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Mitsui K, Lee T, Miyazaki R, Hara N, Nagamine S, Nakamura T, Terui M, Okata S, Nagase M, Nitta G, Watanabe K, Kaneko M, Nagata Y, Nozato T, Ashikaga T. Drug-coated balloon strategy following orbital atherectomy for calcified coronary artery compared with drug-eluting stent: One-year outcomes and optical coherence tomography assessment. Catheter Cardiovasc Interv 2023. [PMID: 37210618 DOI: 10.1002/ccd.30689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/30/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) for calcified coronary artery remains challenging in the drug-eluting stent (DES) era. While recent studies reported the efficacy of orbital atherectomy (OA) combined with DES for calcified lesion, the effectiveness of drug-coated balloon (DCB) following OA has not been fully elucidated. METHODS Between June 2018 and June 2021, 135 patients who received PCI for calcified de novo coronary lesions with OA were enrolled and divided into two groups; OA followed by DCB (n = 43) if the target lesion achieved acceptable preparation, or second- or third-generation DESs (n = 92) if the target lesion showed suboptimal preparation between June 2018 and June 2021. All patients underwent PCI with optical coherence tomography (OCT) imaging. The primary endpoint was 1-year major adverse cardiac event (MACE), that was a composite of cardiac death, nonfatal myocardial infarction, or target lesion revascularization. RESULTS Mean age was 73 years and 82% was male. In OCT analysis, maximum calcium plaque was thicker (median: 1050 µm [interquartile range (IQR): 945-1175 µm] vs. 960 µm [808-1100 µm], p = 0.017), calcification arc tended to larger (median: 265° [IQR: 209-360°] vs. 222° [162-305°], p = 0.058) in patients with DCB than in DES, and the postprocedure minimum lumen area was smaller in DCB compared with minimum stent area in DES (median: 3.83 mm2 [IQR: 3.30-4.52 mm2 ] vs. 4.86 mm2 [4.05-5.82 mm2 ], p < 0.001). However, 1 year MACE free rate was not significantly different between 2 groups (90.3% in DCB vs. 96.6% in DES, log-rank p = 0.136). In the subgroup analysis of 14 patients who underwent follow-up OCT imaging, late lumen area loss was lower in patients with DCB than DES, despite lower lesion expansion rate in DCB than DES. CONCLUSIONS In calcified coronary artery disease, DCB alone strategy (if acceptable lesion preparation was performed with OA) was feasible compared with DES following OA with respect to 1-year clinical outcomes. Our finding indicated using DCB with OA might be reduce late lumen area loss for severe calcified lesion.
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Affiliation(s)
- Kentaro Mitsui
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Tetsumin Lee
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Sho Nagamine
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Tomofumi Nakamura
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Mao Terui
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Shinichiro Okata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Masashi Nagase
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Giichi Nitta
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Masakazu Kaneko
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Yasutoshi Nagata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Toshihiro Nozato
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
| | - Takashi Ashikaga
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Musashino City, Tokyo, Japan
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Harris J, Pouwels KB, Johnson T, Sterne J, Pithara C, Mahadevan K, Reeves B, Benedetto U, Loke Y, Lasserson D, Doble B, Hopewell-Kelly N, Redwood S, Wordsworth S, Mumford A, Rogers C, Pufulete M. Bleeding risk in patients prescribed dual antiplatelet therapy and triple therapy after coronary interventions: the ADAPTT retrospective population-based cohort studies. Health Technol Assess 2023; 27:1-257. [PMID: 37435838 PMCID: PMC10363958 DOI: 10.3310/mnjy9014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Background Bleeding among populations undergoing percutaneous coronary intervention or coronary artery bypass grafting and among conservatively managed patients with acute coronary syndrome exposed to different dual antiplatelet therapy and triple therapy (i.e. dual antiplatelet therapy plus an anticoagulant) has not been previously quantified. Objectives The objectives were to estimate hazard ratios for bleeding for different antiplatelet and triple therapy regimens, estimate resources and the associated costs of treating bleeding events, and to extend existing economic models of the cost-effectiveness of dual antiplatelet therapy. Design The study was designed as three retrospective population-based cohort studies emulating target randomised controlled trials. Setting The study was set in primary and secondary care in England from 2010 to 2017. Participants Participants were patients aged ≥ 18 years undergoing coronary artery bypass grafting or emergency percutaneous coronary intervention (for acute coronary syndrome), or conservatively managed patients with acute coronary syndrome. Data sources Data were sourced from linked Clinical Practice Research Datalink and Hospital Episode Statistics. Interventions Coronary artery bypass grafting and conservatively managed acute coronary syndrome: aspirin (reference) compared with aspirin and clopidogrel. Percutaneous coronary intervention: aspirin and clopidogrel (reference) compared with aspirin and prasugrel (ST elevation myocardial infarction only) or aspirin and ticagrelor. Main outcome measures Primary outcome: any bleeding events up to 12 months after the index event. Secondary outcomes: major or minor bleeding, all-cause and cardiovascular mortality, mortality from bleeding, myocardial infarction, stroke, additional coronary intervention and major adverse cardiovascular events. Results The incidence of any bleeding was 5% among coronary artery bypass graft patients, 10% among conservatively managed acute coronary syndrome patients and 9% among emergency percutaneous coronary intervention patients, compared with 18% among patients prescribed triple therapy. Among coronary artery bypass grafting and conservatively managed acute coronary syndrome patients, dual antiplatelet therapy, compared with aspirin, increased the hazards of any bleeding (coronary artery bypass grafting: hazard ratio 1.43, 95% confidence interval 1.21 to 1.69; conservatively-managed acute coronary syndrome: hazard ratio 1.72, 95% confidence interval 1.15 to 2.57) and major adverse cardiovascular events (coronary artery bypass grafting: hazard ratio 2.06, 95% confidence interval 1.23 to 3.46; conservatively-managed acute coronary syndrome: hazard ratio 1.57, 95% confidence interval 1.38 to 1.78). Among emergency percutaneous coronary intervention patients, dual antiplatelet therapy with ticagrelor, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.47, 95% confidence interval 1.19 to 1.82), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.06, 95% confidence interval 0.89 to 1.27). Among ST elevation myocardial infarction percutaneous coronary intervention patients, dual antiplatelet therapy with prasugrel, compared with dual antiplatelet therapy with clopidogrel, increased the hazard of any bleeding (hazard ratio 1.48, 95% confidence interval 1.02 to 2.12), but did not reduce the incidence of major adverse cardiovascular events (hazard ratio 1.10, 95% confidence interval 0.80 to 1.51). Health-care costs in the first year did not differ between dual antiplatelet therapy with clopidogrel and aspirin monotherapy among either coronary artery bypass grafting patients (mean difference £94, 95% confidence interval -£155 to £763) or conservatively managed acute coronary syndrome patients (mean difference £610, 95% confidence interval -£626 to £1516), but among emergency percutaneous coronary intervention patients were higher for those receiving dual antiplatelet therapy with ticagrelor than for those receiving dual antiplatelet therapy with clopidogrel, although for only patients on concurrent proton pump inhibitors (mean difference £1145, 95% confidence interval £269 to £2195). Conclusions This study suggests that more potent dual antiplatelet therapy may increase the risk of bleeding without reducing the incidence of major adverse cardiovascular events. These results should be carefully considered by clinicians and decision-makers alongside randomised controlled trial evidence when making recommendations about dual antiplatelet therapy. Limitations The estimates for bleeding and major adverse cardiovascular events may be biased from unmeasured confounding and the exclusion of an eligible subgroup of patients who could not be assigned an intervention. Because of these limitations, a formal cost-effectiveness analysis could not be conducted. Future work Future work should explore the feasibility of using other UK data sets of routinely collected data, less susceptible to bias, to estimate the benefit and harm of antiplatelet interventions. Trial registration This trial is registered as ISRCTN76607611. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Jessica Harris
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Koen B Pouwels
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas Johnson
- Department of Cardiology, Bristol Heart Institute, Bristol, UK
