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Shima Y, Taninobu N, Ikuta A, Mushiake K, Tanaka H, Kadota K. Two-year outcomes of endovascular therapy for femoropopliteal arterial lesions for patients with high bleeding risk. Cardiovasc Interv Ther 2024; 39:284-292. [PMID: 38630431 DOI: 10.1007/s12928-024-00999-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 03/22/2024] [Indexed: 06/12/2024]
Abstract
The Academic Research Consortium (ARC) recently published a definition of patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. However, the prevalence of the ARC-HBR criteria in patients undergoing endovascular therapy (EVT) for femoropopliteal arterial lesions has not been thoroughly investigated. The study population comprised 165 patients undergoing initial EVT for femoropopliteal lesions between June 2018 and June 2020. They were divided into two groups according to the ARC-HBR criteria. The primary end point was a composite of all-cause death, Bleeding Academic Research Consortium type 3 or 5 bleeding, and target lesion revascularization (TLR) within 2 years of EVT. The 165 patients were divided into two groups: 125 (75.8%) patients at HBR (HBR group) and 40 (24.2%) patients at no HBR (non-HBR group). The cumulative incidence of the primary endpoint was significantly higher in the HBR group than in the non-HBR group (40.6% vs. 0%, log-rank p < 0.001). The HBR group had a significantly higher risk of all-cause death, major bleeding, and TLR than the non-HBR group (25.2% vs. 0%, log-rank p = 0.004, 13.9% vs. 0%, log-rank p = 0.047, 16.8% vs. 0%, log-rank p = 0.035). Most patients with peripheral artery disease were classified as HBR patients, and HBR patients were at higher risk of death, major bleeding, and TLR than non-HBR patients.
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Affiliation(s)
- Yuki Shima
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan.
| | - Narumi Taninobu
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Akihiro Ikuta
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Kazunori Mushiake
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
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Akin I, Hamdani N, El-Battrawy I. Understanding Differences in Sex-Based Outcomes with Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. Drugs 2024:10.1007/s40265-024-02041-4. [PMID: 38809374 DOI: 10.1007/s40265-024-02041-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/30/2024]
Affiliation(s)
- Ibrahim Akin
- Section of Invasive Cardiology and Electrophysiology, I. Department of Internal Medicine, University Mannheim, Medical Faculty Mannheim, University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Nazha Hamdani
- Institute of Physiology, Department of Cellular and Translational Physiology and Institute for Research and Education (IFL), Molecular and Experimental Cardiology, Ruhr-University Bochum, Bochum, Germany
- HCEMM-SU Cardiovascular Comorbidities Research Group, Department of Pharmacology and Pharmacotherapy, Semmelweis University, 1089, Budapest, Hungary
- Department of Physiology, Cardiovascular Research Institute, Maastricht University, 6229 ER, Maastricht, The Netherlands
| | - Ibrahim El-Battrawy
- Institute of Physiology, Department of Cellular and Translational Physiology and Institute for Research and Education (IFL), Molecular and Experimental Cardiology, Ruhr-University Bochum, Bochum, Germany
- Department of Cardiology, St. Josef Hospital, Ruhr-University of Bochum, Bochum, Germany
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Sambola A, Halvorsen S, Adlam D, Hassager C, Price S, Rosano G, Schiele F, Holmvang L, de Riva M, Rakisheva A, Sulzgruber P, Swahn E. Management of cardiac emergencies in women: a clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the Heart Failure Association (HFA), and the European Heart Rhythm Association (EHRA) of the ESC, and the ESC Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae011. [PMID: 38628674 PMCID: PMC11020263 DOI: 10.1093/ehjopen/oeae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/10/2024] [Accepted: 02/22/2024] [Indexed: 04/19/2024]
Abstract
Cardiac emergencies in women, such as acute coronary syndromes, acute heart failure, and cardiac arrest, are associated with a high risk of adverse outcomes and mortality. Although women historically have been significantly underrepresented in clinical studies of these diseases, the guideline-recommended treatment for these emergencies is generally the same for both sexes. Still, women are less likely to receive evidence-based treatment compared to men. Furthermore, specific diseases affecting predominantly or exclusively women, such as spontaneous coronary dissection, myocardial infarction with non-obstructive coronary arteries, takotsubo cardiomyopathy, and peripartum cardiomyopathy, require specialized attention in terms of both diagnosis and management. In this clinical consensus statement, we summarize current knowledge on therapeutic management of these emergencies in women. Key statements and specific quality indicators are suggested to achieve equal and specific care for both sexes. Finally, we discuss several gaps in evidence and encourage further studies designed and powered with adequate attention for sex-specific analysis.
