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Andersen T, Ueland T, Aukrust P, Nilsen DW, Grundt H, Staines H, Pönitz V, Kontny F. Procollagen type 1 N-terminal propeptide is associated with adverse outcome in acute chest pain of suspected coronary origin. Front Cardiovasc Med 2023; 10:1191055. [PMID: 37731526 PMCID: PMC10507464 DOI: 10.3389/fcvm.2023.1191055] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/14/2023] [Indexed: 09/22/2023] Open
Abstract
Background Extracellular matrix (ECM) is an integral player in the pathophysiology of a variety of cardiac diseases. Cardiac ECM is composed mainly of collagen, of which type 1 is the most abundant with procollagen type 1 N-terminal Propeptide (P1NP) as a formation marker. P1NP is associated with mortality in the general population, however, its role in myocardial infarction (MI) is still uncertain, and P1NP has not been investigated in acute chest pain. The objective of the current study was to assess the role of P1NP in undifferentiated acute chest pain of suspected coronary origin. Methods and results 813 patients from the Risk in Acute Coronary Syndromes study were included. This was a single-center study investigating biomarkers in consecutively enrolled patients with acute chest pain of suspected coronary origin, with a follow-up for up to 7 years. Outcome measures were a composite endpoint of all-cause death, new MI or stroke, as well as its individual components at 1, 2, and 7 years, and cardiac death at 1 and 2 years. In multivariable Cox regression analysis, quartiles of P1NP were significantly associated with the composite endpoint at 1 year of follow-up with a hazard ratio for Q4 of 1.82 (95% CI, 1.12-2.98). There was no other significant association with outcomes at any time points. Conclusion P1NP was found to be an independent biomarker significantly associated with adverse clinical outcome at one year in patients admitted to hospital for acute chest pain of suspected coronary origin. This is the first report in the literature on the prognostic value of P1NP in this clinical setting. Clinicaltrialsygov Identifier NCT00521976.
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Affiliation(s)
- Thomas Andersen
- Department of Anesthesiology, Stavanger University Hospital, Stavanger, Norway
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Thrombosis Research Centre (TREC), Department of Clinical Medicine, UiT—The Arctic University of Norway, Tromsø, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Dennis W.T. Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heidi Grundt
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pulmonology, Stavanger University Hospital, Stavanger, Norway
| | - Harry Staines
- Sigma Statistical Services, Balmullo, United Kingdom
| | - Volker Pönitz
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Drammen Heart Centre, Drammen, Norway
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2
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Nilsen DWT, Røysland M, Ueland T, Aukrust P, Michelsen AE, Staines H, Barvik S, Kontny F, Nordrehaug JE, Bonarjee VVS. The Effect of Protease-Activated Receptor-1 (PAR-1) Inhibition on Endothelial-Related Biomarkers in Patients with Coronary Artery Disease. Thromb Haemost 2022; 123:510-521. [PMID: 36588289 PMCID: PMC10113036 DOI: 10.1055/s-0042-1760256] [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: 01/03/2023]
Abstract
BACKGROUND Vorapaxar has been shown to reduce cardiovascular mortality in post-myocardial infarction (MI) patients. Pharmacodynamic biomarker research related to protease-activated receptor-1 (PAR-1) inhibition with vorapaxar in humans has short follow-up (FU) duration and is mainly focused on platelets rather than endothelial cells. AIM This article assesses systemic changes in endothelial-related biomarkers during vorapaxar treatment compared with placebo at 30 days' FU and beyond, in patients with coronary heart disease. METHODS Local substudy patients in Norway were included consecutively from two randomized controlled trials; post-MI subjects from TRA2P-TIMI 50 and non-ST-segment elevation MI (NSTEMI) patients from TRACER. Aliquots of citrated blood were stored at -80°C. Angiopoietin-2, angiopoietin-like 4, vascular endothelial growth factor, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, E-selectin, von Willebrand factor, thrombomodulin, and plasminogen activator inhibitor-1 and -2 were measured at 1-month FU and at study completion (median 2.3 years for pooled patients). RESULTS A total of 265 consecutive patients (age median 62.0, males 83%) were included. Biomarkers were available at both FUs in 221 subjects. In the total population, angiopoietin-2 increased in patients on vorapaxar as compared with placebo at 1-month FU (p = 0.034). Angiopoietin-like 4 increased (p = 0.028) and plasminogen activator inhibitor-2 decreased (p = 0.025) in favor of vorapaxar at final FU. In post-MI subjects, a short-term increase in E-selectin favoring vorapaxar was observed, p = 0.029. Also, a short-term increase in von Willebrand factor (p = 0.032) favoring vorapaxar was noted in NSTEMI patients. CONCLUSION Significant endothelial biomarker changes during PAR-1 inhibition were observed in post-MI and NSTEMI patients.
