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Barco S, Schmidtmann I, Ageno W, Bauersachs RM, Becattini C, Bernardi E, Beyer-Westendorf J, Bonacchini L, Brachmann J, Christ M, Czihal M, Duerschmied D, Empen K, Espinola-Klein C, Ficker JH, Fonseca C, Genth-Zotz S, Jiménez D, Harjola VP, Held M, Iogna Prat L, Lange TJ, Manolis A, Meyer A, Mustonen P, Rauch-Kroehnert U, Ruiz-Artacho P, Schellong S, Schwaiblmair M, Stahrenberg R, Westerweel PE, Wild PS, Konstantinides SV, Lankeit M. Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial. Eur Heart J 2021; 41:509-518. [PMID: 31120118 DOI: 10.1093/eurheartj/ehz367] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 04/27/2019] [Accepted: 05/13/2019] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban. METHODS AND RESULTS We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%). CONCLUSION Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.
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Affiliation(s)
- Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz, Obere Zahlbacher Strasse 69, 55131 Mainz, Germany
| | - Walter Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Rupert M Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt, Grafenstrasse 9, 64283 Darmstadt, Germany
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Via G. Dottori 1, 06129 Perugia, Italy
| | - Enrico Bernardi
- Department of Emergency Medicine, ULSS n.7, Via Brigata Bisagno 4, 31015 Conegliano (Treviso), Italy
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus", Fetscherstrasse 74, 01307 Dresden, Germany.,Kings Thrombosis Service, Department of Hematology, Kings College London, Denmark Hill, Brixton, SE5 9RS, London, UK
| | - Luca Bonacchini
- S.C. Medicina d'Urgenza e Pronto Soccorso, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell'Ospedale Maggiore 3, 20162 Milano, Italy
| | - Johannes Brachmann
- II Medical Department, Coburg Hospital, Ketschendorfer Strasse 33, 96450 Coburg, Germany
| | - Michael Christ
- Emergency Care (Notfallzentrum), Luzerner Kantonsspital, 6000 Luzern, Switzerland
| | - Michael Czihal
- Division of Vascular Medicine, Hospital of the Ludwig-Maximilians-University, Georgenstrasse 5, 80799 Munich, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Heart Center, Faculty of Medicine, University of Freiburg, Hugstetter Strasse 55, 79106 Freiburg, Germany
| | - Klaus Empen
- Department of Internal Medicine, University Medical Center, Fleischmannstrasse 6, 17489 Greifswald, Germany
| | - Christine Espinola-Klein
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Center for Cardiology, Cardiology 1, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Joachim H Ficker
- Department of Respiratory Medicine, Nuremberg General Hospital/Paracelsus Medical University, Prof.-Ernst-Nathan-Strasse 1, 90419 Nuremberg, Germany
| | - Cândida Fonseca
- Department of Internal Medicine, Hospital S. Francisco Xavier/CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal
| | - Sabine Genth-Zotz
- Department of Internal Medicine I, Katholisches Klinikum Mainz, An der Goldrube 11, 55131 Mainz, Germany
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Universidad de Alcala, IRYCIS, Ctra. Colmenar Viejo, km. 9, 100, 28034 Madrid, Spain
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Tukholmankatu 8A, 00290 Helsinki, Finland
| | - Matthias Held
- Department of Internal Medicine, Medical Mission Hospital, Academic Teaching Hospital of the Julius-Maximilian University of Wuerzburg, Josef-Schneider-Strasse 2, 97080 Wuerzburg, Germany
| | - Lorenzo Iogna Prat
- Department of Emergency Medicine, Santa Maria della Misericordia Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Tobias J Lange
- Department of Internal Medicine II, Division of Pneumology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany
| | - Athanasios Manolis
- Department of Cardiology, General Hospital 'Asklepeion Voulas', Leof. Vasileos Pavlou 1, 166 73 Athens, Greece
| | - Andreas Meyer
- Kliniken Maria Hilf, Klinik für Pneumologie, Krankenhaus St. Franziskus, Viersener Str. 450, 41063 Mönchengladbach, Germany
| | - Pirjo Mustonen
- Department of Medicine, Keski-Suomi Central Hospital and University of Jyväskylä, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Ursula Rauch-Kroehnert
- Department of Cardiology, University Heart Center Berlin, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; German Center for Cardiovascular Research (DZHK), Berlin, Germany
| | - Pedro Ruiz-Artacho
- Emergency Department, Clinico San Carlos Hospital, IdISSC, alle del Prof Martín Lagos, s/n, 28040 Madrid, Spain.,Internal Medicine Department, University Clinic of Navarra, Calle Marquesado de Sta. Marta 1, 28027 Madrid, Spain
| | - Sebastian Schellong
- Vascular Center, Municipal Hospital of Dresden-Friedrichstadt, Friedrichstraße 41, 01067 Dresden, Germany
| | - Martin Schwaiblmair
- Department of Cardiology, Respiratory Medicine and Intensive Care, Klinikum Augsburg, Ludwig-Maximilians-University Munich, Stenglinstrasse 2, 86156 Munich, Germany