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Affiliation(s)
- Antonia Sambola
- Department of Cardiology and Research Institute, University Hospital Vall d’Hebron, Universitat Autònoma, CIBER Cardiovascular diseases (CIBER-CV), Barcelona, Spain
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, P.O. Box 4956 Nydalen, N-0424 Oslo, Norway
- Institue of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, N-0318 Oslo, Norway
| | - David Adlam
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Susanna Price
- Adult Intensive Care Unit, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George’s University Hospital, London, UK
- Cardiology, San Raffaele Cassino Hospital, Cassino, Italy
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Lene Holmvang
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Marta de Riva
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Amina Rakisheva
- Department of Cardiology, City Cardiology Center, Almaty, Kazakhstan
- Department of Cardiology, Qonaev City Hospital, Almaty Region, Kazakhstan
| | - Patrick Sulzgruber
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Eva Swahn
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Lin CF, Tsai CL, Chang YH, Lin DY, Chien LN. Sex-based differences in ischemic cardiovascular and bleeding outcomes following implantation of drug-eluting stent in patients at high bleeding risk. Hellenic J Cardiol 2024:S1109-9666(24)00001-0. [PMID: 38218375 DOI: 10.1016/j.hjc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/28/2023] [Accepted: 01/08/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Patients with high bleeding risk (HBR) may exhibit uncertain adherence to dual antiplatelet therapy (DAPT) following drug-eluting stent (DES) implantation. The current population-based cohort study aimed to investigate the sex-based differences in adverse outcomes among the HBR population by analyzing the National Health Insurance Research Database in Taiwan. METHODS Patients who had HBR features defined by the Academic Research Consortium (ARC) and received DES implantation between January 1, 2007, and December 31, 2017, were enrolled. Propensity score matching was adopted to select 3,981 pairs with similar clinical cardiovascular risks but different sexes. A competing risk model was performed to evaluate the risk of adverse ischemic events (cardiac death, nonfatal myocardial infarction, and ischemic stroke) and any bleeding events in both sexes. Noncardiac death was considered a competing risk. RESULTS Within a 5-year follow-up, the incidence rates (per 1,000 person-year (95% confidence interval (CI)) of composite ischemic events and any bleeding events in males were respectively 44.09 (40.25-48.30) and 42.55 (38.79-46.68), while those in females were respectively 40.18 (36.51-44.23) and 42.35 (38.57-46.51). After adjustment for clinical variables, male patients had a marginally increased risk in the composite ischemic events (adjusted subdistribution hazard ratio (SHR) = 1.15 (1.00-1.31), p = 0.045) and a similar risk of any bleeding events (adjusted SHR = 1.00 (0.88-1.15), p = 0.946) compared with female patients. CONCLUSIONS Of the HBR population, males had an increased risk of ischemic outcomes but a similar risk of bleeding compared with females following DES implantation.
