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Heramvand N, Masyuk M, Muessig JM, Nia AM, Karathanos A, Polzin A, Valgimigli M, Gurbel PA, Tantry US, Kelm M, Jung C. Pharmacosimulation of delays and interruptions during administration of tirofiban: a systematic comparison between EU and US dosage regimens. J Thromb Thrombolysis 2022; 54:301-308. [PMID: 35482154 PMCID: PMC9363357 DOI: 10.1007/s11239-022-02654-0] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 12/01/2022]
Abstract
Tirofiban is a glycoproteine (GP) IIb/IIIa receptor antagonist, which inhibits platelet-platelet aggregation and is a potential adjunctive antithrombotic treatment in patients with acute coronary syndromes (ACS) or high-risk percutaneous coronary interventions (PCI). It is administered intravenously as a bolus followed by continuous infusion. However, the dosage recommendations in the United States (US) and European Union (EU) differ considerably. Furthermore, in routine clinical practice, deviations from the recommendations may occur. The objective of the present study was to investigate the impact of different alterations on tirofiban plasma concentrations in US and EU administration regimens and to give suggestions for delay management in clinical practice. We therefore mathematically simulated the effects of different bolus-infusion delays and infusion interruptions in different scenarios according to the renal function. Here, we provide a systematic assessment of concentration patterns of tirofiban in the US versus EU dosage regimens. We show that differences between the two regimens have important effects on plasma drug levels. Furthermore, we demonstrate that deviations from the proper administration mode affect the concentration of tirofiban. Additionally, we calculated the optimal dosage of a second bolus to rapidly restore the initial concentration without causing overdosage. In conclusion, differences in tirofiban dosing regimens between the U.S and EU and potential infusion interruptions have important effects on drug levels that may impact on degrees of platelet inhibition and thus antithrombotic effects. Thus, the findings of our modelling studies may help to explain differences in clinical outcomes observed in previous clinical trials on tirofiban.
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Affiliation(s)
- Nadia Heramvand
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Maryna Masyuk
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Johanna M Muessig
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Amir M Nia
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Athanasios Karathanos
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Amin Polzin
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Marco Valgimigli
- Cardiocentro Ticino, Lugano and University of Bern, Bern, Switzerland
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Malte Kelm
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.,CARID: Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Christian Jung
- Department of Medicine, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
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Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Chernyak N, Icks A, Kelm M, Brockmeyer M, Wolff G. Clinical efficacy and safety outcomes of bempedoic acid for LDL-C lowering therapy in patients at high cardiovascular risk: a systematic review and meta-analysis. BMJ Open 2022; 12:e048893. [PMID: 35210334 PMCID: PMC8883220 DOI: 10.1136/bmjopen-2021-048893] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Bempedoic acid (BA) is a novel oral low-density lipoprotein cholesterol lowering drug. This systematic review and meta-analysis aims to assess efficacy and safety for clinical outcomes in high cardiovascular (CV) risk patients. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, Google Scholar, Embase, ClinicalTrials.gov, Clinical Trial Results and the American College of Cardiology web site were searched. STUDY SELECTION Randomised controlled trials (RCTs) of BA versus placebo in high CV risk patients reporting clinical outcomes were included. MAIN OUTCOMES AND MEASURES Primary efficacy outcomes were major adverse cardiovascular events (MACE), all-cause mortality, CV mortality and non-fatal myocardial infarction (MI). Safety outcomes included new onset or worsening of diabetes mellitus (DM), muscular disorders, gout and worsening of renal function. RESULTS Six RCTs with a total of 3956 patients and follow-ups of four to 52 weeks were identified. Heterogeneity mainly derived from differing follow-up duration and baseline CV risk. No difference in MACE (OR 0.84; 95% CI 0.61 to 1.15), all-cause mortality (OR 2.37; CI 0.80 to 6.99) and CV mortality (OR 1.66; CI 0.45 to 6.04) for BA versus placebo was observed. BA showed beneficial trends for non-fatal MI (OR 0.57; CI 0.32 to 1.00) and was associated with a lower risk of new-onset or worsening of DM (OR 0.68; CI 0.49 to 0.94), but higher risk of gout (OR 3.29; CI 1.28 to 8.46) and a trend for muscular disorders (OR 2.60; CI 1.15 to 5.91) and worsening of renal function (OR 4.24; CI 0.98 to 18.39). CONCLUSION BA in high CV risk patients showed no significant effects on major CV outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and gout sound a note of caution. Hence, further studies with longer term follow-up in carefully selected populations are needed to clarify the risk/benefit ratio of this novel therapy.
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Affiliation(s)
- Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Athanasios Karathanos
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Torben Krieger
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Nadja Chernyak
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- CARID-Cardiovascular Research Institute Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Chernyak N, Icks A, Kelm M, Brockmeyer M, Wolff G. Clinical efficacy and safety outcomes of bempedoic acid for LDL-C lowering therapy in patients at high cardiovascular risk: a systematic review and meta-analysis. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2936] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Bempedoic acid (BA) is a novel oral low-density lipoprotein cholestrol (LDL-C) lowering drug. Its efficacy and safety for clinical outcomes in high cardiovascular risk patients remains unknown.
Objectives and methods
A systematic review was performed and randomized controlled trials (RCTs) of BA vs. placebo in high cardiovascular risk patients reporting clinical efficacy and safety outcomes were included in a meta-analysis. Cumulative odds ratios (OR) and mean differences with 95% confidence intervals (CI) were reported as summary statistics.
Results
Six RCTs with a total of 3,956 patients and follow-ups of four to 52 weeks were identified. There was no difference in MACE (OR 0.84; CI 0.61, 1.15), all-cause mortality (OR 2.37; CI 0.80, 6.99) and cardiovascular mortality (OR 1.66; CI 0.45, 6.04) for BA vs. placebo. BA showed beneficial trends for nonfatal myocardial infarction (OR 0.57; CI 0.32, 1.00) and was associated with a lower risk of new-onset or worsening of diabetes mellitus (OR 0.68; CI 0.49, 0.94) and non-coronary revascularization (OR 0.41; CI 0.18, 0.95), but higher risk of gout (OR 3.29; CI 1.28, 8.46) and a trend for worsening of renal function (OR 4.24; CI 0.98, 18.39) and muscular disorders (OR 2.60; CI 1.15, 5.91).
Conclusion
Bempedoic acid in high cardiovascular risk patients showed no significant effects on major cardiovascular outcomes in short-term follow-up. Unfavourable effects on muscular disorders, renal function and the incidence of gout sound a note of caution. Hence, further studies with longer-term follow-up are needed to clarify the risk/benefit ratio of this novel therapy.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - N Chernyak
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Icks
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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Brockmeyer M, Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Heinen Y, Bejinariu A, Müller P, Makimoto H, Kelm M, Wolff G. Uninterrupted anticoagulation during catheter ablation for atrial fibrillation: no difference in major bleeding and stroke between direct oral anticoagulants and vitamin K antagonists in an updated meta-analysis of randomised controlled trials. Acta Cardiol 2021; 76:288-295. [PMID: 32056498 DOI: 10.1080/00015385.2020.1724689] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Periprocedural uninterrupted anticoagulation for catheter ablation of atrial fibrillation (AF) became standard after positive results of vitamin K antagonist (VKA) trials. Previous studies of uninterrupted direct oral anticoagulants (DOACs) vs. VKA have given controversial results. We thus aimed to elucidate the risk/benefit ratio of uninterrupted DOAC vs. VKA during catheter ablation of AF in an updated meta-analysis of randomised controlled trials (RCTs). METHODS Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing catheter ablation of AF. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischaemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (MRI), and mortality. RESULTS Six eligible RCTs comprising 2,369 patients were included. There were no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30-1.56; p = .37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20-4.72; p = .97). Pooled meta-analysis of secondary outcomes revealed no significant differences (OR 0.73, p = .49 for composite of major bleeding and stroke or TIA; OR 1.08, p = .52 for minor bleeding; OR 1.12, p = .59 for acute cerebral lesions on MRI; and OR 0.60, p = .64 for all-cause mortality). CONCLUSION Our meta-analysis suggests that uninterrupted DOAC is not superior to VKA in patients undergoing catheter ablation of AF with comparable rates of major bleeding and stroke.
