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Chow JK, Bagai A, Tan MK, Har BJ, Yip AMC, Paniagua M, Elbarouni B, Bainey KR, Paradis JM, Maranda R, Cantor WJ, Eisenberg MJ, Dery JP, Madan M, Cieza T, Matteau A, Roth S, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh RC, Kim HH, Robinson SD, Daneault B, Chong AY, Le May MR, Ahooja V, Gregoire JC, Nadeau PL, Laksman Z, Heilbron B, Yung D, Minhas K, Bourgeois R, Overgaard CB, Bonakdar H, Logsetty G, Lavoie AJ, De LaRochelliere R, Mansour S, Spindler C, Yan AT, Goodman SG. Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program. J Cardiol 2023; 82:153-161. [PMID: 36931433 DOI: 10.1016/j.jjcc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
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Affiliation(s)
| | - Akshay Bagai
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Bryan J Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Basem Elbarouni
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | | | - Warren J Cantor
- University of Toronto, Toronto, Canada; Southlake Regional Health Centre, Newmarket, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Mina Madan
- University of Toronto, Toronto, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Alexis Matteau
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | - Sherryn Roth
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Scarborough Health Network, Toronto, Canada
| | | | | | | | - Ravi Tahiliani
- Central East Regional Cardiac Care Program, Oshawa, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Hahn Hoe Kim
- St. Mary's General Hospital, Kitchener-Waterloo, Canada
| | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, Canada
| | - Benoit Daneault
- Centre hospitalier Universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Canada
| | | | | | | | | | | | | | - Brett Heilbron
- University of British Columbia, Vancouver, Canada; St. Paul's Hospital, Vancouver, Canada
| | - Derek Yung
- Scarborough Health Network, Toronto, Canada
| | - Kunal Minhas
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Ronald Bourgeois
- Moncton Hospital, Dalhousie University Faculty of Medicine, Moncton, Canada
| | | | - Hamid Bonakdar
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Robert De LaRochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Samer Mansour
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | | | - Andrew T Yan
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada.
| | - Shaun G Goodman
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada.
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Dehghani P, Singh J, Singer Z, Booker J, Lavoie AJ, Zimmermann RH, Shavadia JS, Webb JG, Clavel MA, Pibarot P. Catheter-Induced Postextrasystolic Potentiation in the Assessment of Severity of Low-Gradient Aortic Valve Stenosis. Circ Cardiovasc Interv 2023; 16:e012892. [PMID: 37125538 DOI: 10.1161/circinterventions.123.012892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Deciphering which patients with low-gradient aortic valve disease have severe stenosis can be difficult. We aimed to correlate the postextrasystolic potentiation (PESP) with dobutamine stress echocardiography and multidetector computed tomography in patients with low-gradient aortic valve stenosis. METHODS Patients with an aortic valve area ≤1 cm2 and a mean gradient <40 mm Hg were included. Aortic valve stenosis severity was assessed by a core lab with dobutamine stress echocardiography, followed by a multidetector computed tomography aortic valve score if indeterminate. A premature ventricular contraction was induced by intentional catheter contact with the myocardium within the left ventricle. PESP was calculated as a percent change of pre-to-post mean gradient. Multidetector computed tomography was used to measure the aortic valve calcification score, and subsequently, aortic valve calcification density. RESULTS Twenty-eight patients (age, 77±10 years; 19 female) were included. Dobutamine stress echocardiography increased mean gradient from baseline of 25±7 mm Hg to 36±11 mm Hg; pre-premature ventricular contraction mean gradient was 25±7 mm Hg and increased to post-premature ventricular contraction mean gradient of 32±10 mm Hg, representing a PESP of 24±11%. A ≥20% in PESP resulted in 100% sensitivity, 77% specificity, 83% positive predictive value, and 100% negative predictive value for diagnosing severe aortic valve stenosis. There was a significant correlation between PESP and projected aortic valve area and aortic valve calcification density (R=-0.64, P=0.0003; R=0.057, P=0.014, respectively). CONCLUSIONS In patients with low-gradient aortic valve stenosis, catheter-induced premature ventricular contractions during cardiac catheterization causing ≥20% PESP has a 100% sensitivity for severe aortic valve stenosis. Validation of this 20% cutoff in larger groups with correlation to clinical end points is required.
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Jyotpal Singh
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Zachary Singer
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Jeffrey Booker
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Andrea J Lavoie
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Rodney H Zimmermann
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Jay S Shavadia
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - John G Webb
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Marie-Annick Clavel
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
| | - Philippe Pibarot
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada (P.D., J.S., J.B., A.J.L., R.H.Z.)