| | - Jonathan Sterne
- National Institute for Health Research Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | - Christalla Pithara
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | | | - Barney Reeves
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Sabi Redwood
- National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Bristol Trials Centre, University of Bristol, Bristol, UK
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Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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4
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Nakamura M, Kadota K, Takahashi A, Kanda J, Anzai H, Ishii Y, Shibata Y, Yasaka Y, Takamisawa I, Yamaguchi J, Takeda Y, Harada A, Motohashi T, Iijima R, Uemura S, Murakami Y. Relationship Between Platelet Reactivity and Ischemic and Bleeding Events After Percutaneous Coronary Intervention in East Asian Patients: 1-Year Results of the PENDULUM Registry. J Am Heart Assoc 2020; 9:e015439. [PMID: 32394794 PMCID: PMC7660889 DOI: 10.1161/jaha.119.015439] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The balance between ischemic and bleeding events and their association with platelet reactivity in patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI), which differs among regions, is not fully evaluated for East Asians. We examined ischemic/bleeding events and platelet reactivity in Japanese patients undergoing PCI and determined associations between high/low platelet reactivity and clinical outcomes. Methods and Results PENDULUM (Platelet Reactivity in Patients with Drug Eluting Stent and Balancing Risk of Bleeding and Ischemic Event) is a prospective, multicenter registry of Japanese patients with PCI. Primary end points were incidence of first major adverse cardiac and cerebrovascular events (MACCE) and first major bleeding events at 12 months post-PCI. Platelet reactivity (P2Y12 reaction unit [PRU] value) was measured at 12 to 48 hours post-PCI; patients were grouped as having high PRU (>208), optimal PRU (>85 to ≤208), and low PRU (≤85). MACCE and major bleeding occurred in 4.4% and 2.8% of 6267 patients, respectively. The mean±SD PRU value was 182.1±77.1. MACCE was significantly higher in the high PRU (5.7%; n=2227) versus the optimal PRU group (3.6%; n=3002). The hazard ratio (HR) for high PRU versus optimal PRU level was significantly higher for MACCE (adjusted HR, 1.53; 95% CI, 1.14-2.06 [P=0.004]); stent thrombosis followed the same trend. Incidence of major bleeding did not differ significantly between groups. A high PRU level was significantly associated with MACCE in both patients with and patients without acute coronary syndrome. Conclusions These real-world data suggest an association between high platelet reactivity and cardiovascular events in Japanese patients undergoing PCI. The trend was the same in both patients with and patients without acute coronary syndrome. REGISTRATION URL: https://www.umin.ac.jp/ctr. Unique identifier: UMIN 000020332.
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Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Kazushige Kadota
- Department of Cardiology Kurashiki Central Hospital Kurashiki Japan
| | | | - Junji Kanda
- Department of Cardiology Asahi General Hospital Asahi Japan
| | - Hitoshi Anzai
- Department of Cardiology Ota Memorial Hospital Ota Japan
| | - Yasuhiro Ishii
- Department of Cardiology Cardiovascular Center Ogikubo Hospital Tokyo Japan
| | - Yoshisato Shibata
- Department of Cardiology Miyazaki Medical Association Hospital Miyazaki Japan
| | - Yoshinori Yasaka
- Department of Cardiology Himeji Cardiovascular Center Himeji Japan
| | | | - Junichi Yamaguchi
- Department of Cardiology Tokyo Women's Medical University Tokyo Japan
| | - Yoshihiro Takeda
- Department of Cardiology Rinku General Medical Center Izumisano Japan
| | - Atsushi Harada
- Medical Science Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Tomoko Motohashi
- Medical Affairs Planning Department Daiichi Sankyo Co., Ltd. Tokyo Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Shiro Uemura
- Department of Cardiology Kawasaki Medical School Kurashiki Japan
| | - Yoshitaka Murakami
- Department of Medical Statistics School of Medicine Toho University Tokyo Japan
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5
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Pufulete M, Harris J, Sterne JAC, Johnson TW, Lasserson D, Mumford A, Doble B, Wordsworth S, Benedetto U, Rogers CA, Loke Y, Pithara C, Redwood S, Reeves BC. Comprehensive ascertainment of bleeding in patients prescribed different combinations of dual antiplatelet therapy (DAPT) and triple therapy (TT) in the UK: study protocol for three population-based cohort studies emulating 'target trials' (the ADAPTT Study). BMJ Open 2019; 9:e029388. [PMID: 31167875 PMCID: PMC6561407 DOI: 10.1136/bmjopen-2019-029388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/04/2019] [Accepted: 03/12/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION 'Real world' bleeding in patients exposed to different regimens of dual antiplatelet therapy (DAPT) and triple therapy (TT, DAPT plus an anticoagulant) have a clinical and economic impact but have not been previously quantified. METHODS AND ANALYSIS We will use linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data to assemble populations eligible for three 'target trials' in patient groups: percutaneous coronary intervention (PCI); coronary artery bypass grafting (CABG); conservatively managed (medication only) acute coronary syndrome (ACS). Patients ≥18 years old will be eligible if, in CPRD records, they have: ≥1 year of data before the index event; no prescription for DAPT or anticoagulants in the preceding 3 months; a prescription for aspirin or DAPT within 2 months after discharge from the index event. The primary outcome will be any bleeding event (CPRD or HES) up to 12 months after the index event. We will estimate adjusted HR for time to first bleeding event comparing: aspirin and clopidogrel (reference) versus aspirin and prasugrel or aspirin and ticagrelor after PCI; and aspirin (reference) versus aspirin and clopidogrel after CABG and ACS. We will describe rates of bleeding in patients prescribed TT (DAPT plus an anticoagulant). Potential confounders will be identified systematically using literature review, semistructured interviews with clinicians and a short survey of clinicians. We will conduct sensitivity analyses addressing the robustness of results to the study's main limitation-that we will not be able to identify the intervention group for patients whose bleeding event occurs before a DAPT prescription in CPRD. ETHICS AND DISSEMINATION This protocol was approved by the Independent Scientific Advisory Committee for the UK Medicines and Healthcare Products Regulatory Agency Database Research (protocol 16_126R) and the South West Cornwall and Plymouth Research Ethics Committee (17/SW/0092). The findings will be presented in peer-reviewed journals, lay summaries and briefing papers to commissioners/other stakeholders. TRIAL REGISTRATION NUMBER 76607611; Pre-results.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Jonathan A C Sterne
- NIHR Biomedical Research Centre, Department of Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Daniel Lasserson
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Andrew Mumford
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Brett Doble
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Yoon Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Christalla Pithara
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Sabi Redwood
- Ethnography Research Team, National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West (NIHR CLAHRC West), Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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6
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Krumme AA, Glynn RJ, Schneeweiss S, Choudhry NK, Tong AY, Gagne JJ. Defining Exposure in Observational Studies Comparing Outcomes of Treatment Discontinuation. Circ Cardiovasc Qual Outcomes 2018; 11:e004684. [DOI: 10.1161/circoutcomes.118.004684] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 05/21/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Alexis A. Krumme
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
| | - Niteesh K. Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Angela Y. Tong
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
| | - Joshua J. Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, MA (A.A.K., R.J.G., S.S., N.K.C., A.Y.T., J.J.G.)
- Harvard TH Chan School of Public Health, Boston, MA (A.A.K., S.S., J.J.G.)
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7
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Yoshikawa Y, Shiomi H, Watanabe H, Natsuaki M, Kondo H, Tamura T, Nakagawa Y, Morimoto T, Kimura T. Validating Utility of Dual Antiplatelet Therapy Score in a Large Pooled Cohort From 3 Japanese Percutaneous Coronary Intervention Studies. Circulation 2018; 137:551-562. [DOI: 10.1161/circulationaha.117.028924] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/18/2017] [Indexed: 11/16/2022]
Abstract
Background:
The dual antiplatelet therapy (DAPT) score was developed to estimate ischemic and bleeding risks from the DAPT study. However, few studies validated its utility externally. We sought to validate the utility of the DAPT score in the Japanese population.
