therapy in patients with CCS.

FINDINGS

Several studies suggest that long-term antithrombotic therapy is effective in reducing the risk of recurrent MACEs in patients with CCS. Current clinical guidelines recommend single antiplatelet therapy with aspirin as a first-line long-term strategy for patients without indication for oral anticoagulation. However, novel approaches focused on P2Y12 inhibitor monotherapy are emerging. More intensive antithrombotic strategies including long-term dual antiplatelet therapy and dual pathway inhibition further reduce ischemic risk but at the cost of increased bleeding.

IMPLICATIONS

This review highlights the importance of close monitoring and regular reassessment of the risk-benefit balance of antithrombotic therapy in patients with CCS. Overall, long-term antithrombotic therapy with either single antiplatelet therapy or dual antiplatelet therapy/dual pathway inhibition is effective in reducing the risk of MACEs in patients with CCS. The choice of antithrombotic therapy should be individualized based on the patient's clinical profile, particularly for thrombohemorrhagic risk. Future research should focus on identifying the optimal antithrombotic regimen for specific subgroups of patients with prior MI particularly for those with high bleeding risk.

Rationale and design of the TADCLOT trial: A double blind randomized controlled trial comparing twice a day clopidogrel vs ticagrelor in reducing major cardiac events in patients with acute STEMI undergoing primary percutaneous coronary intervention

BACKGROUND

Ticagrelor has been proven superior to clopidogrel in reducing adverse cardiovascular events in patients with acute coronary syndrome (ACS), yet economic factors often favor clopidogrel in real-world clinical practice. Although double dose clopidogrel has shown potential benefits over once-daily regimens, its direct comparison with ticagrelor in ST-elevation myocardial infarction (STEMI) patients remains unexplored.

METHODS AND DESIGN

Twice a Day Clopidogrel vs. Ticagrelor in Reducing Major Cardiac Events in Patients with Acute STEMI Undergoing Primary PCI (TADCLOT) trial is a double-blind, randomized controlled trial conducted at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. It is designed as a superiority trial to evaluate the efficacy and safety of ticagrelor over twice-daily clopidogrel in reducing major adverse cardiac events (MACE) in STEMI patients undergoing primary percutaneous coronary intervention (PCI). Following successful PCI for STEMI, and when the patient is deemed suitable for discharge, patients are randomized 1:1 to receive either ticagrelor (180 mg loading dose followed by 90 mg BID for 30 days) or clopidogrel (600 mg loading dose followed by 75 mg BID for 30 days). The primary endpoint is the rate of major adverse cardiac events (MACE), a composite of death, myocardial infarction, stent thrombosis, target lesion revascularization, or stroke at 30 days following randomization. Secondary endpoints include the individual components of MACE, bleeding complications, and drug discontinuation due to adverse events. Enrollment has reached 88%, with 2,200 patients planned to complete the trial.

IMPLICATIONS

The TADCLOT trial will provide crucial insights into the comparative efficacy of ticagrelor versus twice-daily clopidogrel in reducing early stent thrombosis and improving outcomes in STEMI patients undergoing primary PCI. The trial will particularly contribute valuable insights for post-PCI care, considering both the economic and genetic context of the high risk South Asian population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06318481.

Efficacy and safety of clopidogrel versus aspirin monotherapy in patients at high risk of subsequent cardiovascular event after percutaneous coronary intervention (SMART-CHOICE 3): a randomised, open-label, multicentre trial

BACKGROUND

The optimal strategy for long-term antiplatelet maintenance for patients who underwent percutaneous coronary intervention (PCI) remains uncertain. This study aimed to compare the efficacy and safety of clopidogrel versus aspirin monotherapy in patients who completed a standard duration of dual antiplatelet therapy (DAPT) following PCI with drug-eluting stents.

METHODS

In this multicentre, randomised, open-label trial, patients aged 19 years or older at high risk of recurrent ischaemic events (previous myocardial infarction at any time before enrolment, medication-treated diabetes, or complex coronary lesions) who completed a standard duration of DAPT after PCI were randomly assigned (1:1) to receive clopidogrel (75 mg once a day) or aspirin (100 mg once a day) oral monotherapy at 26 sites in South Korea. The primary endpoint was the cumulative incidence of a composite of death from any cause, myocardial infarction, or stroke, assessed in the intention-to-treat population. Adverse events were captured as part of the secondary endpoints. This trial is registered with ClinicalTrials.gov (NCT04418479). It is closed to accrual and extended follow-up is ongoing.

FINDINGS

Between Aug 10, 2020, and July 31, 2023, 5542 patients were assessed for eligibility and 5506 were randomly assigned (2752 to clopidogrel monotherapy and 2754 to aspirin monotherapy). The median time between PCI and randomisation was 17·5 months (IQR 12·6-36·1 months). During a median follow-up period of 2·3 years (IQR 1·6-3·0), the primary endpoint occurred in 92 patients in the clopidogrel group and 128 patients in the aspirin group (Kaplan-Meier estimated 3-year incidence 4·4% [95% CI 3·4-5·4] vs 6·6% [5·4-7·8]; hazard ratio 0·71 [95% CI 0·54-0·93]; p=0·013). Death from any cause occurred in 50 patients in the clopidogrel group and 70 in the aspirin group (2·4% [1·6-3·1] vs 4·0% [2·9-5·0] at 3 years; 0·71 [0·49-1·02]); myocardial infarction in 23 patients in the clopidogrel group and 42 in the aspirin group (1·0% [0·6-1·4] vs 2·2% [1·4-2·9] at 3 years; 0·54 [0·33-0·90]); and stroke in 23 in the clopidogrel group and 29 in the aspirin group (1·3% [0·7-2·0] vs 1·3% [0·8-1·7] at 3 years; 0·79 [0·46-1·36]). There was no difference in the risk of bleeding between the clopidogrel and aspirin groups (3·0% [2·0-3·9] vs 3·0% [2·2-3·9] at 3 years; 0·97 [0·67-1·42]). Clopidogrel was not associated with a higher incidence of any adverse event compared with aspirin.