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3
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Singh J, Bhagaloo L, Sy E, Lavoie AJ, Dehghani P, Bardutz HA, Mang CS, Buttigieg J, Neary JP. Cardiac impairments in postacute COVID-19 with sustained symptoms: A review of the literature and proof of concept. Physiol Rep 2022; 10:e15430. [PMID: 35993433 PMCID: PMC9393908 DOI: 10.14814/phy2.15430] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/21/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022] Open
Abstract
Although acute COVID-19 is known to cause cardiac damage in some cases, there is still much to learn about the duration and relative permanence of the damage that may occur. Long COVID is a condition that can occur when COVID-19 symptoms remain in the postviral acute period. Varying accounts of long COVID have been described across the literature, however, cardiac impairments are sustained in many individuals and cardiovascular assessment is now considered to be an expected follow-up examination. The purpose of this review and proof of concept is to summarize the current research related to the assessment of cardiac function, including echocardiography and blood biomarker data, during the follow-up period in patients who recovered from COVID-19. Following a literature review, it was found that right ventricular dysfunction along with global longitudinal strain and diastolic dysfunction are common findings. Finally, more severe acute myocardial injury during the index hospitalization appears to exacerbate cardiac function. The available literature implies that cardiac function must be monitored in patients recovered from COVID-19 who remain symptomatic and that the impairments and severity vary from person-to-person. The proof-of-concept analysis of patients with cardiac disease and respiratory disease in comparison to those with sustained symptoms from COVID-19 suggests elevated systolic time interval in those with sustained symptoms from COVID-19, thus reducing heart performance indices. Future research must consider the details of cardiac complications during the acute infection period and relate this to the cardiac function in patients with long COVID during mid- and long-term follow-up.
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Affiliation(s)
- Jyotpal Singh
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
- Department of CardiologyPrairie Vascular Research Inc, Saskatchewan Health AuthorityReginaSaskatchewanCanada
| | - Lanishen Bhagaloo
- Gateway Alliance MedicalReginaSaskatchewanCanada
- College of MedicineUniversity of SaskatchewanSaskatoonSaskatchewanCanada
- Department of Family MedicineSaskatchewan Health AuthorityReginaSaskatchewanCanada
| | - Eric Sy
- Department of Critical CareSaskatchewan Health AuthorityReginaSaskatchewanCanada
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
- College of Graduate and Postdoctoral StudiesUniversity of SaskatchewanSaskatoonSaskatchewanCanada
| | - Andrea J. Lavoie
- Department of CardiologyPrairie Vascular Research Inc, Saskatchewan Health AuthorityReginaSaskatchewanCanada
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
| | - Payam Dehghani
- Department of CardiologyPrairie Vascular Research Inc, Saskatchewan Health AuthorityReginaSaskatchewanCanada
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
| | - Holly A. Bardutz
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
| | - Cameron S. Mang
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
| | - Josef Buttigieg
- Faculty of Science, Department of BiologyUniversity of ReginaReginaSaskatchewanCanada
| | - J. Patrick Neary
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
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Arbel Y, Patel AD, Goodman SG, Tan MK, Suskin N, McKelvie RS, Mathew AL, Ahmed F, Lutchmedial S, Dehghani P, Lavoie AJ, Huynh T, Lavi S, Khan R, Yan AT, Fordyce CB, Heffernan M, Jedrzkiewicz S, Madan M, Ahmed S, Barry C, Dery JP, Bagai A. Provision of a DAPT Score to Cardiologists and Extension of Dual Antiplatelet Therapy Beyond 1 Year After ACS: Randomized Substudy of the Prospective Canadian ACS Reflective II Study. CJC Open 2021; 3:1463-1470. [PMID: 34993458 PMCID: PMC8712544 DOI: 10.1016/j.cjco.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/18/2021] [Indexed: 12/05/2022] Open
Abstract
Background Extension of dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome is associated with a reduction in ischemic events but also increased bleeding. The DAPT score identifies individuals likely to derive overall benefit or harm from DAPT extension. We sought to evaluate the impact of providing the DAPT score to treating physicians on the decision to extend DAPT beyond 1 year after non–ST-segment elevation myocardial infarction. Methods Moderate to high-risk non–ST-segment elevation myocardial infarction patients were enrolled from July 2016 to May 2018 in 13 Canadian hospitals by 52 cardiologists. Participating cardiologists were randomly assigned 1:1 to receive their individual patients’ DAPT scores before the 1-year follow-up visit vs not receiving their patients’ DAPT scores. Rates of DAPT extension were compared among the randomized groups. Results At 1 year, 370 of the 585 (63.2%) patients discharged on DAPT were receiving DAPT. Among patients on DAPT at 1 year, the median (25th, 75th percentile) DAPT score was 2 (1,3). DAPT was extended beyond 1 year in 36.2% randomly assigned to provision of DAPT score vs 35.7% in the control group (P = 0.93). In the subgroup of patients with DAPT score ≥ 2, DAPT extension was 49.5% in the DAPT score provision arm vs 40.4% in the control arm (P = 0.22); among patients with DAPT score < 2, DAPT termination was 78.6% in the DAPT score provision arm vs 70.6% in the control arm (P = 0.26) (P value for interaction = 0.1). Conclusions In this exploratory randomized trial, provision of the DAPT score to treating physicians had no impact on the duration of DAPT treatment beyond 1 year.