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Affiliation(s)
- Maximilian Brockmeyer
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Claudio Parco
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Alexandru Bejinariu
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Patrick Müller
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Hisaki Makimoto
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
- CARID – Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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Spieker M, Marpert J, Afzal S, Karathanos A, Scheiber D, Bönner F, Horn P, Kelm M, Westenfeld R. Right ventricular dysfunction assessed by cardiovascular magnetic resonance is associated with poor outcome in patients undergoing transcatheter mitral valve repair. PLoS One 2021; 16:e0245637. [PMID: 33513199 PMCID: PMC7846001 DOI: 10.1371/journal.pone.0245637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 01/04/2021] [Indexed: 11/19/2022] Open
Abstract
Aims To evaluate whether CMR-derived RV assessment can facilitate risk stratification among patients undergoing transcatheter mitral valve repair (TMVR). Background In patients undergoing TMVR, only limited data exist regarding the role of RV function. Previous studies assessed the impact of pre-procedural RV dysfunction stating that RV failure may be associated with increased cardiovascular mortality after the procedure. Methods Sixty-one patients underwent CMR, echocardiography and right heart catheterization prior TMVR. All-cause mortality and heart failure hospitalizations were assessed during 2-year follow-up. Results According to RV ejection fraction (RVEF) <46%, 23 patients (38%) had pre-existing RV dysfunction. By measures of RV end-diastolic volume index (RVEDVi), 16 patients (26%) revealed RV dilatation. Nine patients (15%) revealed both. RV dysfunction was associated with increased right and left ventricular volumes as well as reduced left ventricular (LV) ejection fraction (all p<0.05). During follow-up, 15 patients (25%) died and additional 14 patients (23%) were admitted to hospital due to heart failure symptoms. RV dysfunction predicted all-cause mortality even after adjustment for LV function. Similarly, RVEDVi was a predictor of all-cause mortality even after adjustment for LVEDVi. Kaplan-Meier survival analysis unraveled that, among patients presenting with CMR indicative of both, RV dysfunction and dilatation, the majority (78%) experienced an adverse event during follow-up (p<0.001). Conclusion In patients undergoing TMVR, pre-existing RV dysfunction and RV dilatation are associated with reduced survival, in progressive additive fashion. The assessment of RV volumes and function by CMR may aid in risk stratification prior TMVR in these high-risk patients.
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Affiliation(s)
- Maximilian Spieker
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Jonathan Marpert
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Shazia Afzal
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Athanasios Karathanos
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Daniel Scheiber
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Florian Bönner
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Patrick Horn
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
- Cardiovascular Research Institute Duesseldorf, Medical Faculty, Heinrich-Heine University, Duesseldorf, Germany
| | - Ralf Westenfeld
- Medical Faculty, Division of Cardiology, Pulmonology and Vascular Medicine, University Hospital Duesseldorf, Heinrich-Heine University Duesseldorf, Duesseldorf, Germany
- * E-mail:
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Parco C, Brockmeyer M, Kosejian L, Quade J, Tröstler J, Bader S, Lin Y, Karathanos A, Krieger T, Heinen Y, Schulze V, Icks A, Jung C, Kelm M, Wolff G. Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort. Int J Cardiol 2021; 329:28-35. [PMID: 33412182 DOI: 10.1016/j.ijcard.2020.12.085] [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] [Received: 08/27/2020] [Revised: 11/18/2020] [Accepted: 12/28/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Risk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients. METHODS AND RESULTS A total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, pGRACE1.0vsGRACE2.0 = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; pACTIONvsNCDR < 0.0001; pGRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (pGRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, pGRACEvsACTION = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); pGRACEvsACTION = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models. CONCLUSIONS In a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.
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Affiliation(s)
- Claudio Parco
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Maximilian Brockmeyer
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Lucin Kosejian
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Julia Quade
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jennifer Tröstler
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Selina Bader
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christian Jung
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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Troestler J, Parco C, Brockmeyer M, Lin Y, Krieger T, Quade J, Bader S, Kosejian L, Karathanos A, Heinen Y, Schulze V, Icks A, Kelm M, Wolff G. Standardized risk management in catheterization procedures for non-ST-segment elevation myocardial infarction: associations with in-hospital clinical outcomes. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1762] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction and purpose
Patient risk in non-ST-segment elevation myocardial infarction (NSTEMI) depends on clinical setting, individual patient variables and procedural characteristics. Standardized risk-adjusted periprocedural management for catheterization procedures using a Standard Operating Procedure (SOP) was investigated to evaluate associations with in-hospital clinical outcomes.
Methods
In 01/2018, our heart center established an SOP for coronary catheterization procedures in NSTEMI, targeting 1) standardized pre-procedural risk assessment using National Cardiovascular Data Registry (NCDR) risk models, and 2) standardized post-procedural risk-adjusted safety measures, including advanced patient monitoring (intermediate/intensive care) and use of vascular closure devices. All patients presenting with invasively-managed NSTEMI in 2018 were retrospectively evaluated for SOP-based pre-procedural risk scoring, SOP-based post-procedural management and in-hospital clinical outcomes of mortality, major bleeding (MB, according to BARC ≥3) and acute kidney injury (AKI, according to KDIGO).
Results
A total of 430 patients (age 72±12 years, 71% male, BMI 27±5) presenting with NSTEMI from 01 to 12/2018 were included, 9.8% presented in cardiogenic shock and 4.7% had suffered a preclinical cardiac arrest. Overall in-hospital mortality was 3.7%, MB occurred in 6.5%. 207 patients (48.1%, SOP+ group) had received both 1) pre-procedural risk assessment and 2) post-procedural risk-adjusted safety measures; the other 223 patients (51.9%, SOP- group) had not received either 1) or 2). There were no significant differences in baseline characteristics and prior-existing medical conditions between groups, however, significantly more patients in SOP- group were treated in emergency settings (39.9% vs. 21.7%, p=0.004). However, significantly more patients in SOP- were treated in emergency settings at higher risk (39.9% (SOP-) vs. 21.7% (SOP+); p<0.001). In univariate analysis, all in-hospital clinical outcomes of mortality (1.4% (SOP+) vs. 5.8% (SOP-); p=0.016), MB (2.9% (SOP+) vs. 9.9% (SOP-); p=0.003) and AKI were significantly lower in the SOP+ group (15.9% (SOP+) vs. 24.2% (SOP-); p=0.033). After correction for the difference in risk between groups due to emergency settings by multivariate logistic regression analysis, MB remained significantly lower in SOP+ (p=0.02), while mortality (p=0.14) and AKI (p=0.19) were not significantly associated with SOP-status anymore.
Conclusion
Standardized risk management in invasively managed NSTEMI was associated with significantly lower rates of in-hospital major bleedings.
Funding Acknowledgement
Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Junior Clinician Scientist Track, Medical faculty, Heinrich-Heine-University Düsseldorf, Germany
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Affiliation(s)
- J Troestler
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Krieger
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - J Quade
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - S Bader
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - L Kosejian
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Heinen
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Icks
- Heinrich Heine University, Institute for Health Services Research and Health Economics, Centre for Health and Society, Duesseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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8
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Karathanos A, Simon I, Brockmeyer M, Lin Y, Parco C, Krieger T, Schulze V, Hellhammer K, Kelm M, Zeus T, Wolff G. Iron status, anemia and functional capacity in adults with congenital heart disease: a single center analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2216] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Iron is essential to the mitochondrial energy production in cardiomyocytes and its depletion is negatively associated with symptoms, functional capacity, quality of life and outcomes in patients with heart failure – independent of anemia. The relevance of iron deficiency in adults with congenital heart disease however has not been evaluated to date, and we thus aimed to evaluate it in an all-comer cohort of patients with congenital heart disease in correlation with symptoms and functional capacity.
Methods and results
527 patient cases from one referral center over 2 years were evaluated concerning their iron status, anemia, functional capacity and ejection fraction of their systemic ventricle. 264 were female, 94 had a shunt lesion, 96 had left-sided obstructive lesions, 181 right-sided lesions, while 108 were considered to have complex lesions and 28 were cyanotic. The median age was 34 years, the mean BMI was 25.2±5 kg/m2, 429 patients had a normal ejection fraction and 34 moderately and severely depressed. 35 patients were classified as NYHA III, and 56 as NYHA II, while their functional capacity was evaluated via cardiopulmonary testing with a mean VO2max/kg of 22.6±6.5 and mean 69±17% of the expected. The mean serum iron concentration was 99.4±42.3 mcg/dL, their mean transferrin saturation was 27.36±13%, the mean ferritin concentration was 130.8±185 ng/mL, the mean soluble transfer factor was 1.3±0.66 mg/l and their mean Hemoglobin 14.8±2 mg/dL, while the mean MCV was 88±5.3 and the mean MCHC 33.7±1.4.
40 patients were anemic according to the WHO definition for anemia, in 28 of those patients that was already known. Iron deficiency according to stratified according to ferritin was present in 53 patients. However, when stratified according to the heart failure guidelines definition for iron deficiency 299 patients were found affected. Using the soluble transferrin receptor (sTfR) and sTfR-ferritin index iron deficiency was suspected in 10 additional individuals. Iron deficiency was associated with the ejection fraction (p=0.0001) - patients with moderately or severely depressed systemic ventricular function more often were diagnosed with iron deficiency (p=0.007)-, while it did not correlate with functional NYHA classification (p=0.622) or functional capacity (p=0.1 and 0.057). Iron deficiency was also not found significantly different amongst congenital defects but did correlate with all laboratory iron studies.