INTERPRETATION

Among patients who were at high risk of recurrent ischaemic events and who completed the standard duration of DAPT following PCI, clopidogrel monotherapy, compared with aspirin monotherapy, significantly reduced the cumulative incidence of a composite of death from any cause, myocardial infarction, and stroke, without an apparent increase in the risk of bleeding.

FUNDING

Dong-A ST.

Antiplatelet and Anticoagulation Therapy in Athletes: A Cautious Compromise… If Possible!

Antiplatelet and anticoagulation therapy are commonly used in the general population and sometimes in athletes experiencing cardiovascular disorders. In these cases, the treatment has to be tailored according to the individual bleeding and thrombotic risk profile, also considering the intrinsic risk of sports activities when advising athletes for eligibility for competitive sports. In athletes, it is necessary to pre-assess the individual bleeding risk, considering not only the personal bleeding risk (usually low in athletes) but also the type of sport the athlete would like to practice, with careful consideration in sports where traumatic collisions are highly likely. Additionally, non-steroidal anti-inflammatory drugs are commonly used among athletes, and antiplatelet therapy may further increase the bleeding risk. Therefore, in selected competitive athletes, the default approach for antithrombotic therapy could be personalized. This review discusses the clinical management challenges of competitive athletes under antithrombotic or antiplatelet therapy, focusing on the intrinsic risks of sports practice and the indications for sports eligibility and disqualification.

Dual Antiplatelet Therapy Prior to Percutaneous Coronary Intervention for Acute Coronary Syndrome: Prevalence and Outcomes in Contemporary Practice

BACKGROUND

Dual antiplatelet therapy (DAPT) is standard following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Preloading is the practice of administering both aspirin and a P2Y12 inhibitor before PCI. DAPT preloading is common practice, however clinical trial evidence demonstrating benefit is lacking.

AIMS

This study aimed to examine the prevalence and associated clinical outcomes of DAPT before PCI for ACS in a contemporary population of Australian patients.

METHODS

Data on consecutive PCI procedures from patients included in the Victorian Cardiac Outcomes Registry (VCOR) from 2014 to 2021 was collected and stratified by administration of DAPT before PCI versus single, or no, antiplatelet therapy.

RESULTS

In total, 42,453 consecutive PCI procedures for ACS were included. Of these, 33,520 (79%) patients were either preloaded or already on DAPT before PCI. Patients on DAPT were younger (63.9 vs. 65.1, p < 0.001) and generally had fewer comorbidities. Unadjusted outcomes were more favorable with pre-loading with lower in-hospital mortality with DAPT (2.6% vs. 5.6%, p < 0.001), and 30-day cardiovascular mortality (0.3% vs. 0.4%, p = 0.039). 30-day major adverse cardiovascular events (MACE) (5.5% vs. 8.8%, p < 0.001) was similarly lower in the preloaded group. Major bleeding in hospital was less common in patients on DAPT (1.0% vs. 1.7%, p < 0.001). However, following adjustment for covariates, there was no difference in in-hospital or 30-day all-cause mortality, MACE or stent thrombosis between groups.

CONCLUSIONS

DAPT before PCI is common in ACS but not independently associated with improvements in in-hospital mortality, MACE, or stent thrombosis.

Impact of D-Dimer on the Prognostic Value of PARIS Thrombosis Risk Score in Acute Coronary Syndrome Patients Undergoing PCI: From a Large Prospective Cohort Study

BACKGROUND

Guideline-recommended PARIS thrombotic risk score predicts coronary thrombosis events (CTE) in Acute Coronary Syndrome (ACS) patients undergoing Percutaneous Coronary Intervention. We aim to evaluate whether D-dimer, a thrombotic biomarker, can predict long-term adverse events and improve the prognostic value of PARIS score.

METHODS AND RESULTS

This is a post-hoc analysis on a prospective cohort of 10,724 Chinese patients undergoing PCI. Patients who presented as ACS were included and stratified according to baseline D-dimer level (cutoff 0.28 µg/mL). The primary endpoint is all-cause death. Secondary endpoints are cardiac death and CTE. A total of 5139 ACS patients with PCI were analyzed, 2735 patients had D-dimer ≥ 0.28 µg/mL, while 2404 patients had D-dimer < 0.28 µg/mL. After adjusting for confounders, patients with higher D-dimer had significantly higher risk of 5-year all-cause death (HR = 1.951, 95% CI: 1.366-2.787) and cardiac death (HR = 2.513, 95% CI: 1.574-4.012), whilst a trend toward higher risk of 5-year CTE (HR = 1.285, 95% CI: 0.956-1.729) was observed. Compared with PARIS score alone, adding D-dimer to the model increased the area under the receiver operating characteristic curve on 5-year all-cause death (0.663-0.701, p = 0.006) and cardiac death (0.652-0.699, p = 0.015), both with significant net reclassification improvement (p < 0.001).

CONCLUSION

In our cohort of ACS patients undergoing PCI, D-dimer independently predicts long-term all-cause death and cardiac death, and improves the predictive value of PARIS score over 5-year all-cause death and cardiac death.

Complex PCI and 1-year outcomes in the OPTIVUS-complex PCI study multivessel cohort

It remains unknown whether intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) can improve the clinical outcomes of complex PCI to a level equivalent to that of non-complex PCI. In the OPTIVUS-Complex PCI (Optimal Intravascular Ultrasound-Guided Complex PCI) Study multivessel cohort, a total of 1011 patients who underwent multivessel PCI involving a target lesion in the left anterior descending coronary artery (LAD) were divided into 2 groups: complex PCI (N = 760) and non-complex PCI groups (N = 251). Complex PCI was defined as a procedure with the following characteristics: 3 vessels treated, 3 stents implanted, 3 lesions treated, bifurcation with 2 stents implanted, total stent length > 60 mm, or target of chronic total occlusion. The primary endpoint was major adverse cardiac and cerebrovascular event (MACCE) defined by a composite of death, myocardial infarction, stroke, or any coronary revascularization. The cumulative 1-year incidences of the primary endpoint and any coronary revascularization were not significantly different between the complex and non-complex PCI groups (10.9% vs. 8.3%, P = 0.24, and 7.7% vs. 4.8%, P = 0.12, respectively). In the multivariable Cox proportional hazards models, there was no significant excess risk of the complex PCI group relative to the non-complex PCI group for the primary endpoint (HR, 1.35; 95%CI, 0.83-2.18; P = 0.22), or for any coronary revascularization (HR, 1.64; 95%CI, 0.87-3.06; P = 0.11). After optimal IVUS-guided multivessel PCI with a target lesion in the LAD, 1-year risk of MACCE or coronary revascularization in patients with complex PCI was numerically higher than that in patients with non-complex PCI.