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Affiliation(s)
- Yaron Arbel
- Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ashish D. Patel
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Mackenzie Health, Richmond Hill, Ontario, Canada
| | - Shaun G. Goodman
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Mary K. Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Neville Suskin
- St Joseph’s Health Care London, Western University, London, Ontario, Canada
| | - Robert S. McKelvie
- St Joseph’s Health Care London, Western University, London, Ontario, Canada
| | - Andrew L. Mathew
- St Joseph’s Health Care London, Western University, London, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Firas Ahmed
- London Health Sciences Centre, London, Ontario, Canada
| | | | - Payam Dehghani
- Saskatchewan Health Authority, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Andrea J. Lavoie
- Saskatchewan Health Authority, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Thao Huynh
- McGill University Health Centre, Montreal, Québec, Canada
| | - Shahar Lavi
- University Hospital, Western University, London, Ontario, Canada
| | - Razi Khan
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Andrew T. Yan
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher B. Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shaheeda Ahmed
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Colin Barry
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Jean-Pierre Dery
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Québec, Canada
| | - Akshay Bagai
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Akshay Bagai, Terrence Donnelly Heart Centre, St Michael’s Hospital, 30 Bond St, Toronto, Ontario Canada. Tel.: +1-416-864-5783; fax: +1-416-864-5989.
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5
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Singh J, Bhagaloo L, Sy E, Lavoie AJ, Dehghani P, Neary P. Novel effects of acute COVID-19 on cardiac mechanical function: Two case studies. Physiol Rep 2021; 9:e14998. [PMID: 34448551 PMCID: PMC8391984 DOI: 10.14814/phy2.14998] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/10/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
The spread of the novel coronavirus 2019 (COVID-19) has caused a global pandemic. The disease has spread rapidly, and research shows that COVID-19 can induce long-lasting cardiac damage. COVID-19 can result in elevated cardiac biomarkers indicative of acute cardiac injury, and research utilizing echocardiography has shown that there is mechanical dysfunction in these patients as well, especially when observing the isovolumic, systolic, and diastolic portions of the cardiac cycle. The purpose of this study was to present two case studies on COVID-19 positive patients who had their cardiac mechanical function assessed every day during the acute period to show that cardiac function in these patients was altered, and the damage occurring can change from day-to-day. Participant 1 showed compromised cardiac function in the systolic time, diastolic time, isovolumic time, and the calculated heart performance index (HPI), and these impairments were sustained even 23 days post-symptom onset. Furthermore, Participant 1 showed prolonged systolic periods that lasted longer than the diastolic periods, indicative of elevated pulmonary artery pressure. Participant 2 showed decreases in systole and consequently, increases in HPI during the 3 days post-symptom onset, and these changes returned to normal after day 4. These results showed that daily observation of cardiac function can provide detailed information about the overall mechanism by which cardiac dysfunction is occurring and that COVID-19 can induce cardiac damage in unique patterns and thus can be studied on a case-by-case basis, day-to-day during infection. This could allow us to move toward more personalized cardiovascular medical treatment.