Conclusions
In this ambulatory population of adults with congenital heart disease we found an association of ejection fraction with iron deficiency, however no association of iron deficiency with functional capacity. The question arising is if a new definition of iron deficiency anemia in congenital heart disease similar to heart failure would be of clinical value.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- A Karathanos
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - I Simon
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - T Krieger
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - K Hellhammer
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
| | - G Wolff
- University Hospital Dusseldorf, Department of Cardiology, Pneumology and Angiology, Dusseldorf, Germany
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9
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Brockmeyer M, Lin Y, Parco C, Karathanos A, Krieger T, Schulze V, Heinen Y, Bejinariu A, Mueller P, Makimoto H, Kelm M, Wolff G. Uninterrupted direct oral anticoagulants and vitamin K antagonists during ablation for atrial fibrillation: an updated meta-analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0569] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Uninterrupted anticoagulation during catheter ablation of atrial fibrillation (CAAF) became standard of care after positive results of trials investigating vitamin K antagonists (VKA). Previous studies and meta-analyses of uninterrupted direct oral anticoagulants (DOAC) vs. VKA have given controversial results. We thus aimed to elucidate the risks and benefits of uninterrupted DOAC vs. VKA during CAAF in an updated meta-analysis of randomized controlled trials (RCTs).
Methods
Online databases were searched for RCTs comparing uninterrupted DOAC to VKA in patients undergoing CAAF until September 2019. Data from retrieved studies were analysed in a comprehensive meta-analysis. Primary safety outcome was major bleeding; primary efficacy outcome was stroke or transient ischemic attack (TIA). Secondary outcomes included a composite of major bleeding and stroke or TIA, minor bleeding, acute cerebral lesions on magnetic resonance imaging (ACL) and mortality.
Results
Six eligible RCTs comprising 2,369 patients were included. Pooled meta-analysis showed no significant differences in DOAC vs. VKA concerning the rates of major bleeding (2.2% vs. 3.8%; odds ratio (OR) 0.69, 95% confidence interval (CI) 0.30–1.56; p=0.37) and stroke or TIA (0.2% vs. 0.2%; OR 0.97, CI 0.20–4.72; p=0.97). There were no significant differences found in secondary outcomes (OR 0.73, p=0.49 for composite of major bleeding and stroke or TIA; OR 1.08, p=0.52 for minor bleeding; OR 1.12, p=0.59 for ACL; and OR=0.60, p=0.64 for all-cause mortality).
Conclusion
Our meta-analysis suggests that uninterrupted periprocedural anticoagulation with DOAC or VKA is characterized by a similar risk/benefit ratio in patients undergoing CAAF with comparable rates of major bleeding and stroke.
Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Medical faculty of the Heinrich-Heine-University Düsseldorf, Germany
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Affiliation(s)
- M Brockmeyer
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - Y Lin
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - C Parco
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - A Karathanos
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - T Krieger
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - V Schulze
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - Y Heinen
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - A Bejinariu
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - P Mueller
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - H Makimoto
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - M Kelm
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
| | - G Wolff
- Heinrich Heine University, Division of Cardiology, Pulmonary Diseases and Vascular Medicine, Dusseldorf, Germany
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10
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Brockmeyer M, Wolff G, Krieger T, Lin Y, Karathanos A, Afzal S, Zeus T, Westenfeld R, Polzin A, Heinen Y, Perings S, Kelm M, Schulze V. Kidney function stratified outcomes of percutaneous left atrial appendage occlusion in patients with atrial fibrillation and high bleeding risk. Acta Cardiol 2020; 75:312-320. [PMID: 30983505 DOI: 10.1080/00015385.2019.1585643] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background: Patients with chronic kidney disease (CKD) and atrial fibrillation have increased risks for stroke and bleeding under oral anticoagulation (OAC). We investigated an alternative therapy of percutaneous left atrial appendage occlusion (LAAO) in CKD patients in this study.Methods: Consecutive patients undergoing LAAO were included in a retrospective analysis and stratified for kidney function into CKD/Non-CKD groups (cutoff eGFR 60 ml/min). Procedural characteristics, in-hospital and follow-up events were analysed and compared between groups.Results: LAAO was performed in 146 patients (81 CKD; 65 Non-CKD), mean follow-up was 391 days. Groups differed in eGFR (40.1 (CKD) vs. 75.1 (Non-CKD) ml/min) and CHA2DS2VASc scores (4.65 ± 1.3 (CKD) vs. 4.06 ± 1.4 (Non-CKD)). Procedural success was 98.6%, contrast-induced acute kidney injury was significantly more frequent in CKD patients (11.1% vs. 0%; p = .004). Follow-up mortality was higher in CKD (10.5/100 PY vs. 4.2/100 PY; p = .156). Follow-up stroke rates were 2.3/100 (CKD) patient-years (PY) and 1.4/100 PY (Non-CKD) (p = 1.000), corresponding to a relative risk reduction (RRR) of 60% (all), 68% (CKD) and 71% (Non-CKD) compared to expected stroke rates. Follow-up major bleeding rates were 3.5/100 PY (CKD) and 4.2/100 PY (Non-CKD), corresponding to RRR of 57% (all), 61% (CKD) and 53% (Non-CKD) compared to OAC.Conclusions: Left atrial appendage occlusion shows comparable efficacy for stroke and bleeding prevention in CKD and Non-CKD patients. CKD patients experience more adverse events during follow-up and a significantly increased risk for periprocedural contrast-induced acute kidney injury.
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Affiliation(s)
- Maximilian Brockmeyer
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Georg Wolff
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Torben Krieger
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yingfeng Lin
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Athanasios Karathanos
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Shazia Afzal
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Tobias Zeus
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ralf Westenfeld
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Amin Polzin
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Yvonne Heinen
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Stefan Perings
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
- Medical Faculty, CARID – Cardiovascular Research Institute Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Schulze
- Medical Faculty, Department of Internal Medicine, Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Düsseldorf, Germany
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11
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Lin Y, Schulze V, Brockmeyer M, Parco C, Karathanos A, Heinen Y, Gliem M, Hartung HP, Antoch G, Jander S, Turowski B, Perings S, Kelm M, Wolff G. Endovascular Thrombectomy as a Means to Improve Survival in Acute Ischemic Stroke: A Meta-analysis. JAMA Neurol 2020; 76:850-854. [PMID: 30958530 DOI: 10.1001/jamaneurol.2019.0525] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality. Objective To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis. Data Sources All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines. Study Selection Ten American Stroke Association/American Heart Association guideline-relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT. Data Extraction and Synthesis Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs. Main Outcomes and Measures Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward). Results In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98; P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01; P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40; P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72; P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials. Conclusions and Relevance This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.
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Affiliation(s)
- Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Claudio Parco
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Athanasios Karathanos
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Yvonne Heinen
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Michael Gliem
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sebastian Jander
- Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Stefan Perings
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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12
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Klein K, Karathanos A, Heinen Y. [Update ESC-Guideline: Management of cardiovascular diseases during pregnancy - What is important?]. Dtsch Med Wochenschr 2019; 144:1709-1713. [PMID: 31791076 DOI: 10.1055/a-0883-7206] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The treatment of pregnant patients with a cardiovascular disease is a special challenge to deal with. Before getting pregnant all cardiac patients should get medical advice accordingly to their risk profile in the modified World Health Organization classification of maternal cardiovascular risk. This article has the aim to give an overview of the new or changed recommendations of the new ESC-Guideline for the management of cardiovascular diseases during pregnancy.
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Affiliation(s)
- Kathrin Klein
- Klinik für Kardiologe, Angiologie und Pneumologie der Universitätsklinik Düsseldorf
| | | | - Yvonne Heinen
- Klinik für Kardiologe, Angiologie und Pneumologie der Universitätsklinik Düsseldorf
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13
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Lin Y, Schulze V, Brockmeyer M, Parco C, Karathanos A, Krieger T, Heinen Y, Gliem M, Hartung HP, Antoch G, Jander S, Turowski B, Perings S, Kelm M, Wolff G. 283Endovascular thrombectomy as a means to improve survival in acute ischemic stroke - A meta-analysis. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0087] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and purpose
Although endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) is guideline-recommended to improve functional recovery, thus far there are only inconclusive data from underpowered singular trials of EVT vs. medical therapy (MT) on mortality. We here aimed to perform a meta-analysis on short-term mortality in guideline-relevant EVT vs. MT randomized controlled trials (RCTs).