Potassium-competitive acid blocker vs proton-pump inhibitor in patients receiving antithrombotic therapy who are at high risk for gastrointestinal bleeding: Rationale and design of the randomized PROTECT- HBR trial

BACKGROUND

Concomitant use of proton pump inhibitor (PPI) is recommended in patients receiving chronic antithrombotic therapy who are at high risk of gastrointestinal (GI) bleeding. However, long-term safety and efficacy of chronic PPI use have been concerned. Potassium-competitive acid blocker (P-CAB) is a novel class of acid suppressants, providing more acid stability, rapid onset of action, less variability with CYP2C19 polymorphisms, and longer duration of action than PPI.

DESIGN

The PROTECT-HBR trial is a multicenter, randomized, double-blind, double-dummy, parallel-group clinical trial. Approximately 3320 patients with known cardiac or vascular disease receiving antithrombotic drugs (either antiplatelet or anticoagulant agents) and who are at high risk of GI bleeding will be randomized to P-CAB (tegoprazan 50mg once daily) or PPI (rabeprazole 20mg once daily) for up to 12 months. The primary endpoint is a composite outcome of upper GI clinical events, including overt or occult GI bleeding, symptomatic gastroduodenal ulcers or erosions, obstruction, or perforation, at 12 months. Secondary endpoints also included cardiovascular events and safety outcomes.

RESULTS

As of December 2024, approximately 1460 patients were enrolled from 32 participating sites in South Korea. The complete enrollment is anticipated at the mid- or late-term of 2025, and the primary results will be available by 2027.

CONCLUSION

PROTECT-HBR is a large-scale, multicenter, clinical trial, which will provide a pivotal comparison of the efficacy and safety of novel P-CAB, tegoprazan with those of PPI, rabeprazole in patients with documented cardiac or vascular disease receiving chronic antithrombotic drugs and at high risk of GI bleeding.

CLINICAL TRIAL REGISTRATION

Potassium-Competitive Acid Blocker versus pROton-Pump Inhibitor for GastroproTECTion Strategies In Patients at High GastroIntestinal Bleeding Risk Receiving Antithrombotic Therapy (PROTECT-HBR): NCT04416581.

De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systematic Review and Individual Patient Data Meta-analysis of Randomized Clinical Trials

BACKGROUND

The role of transitioning from short dual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation remains inconclusive.

PURPOSE

To compare the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT from randomized clinical trials in patients with ACS.

DATA SOURCES

PubMed, EMBASE, Scopus, and ClinicalTrials.gov from inception to 12 December 2024.

STUDY SELECTION

Randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, specifically in patients with ACS undergoing DES implantation.

DATA EXTRACTION

The coprimary end points were an ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).

DATA SYNTHESIS

Individual patient data were obtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with ACS; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina.

LIMITATION

Other de-escalation strategies for modulating antiplatelet therapy were not included.

CONCLUSION

In patients with ACS undergoing DES implantation, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without an increase in ischemic events, regardless of the type of ACS.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42024565855).

Single vs dual antiplatelet therapy after left atrial appendage closure: A propensity score matching analysis

BACKGROUND

Dual antiplatelet therapy and oral anticoagulation in combination with aspirin represent recommended treatment regimens after left atrial appendage closure (LAAC). As most patients receiving LAAC have high bleeding risk, less aggressive antithrombotic treatments are needed, such as single antiplatelet therapy.

OBJECTIVE

We sought to compare both ischemic and bleeding outcomes in patients receiving single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) after successful LAAC.

METHODS

Data on consecutive patients undergoing percutaneous LAAC between 2009 and 2023 were prospectively collected including 1-year follow-up. Propensity score matching was performed for patients discharged under SAPT and DAPT. The primary end point was the 1-year composite of cardiovascular death, stroke, systemic embolism, or device-related thrombosis (DRT). The secondary end points included major bleeding and DRT.

RESULTS

Of 1033 patients discharged with antiplatelet therapy, 154 patients receiving SAPT were compared with 230 matched patients receiving DAPT. The primary end point was similar between the study groups (SAPT 11.0% vs DAPT 8.3%; rate ratio, 1.14; 95% confidence interval [CI], 0.83-1.55; P = .420). Consistently, we found no difference in terms of both major bleeding (SAPT 9.7% vs DAPT 12.6%; hazard ratio, 0.77; 95% CI, 0.43-1.39; P = .387) and DRT (2.6% vs 1.1%; rate ratio, 1.47; 95% CI, 0.89-2.43; P = .130) between the SAPT and DAPT groups.

CONCLUSION

In this propensity score matching analysis of a single-center LAAC cohort, ischemic and bleeding outcomes did not differ at 1 year for patients discharged with SAPT or DAPT. These results have to be confirmed in an adequately powered randomized clinical trial.

Postcardiotomy extracorporeal membrane oxygenation after elective, urgent, and emergency cardiac operations: Insights from the PELS observational study

Background

Outcomes in cardiac surgery are influenced by surgical priority, with higher mortality in emergency cases. Whether this applies to postcardiotomy venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains unknown. This study describes characteristics and outcomes of patients undergoing cardiac operations and requiring VA ECMO, stratified by emergency, urgent, or elective operation.

Methods

This retrospective multicenter observational study included adults requiring postcardiotomy VA ECMO between 2000 and 2020. Preoperative and procedural characteristics, complications, and survival were compared among the 3 patient groups. The association between emergency surgery and in-hospital survival was investigated through mixed Cox proportional hazard models.