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Affiliation(s)
- Jyotpal Singh
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
| | - Lanishen Bhagaloo
- Gateway Alliance Medical ClinicReginaSaskatchewanCanada
- Faculty of MedicineUniversity of SaskatchewanSaskatoonSaskatchewanCanada
| | - Eric Sy
- Department of Critical CareSaskatchewan Health AuthorityReginaSaskatchewanCanada
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
| | - Andrea J. Lavoie
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
- Department of CardiologyPrairie Vascular Research IncSaskatchewan Health AuthorityReginaSaskatchewanCanada
| | - Payam Dehghani
- College of MedicineUniversity of SaskatchewanReginaSaskatchewanCanada
- Department of CardiologyPrairie Vascular Research IncSaskatchewan Health AuthorityReginaSaskatchewanCanada
| | - Patrick Neary
- Faculty of Kinesiology and Health StudiesUniversity of ReginaReginaSaskatchewanCanada
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6
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Patel A, Goodman SG, Tan M, Suskin N, McKelvie R, Mathew AL, Lutchmedial S, Dehghani P, Lavoie AJ, Huynh T, Lavi S, Philipp R, Khan R, Yan AT, Radhakrishnan S, Sedlak T, Brunner N, Kim HH, Cieza T, Kassam S, Fordyce CB, Heffernan M, Jedrzkiewicz S, Madan M, Ahmed S, Barry C, Dery JP, Bagai A. Contemporary use of guideline-based higher potency P2Y12 receptor inhibitor therapy in patients with moderate-to-high risk non-ST-segment elevation myocardial infarction: Results from the Canadian ACS reflective II cross-sectional study. Clin Cardiol 2021; 44:839-847. [PMID: 33982795 PMCID: PMC8207978 DOI: 10.1002/clc.23618] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/11/2021] [Accepted: 04/27/2021] [Indexed: 12/15/2022] Open
Abstract
Background After myocardial infarction, guidelines recommend higher‐potency P2Y12 receptor inhibitors, namely ticagrelor and prasugrel, over clopidogrel. Hypothesis We aimed to determine the contemporary use of higher‐potency antiplatelet therapy in Canadian patients with non‐ST‐elevation myocardial infarction (NSTEMI). Methods A total of 684 moderate‐to‐high risk NSTEMI patients were enrolled in the prospective Canadian ACS Reflective II registry at 12 Canadian hospitals and three clinics in five provinces between July 2016 and May 2018. Multivariable logistic regression modeling was performed to assess factors independently associated with higher‐potency P2Y12 receptor inhibitor use at discharge. Results At hospital discharge, 78.3% of patients were treated with a P2Y12 receptor inhibitor. Among patients discharged on a P2Y12 receptor inhibitor, use of higher‐potency P2Y12 receptor inhibitor was 61.4%. After adjustment, treatment in‐hospital with PCI (OR 4.48, 95%CI 3.34–6.03, p < .0001) was most strongly associated with higher use of higher‐potency P2Y12 receptor inhibitor, while oral anticoagulant use at discharge (OR 0.03, 95%CI 0.01–0.12, p < .0001), and atrial fibrillation (OR 0.40, 95%CI 0.17–0.98, p = .046) were most strongly associated with lower use of higher‐potency P2Y12 receptor inhibitor. Use of higher‐potency P2Y12 receptor inhibitor varied across provinces (range, 21.6%–78.9%). Discussion In contemporary Canadian practice, approximately 60% of moderate‐to‐high risk NSTEMI patients discharged on a P2Y12 receptor inhibitor are treated with a higher‐potency P2Y12 receptor inhibitor. In addition to factors that increase risk of bleeding, interprovincial differences in practice patterns were associated with use of higher‐potency P2Y12 receptor inhibitor at discharge. Opportunities remain for further optimization of evidence‐based, guideline‐recommended antiplatelet therapy use.