Methods:
In a pooled cohort of 3 studies conducted in Japan (the CREDO-Kyoto [Coronary Revascularization Demonstrating Outcome Study in Kyoto] Registry Cohort-2, RESET [Randomized Evaluation of Sirolimus-Eluting Versus Everolimus-Eluting Stent Trial], and NEXT [NOBORI Biolimus-Eluting Versus XIENCE/PROMUS Everolimus-Eluting Stent Trial]), we compared risks for ischemic and bleeding events from 13 to 36 months after percutaneous coronary intervention among patients with a DAPT score ≥2 (high DS) and a DAPT score <2 (low DS).
Results:
Among 12 223 patients receiving drug-eluting stents who were free from ischemic or bleeding events at 13 months after percutaneous coronary intervention, 3944 patients had high DS and 8279 had low DS. The cumulative incidence of primary ischemic end point (myocardial infarction/stent thrombosis) was significantly higher in high DS than in low DS (1.5% versus 0.9%,
P
=0.002), whereas the cumulative incidence of primary bleeding end point (GUSTO moderate/severe) tended to be lower in high DS than in low DS (2.1% versus 2.7%,
P
=0.07). The cumulative incidences of cardiac death, myocardial infarction, and stent thrombosis were also significantly higher in high DS than in low DS (2.0% versus 1.4%,
P
=0.03; 1.5% versus 0.8%,
P
=0.002; 0.7% versus 0.3%,
P
<0.001, respectively), whereas the cumulative incidences of noncardiac death and GUSTO severe bleeding were significantly lower in high DS than in low DS (2.4% versus 3.9%,
P
<0.001; 1.0% versus 1.6%,
P
=0.03, respectively).
Conclusions:
In the current population, the DAPT score successfully stratified ischemic and bleeding risks, although the ischemic event rate was remarkably low even in high DS. Further studies would be warranted to evaluate the utility of prolonged DAPT guided by the DAPT score.
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Affiliation(s)
- Yusuke Yoshikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (Y.Y., H.S., H.W., T.K.)
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (Y.Y., H.S., H.W., T.K.)
| | - Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (Y.Y., H.S., H.W., T.K.)
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, Japan (M.N.)
| | - Hirokazu Kondo
- Department of Cardiology, Tenri Hospital, Japan (H.K., T.T., Y.N.)
| | - Toshihiro Tamura
- Department of Cardiology, Tenri Hospital, Japan (H.K., T.T., Y.N.)
| | | | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan (T.M.)
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Japan (Y.Y., H.S., H.W., T.K.)
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8
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Abe M, Morimoto T, Nakagawa Y, Furukawa Y, Ono K, Kato T, Kadota K, Ando K, Ishii M, Masunaga N, Akao M, Kimura T. Impact of Transient or Persistent Contrast-induced Nephropathy on Long-term Mortality After Elective Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:2146-2153. [PMID: 29106836 DOI: 10.1016/j.amjcard.2017.08.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 08/22/2017] [Accepted: 08/24/2017] [Indexed: 11/24/2022]
Abstract
Contrast-induced nephropathy (CIN) is associated with increased long-term mortality. However, it is still controversial whether CIN is the cause of increased mortality or merely a marker of high-risk patients. The current study population included 5,516 patients who underwent their first elective percutaneous coronary intervention (PCI) in the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry cohort-2. CIN was defined as an elevation in the peak serum creatinine (SCr) of ≥0.5 mg/dl from the baseline within 5 days after PCI. CIN, seen in 218 patients (4.0%), was independently associated with an increased long-term mortality risk (hazard ratio [HR] 1.43, 95% confidence interval [CI],1.11 to 1.83; p = 0.005). SCr data at 1 year (180 to 550 days) after PCI were available in 3,986 patients, who were subdivided into persistent CIN (follow-up SCr elevation ≥0.5 mg/dl: n = 50 [1.3%]), transient CIN (follow-up SCr elevation <0.5 mg/dl: n = 90 [2.3%]), and non-CIN (n = 3,846 [96.5%]). In the landmark analysis at 1 year after PCI, 524 patients (13.1%) died during a median follow-up of 1,521 days. After adjustment for the 37 confounders, persistent CIN, but not transient CIN, was significantly correlated with a higher long-term mortality risk compared with non-CIN (HR 1.84, 95% CI 1.12 to 3.03; p = 0.02, and HR 1.11, 95% CI 0.71 to 1.76; p = 0.6, respectively). In conclusion, only persistent CIN was independently associated with increased long-term mortality.
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9
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Long (>12 Months) and Short (<6 Months) Versus Standard Duration of Dual Antiplatelet Therapy After Coronary Stenting: A Systematic Review and Meta-Analysis. Am J Ther 2017; 24:e468-e476. [DOI: 10.1097/mjt.0000000000000307] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Is a bare-metal stent still useful for improving the outcome of percutaneous coronary intervention? From the FU-Registry. J Cardiol 2017; 69:652-659. [DOI: 10.1016/j.jjcc.2016.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/07/2016] [Accepted: 06/14/2016] [Indexed: 11/17/2022]
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11
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Ichibori Y, Mizote I, Maeda K, Onishi T, Ohtani T, Yamaguchi O, Torikai K, Kuratani T, Sawa Y, Nakatani S, Sakata Y. Clinical Outcomes and Bioprosthetic Valve Function After Transcatheter Aortic Valve Implantation Under Dual Antiplatelet Therapy vs. Aspirin Alone. Circ J 2017; 81:397-404. [PMID: 28123149 DOI: 10.1253/circj.cj-16-0903] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is commonly used after transcatheter aortic valve implantation (TAVI); however, the supporting evidence is limited. To determine if aspirin alone is a better alternative to DAPT, we compared the outcomes of patients treated with DAPT or aspirin alone after TAVI.Methods and Results:We analyzed a total of 144 consecutive patients (92 females, mean age 83±6 years) who underwent implantation of a balloon-expandable transcatheter valve (SAPIEN or SAPIEN XT, Edwards Lifesciences). Patients were divided into DAPT (n=66) or aspirin-alone treatment groups (n=78). At 1 year after TAVI, the composite endpoint, which consisted of all-cause death, myocardial infarction, stroke, and major or life-threatening bleeding complications, occurred significantly less frequently (Kaplan-Meier analysis) in the aspirin-alone group (15.4%) than in the DAPT group (30.3%; P=0.031). Valve function assessed by echocardiography was similar between the 2 treatment groups with respect to effective orifice area (1.78±0.43 cm2in DAPT vs. 1.91±0.46 cm2in aspirin-alone group; P=0.13) and transvalvular pressure gradient (11.1±3.5 mmHg in DAPT vs. 10.3±4.1 mmHg in aspirin-alone group; P=0.31). CONCLUSIONS Treatment with aspirin alone after TAVI had greater safety benefits and was associated with similar valve function as DAPT. These results suggest that treatment with aspirin alone is an acceptable regimen for TAVI patients.