Results

The study cohort comprised 1063 patients (52.2%) with elective operations, 445 (21.8%) with urgent operations, and 528 (26%) with emergency operations. Emergency operations included more coronary artery bypass grafting operations (n = 286; 54.2%; P < .001) and aortic procedures (n = 126; 23.9%; P = .001) in patients with more unstable preoperative hemodynamic conditions compared to elective and urgent patients. VA ECMO was initiated more frequently intraoperatively in emergency patients (n = 353; 66.9%; P < .001). Postoperative bleeding (n = 338; 64.3%; P < .001), stroke (n = 79; 15%; P < .001), and right ventricular failure (n = 124; 25.3%) were more frequent after emergency operations. In-hospital mortality was 60.5% in the elective group, 57.8% in the urgent group, 63.4% in the emergency group (P = .191). The crude hazard ratio for in-hospital mortality in emergency surgery was 1.15 (95% confidence interval [CI], 1.01-1.32; P = .039) and dropped to 1.09 (95% CI, 0.93-1.27; P = .295) after adjustment for indicators of preoperative instability. 5-year survival was comparable in 30-day survivors (P = .083).

Conclusions

One-quarter of postcardiotomy VA ECMOs are implemented after emergency operations. Despite more complications in emergency cases, in-hospital and 5-year survival are comparable between emergency, urgent, or elective operations.

Indobufen-based dual antiplatelet therapy in patients with multivessel coronary disease undergoing drug-eluting stent implantation insight from the OPTION trial

BACKGROUND

It remains unclear whether indobufen-based dual antiplatelet therapy (DAPT) preserves ischemic protection while limiting bleeding risk in patients with multivessel coronary disease (MVD). This study aimed to investigate the efficacy and safety of indobufen-based DAPT in patients with MVD.

METHODS

Patients in the OPTION trial were stratified based on the presence of MVD. We compared the ischemic and bleeding risks of indobufen-based DAPT (indobufen 100mg twice a day plus clopidogrel 75 mg/d for 12 months) vs conventional DAPT (aspirin 100 mg/d plus clopidogrel 75 mg/d for 12 months) in patients with and without MVD, using landmarks at 6 months and 1-year post-percutaneous coronary intervention (PCI).

RESULTS

Patients with MVD tended to be older and contained a higher prevalence of high-risk features. Compared with patients without MVD, those with MVD were at higher risk for net adverse clinical events and ischemic events. The risk of ischemic events between indobufen-based DAPT vs conventional DAPT was similar either in patients with MVD or without MVD during the first and second 6 months. During the first 6 months, indobufen-based DAPT decreased the risk of bleeding events consistently in patients with and without MVD. Of note, during the second 6 months, indobufen-based DAPT continually decreased the risk of bleeding events in patients with MVD but not in those without MVD.

CONCLUSIONS

In patients with MVD, indobufen plus clopidogrel DAPT compared to aspirin plus clopidogrel DAPT could reduce the risk of bleeding events while preserving ischemic protection during both the first and second 6 months post-PCI. Indobufen presents an effective option for patients with MVD, especially those at high ischemic risk requiring DAPT beyond 6 months post-PCI.

TRIAL REGISTRATION

The trial was registered at www.chictr.org. A Randomized Controlled Trial of Indobufen vs Aspirin after Coronary Drug-eluting Stent Implantation: the OPTION Trial (ChiCTR-IIR-17013505).

Perioperative aspirin and coronary artery bypass graft surgery: An updated meta-analysis of randomized controlled trials

BACKGROUND

The decision to continue aspirin before elective coronary artery bypass graft surgery remains contentious because of competing thrombotic and bleeding risks. We performed a contemporary systematic review and meta-analysis to compare outcomes between patients undergoing coronary artery bypass grafting who stopped and continued aspirin before surgery.

METHODS

PubMed, MEDLINE, and CENTRAL databases were searched from inception to 4 October 2023 for randomized controlled trials comparing patients undergoing coronary artery bypass grafting who continued preoperative aspirin with those who discontinued before surgery. Studies with cointervention arms and multivariable-adjusted or propensity matched observational studies were excluded. Summary odds ratios were calculated using a random effects model for dichotomous and continuous variables. Subgroup and sensitivity analyses were conducted in order to explore sources of heterogeneity.

RESULTS

Fifteen eligible randomized controlled trials were included with a total of 6,188 patients. Patients who continued aspirin demonstrated no significant difference in all-cause mortality (odds ratio, 1.37; confidence interval, 0.81-2.33), perioperative myocardial infarction (odds ratio, 0.81; confidence interval, 0.55-1.18), and postoperative blood loss (mean difference, 66.12 mL; confidence interval, -1.45 to 133.69). No significant difference was observed between low-dose and greater doses of aspirin. There was minimal heterogeneity amongst included studies (I2 = 0%, P = .97, I2 = 33%, P = .13, and I2= 76, P = .06, respectively). Studies were of low methodologic quality according to Cochrane Risk of Bias for Randomized Trials.

CONCLUSIONS

This largest to-date systematic review and meta-analysis found no significant difference for risk of all-cause mortality, perioperative myocardial infarction, and postoperative bleeding between patients continuing and stopping aspirin before coronary artery bypass grafting.

The Impact of CYP2C19 Genotype on the Platelet Reactivity Index (PRI) among Chronic Coronary Syndromes (CCS) Patients Undergoing Percutaneous Coronary Intervention (PCI): Affectability of Rapid Genetic Testing

BACKGROUND

In the Asian population, the presence of the CYP2C19 loss-of-function (LOF) allele is a known genetic variation. This allele is associated with a reduced capacity to metabolize clopidogrel into its active forms through the CYP2C19 enzyme, resulting in diminished platelet inhibition and an elevated risk of recurrent cardiovascular events. Regulatory authorities have recommended an alternative P2Y12 inhibitor, ticagrelor, for individuals carrying the LOF allele. Consequently, this study seeks to assess the impact of the CYP2C19 genotype on the Platelet reactivity index (PRI) using a rapid genetic testing approach in Asian patients with chronic coronary syndromes (CCS) who undergo percutaneous coronary intervention (PCI).

METHODS

This prospective study employed a parallel design, single-center design, and randomized approach. Genotyping for the CYP2C19*2 and *3 polymorphisms was conducted using the Nested Allele-Specific Multiplex PCR (NASM-PCR) technique. Patients meeting the inclusion criteria underwent genotyping for CYP2C19 polymorphisms. Following PCI, patients were randomly assigned to receive either ticagrelor or clopidogrel. PRI assessments were performed four hours after loading dose administration. The trial was registered with ClinicalTrials.gov under the identifier NCT05516784.