Methods
All randomized controlled trials (RCT) reporting EVT vs. MT in the latest 2018 American Stroke Association/American Heart Association (ASA/AHA) Guidelines were eligible for inclusion. Data were abstracted by two independent investigators and double-checked by four others. Study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% confidence intervals (CI). Ninety-day mortality and intracranial hemorrhage (ICH) were analyzed.
Results
Ten of the twelve guideline-relevant EVT vs. MT RCTs (DAWN, DEFUSE 3, ESCAPE, EXTEND-IA, MR CLEAN, MR RESCUE, REVASCAT, SWIFT PRIME, THERAPY, THRACE) with 2,313 patients were selected for inclusion. Studies IMS III and SYNTHESIS were excluded due to their very infrequent use of EVT. Stent retrievers (Trevo, Solitaire, Merci) were most frequently applied, followed by thrombus aspiration (Penumbra). Intravenous thrombolysis was administered in addition to EVT in the majority of patients. In the pooled meta-analysis of all eligible RCTs, EVT significantly reduced the risk for 90-day mortality by 3.7% compared to MT (15.0% vs. 18.7%; RR 0.81 with CI 0.68 to 0.98; p=0.03), accounting for a number-needed-to-treat of 27 to prevent one all-cause death. Trends were similar in early-window (RR 0.83) and late-window trials only (RR 0.76). There was no difference in the risk for ICH in EVT vs. MT (4.2% vs. 4.0%; RR 1.11 with CI 0.71 to 1.72; p=0.65). All included trials were published in high-quality journals and risk of bias was judged low.
Conclusions
This meta-analysis lends evidence to EVT benefits for survival already during the first 90 days after acute ischemic stroke. These results further highlight the evolution of interventional techniques in this setting.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - Y Heinen
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Gliem
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - H P Hartung
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Antoch
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Jander
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - B Turowski
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Perings
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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14
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Lin Y, Parco C, Brockmeyer M, Karathanos A, Schulze V, Krieger T, Heinen Y, Perings S, Kelm M, Wolff G. P6268Cardiovascular outcomes of new anti-diabetic agents - A meta-analysis of randomized controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0867] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and purpose
The risk of major cardiovascular events (MACE) is increased in patients with diabetes mellitus. Recently published clinical trials of three different pharmacological classes (DPP4 inhibitors (DPP4i), SGLT2-inhibitors (SGLT2i), GLP-1-receptor-antagonists (GLP1RA)) of new anti-diabetic agents (ADA) showed potential benefits for cardiovascular (CV) outcomes. We thus aimed to perform a meta-analysis of randomized controlled trials (RCTs) of these ADA to elucidate benefits on CV outcomes in diabetic patients.
Methods
Following a systematic online database search, all RCTs reporting CV outcomes of DPP4i, SGLT2i or GLP1RA vs. Placebo in diabetic patients up until December 2018 were eligible for inclusion in the meta-analysis. Studies including patients with acute coronary syndrome (ACS) were excluded. Data were abstracted and analyzed with the inverse-variance method and a random-effects model, hazard ratios (HR) with 95% confidence intervals (CI) were used as summary statistics. CV outcomes of MACE, myocardial infarction (MI), stroke, heart failure (HF), CV death and all-cause mortality were analyzed.
Results
Eleven RCTs (DPP4i: SAVOR, TECOS, CARMELINA; GLP1RA: LEADER, SUSTAIN-6, EXSCEL, Harmony; SGLT2i: EMPA-REG OUTCOME, CANVAS Program, DECLARE) with 109,316 patients were selected for inclusion. ELIXA and EXAMINE were excluded due to their inclusion of patients with ACS, CAROLINA was excluded for lack of placebo-control. In the pooled meta-analysis of all trials, ADA significantly reduced the risk for MACE (Hazard ratio (HR) 0.91, CI 0.86–0.96, p=0.0004), MI (HR 0.91, CI 0.85–0.96, p=0.02), CV death (HR 0.9, CI 0.82–0.99, P=0.02) and all-cause mortality (HR 0.92, CI 0.85–0.99, p=0.03). There was no difference in the risk for stroke (HR 0.94, CI 0.87–1.02, p=0.16) and HF (HR 0.88, CI 0.76–1.02, p=0.08). In agent-specific subgroup analyses, GLP1RA and SGLT2i showed significant reductions in MACE (GLP1RA: HR 0.85, CI 0.78–0.92, p<0.0001; SGLT2i: HR 0.89, CI 0.83–0.96, p=0.001), MI (GLP1RA: HR 0.86, CI 0.76–0.98, p=0.02; SGLT2i: HR 0.88, CI 0.79–0.97, p=0.01) and all-cause mortality (GLP1RA: HR 0.88, CI 0.81–0.95; p=0.001; SGLT2i: HR 0.83, CI 0.70–0.99; p=0.03). GLP1RA significantly reduced risk for stroke (HR 0.85, CI 0.75–0.96, p=0.008) and CV death (HR 0.86, CI 0.78–0.95, p=0.002). SGLT2I were especially effective in the reduction of risk for HF (HR 0.69, CI 0.61–0.79; p<0.0001). DPP4i inhibitors however failed to show superiority in all analyzed outcomes.
Conclusions
This meta-analysis lends evidence to GLP1RA and SGLT2i benefits for MACE, MI and all-cause mortality, while DPP4i failed to show superiority in cardiovascular outcomes. Individualized medication for diabetic patients depending on CV disease status should be considered.
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Affiliation(s)
- Y Lin
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - C Parco
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Brockmeyer
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - A Karathanos
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - V Schulze
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - T Krieger
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - Y Heinen
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - S Perings
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - M Kelm
- University Hospital Duesseldorf, Duesseldorf, Germany
| | - G Wolff
- University Hospital Duesseldorf, Duesseldorf, Germany
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15
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Brockmeyer M, Lin Y, Karathanos A, Parco C, Krieger T, Heinen Y, Albert A, Kelm M, Schulze V, Wolff G. P2792Preoperative levosimendan improves survival in patients with low cardiac output syndrome undergoing cardiac surgery: a meta-analysis of randomized controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.1107] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and purpose
Previous studies and meta-analyses of perioperative levosimendan to improve the outcomes of patients with low cardiac output syndrome (LCOS) undergoing cardiac surgery have given controversial results and the optimal time of infusion of levosimendan remains uncertain. We thus aimed to elucidate the risk/benefit ratio of preoperative levosimendan in a meta-analysis of randomized controlled trials (RCTs).
Methods
Online databases were searched for RCTs comparing preoperative levosimendan to placebo in patients with LCOS undergoing cardiac surgery until February 2019. Data from retrieved studies were abstracted and analyzed in a comprehensive meta-analysis. Primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction, renal failure/replacement therapy, need for inotropic therapy, need for left ventricular assist devices, ventricular arrhythmia and arterial hypotension.
Results
As a result of the online database search, six eligible RCTs with 1,326 patients were included in the meta-analysis. Preoperative levosimendan showed a significant reduction in all-cause mortality (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.29–0.83; p<0.01), renal failure/replacement therapy (OR 0.48, CI 0.29–0.80; p<0.01) and need for inotropic therapy (OR 0.24, CI 0.06–0.95; p=0.04) compared to placebo. There were no significant differences in levosimendan vs. placebo concerning the rates of myocardial infarction (OR 0.61, p=0.38), need for left ventricular assist devices (OR 0.38, p=0.1), ventricular arrhythmia (OR 0.7, p=0.33), and arterial hypotension (OR 1.28, p=0.07).
Conclusions
Preoperative administration of levosimendan may improve survival in patients with low cardiac output syndrome undergoing cardiac surgery. It reduces need for inotropic medical support and renal failure/replace-ment therapy compared to placebo.
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Affiliation(s)
- M Brockmeyer
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - Y Lin
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - A Karathanos
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - C Parco
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - T Krieger
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - Y Heinen
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - A Albert
- Heinrich Heine University, Division of Cardiovascular Surgery, Medical Faculty, Heinrich-Heine-University, Dusseldorf, Germany, Dusseldorf, Germany
| | - M Kelm
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - V Schulze
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
| | - G Wolff
- Heinrich Heine University, Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Dusseldorf, Germany
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16
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Karathanos A, Lin YF, Dannenberg L, Parco C, Schulze V, Brockmeyer M, Krieger T, Jung C, Heinen Y, Perings S, Zeymer U, Kelm M, Polzin A, Wolff G. P957Survival benefits of routine glycoprotein IIb/IIIa inhibitors during primary PCI in ST-segment elevation myocardial infarction: A meta-analysis of randomised controlled trials. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0551] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Cardiovascular guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPI) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI).