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Affiliation(s)
- Ashish Patel
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada.,Canadian Heart Research Centre, Toronto, Canada
| | - Mary Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Neville Suskin
- St Joseph's Health Care London, Western University, Lawson Research Institute, London, Canada
| | - Robert McKelvie
- St Joseph's Health Care London, Western University, Lawson Research Institute, London, Canada
| | - Andrew L Mathew
- St Joseph's Health Care London, Western University, Lawson Research Institute, London, Canada.,University Hospital, London Health Sciences Centre, London, Canada
| | | | - Payam Dehghani
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Thao Huynh
- McGill University Health Centre, Montreal, Canada
| | - Shahar Lavi
- University Hospital, London Health Sciences Centre, London, Canada
| | - Roger Philipp
- Royal Columbian Hospital, Keary Medical Centre, New Westminster, Canada
| | - Razi Khan
- Royal Columbian Hospital, Keary Medical Centre, New Westminster, Canada
| | - Andrew T Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Sam Radhakrishnan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Tara Sedlak
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Nathan Brunner
- Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Hahn Hoe Kim
- St Mary's Regional Cardiac Centre, Kitchener, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | | | | | | | | | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Shaheeda Ahmed
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Colin Barry
- New Brunswick Heart Centre, Saint John, Canada
| | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec City, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Canada
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8
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Kary SJ, Roy CJ, Semchuk WM, Lavoie AJ. Transient Ischemic Attack in a High-Risk Cardiovascular Patient with Renal Dysfunction after Treatment with Rivaroxaban and Clopidogrel: A Case Report. Can J Hosp Pharm 2019. [DOI: 10.4212/cjhp.v72i1.2868] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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9
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Kary SJ, Roy CJ, Semchuk WM, Lavoie AJ. Transient Ischemic Attack in a High-Risk Cardiovascular Patient with Renal Dysfunction after Treatment with Rivaroxaban and Clopidogrel: A Case Report. Can J Hosp Pharm 2019; 72:49-51. [PMID: 30828094 PMCID: PMC6391238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Steven J Kary
- , BSP, ACPR, is with the Saskatchewan Cancer Agency, Saskatoon, Saskatchewan
| | - Caitlin J Roy
- , BSP, ACPR, is with the Saskatchewan Health Authority - Regina Area, Regina, Saskatchewan
| | - William M Semchuk
- , BSP, MSc, PharmD, is with the Saskatchewan Health Authority - Regina Area, Regina, Saskatchewan
| | - Andrea J Lavoie
- , MD, FRCPC, is with the Saskatchewan Health Authority - Regina Area, Regina, Saskatchewan
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Dehghani P, Chopra V, Bell A, Kelly S, Zulyniak L, Booker J, Zimmermann R, Semchuk W, Cheema AN, Lavoie AJ. Southern Saskatchewan Ticagrelor Registry experience. Patient Prefer Adherence 2014; 8:1427-35. [PMID: 25342889 PMCID: PMC4206253 DOI: 10.2147/ppa.s68423] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND As ticagrelor enters into clinical use for acute coronary syndrome, it is important to understand patient/physician behavior in terms of appropriate use, adherence, and event rates. METHODS The Southern Saskatchewan Ticagrelor Registry is a prospective, observational, multicenter cohort study that identifies consecutive patients started on ticagrelor. We aimed to evaluate both on- and off-label use, identify characteristics of patients who prematurely stop ticagrelor, and describe patient/physician behavior contributing to inappropriate stoppage of this medication. RESULTS From April 2012 to September 2013, 227 patients were initiated on ticagrelor, with a mean age of 62.2±12.1 years. The participants were 66% men and had a mean follow up of 157.4±111.7 days. Seventy-four patients (32.4%) had off-label indications. Forty-seven patients (20.7%) prematurely stopped ticagrelor and were more likely to be older, women, nonwhite, present with shock, and complain of dyspnea. Twenty-six of the 47 patients stopped ticagrelor inappropriately because of patient nonadherence (18 patients) and physician advice (eight patients). A composite outcome event of death from vascular causes, myocardial infarction, or stroke occurred in 8.8% of the entire cohort and was more likely to occur in those older then 65 years, those presenting with cardiogenic shock, and those who prematurely stopped ticagrelor. CONCLUSION In this real-world registry of patients started on ticagrelor, a third have off-label indications and a fifth prematurely stop the medication. Premature discontinuation was an independent predictor of major life-threatening bleeding and increased composite event rate of death from vascular causes, myocardial infarction, or stroke.