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Affiliation(s)
- Chao-Feng Lin
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Chia-Ling Tsai
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ya-Hui Chang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Department of Pharmacy, MacKay Memorial Hospital, Taipei, Taiwan
| | - Dai-Yi Lin
- Division of Cardiology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Landi A, Alasnag M, Heg D, Frigoli E, Malik FTN, Gomez-Blazquez I, Pourbaix S, Chieffo A, Spaulding C, Sainz F, Routledge H, Andò G, Testa L, Sciahbasi A, Contractor H, Jepson N, Mieres J, Imran SS, Noor H, Smits PC, Valgimigli M. Abbreviated or Standard Dual Antiplatelet Therapy by Sex in Patients at High Bleeding Risk: A Prespecified Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024; 9:35-44. [PMID: 37991745 PMCID: PMC10666042 DOI: 10.1001/jamacardio.2023.4316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 09/27/2023] [Indexed: 11/23/2023]
Abstract
Importance Abbreviated dual antiplatelet therapy (DAPT) reduces bleeding with no increase in ischemic events in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI). Objectives To evaluate the association of sex with the comparative effectiveness of abbreviated vs standard DAPT in patients with HBR. Design, Setting, and Patients This prespecified subgroup comparative effectiveness analysis followed the Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated vs Standard DAPT Regimen (MASTER DAPT) trial, a multicenter, randomized, open-label clinical trial conducted at 140 sites in 30 countries and performed from February 28, 2017, to December 5, 2019. A total of 4579 patients with HBR were randomized at 1 month after PCI to abbreviated or standard DAPT. Data were analyzed from July 1 to October 31, 2022. Interventions Abbreviated (immediate DAPT discontinuation, followed by single APT for ≥6 months) or standard (DAPT for ≥2 additional months, followed by single APT for 11 months) treatment groups. Main Outcomes and Measures One-year net adverse clinical events (NACEs) (a composite of death due to any cause, myocardial infarction, stroke, or major bleeding), major adverse cardiac or cerebral events (MACCEs) (a composite of death due to any cause, myocardial infarction, or stroke), and major or clinically relevant nonmajor bleeding (MCB). Results Of the 4579 patients included in the analysis, 1408 (30.7%) were women and 3171 (69.3%) were men (mean [SD] age, 76.0 [8.7] years). Ischemic and bleeding events were similar between sexes. Abbreviated DAPT was associated with comparable NACE rates in men (hazard ratio [HR], 0.97 [95% CI, 0.75-1.24]) and women (HR, 0.87 [95% CI, 0.60-1.26]; P = .65 for interaction). There was evidence of heterogeneity of treatment effect by sex for MACCEs, with a trend toward benefit in women (HR, 0.68 [95% CI, 0.44-1.05]) but not in men (HR, 1.17 [95% CI, 0.88-1.55]; P = .04 for interaction). There was no significant interaction for MCB across sex, although the benefit with abbreviated DAPT was relatively greater in men (HR, 0.65 [95% CI, 0.50-0.84]) than in women (HR, 0.77 [95% CI, 0.53-1.12]; P = .46 for interaction). Results remained consistent in patients with acute coronary syndrome and/or complex PCI. Conclusions and Relevance These findings suggest that women with HBR did not experience higher rates of ischemic or bleeding events compared with men and may derive particular benefit from abbreviated compared with standard DAPT owing to these numerically lower rates of events. Trial Registration ClinicalTrials.gov Identifier: NCT03023020.