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Affiliation(s)
- Dennis W T Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Michelle Røysland
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Thor Ueland
- Department of Clinical Medicine, Thrombosis Research Center, UiT - The Arctic University of Norway, Tromsø, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Pål Aukrust
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Annika E Michelsen
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Harry Staines
- Sigma Statistical Services, Balmullo, United Kingdom of Great Britain and Northern Ireland
| | - Ståle Barvik
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Frederic Kontny
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Drammen Heart Center, Drammen, Norway
| | - Jan Erik Nordrehaug
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Andersen T, Ueland T, Aukrust P, Nilsen DW, Grundt H, Staines H, Kontny F. Podocan and Adverse Clinical Outcome in Patients Admitted With Suspected Acute Coronary Syndromes. Front Cardiovasc Med 2022; 9:867944. [PMID: 35669474 PMCID: PMC9163367 DOI: 10.3389/fcvm.2022.867944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
Background Markers of bone and extracellular matrix (ECM) remodeling may be associated with adverse outcomes in atherosclerotic cardiovascular disease. Podocan is a newly discovered ECM glycoprotein, previously not studied in a chest pain population. We wanted to study the association between Podocan levels on admission and the risk of adverse outcomes in a chest pain population with suspected acute coronary syndromes. Methods A total of 815 patients from the Risk markers in Acute Coronary Syndrome (RACS) trial with suspected coronary chest pain were followed for 7 years. Blood samples were taken immediately after inclusion and stored in the biobank. Associations between Podocan and endpoints were assessed with Cox proportional hazards analyses. Results The median admission level of Podocan was 0.674 ng/ml (0.566–0.908 ng/ml). No significant association was found between Podocan quartile levels and all-cause death, neither at 1 year nor 2- or 7-years follow-up (p > 0.05 for all). Furthermore, no significant association could be shown between Podocan and cardiac death, myocardial infarction (MI), stroke, or the composites of all-cause death/MI/stroke or cardiac death/MI/stroke (p > 0.05 for all). Similarly, in a subgroup of patients with Troponin T-positive (n = 432) there was no significant association between Podocan and any of the outcome measures (p > 0.05 for all endpoints and points in time). Conclusion Podocan, a novel ECM biomarker, is not associated with all-cause mortality or other major cardiovascular adverse events in patients admitted with acute chest pain suspected to be of coronary origin. Clinical Trials.gov Identifier: NCT00521976.