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
- Correspondence: Payam Dehghani, Prairie Vascular Research Network (PVRN), Unit 3A, Interventional Cardiology Research Office, Regina General Hospital 1440 14th Avenue, Regina, SK S4P 0W5, Canada, Tel +306 781 7944, Fax +306 781 6997, Email
| | - Varun Chopra
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
| | - Ali Bell
- Regina Qu’Appelle Health Region, Regina, SK, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
| | | | - Jeff Booker
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
| | - Rodney Zimmermann
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
| | | | - Asim N Cheema
- St Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Andrea J Lavoie
- Prairie Vascular Research Network, University of Saskatchewan, Regina, SK, Canada
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Lavoie AJ, Bayturan O, Uno K, Hsu A, Wolski K, Schoenhagen P, Kapadia S, Tuzcu EM, Nissen SE, Nicholls SJ. Plaque progression in coronary arteries with minimal luminal obstruction in intravascular ultrasound atherosclerosis trials. Am J Cardiol 2010; 105:1679-83. [PMID: 20538114 DOI: 10.1016/j.amjcard.2010.01.345] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 01/22/2010] [Accepted: 01/22/2010] [Indexed: 11/25/2022]
Abstract
The relation among the burden of disease, progression of atherosclerosis, and remodeling in angiographically minimally diseased coronary arteries has not been defined. The present analysis included 1,906 patients who participated in 5 prospective clinical trials examining atheroma progression using intravascular ultrasonography. For the present analysis, the patients were stratified according to baseline quantitative coronary angiographic stenosis: <20%, 20% to 35%, and >35%. Patients with a lesser degree of luminal stenosis had less atherosclerosis. However, in the arteries with minimal angiographic stenosis, a large percentage of images contained atheroma, demonstrating the diffuse nature of coronary atherosclerosis. All 3 groups showed evidence of disease progression. The serial changes in vessel dimensions revealed that both the external elastic membrane and lumen volumes decreased in all 3 subgroups, in keeping with vessel and luminal constriction. In conclusion, these findings have demonstrated that patients with at least one luminal stenosis have diffuse atherosclerosis that progressed during 18 to 24 months, making them a target for therapeutic intervention. These minimally diseased arteries demonstrated evidence of vessel and luminal constriction, regardless of the angiographic appearance.
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Bayturan O, Tuzcu EM, Uno K, Lavoie AJ, Hu T, Shreevatsa A, Wolski K, Schoenhagen P, Kapadia S, Nissen SE, Nicholls SJ. Comparison of rates of progression of coronary atherosclerosis in patients with diabetes mellitus versus those with the metabolic syndrome. Am J Cardiol 2010; 105:1735-9. [PMID: 20538123 DOI: 10.1016/j.amjcard.2010.01.359] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 01/29/2010] [Accepted: 01/29/2010] [Indexed: 11/17/2022]
Abstract
Diabetes mellitus (DM) and metabolic syndrome (MS) are associated with adverse cardiovascular outcomes. However, the extent and progression of coronary atherosclerosis for these conditions have not been directly compared. Three thousand four hundred fifty-nine patients with coronary artery disease underwent serial evaluation of atheroma burden by intravascular ultrasound. Patients with DM, MS, or neither diagnosis were compared with regard to plaque burden, progression, and arterial remodeling. Among the 3 groups, patients with MS had the largest number of individual cardiovascular risk factors. Patients with DM demonstrated more extensive atherosclerosis burden with a greater percent atheroma volume compared to patients with MS or those with neither diagnosis (40.3 +/- 9.0%, 37.6 +/- 8.9%, and 38.1 +/- 9.1%, p <0.001) and total atheroma volume (198.3 +/- 85.9, 190.7 +/- 85.0, and 186.3 +/- 79.1 mm(3), p = 0.05). MS compared to neither diagnosis was accompanied by expansion of the external elastic membrane (501.3 +/- 174.3 vs 484.4 +/- 160.7 mm(3), p = 0.02), whereas DM was associated with lumen constriction (290.6 +/- 111.7 vs 298.1 +/- 105.5 mm(3), p <0.0001). On serial evaluation, DM, but not MS, was associated with greater progression of percent atheroma volume compared to neither diagnosis (+0.8 +/- 0.3, +0.3 +/- 0.2, and +0.1 +/- 0.2%, p <0.0001) and total atheroma volume (-1.0 +/- 1.8, -3.3 +/- 1.8, and -4.0 +/- 1.8 mm(3), p = 0.001). Meeting criteria for MS was not associated with greater disease progression in patients with DM. In conclusion, despite having fewer individual risk factors, DM is associated with greater plaque progression and more constrictive remodeling than MS. This finding highlights the deleterious effects of DM on the arterial wall independent of its associated metabolic abnormalities.
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Affiliation(s)
- Ozgur Bayturan
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Uno K, Nicholls SJ, Després JP, Shao M, Hu T, Schoenhagen P, Bayturan O, Lavoie AJ, Shreevatsa A, Kapadia S, Menon V, Gaudin C, Job B, Tuzcu EM, Nissen SE. ARTERIAL WALL REMODELING IN ASSOCIATION WITH ABDOMINAL OBESITY, ADIPOCYTOKINES AND PROGRESSION OF CORONARY ATHEROSCLEROSIS: INSIGHTS FROM THE STRADIVARIUS STUDY. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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