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Affiliation(s)
- Antonio Landi
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Dik Heg
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Enrico Frigoli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Ivan Gomez-Blazquez
- Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre, Madrid, Spain
| | - Suzanne Pourbaix
- Department of Cardiology, Hospital de al Citadelle Liège, Liège, Belgium
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Christian Spaulding
- Department of Cardiology, European Hospital Georges Pompidou, Assistance Publique–Hopitaux de Paris, Paris Cité University and Institut National de la Santé et de la Recherche Médicale U970, Paris, France
| | - Fermin Sainz
- Division of Cardiology, Hospital Universitario Marques de Valdecilla, Instituto de Investigación Marques de Valdecilla, Santander, Spain
| | - Helen Routledge
- Department of Cardiology, Worcestershire Royal Hospital, Worcester, United Kingdom
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Testa
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Hussain Contractor
- Department of Cardiovascular Medicine, Manchester University NHS (National Health Service) Foundation Trust, Wythenshawe Hospital, Manchester, United Kingdom
| | - Nigel Jepson
- Department of Cardiology, Prince of Wales Hospital, Sydney, Australia
- Department of Cardiology, University of New South Wales, Sydney, New South Wales, Australia
| | - Juan Mieres
- Cardiovascular Research Center, Otamendi Hospital, Buenos Aires, Argentina
| | | | - Husam Noor
- Mohammed Bin Khalifa Specialist Cardiac Centre, Awali, Kingdom of Bahrain
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- University of Bern, Bern, Switzerland
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Shin ES, Her AY, Kim B, Hahn JY, Song YB, Lee JM, Park TK, Yang JH, Choi JH, Choi SH, Lee SH, Gwon HC. Sex-Based Outcomes of P2Y12 Inhibitor Monotherapy After Three Months of Dual Antiplatelet Therapy in Patients Undergoing Percutaneous Coronary Intervention. J Korean Med Sci 2023; 38:e383. [PMID: 37987108 PMCID: PMC10659928 DOI: 10.3346/jkms.2023.38.e383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 08/22/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI) in the SMART-CHOICE trial, P2Y12 inhibitor monotherapy after three months of dual antiplatelet therapy (DAPT) achieved clinical outcomes comparable to those of 12 months of DAPT. Nonetheless, the effects of sex on these outcomes remain unknown. METHODS This open-label, non-inferiority, randomized study, conducted in 33 hospitals in South Korea, included 2,993 patients undergoing PCI with drug-eluting stents. Patients were randomly assigned to receive DAPT (aspirin plus a P2Y12 inhibitor) for three months then P2Y12 inhibitor alone for nine months, or DAPT for the entire 12 months. The primary endpoints were major adverse cardiac and cerebrovascular events (a composite of all-cause death, myocardial infarction, or stroke) 12 months after the index procedure. The bleeding endpoints were Bleeding Academic Research Consortium (BARC) bleeding types 2 to 5. RESULTS Of the patients, 795 (26.6%) were women, who were older and had a higher prevalence of hypertension, diabetes, and dyslipidemia than men. The sexes exhibited comparable primary endpoints (adjusted hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.55-1.55; P = 0.770) and bleeding endpoints (adjusted HR, 1.07; 95% CI, 0.63-1.81; P = 0.811). P2Y12 inhibitor monotherapy vs DAPT was associated with lower risk of BARC type 2 to 5 bleeding in women (adjusted HR, 0.40; 95% CI, 0.16-0.98; P = 0.045) but the difference was not statistically significant when using the Bonferroni correction. The primary endpoints were similar between treatment groups in both sexes. CONCLUSION In both sexes undergoing PCI, P2Y12 inhibitor monotherapy after three months of DAPT achieved similar risks of the primary endpoints and the bleeding events compared with prolonged DAPT. Therefore, the benefits of early aspirin withdrawal with ongoing P2Y12 inhibitors may be comparable in women and men. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02079194.
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Affiliation(s)
- Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University College of Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Bitna Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Occhipinti G, Greco A, Angiolillo DJ, Capodanno D. Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes. Expert Opin Drug Saf 2023; 22:669-683. [PMID: 37542468 DOI: 10.1080/14740338.2023.2245331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex. AREAS COVERED This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed. EXPERT OPINION Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Laborante R, Borovac JA, Galli M, Rodolico D, Ciliberti G, Restivo A, Cappannoli L, Arcudi A, Vergallo R, Zito A, Princi G, Leone AM, Aurigemma C, Romagnoli E, Montone RA, Burzotta F, Trani C, D’Amario D. Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome? Front Cardiovasc Med 2022; 9:1009475. [PMID: 36386309 PMCID: PMC9659635 DOI: 10.3389/fcvm.2022.1009475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2022] [Indexed: 08/11/2023] Open
Abstract
The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.