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Affiliation(s)
- Yasuhiro Ichibori
- Cardiovascular Medicine, Osaka University Graduate School of Medicine
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12
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Abo-Salem E, Alsidawi S, Jamali H, Effat M, Helmy T. Optimal Duration of Dual Antiplatelet Therapy after Drug-Eluting Stents: Meta-Analysis of Randomized Trials. Cardiovasc Ther 2016; 33:253-63. [PMID: 26010419 DOI: 10.1111/1755-5922.12137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent implantation (DES) is not certain. The AHA/ACC guidelines recommend 12 months of DAPT based on observational trials. Recently, several large randomized controlled trials (RCT) suggested a noninferiority of shorter duration of DAPT and other trials showed a benefit from extended duration of DAPT after 12 months of DES implantation. METHODS PubMed databases were searched for RCTs comparing the continued use of DAPT to shorter duration of DAPT (aspirin alone) for variable durations beyond 3 months of DES implantation. Our analysis was limited to trials with clinical outcomes. Odds ratio (OR) and 95% confidence intervals (CI) were calculated using fixed and random-effects models. Subgroup analyses were performed for second generation DES and for trials comparing 12 months of DAPT vs. earlier interruption or longer duration of DAPT. RESULTS We identified 10 RCTs including 32,136 subjects randomized to continued use of DAPT vs. aspirin alone for variable durations after 3 months of DES implantation. There was no significant heterogeneity among studies (Q test P > 0.1). Compared to shorter DAPT, longer DAPT resulted in a significant reduction in stent thrombosis (0.3% vs. 0.7%, P < 0.01) and myocardial infarction (1.3% vs. 2%, P < 0.01), and a significant increase in major bleeding (0.8% vs. 0.4%, P < 0.01). There was no difference in cardiac deaths or stroke. All-cause deaths were slightly lower with shorter DAPT compared to longer DAPT (OR 0.8, 95% CI 0.7 to 0.99, P = 0.04). A small number of subjects were included between 3 and 6 months after DES implantation. CONCLUSION DAPT continued beyond 6 months after second generation DES implantation decreases stent thrombosis and myocardial infarction, but increases major bleeding and all-causes mortality compared to shorter DAPT (aspirin alone). There was no difference in cardiac mortality or stroke.
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Affiliation(s)
- Elsayed Abo-Salem
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Said Alsidawi
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Hina Jamali
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Mohamed Effat
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Tarek Helmy
- Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
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13
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Prolonged Clopidogrel Use is Associated with Improved Clinical Outcomes Following Drug-Eluting But Not Bare Metal Stent Implantation. Am J Cardiovasc Drugs 2016; 16:111-8. [PMID: 26749409 DOI: 10.1007/s40256-015-0155-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guidelines recommend clopidogrel use for 6-12 months following drug-eluting stent (DES) implantation and 1-12 months following bare metal stent (BMS) implantation. The role of clopidogrel beyond 12 months is unclear. METHODS We linked hospital administrative, community pharmacy and cardiac revascularization data to determine clopidogrel use and outcomes for all patients (those with acute presentations and those with stable angina) receiving a coronary stent in British Columbia 2004-2006, with follow-up until the end of 2008. Cox proportional hazard regression was performed to evaluate the effect of clopidogrel duration (≤12 vs. >12 months) on outcomes following BMS or DES implantation. Patients who died ≤12 months from index stent placement were excluded. RESULTS A total of 15,629 patients were included in the study. Of 3599 patients who received at least one DES and 12,030 patients who received only BMS, 1326 (37 %) and 2121 (18 %), respectively, filled a prescription for clopidogrel >12 months from the index procedure. The mean duration of clopidogrel was 406 ± 35 days and 407 ± 37 days in the prolonged use (>12 months) DES and BMS cohorts, respectively, compared with 224 ± 112 days (p < 0.001) and 122 ± 117 days (p < 0.001), respectively, for patients receiving clopidogrel ≤12 months. Clopidogrel use beyond 12 months was associated with a reduction in mortality [hazard ratio (HR) 0.66, 95 % confidence interval (CI) 0.45-0.97] and the composite of mortality and readmission for myocardial infarction (HR 0.72, 95 % CI 0.55-0.94) in patients treated with DES, but not BMS alone. Prolonged clopidogrel use was not associated with bleeding-related mortality. CONCLUSIONS Clopidogrel use beyond 12 months was associated with a reduction in death and hospitalization for myocardial infarction following DES, but not BMS, implantation. Our findings support a longer duration of clopidogrel therapy for patients treated with DES.
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14
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Yano M, Natsuaki M, Morimoto T, Nakagawa Y, Kawai K, Miyazaki S, Muramatsu T, Shiode N, Namura M, Sone T, Oshima S, Nishikawa H, Hiasa Y, Hayashi Y, Nobuyoshi M, Mitsudo K, Kimura T. Antiplatelet therapy discontinuation and stent thrombosis after sirolimus-eluting stent implantation: Five-year outcome of the j-Cypher Registry. Int J Cardiol 2015; 199:296-301. [DOI: 10.1016/j.ijcard.2015.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Revised: 03/11/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
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15
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Ziada KM, Abdel-Latif AK, Charnigo R, Moliterno DJ. Safety of an abbreviated duration of dual antiplatelet therapy (≤6 months) following second-generation drug-eluting stents for coronary artery disease: A systematic review and meta-analysis of randomized trials. Catheter Cardiovasc Interv 2015; 87:722-732. [PMID: 26309050 DOI: 10.1002/ccd.26110] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 06/27/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is recommended for ≥12 months following coronary drug-eluting stents (DES) to reduce risk of major adverse ischemic events. Randomized trials suggest an abbreviated DAPT duration (≤6 months) is adequately protective. However, these trials are individually underpowered to detect differences in rare but serious events such as stent thrombosis (ST). OBJECTIVES We performed a meta-analysis of published randomized trials to define the impact of abbreviated DAPT (≤6 months) on death, myocardial infarction (MI), stent thrombosis (ST), and bleeding complications compared to standard-duration DAPT (≥12 months). METHODS Seven randomized controlled trials comparing abbreviated vs. standard DAPT regimens following DES use were identified by two independent investigators. Study characteristics were reviewed and clinical endpoint data were abstracted and analyzed in aggregate using fixed and random-effects models. RESULTS The seven trials included 15,874 randomized patients. Second-generation DES were used in most patients. Compared to standard-duration DAPT, abbreviated DAPT was not associated with an increase in mortality (OR 0.93; CI: 0.73 to 1.17; P = 0.52), MI (OR 1.14; CI: 0.89 to 1.45; P = 0.30) or ST (OR 1.25; CI: 0.81 to 1.93; P = 0.31). Abbreviated DAPT was associated with significantly fewer major bleeding complications (OR 0.52; CI: 0.34 to 0.82; P = 0.005). The results were consistent between fixed and random-effects models, with no heterogeneity. Sensitivity analyses adjusting for inclusion of bare metal stents, 1st generation DES and/or abbreviated DAPT regimens of 3 months resulted in similar conclusions. CONCLUSIONS In a meta-analysis of >15,000 patients primarily treated with second-generation DES, abbreviated-duration DAPT (≤6 months) was associated with a significant reduction in major bleeding complications with no evidence of a significant increase in risk of death, MI or ST. Accordingly, abbreviated DAPT should be strongly considered for patients receiving second generation DES.
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Affiliation(s)
- Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - Ahmed K Abdel-Latif
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - Richard Charnigo
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
| | - David J Moliterno
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky and the Lexington VA Medical Center, Lexington, KY
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16
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Montalescot G, Brieger D, Dalby AJ, Park SJ, Mehran R. Duration of Dual Antiplatelet Therapy After Coronary Stenting. J Am Coll Cardiol 2015; 66:832-847. [DOI: 10.1016/j.jacc.2015.05.053] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 11/24/2022]
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17
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Long-Term Outcomes After Coronary Stent Implantation in Patients Presenting With Versus Without Acute Myocardial Infarction (an Observation from Coronary Revascularization Demonstrating Outcome Study-Kyoto Registry Cohort-2). Am J Cardiol 2015; 116:15-23. [PMID: 26068701 DOI: 10.1016/j.amjcard.2015.03.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/17/2015] [Accepted: 03/17/2015] [Indexed: 11/21/2022]
Abstract
It has not been adequately addressed yet how long the excess cardiovascular event risk persists after acute myocardial infarction (AMI) compared with stable coronary artery disease. Of 10,470 consecutive patients who underwent percutaneous coronary intervention either with sirolimus-eluting stent (SES) only or with bare-metal stent (BMS) only in the Coronary Revascularization Demonstrating Outcome Study-Kyoto Registry Cohort-2, 3,710 (SES: n = 820 and BMS: n = 2,890) and 6,760 patients (SES: n = 4,258 and BMS: n = 2,502) presented with AMI (AMI group) and without AMI (non-AMI group), respectively. During the median 5-year follow-up, the excess adjusted risk of the AMI group relative to the non-AMI group for the primary outcome measure (cardiac death or myocardial infarction) was significant (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.30 to 1.80, p <0.001). However, the excess event risk was limited to the early period within 3 months. Late adjusted risk beyond 3 months was similar between the AMI and non-AMI groups (HR 1.16, 95% CI 0.95 to 1.41, p = 0.15). The higher risk of the AMI group relative to the non-AMI group for stent thrombosis (ST) was significant within 3 months (HR 3.38, 95% CI 2.04 to 5.60, p <0.001), whereas the risk for ST was not different between the 2 groups beyond 3 months (HR 1.11, 95% CI 0.65 to 1.90, p = 0.70). There were no interactions between the types of stents implanted and the risk of the AMI group relative to the non-AMI groups for all the outcome measures including ST. In conclusion, patients with AMI compared with those without AMI were associated with similar late cardiovascular event risk beyond 3 months after percutaneous coronary intervention despite their higher early risk within 3 months.