RESULTS

Among the 94 patients recruited for the study, 40 (42.55%) were identified as carriers of the LOF allele for CYP2C19*2 and *3 (*1/*2, *2/*2, *1/*3). Out of the 84 patients evaluated for PRI (44 receiving clopidogrel and 40 receiving ticagrelor), 21 (47.7%) of the clopidogrel group and 39 (97.5%) of the ticagrelor group exhibited a favorable response to antiplatelet therapy (PRI < 50). Patients treated with ticagrelor demonstrated superior antiplatelet responses compared to those receiving clopidogrel, regardless of LOF carrier status (P = 0.005 and < 0.001 for non-LOF and LOF carriers, respectively).

CONCLUSION

NASM-PCR as a rapid genetic test holds promise for personalizing antiplatelet therapy in Asian CCS patients.

Early vs Delayed Bypass Surgery in Patients With Acute Coronary Syndrome Receiving Ticagrelor: The RAPID CABG Randomized Open-Label Noninferiority Trial

Importance

Perioperative bleeding is a major concern in patients receiving ticagrelor for acute coronary syndromes (ACS) when coronary artery bypass graft (CABG) surgery is required.

Objective

To evaluate whether early CABG surgery at 2 to 3 days after ticagrelor cessation is noninferior to waiting 5 to 7 days.

Design, Setting, and Participants

RAPID CABG was a noninferiority, open-label randomized trial with 6 months of follow-up. Participants were patients with ACS who had received ticagrelor and required CABG. Patients were enrolled in tertiary centers in Canada between January 2016 and March 2021. Data were analyzed from March 2021 to December 2023.

Intervention

Early or delayed CABG.

Main Outcomes and Measures

The primary outcome was based on noninferiority comparison of class 3 or 4 universal definition of perioperative bleeding (UDPB). Noninferiority was prespecified as 8% between groups. Twelve-hour chest tube drainage was reported as a noninferiority comparison. Other bleeding, ischemic, and length-of-stay outcomes were assessed for superiority.

Results

Among 143 randomized patients, the median (IQR) age was 65 (58-72) years; there were 117 male patients (82%) and 26 female (18%). Of these, 123 patients (86.0%) underwent surgery in the allocated time frame (per protocol). The median (IQR) time to surgery was 3 (2-3) days in the early group and 6 (5-7) days in the delayed group (P < .001). In a per-protocol analysis, severe or massive UDPB occurred in 3 of 65 early-group patients (4.6%) and 3 of 58 patients (5.2%) in the delayed group (between-group difference, -0.6%; 95% CI, -8.3% to 7.1%; P = .03 for noninferiority). Median (IQR) chest tube drainage was 470 (330-650) mL vs 495 (380-610) mL (between-group difference -25 mL; 95% CI, -111.25 to 35; P = .01 for noninferiority). Median (IQR) hospital stay was 9 (7-13) days and 12 (10-15) days for the early and delayed groups (P < .001).

Conclusion and Relevance

This study found that an early surgical strategy, 2 to 3 days after ticagrelor cessation, was noninferior in incurring perioperative bleeding. The data support a reduction in the delay between ticagrelor cessation and CABG surgery and may decrease hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT02668562.

Temporal trends of characteristics and management of patients with suspected MINOCA

BACKGROUND

Myocardial infarction without obstructive coronary artery disease (MINOCA) is a challenging condition which requires appropriate management and therapy. Although specific guidelines and recommendations for this condition have been introduced, there are few data about management implementation over time. The aim of this study is to compare two cohorts of patients affected by suspected MINOCA to assess the temporal trends change in the clinical characteristics and management.

METHODS

Two patient cohorts were retrospectively selected from a single centre (Cardiology Department of Perugia University Hospital) and compared to investigate the differences in characteristics and management before and after the release of 2018 MINOCA guidelines. The Group included patients enrolled from January 2006 to December 2014, and the Group 2 from July 1st, 2020, to July 31st, 2023.

RESULTS

Group 1 included 150 patients and Group 2 83 patients. Compared to group 1, group 2 showed higher prevalence of hypercholesterolemia (57 % vs 27 % p < 0,001), prior acute myocardial infarction (23 % vs 5 %, p <0,001), preserved left ventricular ejection fraction (90 % vs 67 %, p = 0,03), use of cardiovascular magnetic resonance (27 % vs 0 %,p < 0.001), prescription of beta-blockers (69 % vs 31 %,p < 0.001), calcium channel blockers (46 % vs 16 %, p < 0.001), statins (81 % vs 59 %, p = 0.03) and a less frequent occurrence of ST-elevation on admission ECG (9 % vs 24 %, p = 0.005), prescription of dual antiplatelet therapy (20 % vs 58 %, p < 0.001) and nitrates (12 % vs 54 %, p < 0.001).

CONCLUSIONS

In the present study, characteristics and management of patients with suspected MINOCA has significantly changed over time. However, discrepancies with guidelines recommendation still exist and implementation strategies are needed to fill this gap and improve clinical practice.

Stepwise dual antiplatelet therapy de-escalation in patients after drug coated balloon angioplasty (REC-CAGEFREE II): multicentre, randomised, open label, assessor blind, non-inferiority trial

OBJECTIVES

To investigate whether a less intense antiplatelet regimen could be used for people receiving drug coated balloons.

DESIGN

Multicentre, randomised, open label, assessor blind, non-inferiority trial (REC-CAGEFREE II).

SETTING

41 hospitals in China between 27 November 2021 and 21 January 2023.

PARTICIPANTS

1948 adults (18-80 years) with acute coronary syndrome who received treatment exclusively with paclitaxel-coated balloons according to the international drug coated balloon consensus.

INTERVENTIONS

Participants were randomly assigned (1:1) to either the stepwise dual antiplatelet therapy (DAPT) de-escalation group (n=975) consisting of aspirin plus ticagrelor for one month, followed by five months of ticagrelor monotherapy, and then six months of aspirin monotherapy, or to the standard DAPT group (n=973) consisting of aspirin plus ticagrelor for 12 months.