Purpose
This study aimed to evaluate routine GPI use in STEMI treated with primary PCI.
Methods
Online databases were systematically searched for randomised controlled trials (RCTs) of routine GPI vs. control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis using Mantel-Haenszel estimates of risk ratios (RR) as summary statistics.
Results
After systematic review, twenty-one RCTs with 8,585 patients were included: ten trials randomized tirofiban (T), nine abciximab (A), one eptifibatide (E), one trial used A+T; only one trial used DAPT with prasugrel/ ticagrelor. Routine GPI were associated with a significant reduction in all-cause mortality at 30 days (2.4% (GPI) vs. 3.2%; risk ratio (RR) 0.72; p=0.01) and 6 months (3.7% vs. 4.8%; RR 0.76; p=0.02), and a reduction in recurrent MI (1.1% vs. 2.1%; RR 0.55; p=0.0006), repeat revascularization (2.5% vs. 4.1%; RR 0.63; p=0.0001), TIMI flow <3 after PCI (5.4% vs. 8.2%; RR 0.61; p<0.0001) and ischemic stroke (RR 0.42; p=0.04). Major (4.7% vs. 3.4%; RR 1.35; p=0.005) and minor bleedings (7.2% vs. 5.1%; RR 1.39; p=0.006) but not intracranial bleedings (0.1% vs. 0%; RR 2.7; p=0.37) were significantly increased under routine GPI.
Conclusions
Routine GPI administration during primary PCI in STEMI resulted in mortality reduction, driven by reductions in recurrent ischemic events – however predominantly in trials pre-prasugrel/ticagrelor. Trials in contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
| | - Y F Lin
- University of Dusseldorf, Duesseldorf, Germany
| | | | - C Parco
- University of Dusseldorf, Duesseldorf, Germany
| | - V Schulze
- University of Dusseldorf, Duesseldorf, Germany
| | | | - T Krieger
- University of Dusseldorf, Duesseldorf, Germany
| | - C Jung
- University of Dusseldorf, Duesseldorf, Germany
| | - Y Heinen
- University of Dusseldorf, Duesseldorf, Germany
| | - S Perings
- University of Dusseldorf, Duesseldorf, Germany
| | - U Zeymer
- University of Dusseldorf, Duesseldorf, Germany
| | - M Kelm
- University of Dusseldorf, Duesseldorf, Germany
| | - A Polzin
- University of Dusseldorf, Duesseldorf, Germany
| | - G Wolff
- University of Dusseldorf, Duesseldorf, Germany
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17
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Wolff G, Klein K, Parco C, Lin Y, Maier O, Karathanos A, Brockmeyer M, Zeus T, Polzin A, Westenfeld R, Jung C, Blehm A, Lichtenberg A, Kelm M, Veulemans V. P1853Comparative evaluation of risk model performance for prediction of 30-day mortality in transcatheter aortic valve replacement. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0604] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background and purpose
EuroSCORE (ES) and Society of Thoracic Surgeons (STS) risk prediction models are routinely used to guide decision-making for transcatheter aortic valve replacement (TAVR), however their accuracy remains limited, especially in very old and high-risk patients. New and updated scoring models have thus been developed to improve risk stratification. We performed a comparative evaluation of classical and new risk scoring models for prediction of 30d mortality in transcatheter aortic valve interventions.
Methods and results
A total of 1,569 patients undergoing transfemoral (TF, n=1.235) or transapical (TA, n=334) TAVR from 2009 to 2018 were included in a single-center all-comer analysis. Six risk scoring models (logES_I, ES_II, STS-PROM, FRANCE-2, OBSERVANT, GAV-2) were calculated for all patients and evaluated for prediction of 30d mortality in their model discrimination (c-indices with 95% confidence intervals (CI)) and calibration (graphical evaluation). Mean classical risk scores confirmed an intermediate-to-high-risk patient collective (logES_I 27.0±16.9%; STS-PROM 7.0±6.4%), mean 30-day mortality was 3.4% (TF 2.3%; TA 7.8%). Overall discrimination performance was best in FRANCE-2 (c-index 0.73, 95% CI 0.67–0.80), followed by STS-PROM (c-index 0.68, 95% CI 0.62–0.75), OBSERVANT (c-index 0.68, 95% CI 0.61–0.76), ES_II (c-index 0.64) and logES_I and GAV-2 (both c-indices 0.63). FRANCE-2 discriminated best in TF TAVR (c-index 0.72; range of c-indices 0.63 to 0.72), while OBSERVANT performed best in TA TAVR (c-index 0.70; range of c-indices 0.61 to 0.70). All risk scoring models – with the exception of lowest-risk deciles of STS-PROM and ES_II – showed an overestimation of mortality probability in all risk strata.
Conclusion
FRANCE-2 and OBSERVANT risk models showed superior discrimination performance to classical risk scoring models in TF and TA TAVR, however all models tended to overestimate mortality probability.
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Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - K Klein
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Parco
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - O Maier
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Polzin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - R Westenfeld
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - C Jung
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Blehm
- University Hospital Dusseldorf, Cardiovascular surgery, Dusseldorf, Germany
| | - A Lichtenberg
- University Hospital Dusseldorf, Cardiovascular surgery, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Veulemans
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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18
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Karathanos A, Lin Y, Dannenberg L, Parco C, Schulze V, Brockmeyer M, Jung C, Heinen Y, Perings S, Zeymer U, Kelm M, Polzin A, Wolff G. Routine Glycoprotein IIb/IIIa Inhibitor Therapy in ST-Segment Elevation Myocardial Infarction: A Meta-analysis. Can J Cardiol 2019; 35:1576-1588. [PMID: 31542257 DOI: 10.1016/j.cjca.2019.05.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/01/2019] [Accepted: 05/01/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPIs) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate routine GPI use in STEMI treated with primary percutaneous coronary intervention. METHODS Online databases were searched for randomized controlled trials of routine GPI vs control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis. Twenty-one randomized controlled trials with 8585 patients were included: 10 trials randomized tirofiban, 9 abciximab, 1 trial eptifibatide, and 1 trial used abciximab+tirofiban; only 1 trial used dual antiplatelet therapy with prasugrel/ticagrelor. RESULTS Routine GPI use was associated with a significant reduction in all-cause mortality at 30 days (2.4% [GPI] vs 3.2%; risk ratio [RR], 0.72; P = 0.01) and 6 months (3.7% vs 4.8%; RR, 0.76; P = 0.02), and a reduction in recurrent myocardial infarction (1.1% vs 2.1%; RR, 0.55; P = 0.0006), repeat revascularization (2.5% vs 4.1%; RR, 0.63; P = 0.0001), thrombolysis in myocardial infarction flow <3 after percutaneous coronary intervention (5.4% vs 8.2%; RR, 0.61; P < 0.0001), and ischemic stroke (RR, 0.42; P = 0.04). Major (4.7% vs 3.4%; RR, 1.35; P = 0.005) and minor bleedings (7.2% vs 5.1%; RR, 1.39; P = 0.006) but not intracranial bleedings (0.1% vs 0%; RR, 2.7; P = 0.37) were significantly increased under routine GPI. CONCLUSIONS Routine GPI administration in STEMI resulted in a reduction in mortality, driven by reductions in recurrent ischemic events-however predominantly in pre-prasugrel/ticagrelor trials. Trials with contemporary STEMI management are needed to confirm these findings.
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Affiliation(s)
| | - Yingfeng Lin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Lisa Dannenberg
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Claudio Parco
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Volker Schulze
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | | | - Christian Jung
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Yvonne Heinen
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Stefan Perings
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Uwe Zeymer
- Heart Center Ludwigshafen, Clinic for Cardiology, Pulmonology, Vascular and Intensive Care Medicine, Ludwigshafen, Germany
| | - Malte Kelm
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany; CARID-Cardiovascular Research Institute Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Georg Wolff
- University Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
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19
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Karathanos A, Piayda K, Zeus T. Pulmonalklappenerkrankungen: interventionelle und operative Therapieoptionen. Aktuel Kardiol 2019. [DOI: 10.1055/a-0807-3730] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
ZusammenfassungErkrankungen der Pulmonalklappe (PK) sind selten und spielen in der Erwachsenenkardiologie eine untergeordnete Rolle. Ätiologisch dominieren angeborene PK-Vitien. Erworbene Vitien entstehen häufig durch die Degeneration einer bereits eingesetzten Bioprothese. Die Echokardiografie bildet die unverzichtbare diagnostische Basis. Um eine optimale therapeutische Entscheidung zu treffen, ist darüber hinaus die multimodale Bildgebung von entscheidender Bedeutung. Aufgrund der rechtskardialen, hämodynamischen Kompensationsmechanismen weisen betroffene Patienten häufig jahrzehntelang keine Symptome auf. Eine Entscheidung zur operativen oder interventionellen Therapie wird anhand des klinischen Verlaufs und des Schweregrades der Erkrankung gefällt. Falls technisch möglich sollte ein interventionelles Vorgehen, insbesondere bei voroperierten Patienten, einem operativen Verfahren gegenüber bevorzugt werden. Der Eingriff sowie die empfohlenen lebenslangen Nachuntersuchungen sollten in einem Schwerpunktzentrum für Erwachsene mit angeborenen Herzfehlern erfolgen. Auf eine Endokarditisprophylaxe und eine patientenadaptierte Gerinnungstherapie ist nach Klappenersatz zu achten.