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18
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Verdoia M, Schaffer A, Barbieri L, Montalescot G, Collet JP, Colombo A, Suryapranata H, De Luca G. Optimal Duration of Dual Antiplatelet Therapy After DES Implantation: A Meta-Analysis of 11 Randomized Trials. Angiology 2015; 67:224-38. [PMID: 26069031 DOI: 10.1177/0003319715586500] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Despite new-generations of drug-eluting stents (DESs), the optimal duration of dual antiplatelet therapy (DAPT) remains controversial. We performed a meta-analysis of randomized trials (RTs) evaluating the effectiveness and safety of shorter versus longer DAPT duration strategies in patients undergoing percutaneous coronary interventions with DES. Literature and main scientific session abstracts were searched. The primary end point was mortality. Secondary end points were (1) cardiovascular mortality, (2) nonfatal myocardial infarction, (3) definite/probable stent thrombosis (ST), and (4) major bleedings. We included 11 RTs (n = 32 372 patients). Shorter DAPT duration reduced mortality (odds ratio, OR [95% confidence interval, CI] = 0.85 [0.71-1], P = .05; p heterogeneity = 0.91). Similar results were observed when comparing 3 to 6 versus 12 months DAPT, while a significant increase in recurrent ischemic events was found for 6 to 12 months DAPT versus extended treatment (myocardial infarction: OR [95%CI] = 1.66 [1.37-2], P < .00001; phet = 0.13 and ST: OR [95%CI] = 2.47 [1.72-3.45], P < .00001; phet = 0.12), however, counterbalanced by a significant reduction in major bleeding (OR [95%CI] = 0.60 [0.47-0.76], P < .0001; phet = 0.38) and a trend in lower mortality. Thus, among selected patients undergoing DES implantation, a shorter DAPT strategy is associated with reduction in mortality and major bleeding but a higher risk of myocardial infarction and ST. A short duration (3-6 months) of DAPT appears as the safest strategy, while a prolonged duration (24-36 months) reduces thrombotic complications but with an excess in major bleeding complications.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità," Eastern Piedmont University, Novara, Italy
| | - Alon Schaffer
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità," Eastern Piedmont University, Novara, Italy
| | - Lucia Barbieri
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità," Eastern Piedmont University, Novara, Italy
| | - Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Pitié-Salpêtrière (AP-HP, ACTION Group, University Paris 6), Paris, France
| | - Jean-Philippe Collet
- Institut de Cardiologie, Centre Hospitalier Pitié-Salpêtrière (AP-HP, ACTION Group, University Paris 6), Paris, France
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Scientific Institute and EMO-GVM Centro Cuore Columbus, Milan, Italy
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità," Eastern Piedmont University, Novara, Italy
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19
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Watanabe H, Morimoto T, Natsuaki M, Furukawa Y, Nakagawa Y, Kadota K, Yamaji K, Ando K, Shizuta S, Shiomi H, Tada T, Tazaki J, Kato Y, Hayano M, Abe M, Tamura T, Shirotani M, Miki S, Matsuda M, Takahashi M, Ishii K, Tanaka M, Aoyama T, Doi O, Hattori R, Kato M, Suwa S, Takizawa A, Takatsu Y, Shinoda E, Eizawa H, Takeda T, Lee JD, Inoko M, Ogawa H, Hamasaki S, Horie M, Nohara R, Kambara H, Fujiwara H, Mitsudo K, Nobuyoshi M, Kita T, Kastrati A, Kimura T. Antiplatelet therapy discontinuation and the risk of serious cardiovascular events after coronary stenting: observations from the CREDO-Kyoto Registry Cohort-2. PLoS One 2015; 10:e0124314. [PMID: 25853836 PMCID: PMC4390156 DOI: 10.1371/journal.pone.0124314] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 02/27/2015] [Indexed: 02/02/2023] Open
Abstract
Relation of antiplatelet therapy (APT) discontinuation with the risk of serious cardiovascular events has not been fully addressed yet. This study is aimed to evaluate the risk of ischemic event after APT discontinuation based on long-term APT status of large cohort. In the CREDO-Kyoto Registry Cohort-2 enrolling 15939 consecutive patients undergoing first coronary revascularization, 10470 patients underwent percutaneous coronary intervention either with bare-metal stents (BMS) only (N=5392) or sirolimus-eluting stents (SES) only (N=5078). Proportions of patients taking dual-APT were 67.3% versus 33.4% at 1-year, and 48.7% versus 24.3% at 5-year in the SES and BMS strata, respectively. We evaluated daily APT status (dual-, single- and no-APT) and linked the adverse events to the APT status just 1-day before the events. No-APT as compared with dual- or single-APT was associated with significantly higher risk for stent thrombosis (ST) beyond 1-month after SES implantation (cumulative incidence rates beyond 1-month: 1.23 versus 0.15/0.29, P<0.001/P<0.001), while higher risk of no-APT for ST was evident only until 6-month after BMS implantation (incidence rates between 1- and 6-month: 8.43 versus 0.71/1.20, P<0.001/P<0.001, and cumulative incidence rates beyond 6-month: 0.31 versus 0.11/0.08, P=0.16/P=0.08). No-APT as compared with dual- or single-APT was also associated with significantly higher risk for spontaneous myocardial infarction (MI) and stroke regardless of the types of stents implanted. Single-APT as compared with dual-APT was not associated with higher risk for serious adverse events, except for the marginally higher risk for ST in the SES stratum. In conclusion, discontinuation of both aspirin and thienopyridines was associated with increased risk for serious cardiovascular events including ST, spontaneous MI and stroke beyond 1-month after coronary stenting.