| | - Raoul Stahrenberg
- Helios Albert-Schweitzer-Klinik, Albert-Schweitzer-Weg 1, 37154 Northeim, Germany
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3318 AT Dordrecht, The Netherlands
| | - Philipp S Wild
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany.,Center for Cardiology, Preventive Cardiology and Preventive Medicine, University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Langenbeckstrasse 1, Building 403, 55131 Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité - University Medicine Berlin, Augustenburgerplatz 1, 13353 Berlin, Germany.,Clinic of Cardiology and Pneumology, Heart Center, University Medical Center Goettingen, Robert-Koch-Strasse 40, 37075 Goettingen, Germany
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Goel H, Melot J, Krinock MD, Kumar A, Nadar SK, Lip GYH. Heart-type fatty acid-binding protein: an overlooked cardiac biomarker. Ann Med 2020; 52:444-461. [PMID: 32697102 PMCID: PMC7877932 DOI: 10.1080/07853890.2020.1800075] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Cardiac troponins (cTn) are currently the standard of care for the diagnosis of acute coronary syndromes (ACS) in patients presenting to the emergency department (ED) with chest pain (CP). However, their plasma kinetics necessitate a prolonged ED stay or overnight hospital admission, especially in those presenting early after CP onset. Moreover, ruling out ACS in low-risk patients requires prolonged ED observation or overnight hospital admission to allow serial measurements of c-Tn, adding cost. Heart-type fatty acid-binding protein (H-FABP) is a novel marker of myocardial injury with putative advantages over cTn. Being present in abundance in the myocellular cytoplasm, it is released rapidly (<1 h) after the onset of myocardial injury and could potentially play an important role in both earlier diagnosis of high-risk patients presenting early after CP onset, as well as in risk-stratifying low-risk patients rapidly. Like cTn, H-FABP also has a potential role as a prognostic marker in other conditions where the myocardial injury occurs, such as acute congestive heart failure (CHF) and acute pulmonary embolism (PE). This review provides an overview of the evidence examining the role of H-FABP in early diagnosis and risk stratification of patients with CP and in non-ACS conditions associated with myocardial injury. Key messages Heart-type fatty acid-binding protein is a biomarker that is elevated early in myocardial injury The routine use in the emergency department complements the use of troponins in ruling out acute coronary syndromes in patients presenting early with chest pain It also is useful in risk stratifying patients with other conditions such as heart failure and acute pulmonary embolism.
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Affiliation(s)
- Harsh Goel
- Department of Medicine, St. Luke's University Hospital, Bethlehem, PA, USA.,Luis Katz School of Medicine, Temple University, Philadelphia, USA
| | - Joshua Melot
- Department of Medicine, St. Luke's University Hospital, Bethlehem, PA, USA
| | - Matthew D Krinock
- Department of Medicine, St. Luke's University Hospital, Bethlehem, PA, USA
| | - Ashish Kumar
- Department of Medicine, Wellspan York Hospital, York, PA, USA
| | - Sunil K Nadar
- Department of Medicine, Sultan Qaboos University, Muscat, Oman
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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5
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Heiss C, Pitcher A, Belch JJF, De Carlo M, Reinecke H, Baumgartner I, Mazzolai L, Aboyans V. The year in cardiology: aorta and peripheral circulation. Eur Heart J 2020; 41:501-508b. [DOI: 10.1093/eurheartj/ehz939] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/11/2019] [Indexed: 02/07/2023] Open
Abstract
Abstract
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Affiliation(s)
- Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, Stag Hill 14AY04, Guildford GU2 7XH, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, UK
| | - Alex Pitcher
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - Jill J F Belch
- The Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Ninewells Hospital, Dundee DD1 9SY, UK
| | - Marco De Carlo
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, via Paradisa 2, 56100 Pisa, Italy
| | - Holger Reinecke
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Iris Baumgartner
- Clinical and Interventional Angiology, Swiss Cardiovascular Center Bern, Insel Group AG, University Hospital Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Lucia Mazzolai
- Division of Angiology, Department of Heart and Vessel, Lausanne University Hospital, Ch du Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, 2, Martin Luther King Ave., 87042 Limoges, France
- Inserm 1094, Limoges School of Medicine, Ave Dr. Marcland, 87025 Limoges, France
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