MAIN OUTCOME MEASURES

The primary endpoint was net adverse clinical events (all cause death, stroke, myocardial infarction, revascularisation, and Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding) at 12 months in the intention-to-treat population. Non-inferiority was established if the upper limit of the one sided 95% confidence interval (CI) for the absolute risk difference was smaller than 3.2%.

RESULTS

The mean age of participants was 59.2 years, 74.9% were men, 30.5% had diabetes, and 20.6% were at high bleeding risk. 60.9% of treated lesions were in small vessels, and 17.8% were in-stent restenosis. The mean drug coated balloon diameter was 2.72 mm (standard deviation 0.49). At 12 months, the primary endpoint occurred in 87 (8.9%) participants in the stepwise de-escalation group and 84 (8.6%) in the standard group (difference 0.36%; upper boundary of the one sided 95% CI 2.47%; Pnon-inferiority=0.013). In the stepwise de-escalation versus standard groups, BARC type 3 or 5 bleeding occurred in four versus 16 participants (0.4% v 1.6%, difference -1.19% (95% CI -2.07% to -0.31%), P=0.008), and all cause death, stroke, myocardial infarction, and revascularisation occurred in 84 versus 74 participants (8.6% v 7.6%, difference 1.05% (95% CI -1.37% to 3.47%), P=0.396). Treated as having hierarchical clinical importance by the win ratio method, more wins were noted with the stepwise de-escalation group (14.4% wins) compared with the standard group (10.1% wins) for the predefined hierarchical composite endpoint of all cause death, stroke, myocardial infarction, BARC type 3 bleeding, revascularisation, and BARC type 2 bleeding (win ratio 1.43 (95% CI 1.12 to 1.83), P=0.004). Results from the per-protocol and the intention-to-treat analysis were similar.

CONCLUSIONS

Among participants with acute coronary syndrome who could be treated by drug coated balloons exclusively, a stepwise DAPT de-escalation was non-inferior to 12 month DAPT for net adverse clinical events.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04971356.

Final 5-year outcomes of the Epic02 - RANGO study: A real-world registry of the durable fluoroacrylate polymer-based sirolimus-eluting Angiolite® stent

BACKGROUND

Clinical results at mid-term of Angiolite, a cobalt-chromium sirolimus-eluting stent, in a non-selected, real-world population were demonstrated to be excellent. 5-year follow-up was planned to exclude late complications.

METHODS

We conducted an observational, prospective, multicenter study (RANGO) in different clinical indications with independent event adjudication and data monitoring. All consecutive patients with at least 1 Angiolite stent implanted who gave their informed consent were included. The primary endpoint was the occurrence of target lesion failure (TLF). The secondary endpoints were the individual components of the primary endpoint, Patient-oriented Composite Endpoint (PoCE), and stent thrombosis. We present the 5-year clinical results in the entire population and in 2 predefined subgroups: diabetics and small-vessel disease (≤2.5 mm).

RESULTS

646 patients with high-risk features (previous MI 18.4 %, previous coronary revascularization 23.4 %, ST-elevation MI 23.1 %, and multivessel disease 47.8 %) were included. Only 18 patients (2.8 %) were lost at 5-years follow-up. The final outcomes were: TLF 8.7 %, PoCE 21.8 %, and stent thrombosis 1.2 %. The small-vessel subgroup showed slightly worse results (TLF, 10.3 %; PoCE, 24.1 %; thrombosis, 0 %), as diabetic subgroup also did (TLF, 11.1 %; PoCE, 29.1 %; thrombosis, 1.0 %). Multivariable analysis showed variables significantly associated with TLF: chronic kidney disease, prior PCI or CABG and lesion calcification; and those associated with PoCE were age, atrial fibrillation, prior PCI, lesion calcification and chronic kidney disease.

CONCLUSIONS

The 5-years results of this observational study of Angiolite stent in a real-world population corroborate the outstanding results observed in the mid-term. No signals of late complications were detected.

Comparative effectiveness of potassium-competitive acid blockers and proton pump inhibitors in dual antiplatelet therapy patients: a nationwide cohort study

BACKGROUND

Proton pump inhibitors (PPIs) are widely used in combination with dual antiplatelet therapy (DAPT) to reduce the risk of gastrointestinal bleeding; however, some PPIs may interfere with clopidogrel metabolism through CYP2C19 inhibition. Potassium-competitive acid blockers (P-CABs) have emerged as alternatives to PPIs, although their effectiveness in patients receiving DAPT have not been sufficiently explored.

AIM

This study aimed to compare the effectiveness of PPIs and P-CABs in preventing cardiovascular events and gastrointestinal bleeding among patients receiving DAPT after coronary stent implantation.

METHOD

A retrospective cohort design was employed using nationwide claim data from South Korea. The study included patients who received aspirin-clopidogrel DAPT with PPI or P-CAB for a minimum of 60 days. After applying propensity score matching (PSM) at a 1:1 ratio, survival analysis was conducted. The primary outcome was a composite of acute myocardial infarction, ischemic stroke, revascularization, and in-hospital mortality. Secondary outcomes involved the individual components of the composite outcome and gastrointestinal bleeding.

RESULTS

The initial cohort included 39,234 patients in the PPI group and 3,434 in the P-CAB group. After 1:1 PSM, 3,434 patients were included in each group. No statistically significant differences were observed between the PPI and P-CAB groups for the primary outcome (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.68-1.07; p = 0.167) and gastrointestinal bleeding (HR, 1.36; 95% CI, 0.76-2.42; p = 0.3).

CONCLUSION

Both PPIs and P-CABs appear to be viable options for acid suppression in patients undergoing DAPT, with no significant differences in cardiovascular or gastrointestinal outcomes.

Prognostic Relevance of Type 4a Myocardial Infarction and Periprocedural Myocardial Injury in Patients With Non-ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Periprocedural myocardial injury (PMI) with or without type 4a myocardial infarction (MI) might occur in patients with non-ST-segment-elevation MI (NSTEMI) after percutaneous coronary intervention (PCI). This study investigated the incidence and prognostic relevance of these events, according to current definitions, in patients with NSTEMI undergoing PCI. The best cardiac troponin I (cTnI) threshold of PMI for prognostic stratification is also suggested.