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Affiliation(s)
- Hirotoshi Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Division of Genera Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Kazushige Kadota
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kyohei Yamaji
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Ando
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomohisa Tada
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshihiro Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mamoru Hayano
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuru Abe
- Division of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Takashi Tamura
- Division of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Manabu Shirotani
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Nara, Japan
| | - Shinji Miki
- Division of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Mitsuo Matsuda
- Division of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | | | - Katsuhisa Ishii
- Division of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Masaru Tanaka
- Division of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Takeshi Aoyama
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Osamu Doi
- Division of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ryuichi Hattori
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Masayuki Kato
- Division of Cardiology, Maizuru Kyosai Hospital, Maizuru, Japan
| | - Satoru Suwa
- Division of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Akinori Takizawa
- Division of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiki Takatsu
- Division of Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan
| | - Eiji Shinoda
- Division of Cardiology, Hamamatsu Rosai Hospital, Hamamatsu, Japan
| | - Hiroshi Eizawa
- Division of Cardiology, Nishi-Kobe Medical Center, Kobe, Japan
| | - Teruki Takeda
- Division of Cardiology, Koto Memorial Hospital, Higashioumi, Japan
| | - Jong-Dae Lee
- Division of Cardiology, University of Fukui Hospital, Fukui, Japan
| | - Moriaki Inoko
- Cardiovascular Center, the Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shuichi Hamasaki
- Department of Cardiovascular, Respiratory and Metabolic Medicine, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Minoru Horie
- Department of Cardiovascular and Respiratory, Shiga University of Medical Science, Otsu, Japan
| | - Ryuji Nohara
- Division of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Hirofumi Kambara
- Division of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Hisayoshi Fujiwara
- Division of Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan
| | - Kazuaki Mitsudo
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | | | - Toru Kita
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- * E-mail:
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Palmerini T, Sangiorgi D, Valgimigli M, Biondi-Zoccai G, Feres F, Abizaid A, Costa RA, Hong MK, Kim BK, Jang Y, Kim HS, Park KW, Mariani A, Della Riva D, Genereux P, Leon MB, Bhatt DL, Bendetto U, Rapezzi C, Stone GW. Short- Versus Long-Term Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation. J Am Coll Cardiol 2015; 65:1092-102. [PMID: 25790880 DOI: 10.1016/j.jacc.2014.12.046] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/18/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Diego Sangiorgi
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Marco Valgimigli
- Erasmus Medical Center, Thoraxcenter, Rotterdam, the Netherlands
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | | | | | - Myeong-Ki Hong
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital and Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Andrea Mariani
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Diego Della Riva
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Philippe Genereux
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Martin B Leon
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | | | - Claudio Rapezzi
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York.
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21
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Antiplatelet therapy after drug-eluting stent implantation. J Cardiol 2015; 65:98-104. [DOI: 10.1016/j.jjcc.2014.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 09/05/2014] [Indexed: 12/27/2022]
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22
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Should antiplatelet medications be held before cervical epidural injections? PM R 2015; 6:442-50. [PMID: 24863733 DOI: 10.1016/j.pmrj.2014.04.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 04/25/2014] [Indexed: 01/08/2023]
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23
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Chang TI, Montez-Rath ME, Shen JI, Solomon MD, Chertow GM, Winkelmayer WC. Thienopyridine use after coronary stenting in low income patients enrolled in medicare part D receiving maintenance dialysis. J Am Heart Assoc 2014; 3:e001356. [PMID: 25336465 PMCID: PMC4323824 DOI: 10.1161/jaha.114.001356] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary stenting in patients on dialysis has increased by nearly 50% over the past decade, despite heightened risks of associated stent thrombosis and bleeding relative to the general population. We examined clopidogrel, prasugrel or ticlopidine use after percutaneous coronary intervention (PCI) with stenting in patients on dialysis. We conducted 3-, 6-, and 12-month landmark analyses to test the hypothesis that thienopyridine discontinuation prior to those time points would be associated with higher risks of death, myocardial infarction, or repeat revascularization, and a lower risk of major bleeding episodes compared with continued thienopyridine use. METHODS AND RESULTS Using the US Renal Data System, we identified 8458 patients on dialysis with Medicare Parts A+B+D undergoing PCI with stenting between July 2007 and December 2010. Ninety-nine percent of all thienopyridine prescriptions were for clopidogrel. At 3 months, 82% of patients who received drug-eluting stents (DES) had evidence of thienopyridine use. These proportions fell to 62% and 40% at 6 and 12 months, respectively. In patients who received a bare-metal stent (BMS), 70%, 34%, and 26% of patients had evidence of thienopyridine use at 3, 6, and 12 months, respectively. In patients who received a DES, there was a suggestion of higher risks of death or myocardial infarction associated with thienopyridine discontinuation in the 3-, 6-, and 12-months landmark analyses, but no higher risk of major bleeding episodes. In patients who received a BMS, there were no differences in death or cardiovascular events, and possibly lower risk of major bleeding with thienopyridine discontinuation in the 3- and 6-month landmark analyses. CONCLUSIONS The majority of patients on dialysis who undergo PCI discontinue thienopyridines before 1 year regardless of stent type. While not definitive, these data suggest that longer-term thienopyridine use may be of benefit to patients on dialysis who undergo PCI with DES.
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Affiliation(s)
- Tara I Chang
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Maria E Montez-Rath
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Jenny I Shen
- Division of Nephrology and Hypertension, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Torrance, CA (J.I.S.)
| | - Matthew D Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (M.D.S.)
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.)
| | - Wolfgang C Winkelmayer
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA (T.I.C., M.E.M.R., G.M.C., W.C.W.) Section of Nephrology, Baylor College of Medicine, Houston, TX 77030-3411 (W.C.W.)
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24
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Percutaneous coronary intervention versus coronary artery bypass grafting in patients with end-stage renal disease requiring dialysis (5-year outcomes of the CREDO-Kyoto PCI/CABG Registry Cohort-2). Am J Cardiol 2014; 114:555-61. [PMID: 24996550 DOI: 10.1016/j.amjcard.2014.05.034] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/13/2014] [Accepted: 05/13/2014] [Indexed: 11/23/2022]
Abstract
Ischemic heart disease is a major risk factor for morbidity and mortality in patients with end-stage renal disease. However, long-term benefits of percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in those patients is still unclear in the drug-eluting stent era. We identified 388 patients with multivessel and/or left main disease with end-stage renal disease requiring dialysis among 15,939 patients undergoing first coronary revascularization enrolled in the Coronary REvascularization Demonstrating Outcome Study in Kyoto PCI/CABG Registry Cohort-2 (PCI: 258 patients and CABG: 130 patients). The CABG group included more patients with 3-vessel (38% vs 57%, p <0.001) and left main disease (10% vs 34%, p <0.001). Preprocedural Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery score in the CABG group was significantly higher than that in the PCI group (23.5 ± 8.7 vs 29.4 ± 11.0, p <0.001). Unadjusted 30-day mortality was 2.7% for PCI and 5.4% for CABG. Cumulative 5-year all-cause mortality was 52.3% for PCI and 49.9% for CABG. Propensity score-adjusted all-cause mortality was not different between PCI and CABG (hazard ratio [HR] 1.33, 95% confidence interval [CI] 0.85 to 2.09, p = 0.219). However, the excess risk of PCI relative to CABG for cardiac death was significant (HR 2.10, 95% CI 1.11 to 3.96, p = 0.02). The risk of sudden death was also higher after PCI (HR 4.83, 95% CI 1.01 to 23.08, p = 0.049). The risk of myocardial infarction after PCI tended to be higher than after CABG (HR 3.30, 95% CI 0.72 to 15.09, p = 0.12). The risk of any coronary revascularization after PCI was markedly higher after CABG (HR 3.78, 95% CI 1.91 to 7.50, p <0.001). Among the 201 patients who died during the follow-up, 94 patients (47%) died from noncardiac morbidities such as stroke, respiratory failure, and renal failure. In patients with multivessel and/or left main disease undergoing dialysis, 5-year outcomes revealed that CABG relative to PCI reduced the risk of cardiac death, sudden death, myocardial infarction, and any revascularization. However, the risk of all-cause death was not different between PCI and CABG.