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Affiliation(s)
| | - Kerstin Piayda
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf
| | - Tobias Zeus
- Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf
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20
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Klein K, Karathanos A, Heinen Y, Zeus T. Notfallsonografie des Herzens – Schritt für Schritt. Dtsch Med Wochenschr 2018; 143:1397-1404. [DOI: 10.1055/a-0367-0649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Abstract
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21
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Wolff G, Karathanos A, Dannenberg L, Lin Y, Brockmeyer M, Heinen Y, Zeus T, Kelm M, Polzin A, Schulze V. P3624Glycoprotein IIb/IIIa inhibitor therapy in ST-segment elevation myocardial infarction: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - L Dannenberg
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Heinen
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Polzin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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22
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Wolff G, Lin Y, Karathanos A, Brockmeyer M, Heinen Y, Zeus T, Polzin A, Kelm M, Schulze V. P3593Interventional patent foramen ovale closure or medical therapy for cryptogenic ischemic stroke: an updated meta-analysis of randomized controlled trials. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Heinen
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - T Zeus
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Polzin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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23
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Wolff G, Lin Y, Quade J, Bader S, Kosejian L, Karathanos A, Brockmeyer M, Heinen Y, Kelm M, Schulze V. P6355Validation of an NCDR-score-based risk model for cardiac catheterization procedures in a european population. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- G Wolff
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Lin
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - J Quade
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - S Bader
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - L Kosejian
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - A Karathanos
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Brockmeyer
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - Y Heinen
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - M Kelm
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
| | - V Schulze
- University Hospital Dusseldorf, Cardiology, Pulmonology and Angiology, Dusseldorf, Germany
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Schulze V, Lin Y, Karathanos A, Brockmeyer M, Zeus T, Polzin A, Perings S, Kelm M, Wolff G. Patent foramen ovale closure or medical therapy for cryptogenic ischemic stroke: an updated meta-analysis of randomized controlled trials. Clin Res Cardiol 2018; 107:745-755. [DOI: 10.1007/s00392-018-1224-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 02/26/2018] [Indexed: 10/17/2022]
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25
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Münzer P, Liu G, Towhid S, Karathanos A, Tavlaki E, Geisler T, Seizer P, May A, Bigalke B, Borst O, Gawaz M, Tolios A, Gatidis S, Lang F. Increased platelet Ca2+ channel Orai1 expression upon platelet activation and in patients with acute myocardial infarction. Thromb Haemost 2017; 110:386-9. [DOI: 10.1160/th12-09-0701] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 05/05/2013] [Indexed: 11/05/2022]
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26
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Wolff G, Lin Y, Karathanos A, Brockmeyer M, Wolters S, Nowak B, Fuernkranz A, Makimoto H, Kelm M, Schulze V. 2920Implantable cardioverter/defibrillators for primary prevention in dilated cardiomyopathy post-DANISH: an updated meta-analysis and systematic review of randomized controlled trials. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.2920] [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: 11/14/2022] Open
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27
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Wolff G, Navarese E, Brockmeyer M, Lin Y, Karathanos A, Kolodziejczak M, Kubica J, Zeus T, Westenfeld R, Andreotti F, Kelm M, Schulze V. P4011Efficacy and safety of perioperative aspirin therapy in non-cardiac surgery: a systematic review and comprehensive meta-analysis of randomized controlled trials. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx504.p4011] [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: 11/14/2022] Open
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28
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Wolff G, Lin Y, Karathanos A, Brockmeyer M, Wolters S, Nowak B, Fürnkranz A, Makimoto H, Kelm M, Schulze V. Implantable cardioverter/defibrillators for primary prevention in dilated cardiomyopathy post-DANISH: an updated meta-analysis and systematic review of randomized controlled trials. Clin Res Cardiol 2017; 106:501-513. [PMID: 28213711 DOI: 10.1007/s00392-017-1079-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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] [Received: 10/18/2016] [Accepted: 01/10/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sudden cardiac death (SCD) is frequent in patients with heart failure due to dilated cardiomyopathy (DCM). Implantable cardioverter/defibrillator (ICD) device therapy is currently used for primary prevention. However, publication of the DANISH trial has recently given reason for doubt, showing no significant improvement in all-cause mortality in comparison to contemporary medical therapy. METHODS We performed a meta-analysis of all randomized controlled trials comparing ICD therapy to medical therapy (MT) for primary prevention in DCM. The primary outcome was all-cause mortality; secondary analyses were performed on sudden cardiac death, cardiovascular death and non-cardiac death. RESULTS Five trials including a total of 2992 patients were included in the pooled analysis. Compared to contemporary medical treatment there was a significant mortality reduction with ICD device therapy [odds ratio (OR) 0.77, 95% confidence interval (CI) 0.64-0.93; p = 0.006]. SCD was decreased significantly (OR 0.43, CI 0.27-0.69; p = 0.0004), while cardiovascular death and non-cardiac death showed no differences. Sensitivity analyses showed no influence of amiodarone therapy on overall results. Analysis of MT details revealed the DANISH population to adhere the most to current guideline recommendations. In addition, it was the only study including a substantial amount of CRT devices (58%). CONCLUSIONS Our meta-analysis of all available randomized evidence shows a survival benefit of ICD therapy for primary prevention in DCM. DANISH results suggest an attenuation of this ICD advantage when compared to contemporary medical and cardiac resynchronization therapy. Until larger trials have confirmed this finding, ICD therapy should remain the recommendation for primary prevention of SCD in DCM.
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Affiliation(s)
- Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Yingfeng Lin
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Athanasios Karathanos
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Susanne Wolters
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Bernd Nowak
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Alexander Fürnkranz
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.,Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Hisaki Makimoto
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Volker Schulze
- Division of Cardiology, Pulmonology and Vascular Medicine, Department of Internal Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany
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Geisler T, Booth J, Tavlaki E, Karathanos A, Müller K, Droppa M, Gawaz M, Yanez-Lopez M, Davidson SJ, Stables RH, Banya W, Zaman A, Flather M, Dalby M. High Platelet Reactivity in Patients with Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention: Randomised Controlled Trial Comparing Prasugrel and Clopidogrel. PLoS One 2015; 10:e0135037. [PMID: 26317618 PMCID: PMC4552627 DOI: 10.1371/journal.pone.0135037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/16/2015] [Indexed: 11/20/2022] Open
Abstract
Background Prasugrel is more effective than clopidogrel in reducing platelet aggregation in acute coronary syndromes. Data available on prasugrel reloading in clopidogrel treated patients with high residual platelet reactivity (HRPR) i.e. poor responders, is limited. Objectives To determine the effects of prasugrel loading on platelet function in patients on clopidogrel and high platelet reactivity undergoing percutaneous coronary intervention for acute coronary syndrome (ACS). Patients Patients with ACS on clopidogrel who were scheduled for PCI found to have a platelet reactivity ≥40 AUC with the Multiplate Analyzer, i.e. “poor responders” were randomised to prasugrel (60 mg loading and 10 mg maintenance dose) or clopidogrel (600 mg reloading and 150 mg maintenance dose). The primary outcome measure was proportion of patients with platelet reactivity <40 AUC 4 hours after loading with study medication, and also at one hour (secondary outcome). 44 patients were enrolled and the study was terminated early as clopidogrel use decreased sharply due to introduction of newer P2Y12 inhibitors. Results At 4 hours after study medication 100% of patients treated with prasugrel compared to 91% of those treated with clopidogrel had platelet reactivity <40 AUC (p = 0.49), while at 1 hour the proportions were 95% and 64% respectively (p = 0.02). Mean platelet reactivity at 4 and 1 hours after study medication in prasugrel and clopidogrel groups respectively were 12 versus 22 (p = 0.005) and 19 versus 34 (p = 0.01) respectively. Conclusions Routine platelet function testing identifies patients with high residual platelet reactivity (“poor responders”) on clopidogrel. A strategy of prasugrel rather than clopidogrel reloading results in earlier and more sustained suppression of platelet reactivity. Future trials need to identify if this translates into clinical benefit. Trial Registration ClinicalTrials.gov NCT01339026
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Affiliation(s)
- Tobias Geisler
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
- * E-mail:
| | - Jean Booth
- Clinical Trials & Evaluation Unit, Royal Brompton Hospital, London, United Kingdom
| | - Elli Tavlaki
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
| | - Athanasios Karathanos
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
| | - Karin Müller
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
| | - Michal Droppa
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
| | - Meinrad Gawaz
- Klinikum der Eberhard-Karls-Universität Tübingen, Abteilung für Kardiologie und Kreislauferkrankungen, Tübingen, Germany
| | - Monica Yanez-Lopez
- Clinical Trials & Evaluation Unit, Royal Brompton Hospital, London, United Kingdom
| | - Simon J. Davidson
- Dept. Haematology, Royal Brompton&Harefield NHS Foundation Trust, London, United Kingdom
| | - Rod H. Stables
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Winston Banya
- Clinical Trials & Evaluation Unit, Royal Brompton Hospital, London, United Kingdom
| | - Azfar Zaman
- Freeman Hospital and Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Marcus Flather
- Norfolk and Norwich University Hospitals NHS Foundation Trust and Norwich Medical School, University of East Anglia, Norfolk, United Kingdom
| | - Miles Dalby
- Harefield Hospital, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
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Droppa M, Karathanos A, Gawaz M, Geisler T. Individualised dual antiplatelet therapy in a patient with short bowel syndrome after acute myocardial infarction with coronary artery stenting. BMJ Case Rep 2015; 2015:bcr-2014-205227. [PMID: 26150610 DOI: 10.1136/bcr-2014-205227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Short bowel syndrome after extensive surgical resection of the intestine is characterised by inadequate digestion and absorption of nutrients. Additional clinical problems include impaired absorption and metabolism of diverse drugs requiring individualised medical therapy or alternative treatments. We report a case of individualised dual antiplatelet therapy in a patient who underwent an extensive intestinal resection complicated by acute myocardial infarction requiring percutaneous coronary intervention and stent implantation. Genetic testing of CYP2C19 gene polymorphisms and platelet aggregation testing were used to assess responses to aspirin, clopidogrel, prasugrel and ticagrelor. Given its unique pharmacokinetics with good absorption and without need of metabolism to an active substance, ticagrelor appears to be the best for patients with short bowel syndrome who require dual antiplatelet therapy after coronary stent implantation.