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Affiliation(s)
- Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Josip Andjelo Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Cappannoli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Arcudi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D’Amario
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Sun Y, Feng L, Li X, Wang Z, Gao R, Wu Y. In-hospital major bleeding in patients with acute coronary syndrome medically treated with dual anti-platelet therapy: Associated factors and impact on mortality. Front Cardiovasc Med 2022; 9:878270. [DOI: 10.3389/fcvm.2022.878270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveMajor bleeding is associated with poor hospital prognosis in patients with acute coronary syndrome (ACS). Despite its clinical importance, there are limited studies on the incidence and risk factors for major bleeding in ACS patients with dual anti-platelet therapy (DAPT) without access to revascularization.MethodsWe analyzed data from 19,186 patients on DAPT after ACS with no access to revascularization from Clinical Pathway for Acute Coronary Syndrome in China Phase 3 (CPACS-3) cohort, which was conducted from 2011 to 2014. Major bleeding included intracranial hemorrhage, clinically significant bleeding, or bleeding requiring blood transfusion. Factors associated with in-hospital major bleeding were assessed using Poisson regressions with generalized estimating equations to account for the clustering effect.ResultsA total of 75 (0.39%) patients experienced major bleeding during hospitalization. Among subtypes of ACS, 0.65% of patients with STEMI, 0.33% with NSTEMI, and 0.13% with unstable angina had in-hospital major bleeding (p < 0.001). The patients who experienced major bleeding had a longer length of stay (median 12 vs. 9 days, p = 0.011) and a higher all-cause in-hospital death rate (22.7 vs. 3.7%, p < 0.001). Multivariable analysis showed advancing age (RR = 1.52 for every 10 years increase, 95% CI: 1.13, 2.05), impaired renal function (RR = 1.79, 95% CI: 1.10, 2.92), use of fibrinolytic drugs (RR = 2.93, 95% CI: 1.55, 5.56), and severe diseases other than cardiovascular and renal diseases (RR = 5.56, 95% CI: 1.10, 28.07) were associated with increased risk of major bleeding, whereas using renin–angiotensin system inhibitors (RR = 0.54, 95% CI: 0.36, 0.81) was associated with decreased risk of major bleeding. These independent factors together showed good predictive accuracy with an AUC of 0.788 (95% CI: 0.734, 0.841).ConclusionAmong ACS patients on DAPT, advancing age, impaired renal function, thrombolytic treatment, and severe comorbidities were independently associated with a higher risk of in-hospital major bleeding.
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10
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de Miguel-Balsa E. Risk stratification and health inequalities in women with acute coronary syndrome: time to move on. Lancet 2022; 400:710-711. [PMID: 36049492 DOI: 10.1016/s0140-6736(22)01607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Eva de Miguel-Balsa
- Intensive and Coronary Care Unit, Intensive Care Medicine, Hospital General Universitario de Elche, Alicante, Spain; Department of Clinical Medicine, Universidad Miguel Hernández, Elche 03203, Spain.
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11
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Madan M, Abbott JD, Lennon R, So DYF, MacDougall AM, McLaughlin MA, Murthy V, Saw J, Rihal C, Farkouh ME, Pereira NL, Goodman SG. Sex-Specific Differences in Clinical Outcomes After Percutaneous Coronary Intervention: Insights from the TAILOR-PCI Trial. J Am Heart Assoc 2022; 11:e024709. [PMID: 35699175 PMCID: PMC9238632 DOI: 10.1161/jaha.121.024709] [Citation(s) in RCA: 0] [Impact Index Per Article: 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 TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to decreased Clopidogrel Response After Percutaneous Coronary Intervention) studied genotype-guided selection of antiplatelet therapy after percutaneous coronary intervention versus conventional therapy with clopidogrel. The presence of CYP2C19 loss-of-function alleles in patients treated with clopidogrel may be associated with increased risk for ischemic events. We report a prespecified sex-specific analysis of genotyping and associated cardiovascular outcomes from this study. Methods and Results Associations between sex and major adverse cardiac events (MACE: cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia) and Bleeding Academic Research Consortium (BARC) bleeding at 12 months were analyzed using Cox proportional-hazards models. Among 5276 randomized patients, loss-of-function carriers were observed in ≈36% of both sexes, and >80% of carriers were heterozygotes. At 12 months, after adjustment for baseline differences, risks of MACE (HR , 1.28 [0.97 to 1.68]; P=0.088) and BARC bleeding (hazard ratio [HR], 1.36 [0.91 to 2.05]; P=0.14) were comparable among women and men. There were no significant interactions between sex and treatment strategy for MACE interaction P value (Pint=0.59) or BARC bleeding (Pint=0.47) nor for sex and genotype (MACE Pint=0.15, and BARC bleeding Pint=0.60). Conclusions CYP2C19 loss-of-function alleles were present in ≈1 in 3 women and men. Women had similar adjusted risks of MACE and bleeding as men following percutaneous coronary intervention. Genotype-guided therapy did not significantly reduce the risk of MACE or bleeding relative to conventional therapy for both sexes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01742117.