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25
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Thim T, Johansen MB, Chisholm GE, Schmidt M, Kaltoft A, Sørensen HT, Thuesen L, Kristensen SD, Bøtker HE, Krusell LR, Lassen JF, Thayssen P, Jensen LO, Tilsted HH, Maeng M. Clopidogrel discontinuation within the first year after coronary drug-eluting stent implantation: an observational study. BMC Cardiovasc Disord 2014; 14:100. [PMID: 25125079 PMCID: PMC4135343 DOI: 10.1186/1471-2261-14-100] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 08/01/2014] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The impact of adherence to the recommended duration of dual antiplatelet therapy after first generation drug-eluting stent implantation is difficult to assess in real-world settings and limited data are available. METHODS We followed 4,154 patients treated with coronary drug-eluting stents in Western Denmark for 1 year and obtained data on redeemed clopidogrel prescriptions and major adverse cardiovascular events (MACE, i.e., cardiac death, myocardial infarction, or stent thrombosis) from medical databases. RESULTS Discontinuation of clopidogrel within the first 3 months after stent implantation was associated with a significantly increased rate of MACE at 1-year follow-up (hazard ratio (HR) 2.06; 95% confidence interval (CI): 1.08-3.93). Discontinuation 3-6 months (HR 1.29; 95% CI: 0.70-2.41) and 6-12 months (HR 1.29; 95% CI: 0.54-3.07) after stent implantation were associated with smaller, not statistically significant, increases in MACE rates. Among patients who discontinued clopidogrel, MACE rates were highest within the first 2 months after discontinuation. CONCLUSIONS Discontinuation of clopidogrel was associated with an increased rate of MACE among patients treated with drug-eluting stents. The increase was statistically significant within the first 3 months after drug-eluting stent implantation but not after 3 to 12 months.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
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Goto K, Nakai K, Shizuta S, Morimoto T, Shiomi H, Natsuaki M, Yahata M, Ota C, Ono K, Makiyama T, Nakagawa Y, Furukawa Y, Kadota K, Takatsu Y, Tamura T, Takizawa A, Inada T, Doi O, Nohara R, Matsuda M, Takeda T, Kato M, Shirotani M, Eizawa H, Ishii K, Lee JD, Takahashi M, Horie M, Takahashi M, Miki S, Aoyama T, Suwa S, Hamasaki S, Ogawa H, Mitsudo K, Nobuyoshi M, Kita T, Kimura T. Anticoagulant and antiplatelet therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Am J Cardiol 2014; 114:70-8. [PMID: 24925801 DOI: 10.1016/j.amjcard.2014.03.060] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/28/2014] [Accepted: 03/28/2014] [Indexed: 11/17/2022]
Abstract
The prevalence, intensity, safety, and efficacy of oral anticoagulation (OAC) in addition to dual antiplatelet therapy (DAPT) in "real-world" patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not yet been fully evaluated. In the Coronary REvascularization Demonstrating Outcome Study in Kyoto registry cohort-2, a total of 1,057 patients with AF (8.3%) were identified among 12,716 patients undergoing first PCI. Cumulative 5-year incidence of stroke was higher in patients with AF than in no-AF patients (12.8% vs 5.8%, p <0.0001). Although most patients with AF had CHADS2 score ≥2 (75.2%), only 506 patients (47.9%) received OAC with warfarin at hospital discharge. Cumulative 5-year incidence of stroke in the OAC group was not different from that in the no-OAC group (13.8% vs 11.8%, p = 0.49). Time in therapeutic range (TTR) was only 52.6% with an international normalized ratio of 1.6 to 2.6, and only 154 of 409 patients (37.7%) with international normalized ratio data had TTR ≥65%. Cumulative 5-year incidence of stroke in patients with TTR ≥65% was markedly lower than that in patients with TTR <65% (6.9% vs 15.1%, p = 0.01). In a 4-month landmark analysis in the OAC group, there was a trend for higher cumulative incidences of stroke and major bleeding in the on-DAPT (n = 286) than in the off-DAPT (n = 173) groups (15.1% vs 6.7%, p = 0.052 and 14.7% vs 8.7%, p = 0.10, respectively). In conclusion, OAC was underused and its intensity was mostly suboptimal in real-world patients with AF undergoing PCI, which lead to inadequate stroke prevention. Long-term DAPT in patients receiving OAC did not reduce stroke incidence.
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Affiliation(s)
- Koji Goto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kentaro Nakai
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Takeshi Morimoto
- Division of General Medicine, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Mitsuhiko Yahata
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Chihiro Ota
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | | | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kazushige Kadota
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshiki Takatsu
- Division of Cardiology, Hyogo Prefectural Amagasaki Hospital, Amagasaki, Japan
| | - Takashi Tamura
- Division of Cardiology, Japanese Red Cross Society Wakayama Medical Center, Wakayama, Japan
| | - Akinori Takizawa
- Division of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Tsukasa Inada
- Division of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Osamu Doi
- Division of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Ryuji Nohara
- Division of Cardiology, Cardiovascular Center, the Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Mitsuo Matsuda
- Division of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Teruki Takeda
- Division of Cardiology, Koto Memorial Hospital, Higashioumi, Japan
| | - Masayuki Kato
- Division of Cardiology, Maizuru Kyosai Hospital, Maizuru, Japan
| | - Manabu Shirotani
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Nara, Japan
| | - Hiroshi Eizawa
- Division of Cardiology, Nishi-Kobe Medical Center, Kobe, Japan
| | - Katsuhisa Ishii
- Division of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Jong-Dae Lee
- Division of Cardiology, University of Fukui Hospital, Fukui, Japan
| | | | - Minoru Horie
- Department of Cardiovascular and Respiratory, Shiga University of Medical Science, Otsu, Japan
| | | | - Shinji Miki
- Division of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | - Takeshi Aoyama
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Satoru Suwa
- Division of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka Japan
| | - Shuichi Hamasaki
- Department of Cardiovascular, Respiratory and Metabolic Medicine, Graduate School of Medicine, Kagoshima University, Kagoshima, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuaki Mitsudo
- Division of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | | | - Toru Kita
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Donahue M, Briguori C. Coronary artery stenting in elderly patients: where are we now. Interv Cardiol 2014. [DOI: 10.2217/ica.14.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Czarny MJ, Nathan AS, Yeh RW, Mauri L. Adherence to dual antiplatelet therapy after coronary stenting: a systematic review. Clin Cardiol 2014; 37:505-13. [PMID: 24797884 DOI: 10.1002/clc.22289] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 03/26/2014] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Adherence to dual antiplatelet therapy (DAPT) is critical after coronary stenting. Although adherence rates are frequently assessed in clinical trials, adherence rates in the unselected population recommended for treatment but beyond clinical trials are largely unknown. Therefore, we performed a systematic review of published observational studies to describe rates of DAPT adherence, trends in DAPT use over time, and patient-level factors associated with nonadherence. HYPOTHESIS DAPT adherence declines with increasing time after drug-eluting stent implantation. METHODS PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, and Web of Knowledge were searched through November 20, 2012 for studies including patients receiving 1 or more drug-eluting stents and reporting the use of aspirin and/or thienopyridines, or assessing factors associated with nonadherence to DAPT after bare metal or drug-eluting stent placement. RESULTS We included 34 studies in the description of DAPT adherence and 11 studies in the description of factors associated with nonadherence. Adherence to DAPT and thienopyridines was high at 1 month but declined by 12 months. Aspirin adherence was at least 90% throughout. Factors associated with nonadherence included bleeding, lower education level, immigrant status, and lack of education regarding DAPT. CONCLUSIONS DAPT adherence is suboptimal at 12 months, and interventions to increase adherence should focus on reducing bleeding risk and improving communication between patients and physicians.