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Affiliation(s)
- Thomas Andersen
- Department of Anesthesiology, Stavanger University Hospital, Stavanger, Norway
- *Correspondence: Thomas Andersen
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Dennis W. Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Heidi Grundt
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pulmonology, Stavanger University Hospital, Stavanger, Norway
| | - Harry Staines
- Sigma Statistical Services, Balmullo, United Kingdom
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Drammen Heart Center, Drammen, Norway
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Gregersen I, Michelsen AE, Lunde NN, Åkerblom A, Lakic TG, Skjelland M, Ryeng Skagen K, Becker RC, Lindbäck J, Himmelmann A, Solberg R, Johansen HT, James SK, Siegbahn A, Storey RF, Kontny F, Aukrust P, Ueland T, Wallentin L, Halvorsen B. Legumain in Acute Coronary Syndromes: A Substudy of the PLATO (Platelet Inhibition and Patient Outcomes) Trial. J Am Heart Assoc 2020; 9:e016360. [PMID: 32809893 PMCID: PMC7660754 DOI: 10.1161/jaha.120.016360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The cysteine protease legumain is increased in patients with atherosclerosis, but its causal role in atherogenesis and cardiovascular disease is still unclear. The aim of the study was to investigate the association of legumain with clinical outcome in a large cohort of patients with acute coronary syndrome. Methods and Results Serum levels of legumain were analyzed in 4883 patients with acute coronary syndrome from a substudy of the PLATO (Platelet Inhibition and Patient Outcomes) trial. Levels were analyzed at admission and after 1 month follow-up. Associations between legumain and a composite of cardiovascular death, spontaneous myocardial infarction or stroke, and its individual components were assessed by multivariable Cox regression analyses. At baseline, a 50% increase in legumain level was associated with a hazard ratio (HR) of 1.13 (95% CI, 1.04-1.21), P=0.0018, for the primary composite end point, adjusted for randomized treatment. The association remained significant after adjustment for important clinical and demographic variables (HR, 1.10; 95% CI, 1.02-1.19; P=0.013) but not in the fully adjusted model. Legumain levels at 1 month were not associated with the composite end point but were negatively associated with stroke (HR, 0.62; 95% CI, 0.44-0.88; P=0.0069), including in the fully adjusted model (HR, 0.57; 95% CI, 0.37-0.88; P=0.0114). Conclusions Baseline legumain was associated with the primary outcome in patients with acute coronary syndrome, but not in the fully adjusted model. The association between high levels of legumain at 1 month and decreased occurrence of stroke could be of interest from a mechanistic point of view, illustrating the potential dual role of legumain during atherogenesis and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00391872.
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Affiliation(s)
- Ida Gregersen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
| | - Annika E Michelsen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
| | - Ngoc Nguyen Lunde
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Axel Åkerblom
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Tatevik G Lakic
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Mona Skjelland
- Department of Neurology Oslo University Hospital Rikshospitalet Oslo Norway
| | | | - Richard C Becker
- Division of Cardiovascular Health and Disease Heart, Lung and Vascular Institute Academic Health Center Cincinnati OH
| | - Johan Lindbäck
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | | | - Rigmor Solberg
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Harald T Johansen
- Section of Pharmacology and Pharmaceutical Biosciences Department of Pharmacy University of Oslo Norway
| | - Stefan K James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease University of Sheffield Sheffield United Kingdom
| | - Frederic Kontny
- Department of Cardiology Stavanger University Hospital Stavanger Norway.,Drammen Heart Center Drammen Norway
| | - Pål Aukrust
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway.,Section of Clinical Immunology and Infectious Diseases Oslo University Hospital Rikshospitalet Oslo Norway.,K.G. Jebsen TREC The Faculty of Health Sciences The Arctic University of Tromsø Tromsø Norway
| | - Thor Ueland
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway.,K.G. Jebsen TREC The Faculty of Health Sciences The Arctic University of Tromsø Tromsø Norway
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | - Bente Halvorsen
- Research Institute for Internal Medicine Oslo University Hospital Rikshospitalet Oslo Norway.,Institute of Clinical Medicine Faculty of Medicine University of Oslo Norway
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5
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Franchi F, James SK, Ghukasyan Lakic T, Budaj AJ, Cornel JH, Katus HA, Keltai M, Kontny F, Lewis BS, Storey RF, Himmelmann A, Wallentin L, Angiolillo DJ. Impact of Diabetes Mellitus and Chronic Kidney Disease on Cardiovascular Outcomes and Platelet P2Y 12 Receptor Antagonist Effects in Patients With Acute Coronary Syndromes: Insights From the PLATO Trial. J Am Heart Assoc 2020; 8:e011139. [PMID: 30857464 PMCID: PMC6475041 DOI: 10.1161/jaha.118.011139] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background There are limited data on how the combination of diabetes mellitus (DM) and chronic kidney disease (CKD) affects cardiovascular outcomes as well as response to different P2Y12 receptor antagonists, which represented the aim of the present investigation. Methods and Results In this post hoc analysis of the PLATO (Platelet Inhibition and Patient Outcomes) trial, which randomized acute coronary syndrome patients to ticagrelor versus clopidogrel, patients (n=15 108) with available DM and CKD status were classified into 4 groups: DM+/CKD+ (n=1058), DM+/CKD− (n=2748), DM−/CKD+ (n=2160), and DM−/CKD− (n=9142). The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke at 12 months. The primary safety end point was PLATO major bleeding. DM+/CKD+ patients had a higher incidence of the primary end point compared with DM−/CKD− patients (23.3% versus 7.1%; adjusted hazard ratio 2.22; 95% CI 1.88–2.63; P<0.001). Patients with DM+/CKD− and DM−/CKD+ had an intermediate risk profile. The same trend was shown for the individual components of the primary end point and for major bleeding. Compared with clopidogrel, ticagrelor reduced the incidence of the primary end point consistently across subgroups (P‐interaction=0.264), but with an increased absolute risk reduction in DM+/CKD+. The effects on major bleeding were also consistent across subgroups (P‐interaction=0.288). Conclusions In acute coronary syndrome patients, a gradient of risk was observed according to the presence or absence of DM and CKD, with patients having both risk factors at the highest risk. Although the ischemic benefit of ticagrelor over clopidogrel was consistent in all subgroups, the absolute risk reduction was greatest in patients with both DM and CKD. Clinical Trial Registration URL: http://www.clinicatrials.gov. Unique identifier: NCT00391872.