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Affiliation(s)
- Mina Madan
- Schulich Heart CentreSunnybrook Health Sciences CentreUniversity of Toronto Toronto Ontario Canada
| | - J Dawn Abbott
- Division of Cardiology Lifespan Cardiovascular Institute Warren Alpert Medical School of Brown University Providence RI
| | - Ryan Lennon
- Department of Quantitative Health Sciences Mayo Clinic Rochester MN
| | - Derek Y F So
- University of Ottawa Heart Institute Ottawa Ontario Canada
| | | | | | | | - Jacqueline Saw
- Vancouver General HospitalUniversity of British Columbia Vancouver British Columbia Canada
| | - Charanjit Rihal
- Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Michael E Farkouh
- Peter Munk Cardiac CentreUniversity of Toronto Ontario Canada.,Heart and Stroke Richard Lewar CentreUniversity of Toronto Ontario Canada
| | | | - Shaun G Goodman
- St. Michael's HospitalUniversity of Toronto Ontario Canada.,Canadian VIGOUR Centre University of Alberta Edmonton Alberta Canada
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12
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Nardin M, Cao D, Mehran R, Chandiramani R, Chiarito M, Sartori S, Qiu H, Zhang Z, Golani E, Nicolas J, Baber U, Dangas G, De Luca G, Stefanini GG, Sweeny J, Sharma SK, Kini A. Sex-Related Differences in the Prevalence and Prognostic Value of the Academic Research Consortium for High Bleeding Risk Criteria. Circ Cardiovasc Interv 2021; 14:e010392. [PMID: 34474588 DOI: 10.1161/circinterventions.120.010392] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Matteo Nardin
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.).,Department of Medical and Surgical Sciences, University of Brescia, Italy (M.N.).,Division of Medicine, ASST Spedali Civili, Brescia, Italy (M.N.)
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.).,Department of Internal Medicine, Albert Einstein College of Medicine/Jacobi medical center, Bronx, New York (R.C.)
| | - Mauro Chiarito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (M.C., G.G.S.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (M.C., G.G.S.)
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Hanbo Qiu
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Ekta Golani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City (U.B.)
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Giuseppe De Luca
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy (G.D.L.).,Division of Cardiology, AOU Maggiore della Carità, Novara, Italy (G.D.L.)
| | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy (M.C., G.G.S.).,IRCCS Humanitas Research Hospital, Rozzano-Milan, Italy (M.C., G.G.S.)
| | - Joseph Sweeny
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
| | - Annapoorna Kini
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (M.N., D.C., R.M., R.C., M.C., S.S., H.Q., Z.Z., E.G., J.N., G.D., J.S., S.K.S., A.K.)