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Affiliation(s)
- Michal Droppa
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
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Droppa M, Tschernow D, Müller KAL, Tavlaki E, Karathanos A, Stimpfle F, Schaeffeler E, Schwab M, Tolios A, Siller-Matula JM, Gawaz M, Geisler T. Evaluation of clinical risk factors to predict high on-treatment platelet reactivity and outcome in patients with stable coronary artery disease (PREDICT-STABLE). PLoS One 2015; 10:e0121620. [PMID: 25799149 PMCID: PMC4370634 DOI: 10.1371/journal.pone.0121620] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/02/2015] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES This study was designed to identify the multivariate effect of clinical risk factors on high on-treatment platelet reactivity (HPR) and 12 months major adverse events (MACE) under treatment with aspirin and clopidogrel in patients undergoing non-urgent percutaneous coronary intervention (PCI). METHODS 739 consecutive patients with stable coronary artery disease (CAD) undergoing PCI were recruited. On-treatment platelet aggregation was tested by light transmittance aggregometry. Clinical risk factors and MACE during one-year follow-up were recorded. An independent population of 591 patients served as validation cohort. RESULTS Degree of on-treatment platelet aggregation was influenced by different clinical risk factors. In multivariate regression analysis older age, diabetes mellitus, elevated BMI, renal function and left ventricular ejection fraction were independent predictors of HPR. After weighing these variables according to their estimates in multivariate regression model, we developed a score to predict HPR in stable CAD patients undergoing elective PCI (PREDICT-STABLE Score, ranging 0-9). Patients with a high score were significantly more likely to develop MACE within one year of follow-up, 3.4% (score 0-3), 6.3% (score 4-6) and 10.3% (score 7-9); odds ratio 3.23, P=0.02 for score 7-9 vs. 0-3. This association was confirmed in the validation cohort. CONCLUSIONS Variability of on-treatment platelet function and associated outcome is mainly influenced by clinical risk variables. Identification of high risk patients (e.g. with high PREDICT-STABLE score) might help to identify risk groups that benefit from more intensified antiplatelet regimen. Additional clinical risk factor assessment rather than isolated platelet function-guided approaches should be investigated in future to evaluate personalized antiplatelet therapy in stable CAD-patients.
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Affiliation(s)
- Michal Droppa
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Dimitri Tschernow
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Karin A. L. Müller
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Elli Tavlaki
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Fabian Stimpfle
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Elke Schaeffeler
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
- Department of Clinical Pharmacology, University Hospital of Tübingen, Tübingen, Germany
| | - Alexander Tolios
- Laboratory Medicine Institute, Medical Center of the University of Munich, Munich, Germany
| | | | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
- * E-mail:
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Patzelt J, Mueller K, Breuning S, Karathanos A, Schleicher R, Seizer P, Gawaz M, Langer H, Geisler T. Expression of anaphylatoxin receptors on platelets in patients with coronary heart disease. Atherosclerosis 2015; 238:289-95. [DOI: 10.1016/j.atherosclerosis.2014.12.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 10/15/2014] [Accepted: 12/04/2014] [Indexed: 01/06/2023]
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Stimpfle F, Karathanos A, Droppa M, Metzger J, Rath D, Müller K, Tavlaki E, Schäffeler E, Winter S, Schwab M, Gawaz M, Geisler T. Impact of point-of-care testing for CYP2C19 on platelet inhibition in patients with acute coronary syndrome and early dual antiplatelet therapy in the emergency setting. Thromb Res 2014; 134:105-10. [PMID: 24856643 DOI: 10.1016/j.thromres.2014.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/11/2014] [Accepted: 05/05/2014] [Indexed: 11/29/2022]
Abstract
AIMS Only limited data exist about the role of point of care CYP2C19 testing in the acute setting in the early phase of acute coronary syndromes (ACS). Therefore, the present study was designed to investigate the impact of CYP2C19 loss-of-function point-of-care (POC) genotyping in patients presenting with acute coronary syndromes (ACS) and treated with dual antiplatelet therapy in the emergency setting. METHODS AND RESULTS 137 subjects with ACS scheduled for percutaneous coronary intervention were consecutively enrolled. Pre- and on-treatment platelet aggregation was assessed by multiple electrode aggregometry (MEA) after stimulation with adenosine diphosphate (ADP). Patients were loaded according to current guideline adherent indications and contraindications for use of P2Y12 inhibitors in ACS. POC genotyping for CYP2C19*2 was performed in the emergency room after obtaining a buccal swab using the Spartan RX CYP2C19 system and obtaining patient's informed consent. Prasugrel and ticagrelor treated patients had significantly lower PR compared to clopidogrel-treated patients. The benefits of prasugrel and ticagrelor compared to clopidogrel treated patients in terms of platelet inhibition were more pronounced in CYP2C19*2 carriers. Non-carriers showed similar inhibition regardless of particular P2Y12 inhibitor treatment. Statistical analyses adjusting for factors associated with response (e.g. smoking) revealed that CYP2C19*2 allele carrier status and loading with different type of P2Y12 receptor blockers were significant predictors of on-treatment platelet reactivity in the early phase of ACS. CONCLUSION The results of this pilot study of treatment of patients in the early phase of ACS indicate that CYP2C19*2 POC genotyping might help to identify patients at risk with poor response to clopidogrel treatment, thereby benefiting from reloading and switching to alternative P2Y12 receptor inhibition.
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Affiliation(s)
- Fabian Stimpfle
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michal Droppa
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Janina Metzger
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Dominik Rath
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Karin Müller
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Elli Tavlaki
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Elke Schäffeler
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; University Tübingen, Tübingen, Germany
| | - Stefan Winter
- Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany; University Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Department of Clinical Pharmacology, University Hospital of Tübingen, Tübingen, Germany; Dr Margarete Fischer-Bosch-Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine, University Hospital of Tübingen, Tübingen, Germany.