METHODS

Consecutive patients with NSTEMI from January 2017 to April 2022 undergoing PCI with stable or falling pre-PCI cTnI levels were enrolled. According to the Fourth Universal Definition of Myocardial Infarction, the study population was stratified into those experiencing (1) PMI with type 4a MI, (2) PMI without type 4a MI, or (3) no PMI. Post-PCI cTnI increase >20% with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit within 48 hours after PCI was used to define PMI. The primary end point was 1-year all-cause mortality, and the secondary end point consisted of major adverse cardiovascular events at 1 year, including all-cause mortality, nonfatal reinfarction, urgent revascularization, nonfatal ischemic stroke, and hospitalization for heart failure. Internal validation was performed in patients enrolled between May 2022 and April 2023.

RESULTS

Among 1412 patients with NSTEMI undergoing PCI with stable or falling cTnI levels at baseline, 240 (17%) experienced PMI with type 4a MI, 288 (20.4%) experienced PMI without type 4a MI, and 884 (62.6%) experienced no PMI. PMI was associated with an increased risk of adverse clinical outcomes, with patients with type 4a MI demonstrating the highest rates of 1-year all-cause mortality and major adverse cardiovascular events. A post-PCI ΔcTnI >20% but ≤40% showed similar outcomes to patients without PMI, whereas >40% was identified as the optimal threshold for prognostically relevant PMI, confirmed in an internal validation cohort of 305 patients.

CONCLUSIONS

Periprocedural ischemic events were frequent in patients with NSTEMI undergoing PCI with prognostic implications. A post-PCI ΔcTnI >40%, combined with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit, was identified as the optimal threshold for diagnosing prognostically relevant PMI. Recognizing these events may improve risk stratification and management of patients with NSTEMI.

Outcomes After Noncardiac Surgery Performed Within 2 Years of Percutaneous Coronary Intervention

BACKGROUND

Limited data exist on noncardiac surgery patients with prior percutaneous coronary intervention (PCI) in the contemporary era. The objective was to examine rate, characteristics, and outcomes of patients who underwent noncardiac surgery within 2 years of PCI and develop a risk model of factors that predict long-term postoperative outcomes among patients with recent PCI.

METHODS AND RESULTS

Patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent noncardiac surgery between October 1, 2017 and September 30, 2021 were included. Patients with versus without PCI within 2 years were propensity matched to examine major adverse cardiovascular events (MACE), defined as a 1-year composite of mortality, revascularization, and rehospitalization for myocardial infarction or stroke. Among patients with recent PCI, multivariable logistic regression was used to develop a risk model to predict 1-year postoperative MACE. Among 334 828 patients undergoing surgery, 2297 (0.68%) had PCI within 2 years. Among 9160 propensity-matched veterans, there was no difference in MACE between patients with and without preceding PCI (hazard ratio [HR], 1.04 [95% CI, 0.96-1.17]). Patients with versus without preceding PCI within 2 years had lower risk of all-cause death (HR, 0.83 [95% CI, 0.72-0.96]) but higher risk of revascularization (HR, 1.88 [95% CI, 1.50-2.36]) at 1 year. A 13-component MACE prediction model among patients with recent PCI had moderate discrimination (area under the receiver operating characteristic curve 0.73 derivation, 0.72 validation).

CONCLUSIONS

Among patients who underwent surgery, risk of MACE did not differ, but the risk of revascularization was higher and all-cause death was lower in patients with versus without recent PCI. A risk model can be used to stratify risk of surgery among patients with preceding PCI.

Associations Between Ticagrelor Use and the Risk of Infections: A Mendelian Randomization Study

BACKGROUND

We conducted a Mendelian randomization (MR) study to elucidate the anti-infective effects of ticagrelor.

METHODS

Single-nucleotide polymorphisms (SNPs) associated with serum levels of ticagrelor or its major metabolite AR-C124910XX (ARC) in the Platelet Inhibition and Patient Outcomes trial were selected as genetic proxies for ticagrelor exposure. Positive control analyses indicated that genetically surrogated serum ticagrelor levels (6 SNPs) but not ARC levels (2 SNPs) were significantly associated with lower risks of coronary heart disease. Therefore, the 6 SNPs were used as genetic instruments for ticagrelor exposure, and the genome-wide association study data for 5 infection outcomes were derived from the UK Biobank and FinnGen consortium.

RESULTS

The 2-sample MR analyses based on inverse variance-weighted methods indicated that genetic liability to ticagrelor exposure could reduce the risk of bacterial pneumonia (odds ratio, 0.82; 95% CI, .71-.95; P = 8.75E-03) and sepsis (odds ratio, 0.83; 95% CI, .73-.94; P = 3.69E-03); however, no causal relationship was detected between ticagrelor exposure and upper respiratory infection, pneumonia, and urinary tract infection. Extensive sensitivity analyses corroborated these findings.

CONCLUSIONS

Our MR study provides further evidence for the preventive effects of ticagrelor on bacterial pneumonia and sepsis.

Intravascular Imaging-Guided Versus Angiography-Guided Complex PCI in Patients With High Bleeding Risk: A Secondary Analysis of the RENOVATE-COMPLEX PCI Trial

BACKGROUND

Although patients with high bleeding risk (HBR) often have complex coronary artery lesions, it is not known whether intravascular imaging-guided percutaneous coronary intervention (PCI) improves their prognosis. We sought to investigate the benefit of intravascular imaging-guided PCI for complex coronary artery lesions in patients with HBR.

METHODS

This was a secondary analysis of the RENOVATE-COMPLEX-PCI trial (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) in which patients with complex coronary artery lesions undergoing PCI were enrolled at 20 sites in Korea from May 2018 through May 2021. Patients were randomized to receive intravascular imaging-guided PCI or angiography-guided PCI and classified according to the presence of HBR. The primary end point was target vessel failure, which was a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization.