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13
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Ferreira MCM, Oliveira MVD, Paiva MSM, Lemke V, Mangione F, Oliveira GMMD. Closing the Gender Gap in Ischemic Heart Diseases and Myocardial Infarction. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20210001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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14
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Spirito A, Gragnano F, Corpataux N, Vaisnora L, Galea R, Svab S, Gargiulo G, Siontis GCM, Praz F, Lanz J, Billinger M, Hunziker L, Stortecky S, Pilgrim T, Capodanno D, Urban P, Pocock S, Mehran R, Heg D, Windecker S, Räber L, Valgimigli M. Sex-Based Differences in Bleeding Risk After Percutaneous Coronary Intervention and Implications for the Academic Research Consortium High Bleeding Risk Criteria. J Am Heart Assoc 2021; 10:e021965. [PMID: 34098740 PMCID: PMC8477884 DOI: 10.1161/jaha.121.021965] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Female sex was not included among the high bleeding risk (HBR) criteria by the Academic Research Consortium (ARC) as it remains unclear whether it constitutes an HBR condition after percutaneous coronary intervention. We investigated whether female sex associates with HBR and assessed the performance of ARC HBR criteria separately in women and men. Methods and Results Among all consecutive patients undergoing percutaneous coronary intervention between 2009 and 2018, bleeding occurrences up to 1 year were prospectively collected and centrally adjudicated. All but one of the originally defined ARC HBR criteria were assessed, and the ARC HBR score generated accordingly. Among 16 821 patients, 25.6% were women. Compared with men, women were older and had lower creatinine clearance and hemoglobin values. After adjustment, female sex was independently associated with access‐site (adjusted hazard ratio, 2.14; 95% CI, 1.22–3.74; P=0.008) but not with overall or non–access‐site 1‐year Bleeding Academic Research Consortium 3 or 5 bleeding. This association remained consistent when the femoral but not the radial approach was chosen. The ARC HBR score discrimination, using the original criteria, was lower among women than men (c‐index 0.644 versus 0.688; P=0.048), whereas a revised ARC HBR score, in which age, creatinine clearance, and hemoglobin were modeled as continuous rather than dichotomized variables, performed similarly in both sexes. Conclusions Female sex is an independent predictor for access‐site bleeding but not for overall bleeding events at 1 year after percutaneous coronary intervention. The ARC HBR framework shows an overall good performance in both sexes, yet is lower in women than men, attributable to dichotomization of age, creatinine clearance, and hemoglobin values, which are differently distributed between sexes. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02241291.
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Affiliation(s)
| | - Felice Gragnano
- Department of Cardiology Bern University Hospital Bern Switzerland.,Division of Cardiology Department of Translational Medicine University of Campania "Luigi Vanvitelli Caserta Italy
| | - Noé Corpataux
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Lukas Vaisnora
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Roberto Galea
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Stefano Svab
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences Federico II University of Naples Naples Italy
| | | | - Fabien Praz
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Jonas Lanz
- Department of Cardiology Bern University Hospital Bern Switzerland
| | | | - Lukas Hunziker
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Stefan Stortecky
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Thomas Pilgrim
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Davide Capodanno
- Division of Cardiology Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele" University of Catania Catania Italy
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine London United Kingdom
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Dik Heg
- Clinical Trial Unit Bern University of Bern Switzerland
| | | | - Lorenz Räber
- Department of Cardiology Bern University Hospital Bern Switzerland
| | - Marco Valgimigli
- Department of Cardiology Bern University Hospital Bern Switzerland.,Istituto Cardiocentro Ticino Ente Ospedaliero Cantonale Lugano Switzerland
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15
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Shima Y, Miura K, Shimada T, Ohya M, Murai R, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Impact of ischemic risk factors on long-term outcomes in patients with and without high bleeding risk. Int J Cardiol 2020; 326:12-18. [PMID: 33152414 DOI: 10.1016/j.ijcard.2020.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
Background The current guidelines have recommended to shorten the dual antiplatelet therapy duration in patients at high bleeding risk (HBR) to minimize the bleeding complications. The impact of ischemic risk factors (IRF) on long-term ischemic events in patients with and without HBR after percutaneous coronary intervention remains unclear. Methods The study population comprised 1219 patients who were treated with everolimus-eluting stents between 2010 and 2011. The mean follow-up period was 2996 ± 433 days. HBR was defined as set by the Academic Research Consortium. IRF was defined as high-risk features of stent-driven recurrent ischemic events endorsed in the 2017 European Society of Cardiology Guidelines. Major bleeding was defined as the occurrence of Bleeding Academic Research Consortium type 3 or 5 bleeding. Primary ischemic events included myocardial infarction, definite stent thrombosis, and cardiac death. Results The 1219 patients were divided into two groups: 614 patients at HBR (HBR group) and 605 patients at no HBR (non-HBR group). The rate of IRF patients was significantly higher in the HBR group than in the non-HBR group (81.4% versus 47.6%, P < 0.001). The cumulative rate of ischemic events in the HBR group was significantly higher in IRF patients than in non-IRF patients (21.0% versus 7.0%, log rank P < 0.001), whereas that in the non-HBR group was not significantly different between IRF and non-IRF patients (10.1% versus 6.3%, log rank P = 0.09). Conclusions More than 80% of HBR patients treated with everolimus-eluting stents were at IRF. A combination of HBR and IRF may increase the risk of long-term ischemic events.