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Affiliation(s)
- Matthew J Czarny
- Cardiology Division, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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D'Ascenzo F, Colombo F, Barbero U, Moretti C, Omedè P, Reed MJ, Tarantini G, Frati G, Di Nicolantonio JJ, Biondi Zoccai G, Gaita F. Discontinuation of dual antiplatelet therapy over 12 months after acute coronary syndromes increases risk for adverse events in patients treated with percutaneous coronary intervention: systematic review and meta-analysis. J Interv Cardiol 2014; 27:233-41. [PMID: 24627967 DOI: 10.1111/joic.12107] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Duration of dual antiplatelet therapy (DAPT) following acute coronary syndrome (ACS) hospitalization remains to be defined, both for patients treated medically and for those undergoing percutaneous transluminal coronary angioplasty (PTCA). METHODS PubMed, Cochrane, and Google Scholar were systematically searched for studies including patients presenting with ACS, and treated either with DAPT longer than or shorter than 12 months. Multivariable-adjusted risk estimates for death and recurrent ACS with stopping DAPT after 12 months (odds ratios [OR] 95% confidence intervals [CI]) were pooled after logarithmic transformation according to random-effect models with inverse-variance weighting. RESULTS Five studies with 49,586 patients were included. Median age was 66 (64-67) years, with 67% (65-75) males. Myocardial infarction (MI) represented the admission diagnosis for 88% (60-100) of the patients, and 66% (50-74) were treated with stenting. After a follow-up of 2.1 years (1.5-2.7), 40% (35-46) still on DAPT after 12 months and the rates of death or recurrent ACS were 16.6 (14.5-17.0). Risk of adverse events for patients stopping DAPT after 1 year was significantly increased (OR = 1.19 [1.07-1.32]) for those receiving stents, but not for patients managed medically (OR = 1.13 [0.95-1.35]). The increased risk did not vary according to age, gender, myocardial infarction as admission diagnosis, and kind of stent. CONCLUSIONS Interruption of DAPT over 12 months after ACS increases the risk of adverse events for patients treated with PTCA, but not for those managed conservatively, independently from baseline features and admission diagnosis. This hypothesis-generating finding should be tested in randomized controlled trials.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Division of Cardiology, University of Turin, Città Della Salute e Delle Scienze San Giovanni Battista, Turin, Italy; Meta-analysis and Evidence Based Medicine Training in Cardiology (METCARDIO), Wegmans Pharmacy Ithaca, Ithaca, New York
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Bonhomme F, Fontana P, Reny JL. How to manage prasugrel and ticagrelor in daily practice. Eur J Intern Med 2014; 25:213-20. [PMID: 24529662 DOI: 10.1016/j.ejim.2014.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 01/20/2014] [Accepted: 01/22/2014] [Indexed: 12/13/2022]
Abstract
Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapider and more potent inhibition of platelet P2Y12 receptor than clopidogrel. In combination with aspirin, these new P2Y12 inhibitors are now the first line treatments for patients with acute coronary syndrome. However, these potent antiplatelet agents introduce a new paradigm in the daily management of antithrombotic drugs, particularly when an invasive procedure is planned. The pharmacology of these antiplatelet agents, and the results of the main clinical trials, are reviewed with a special focus on good prescription practices (indications, contra-indications, drug interactions), and on peri-operative management. Strategies are proposed for safely reducing the bleeding risk in elderly patients, in patients requiring concomitant oral anticoagulant therapy, or in patients with an increased haemorrhagic risk.
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Affiliation(s)
- Fanny Bonhomme
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Anaesthesiology, Geneva University Hospitals, Geneva, Switzerland.
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Luc Reny
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Switzerland; Division of General Internal Medicine and Rehabilitation, Trois-Chêne, Geneva University Hospitals, Geneva, Switzerland
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31
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Campo G, Tebaldi M, Vranckx P, Biscaglia S, Tumscitz C, Ferrari R, Valgimigli M. Short- Versus Long-Term Duration of Dual Antiplatelet Therapy in Patients Treated for In-Stent Restenosis. J Am Coll Cardiol 2014; 63:506-12. [DOI: 10.1016/j.jacc.2013.09.043] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 09/04/2013] [Accepted: 09/22/2013] [Indexed: 12/22/2022]
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Takada K, Ishikawa S, Yokoyama N, Hosogoe N, Isshiki T. Effects of Eicosapentaenoic Acid on Platelet Function in Patients Taking Long-Term Aspirin Following Coronary Stent Implantation. Int Heart J 2014; 55:228-33. [DOI: 10.1536/ihj.13-295] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kaoru Takada
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Shuichi Ishikawa
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Naoyuki Yokoyama
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Naoyoshi Hosogoe
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Takaaki Isshiki
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
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Varenhorst C, Jensevik K, Jernberg T, Sundstrom A, Hasvold P, Held C, Lagerqvist B, James S. Duration of dual antiplatelet treatment with clopidogrel and aspirin in patients with acute coronary syndrome. Eur Heart J 2013; 35:969-78. [DOI: 10.1093/eurheartj/eht438] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Circulation: Cardiovascular Interventions
Editors’ Picks. Circ Cardiovasc Interv 2013. [DOI: 10.1161/circinterventions.113.000848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lee M, Saver JL, Hong KS, Wu HC, Ovbiagele B. Risk of Intracranial Hemorrhage With Protease-Activated Receptor-1 Antagonists. Stroke 2012; 43:3189-95. [DOI: 10.1161/strokeaha.112.670604] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Recent clinical trial data suggest that protease-activated receptor-1 (PAR-1) antagonists may increase the risk of intracranial hemorrhage. Our objective was to investigate the qualitative and quantitative risks of intracranial hemorrhage in patients receiving PAR-1 antagonist therapy.
Methods—
Pubmed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov from 1966 to May 2012, were searched to identify relevant studies. We included randomized controlled trials that included a comparison of PAR-1 antagonist with placebo and in which the total number of patients and intracranial hemorrhage events were reported separately for active treatment and control groups. Summary incidence rates, relative risks, and 95% confidence intervals (CIs) were calculated using random-effects models. Between-study heterogeneity was assessed using the
I
2
statistic.
Results—
In 9 PAR-1 antagonist trials with 42000 patients with a history of thrombotic vascular disease or acute coronary syndrome, PAR-1 antagonist treatment was associated with increased risk of intracranial hemorrhage (0.59% vs 0.30%; relative risk, 1.98; 95% CI, 1.46–2.68;
P
<0.00001; number needed to harm, 345). There was no heterogeneity across trials (
P
=0.84;
I
2
=0%), PAR-1 antagonist agent (
P
=0.52), treatment duration (
P
=0.38), or trial-qualifying event (
P
=0.59). Risk of death from any cause or a cardiovascular cause did not differ between active treatment and control groups.
Conclusion—
In a pooled analysis of data from 9 trials, PAR-1 antagonist therapy was associated with an increased risk for intracranial hemorrhage.
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Affiliation(s)
- Meng Lee
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi (M.L.) and Linkuo (H.-C.W.), Taiwan; Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA (J.L.S.); Department of Neurology, Ilsan Paik Hospital, Inje University, South Korea (K.-S.H.); and Department of Neurosciences, Medical University of South Carolina, Charleston, SC (B.O.)
| | - Jeffrey L. Saver
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi (M.L.) and Linkuo (H.-C.W.), Taiwan; Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA (J.L.S.); Department of Neurology, Ilsan Paik Hospital, Inje University, South Korea (K.-S.H.); and Department of Neurosciences, Medical University of South Carolina, Charleston, SC (B.O.)
| | - Keun-Sik Hong
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi (M.L.) and Linkuo (H.-C.W.), Taiwan; Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA (J.L.S.); Department of Neurology, Ilsan Paik Hospital, Inje University, South Korea (K.-S.H.); and Department of Neurosciences, Medical University of South Carolina, Charleston, SC (B.O.)
| | - Hsiu-Chuan Wu
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi (M.L.) and Linkuo (H.-C.W.), Taiwan; Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA (J.L.S.); Department of Neurology, Ilsan Paik Hospital, Inje University, South Korea (K.-S.H.); and Department of Neurosciences, Medical University of South Carolina, Charleston, SC (B.O.)
| | - Bruce Ovbiagele
- From the Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi (M.L.) and Linkuo (H.-C.W.), Taiwan; Stroke Center, Geffen School of Medicine, University of California, Los Angeles, CA (J.L.S.); Department of Neurology, Ilsan Paik Hospital, Inje University, South Korea (K.-S.H.); and Department of Neurosciences, Medical University of South Carolina, Charleston, SC (B.O.)
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Witzenbichler B. Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation. J Am Coll Cardiol 2012; 60:1349-51. [DOI: 10.1016/j.jacc.2012.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 07/24/2012] [Accepted: 08/07/2012] [Indexed: 10/27/2022]
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