RESULTS

Of 1639 trial population, 478 patients met HBR criteria. There was no significant difference in the risk of the primary end point between HBR and non-HBR patients (11.8% versus 8.2%; adjusted hazard ratio [HR], 1.05 [95% CI, 0.72-1.54]; P=0.790). However, patients with HBR were at higher risk for cardiac death or spontaneous target vessel-related myocardial infarction (adjusted HR, 2.04 [95% CI, 1.09-3.80]; P=0.025), all-cause death (adjusted HR, 3.30 [95% CI, 1.93-5.62]; P<0.001), and cardiac death (adjusted HR, 2.36 [95% CI, 1.10-5.09]; P=0.028). Intravascular imaging-guided PCI showed a lower risk of the primary end point compared with angiography-guided PCI in both HBR patients (9.7% versus 15.8%; adjusted HR, 0.57 [95% CI, 0.31-1.02]; P=0.060) and non-HBR patients (6.9% versus 10.8%; adjusted HR, 0.65 [95% CI, 0.43-0.99]; P=0.045), without significant interaction (P for interaction=0.796).

CONCLUSIONS

Patients with HBR were associated with an increased risk of adverse cardiovascular events after complex PCI compared with those without HBR. Intravascular imaging-guided PCI showed a lower risk of the target vessel failure without significant interaction between treatment strategy and the presence of HBR in patients undergoing complex PCI.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.

Myocardial Infarction Platelet Gene Expression Signatures in Women

Although platelets play a critical pathogenic role in myocardial infarction (MI), few studies have characterized the MI platelet transcriptome in the acute or chronic setting in women. We report that transcripts associated with the actin cytoskeleton, Rho family GTPases, mitochondrial dysfunction, and inflammatory signaling are enriched in platelets from MI patients in the acute setting (n = 40, MI; n = 38, control) and do not significantly change over time. Furthermore, 79 platelet genes chronically elevated or suppressed after MI are associated with future cardiovascular events in an independent high-risk cohort (n = 135). Compared with women with MI with nonobstructive coronary arteries, platelets from women with MI and obstructive coronary artery disease were enriched in neutrophil activation and proinflammatory signaling pathways driven by increased tumor necrosis factor (TNF)-α signaling. Hierarchic clustering of the MI transcriptomic profile identified 3 subgroups with distinctive biological pathways and MI correlates. Our data demonstrate that platelets from MI patients are phenotypically different from MI-naïve patients in the acute and chronic settings and reveal a platelet transcriptomic signature with distinct clinical features.

Prognostic effect of sex according to shock severity in patients with acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

Sex disparities in cardiogenic shock (CS) treatment are controversial, and the prognostic implications of sex remain unclear in CS caused by acute myocardial infarction (AMI).

OBJECTIVES

This study aimed to evaluate the prognostic effect of sex according to the severity of CS in patients undergoing percutaneous coronary intervention (PCI) for AMI complicated by CS.

METHODS

We assessed 695 patients from 12 tertiary centers in South Korea who underwent PCI for AMI complicated by CS, and analyzed outcomes by sex (female [n = 184] vs. male [n = 511]). We compared a 12-month patient-oriented composite endpoint (POCE, defined as a composite of all-cause mortality, myocardial infarction, re-hospitalization due to heart failure, and repeat revascularization) between the sexes, respective of SCAI shock stage C&D or E. Propensity score-matched analysis was performed to reduce bias.

RESULTS

We found that the female group was older and had higher vasoactive-inotropic and IABP-SHOCK II scores than the male group, with findings consistent across SCAI shock stages. During the 12-month follow-up period, multivariate analysis revealed no significant differences in POCE (HR 1.01, 95% CI 0.67-1.53, p = 0.963 for SCAI stage C&D, HR 1.24, 95% CI 0.84-1.84, p = 0.286 for SCAI stage E) between females and males. After propensity score matching, the incidence of POCE (HR 1.47, 95% CI 0.79-2.72, p = 0.220 for SCAI stage C&D, HR 0.88, 95% CI 0.49-1.57, p = 0.665 for SCAI stage E) was similar between sexes.

CONCLUSIONS

Sex does not appear to influence the risk of 12-month POCE in patients treated with PCI for CS caused by AMI, irrespective of shock severity.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT02985008. RESCUE (REtrospective and prospective observational Study to investigate Clinical oUtcomes and Efficacy of left ventricular assist device for Korean patients with cardiogenic shock), NCT02985008, Registered December 5, 2016 - retrospectively and prospectively.

IRB INFORMATION

This study was approved by the institutional review board of Samsung Medical Center (Reference number: 2016-03-130).

The importance of intensive follow-up and achieving optimal chronic antithrombotic treatment in hospitalized medical patients with anemia: A prospective cohort study

BACKGROUND

Anemia is a global health concern, particularly among the elderly on chronic antithrombotic treatment. Close monitoring of hemoglobin (Hb) levels and achievement of an optimized treatment significantly enhance patients' quality of life. This study aimed to examine the impact of antithrombotic treatment on Hb levels and readmissions in hospitalized patients with anemia.

METHODS

This is a prospective cohort study of patients admitted to the Department of Internal Medicine of the University Hospital of Heraklion, Greece, from November 2021 to October 2022 with the diagnosis of anemia while receiving antithrombotic treatment. Data regarding demographics, past medical history, and laboratory and endoscopy findings were recorded. For those receiving inappropriate therapy according to international guidelines, antithrombotic treatment was optimized. Subsequent follow-ups occurred at one and six months post-discharge. Six- and twelve-month anemia-caused readmissions, as well as annual mortality, were evaluated.

RESULTS

In total, 104 patients were assessed. Among them, 34.6% were on antiplatelets, 56.7% were on anticoagulants, and 8.7% were on combination treatment. The mean age was 80 ± 8.2 years, and 54.8% were males. On admission, mean Hb levels were 6.86 ± 1.23 g/dL, while 56 (53.8%) patients had severe anemia. Gastroscopy and colonoscopy were performed in 75.0% and 41.4% of patients, respectively, confirming gastrointestinal bleeding in most of the cases. Treatment optimization was carried out for 56 patients. Follow-up revealed elevated Hb levels after one and six months post-discharge, while anemia-related readmissions stayed below 10%.

CONCLUSIONS

Most hospitalized anemic patients on antithrombotic treatment had endoscopic findings favoring gastrointestinal bleeding. Half received inappropriate antithrombotic therapy. Treatment optimization and regular follow-up improved Hb levels and reduced readmissions.