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Affiliation(s)
- Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan.
| | - Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takenobu Shimada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Syunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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16
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Chandiramani R, Cao D, Claessen BE, Sorrentino S, Guedeney P, Blum M, Goel R, Roumeliotis A, Krucoff M, Kozuma K, Ge J, Seth A, Makkar R, Bangalore S, Bhatt DL, Angiolillo DJ, Ruster K, Wang J, Saito S, Neumann FJ, Hermiller J, Valgimigli M, Mehran R. Sex-Related Differences in Patients at High Bleeding Risk Undergoing Percutaneous Coronary Intervention: A Patient-Level Pooled Analysis From 4 Postapproval Studies. J Am Heart Assoc 2020; 9:e014611. [PMID: 32223396 PMCID: PMC7428610 DOI: 10.1161/jaha.119.014611] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Women have been associated with higher rates of recurrent events after percutaneous coronary intervention than men, possibly attributable to advanced age at presentation and greater comorbidities. These factors also put women at higher risk of bleeding, which may influence therapeutic strategies and clinical outcomes. Methods and Results We performed a patient‐level pooled analysis of 4 postapproval registries to evaluate sex‐related differences in patients at high bleeding risk (HBR) undergoing percutaneous coronary intervention. HBR required fulfillment of at least 1 major or 2 minor criteria of the Academic Research Consortium definition. Outcomes of interest were major bleeding and major adverse cardiac events (composite of cardiac death, myocardial infarction, or definite/probable stent thrombosis). Of the total 10 502 patients, 2832 (27.0%) were women. The prevalence of HBR was higher in women compared with men (29.0% versus 20.5%, P<0.0001). Women at HBR were older and had more comorbidities, while men at HBR were more often smokers, with prior myocardial infarction and more complex coronary lesions. At 4 years, women at HBR had significantly higher major bleeding compared with men at HBR (10.8% versus 6.2%, P<0.0001); however, this difference was attenuated after multivariable adjustment (hazard ratio, 0.92; 95% CI, 0.41–2.08). Major adverse cardiac event rates between groups were similar (12.2% versus 12.6%, P=0.82) and remained consistent after adjustment (hazard ratio, 0.64; 95% CI, 0.32–1.28). Conclusions The prevalence of HBR was higher in women compared with men, with considerable differences in the distribution of criteria. Women at HBR experienced higher rates of major bleeding but similar major adverse cardiac event rates compared with men at HBR at 4 years.
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Affiliation(s)
- Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Sabato Sorrentino
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Paul Guedeney
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.,Sorbonne Université ACTION study group INSERM UMR_S 1166 Institut de Cardiologie Hôpital Pitié-Salpêtrière (AP-HP) Paris France
| | - Moritz Blum
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Anastasios Roumeliotis
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | | | | | - Junbo Ge
- Zhongshan Hospital Fudan University Shanghai China
| | - Ashok Seth
- Fortis Escorts Heart Institute New Delhi India
| | - Raj Makkar
- Cedars-Sinai Medical Center Los Angeles CA
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center Harvard Medical School Boston MA
| | - Dominick J Angiolillo
- Division of Cardiology University of Florida College of Medicine-Jacksonville Jacksonville FL
| | | | | | | | | | | | | | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
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