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Affiliation(s)
- Francesco Franchi
- 1 University of Florida, College of Medicine-Jacksonville Jacksonville FL
| | - Stefan K James
- 2 Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden.,3 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
| | | | - Andrzej J Budaj
- 4 Postgraduate Medical School Grochowski Hospital Warsaw Poland
| | - Jan H Cornel
- 5 Department of Cardiology Noordwest Ziekenhuisgroep Alkmaar Netherlands
| | - Hugo A Katus
- 6 Medizinishe Klinik Universitätsklinikum Heidelberg Heidelberg Germany
| | - Matyas Keltai
- 7 Hungarian Institute of Cardiology Semmelweis University Budapest Hungary
| | - Frederic Kontny
- 8 Department of Cardiology Stavanger University Hospital Stavanger Norway
| | | | - Robert F Storey
- 10 Department of Infection, Immunity and Cardiovascular Disease University of Sheffield United Kingdom
| | | | - Lars Wallentin
- 2 Department of Medical Sciences Cardiology Uppsala University Uppsala Sweden.,3 Uppsala Clinical Research Center Uppsala University Uppsala Sweden
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6
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Dellborg M, Bonaca MP, Storey RF, Steg PG, Im KA, Cohen M, Bhatt DL, Oude Ophuis T, Budaj A, Hamm C, Spinar J, Kiss RG, Lopez-Sendon J, Kamensky G, Van de Werf F, Ardissino D, Kontny F, Montalescot G, Johanson P, Bengtsson O, Himmelmann A, Braunwald E, Sabatine MS. Efficacy and safety with ticagrelor in patients with prior myocardial infarction in the approved European label: insights from PEGASUS-TIMI 54. Eur Heart J Cardiovasc Pharmacother 2020; 5:200-206. [PMID: 31218354 PMCID: PMC6749839 DOI: 10.1093/ehjcvp/pvz020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/24/2019] [Accepted: 06/07/2019] [Indexed: 12/03/2022]
Abstract
Aims In PEGASUS-TIMI 54, ticagrelor significantly reduced the risk of the composite of major adverse cardiovascular (CV) events by 15–16% in stable patients with a prior myocardial infarction (MI) 1–3 years earlier. We report the efficacy and safety in the subpopulation recommended for treatment in the European (EU) label, i.e. treatment with 60 mg b.i.d. initiated up to 2 years from the MI, or within 1 year after stopping previous adenosine diphosphate receptor inhibitor treatment. Methods and results Of the 21 162 patients enrolled in PEGASUS-TIMI 54, 10 779 patients were included in the primary analysis for this study, randomized to ticagrelor 60 mg (n = 5388) or matching placebo (n = 5391). The cumulative proportions of patients with events at 36 months were calculated by the Kaplan–Meier (KM) method. The composite of CV death, MI, or stroke occurred less frequently in the ticagrelor group (7.9% KM rate vs. 9.6%), hazard ratio (HR) 0.80 [95% confidence interval (CI) 0.70–0.91; P = 0.001]. Ticagrelor also reduced the risk of all-cause mortality, HR 0.80 (0.67–0.96; P = 0.018). Thrombolysis in myocardial infarction major bleeding was more frequent in the ticagrelor group 2.5% vs. 1.1%; HR 2.36 (1.65–3.39; P < 0.001). The corresponding HR for fatal or intracranial bleeding was 1.17 (0.68–2.01; P = 0.58). Conclusion In PEGASUS-TIMI 54, treatment with ticagrelor 60 mg as recommended in the EU label, was associated with a relative risk reduction of 20% in CV death, MI, or stroke. Thrombolysis in myocardial infarction major bleeding was increased, but fatal or intracranial bleeding was similar to placebo. There appears to be a favourable benefit-risk ratio for long-term ticagrelor 60 mg in this population. Clinical trial registration http://www.clinicaltrials.gov NCT01225562
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Affiliation(s)
- Mikael Dellborg
- Department of Medicine, University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital/Östra, Diagnosvägen 11, Gothenburg, Sweden