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Geisler T, Müller K, Karathanos A, Bocksch W, Gawaz M, Deliargyris E, Bernstein D, Lincoff AM, Mehran R, Dangas G, Stone GW. Impact of antithrombotic treatment on short-term outcomes after percutaneous coronary intervention for left main disease: a pooled analysis from REPLACE-2, ACUITY, and HORIZONS-AMI trials. EUROINTERVENTION 2014; 10:97-104. [DOI: 10.4244/eijv10i1a16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Antiplatelet therapy is the cornerstone of the treatment for patients with coronary artery disease (CAD). Dual therapy with clopidogrel and aspirin is currently the standard treatment after percutaneous coronary interventions. However, despite the use of clopidogrel, a considerable number of patients continue to suffer major adverse cardiac events. There is a growing degree of evidence supporting high on-treatment platelet reactivity (HPR) as a predictive factor for recurrent ischemic complications. Numerous studies have shown an interindividual variability of responsiveness to clopidogrel and aspirin, which is one of the reasons for HPR. There is yet to be established an assay for antiplatelet drug response as the gold standard. This paper provides a background to the current controversies surrounding the issue of testing for the effectiveness of antiplatelet therapy and reviews the various genetic and phenotype-based laboratory tests to measure aspirin and clopidogrel response and their correlation with clinical outcomes. On the basis of the current evidence and trying to be cost-effective, testing should be considered on a case-by-case basis, especially in patients who present with an acute coronary syndrome or stent thrombosis. In the case of stable CAD, we think that testing might be helpful in particular risk groups of patients to avoid ischemic or bleeding complications.
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Affiliation(s)
- Athanasios Karathanos
- Department of Cardiology and Cardiovascular Medicine, University Hospital Tübingen, Ottfried-Müller-Straße 10, 72076, Tübingen, Germany
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Müller KAL, Karathanos A, Tavlaki E, Stimpfle F, Meissner M, Bigalke B, Stellos K, Schwab M, Schaeffeler E, Müller II, Gawaz M, Geisler T. Combination of high on-treatment platelet aggregation and low deaggregation better predicts long-term cardiovascular events in PCI patients under dual antiplatelet therapy. Platelets 2013; 25:439-46. [PMID: 24102318 DOI: 10.3109/09537104.2013.829914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
High on-treatment platelet reactivity is associated with short-term major cardiovascular (CV) events in patients undergoing percutaneous coronary intervention (PCI). Maximum and final aggregation assessed by light transmission aggregometry (LTA) have both been used to predict short-term outcome after PCI, however their long-term prognostic impact remains controversial. There is currently no information regarding the prognostic role of deaggregation and its added value in combination with established aggregation parameters. About 1279 patients with symptomatic coronary artery disease (CAD) undergoing PCI were enrolled in this monocentric study. On-treatment platelet aggregation under clopidogrel maintenance therapy, as well as deaggregation was determined by maximum and final aggregation (5 min after adding of the agonist). Deaggregation was defined as slope of the tangent between Aggmax +0.5 min. Primary endpoints were the composite of myocardial infarction, stroke, and CV death or stent thrombosis according to the ARC criteria. Low deaggregation, defined as values in the lowest tertile (<1.5), was more frequent in patients with acute coronary syndromes (ACS) compared to patients with stable angina pectoris (SAP), ACS: 29.6% vs. SAP: 22.0%, p = 0.001. The combination of high on-treatment platelet reactivity, defined by the upper tertile of Aggmax and low deaggregation, was associated with significantly increased risk for combined long-term CV events. The combination of low deaggregation and high on-treatment platelet reactivity is associated with higher risk for recurrent events in patients with CAD undergoing PCI. Thus, deaggregation might be a more sensitive parameter providing added value in terms of risk prediction for long-term recurrent CV events in relation with established aggregation parameters.
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Affiliation(s)
- K A L Müller
- Medizinische Klinik III, Kardiologie und Kreislauferkrankungen, Universitätsklinikum Tübingen , Tübingen , Germany and
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Müller II, Müller KAL, Schönleber H, Karathanos A, Schneider M, Jorbenadze R, Bigalke B, Gawaz M, Geisler T. Macrophage migration inhibitory factor is enhanced in acute coronary syndromes and is associated with the inflammatory response. PLoS One 2012; 7:e38376. [PMID: 22693633 PMCID: PMC3367911 DOI: 10.1371/journal.pone.0038376] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 05/04/2012] [Indexed: 12/15/2022] Open
Abstract
Background Chronic inflammation promotes atherosclerosis in cardiovascular disease and is a major prognostic factor for patients undergoing percutaneous coronary intervention (PCI). Macrophage migration inhibitory factor (MIF) is involved in the progress of atherosclerosis and plaque destabilization and plays a pivotal role in the development of acute coronary syndromes (ACS). Little is known to date about the clinical impact of MIF in patients with symptomatic coronary artery disease (CAD). Methods and Results In a pilot study, 286 patients with symptomatic CAD (n = 119 ACS, n = 167 stable CAD) undergoing PCI were consecutively evaluated. 25 healthy volunteers served as control. Expression of MIF was consecutively measured in patients at the time of PCI. Baseline levels of interleukin 6 (IL-6), “regulated upon activation, normal T-cell expressed, and secreted” (RANTES) and monocyte chemoattractant protein-1 (MCP-1) were measured by Bio-Plex Cytokine assay. C-reactive protein (CRP) was determined by Immunoassay. Patients with ACS showed higher plasma levels of MIF compared to patients with stable CAD and control subjects (median 2.85 ng/mL, interquartile range (IQR) 3.52 versus median 1.22 ng/mL, IQR 2.99, versus median 0.1, IQR 0.09, p<0.001). Increased MIF levels were associated with CRP and IL-6 levels and correlated with troponin I (TnI) release (spearman rank coefficient: 0.31, p<0.001). Patients with ACS due to plaque rupture showed significantly higher plasma levels of MIF than patients with flow limiting stenotic lesions (p = 0.002). Conclusion To our knowledge this is the first study, demonstrating enhanced expression of MIF in ACS. It is associated with established inflammatory markers, correlates with the extent of cardiac necrosis marker release after PCI and is significantly increased in ACS patients with “culprit” lesions. Further attempts should be undertaken to characterize the role of MIF for risk assessment in the setting of ACS.
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Affiliation(s)
- Iris I. Müller
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Karin A. L. Müller
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Heiko Schönleber
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Athanasios Karathanos
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Martina Schneider
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Rezo Jorbenadze
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Boris Bigalke
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
| | - Meinrad Gawaz
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
- * E-mail: (MG); (TG)
| | - Tobias Geisler
- Kardiologie und Kreislauferkrankungen, Medizinische Klinik III, Eberhard Karls Universität, Tübingen, Germany
- * E-mail: (MG); (TG)
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Bassiakou E, Valsamidis D, Loukeri A, Karathanos A. The distance from the skin to the epidural and subarachnoid spaces in parturients scheduled for caesarean section. Minerva Anestesiol 2011; 77:154-159. [PMID: 21102403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND The purpose of this study was to measure the skin to epidural space distance (SED), the skin to subarachnoid space distance (SSD) and the epidural to subarachnoid space distance (ESD) at the L3-4 interspace in parturients scheduled for caesarean section (CS) and to investigate whether any correlations exist between these distances and various physical and anthropometric parameters. METHODS This study consisted of 332 parturients scheduled for CS. The epidural space was identified by noting the loss of resistance to air at the L3-4 intervertebral space with a Tuohy needle, thus permitting measurement of the SED. The spinal needle was introduced through the Tuohy needle and, after identification of the subarachnoid space, was locked in the epidural needle. The distance between the tip of the Tuohy needle and tip of spinal needle (ESD) was recorded. This number was added to the SED to obtain the SSD value. RESULTS Mean values ± standard deviations for SED, SSD and ESD were 5.6 ± 1.6 cm, 6.5 ± 1.2 cm and 0.9 ± 0.5 cm, respectively. Statistically significant correlations were observed between SED, SSD and ESD with body mass index and body weight of the parturients, as well as between the SED and the parturient's height. Furthermore, a significant negative correlation was observed between the ESD and gestational age. Finally, a significant correlation existed between the SSD and ESD. CONCLUSION Measurements of SED, SSD and ESD in parturients and the correlations between these distances to various physical and anthropometric parameters may be of potential value for combined spinal-epidural anesthesia (CSEA) in parturients scheduled for CS.
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Affiliation(s)
- E Bassiakou
- Department of Anesthesiology, Alexandra General Hospital, Athens, Greece.
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Abstract
We report a case of neurogenic diabetes insipidus in a premature infant. It was treated with desmopressin, which appears to be the drug of choice for the treatment of this disease in early infancy.
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Strintzi-Paschalaki N, Karathanos A, Demopoulos H, Malamitsi-Puchner A, Triantaphyllidis A. Neurobehavioral responses of newborn infants after maternal epidural v.s. general anaesthesia. Rev Med Chir Soc Med Nat Iasi 1982; 86:619-21. [PMID: 7170517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Karathanos A, Giacoia GP. Should Oklahoma screen newborns for galactosemia? J Okla State Med Assoc 1981; 74:169-72. [PMID: 6788914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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