| | - Marc P Bonaca
- Harvard Medical School, TIMI Study Group, Boston, MA, USA
| | | | - P Gabriel Steg
- University Paris Diderot, INSERM Unite 1148, Hôptial Bichat, Paris, France
| | - Kyung A Im
- Harvard Medical School, TIMI Study Group, Boston, MA, USA
| | - Marc Cohen
- Newark Beth Israel Medical Center, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Deepak L Bhatt
- Harvard Medical School, TIMI Study Group, Boston, MA, USA
| | | | - Andrezej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Christian Hamm
- Kerckhoff Heart Center, Bad Nauheim, University of Giessen, Giessen, Germany
| | | | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | | | - Gabriel Kamensky
- Department of Noninvasive Cardiovascular Diagnostics, Vth Internal Clinic, University Hospital Bratislava, Bratislava, Slovakia
| | | | - Diego Ardissino
- Division of Cardiology, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Drammen Heart Center, Drammen, Norway
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, INSERM-UMRS 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
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7
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Furtado RHM, Nicolau JC, Magnani G, Im K, Bhatt DL, Storey RF, Steg PG, Spinar J, Budaj A, Kontny F, Corbalan R, Kiss RG, Abola MT, Johanson P, Jensen EC, Braunwald E, Sabatine MS, Bonaca MP. Long-term ticagrelor for secondary prevention in patients with prior myocardial infarction and no history of coronary stenting: insights from PEGASUS-TIMI 54. Eur Heart J 2019; 41:1625-1632. [DOI: 10.1093/eurheartj/ehz821] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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] [Received: 06/25/2019] [Revised: 10/02/2019] [Accepted: 11/02/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aims
PEGASUS-TIMI 54 demonstrated that long-term dual antiplatelet therapy (DAPT) with aspirin and ticagrelor reduced the risk of major adverse cardiovascular events (MACE), with an acceptable increase in bleeding, in patients with prior myocardial infarction (MI). While much of the discussion around prolonged DAPT has been focused on stented patients, patients with prior MI without prior coronary stenting comprise a clinically important subgroup.
Methods and results
This was a pre-specified analysis from PEGASUS-TIMI 54, which randomized 21 162 patients with prior MI (1–3 years) and additional high-risk features to ticagrelor 60 mg, 90 mg, or placebo twice daily in addition to aspirin. A total of 4199 patients had no history of coronary stenting at baseline. The primary efficacy outcome (MACE) was the composite of cardiovascular death, MI, or stroke. Patients without history of coronary stenting had higher baseline risk of MACE [13.2% vs. 8.0%, adjusted hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.15–1.73, in the placebo arm]. The relative risk reduction in MACE with ticagrelor (pooled doses) was similar in patients without (HR 0.82, 95% CI 0.68–0.99) and with prior stenting (HR 0.85, 95% CI 0.75–0.96; P for interaction = 0.76).
Conclusion
Long-term ticagrelor reduces thrombotic events in patients with prior MI regardless of whether they had prior coronary stenting. These data highlight the benefits of DAPT in prevention of spontaneous atherothrombotic events and indicate that long-term ticagrelor may be considered in high-risk patients with prior MI even if they have not been treated with stenting.
ClinicalTrials.gov Identifier
NCT01225562.
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Affiliation(s)
- Remo H M Furtado
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Eneas de Carvalho Aguiar 44, 05403 Sao Paulo, Brazil
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas da Faculdade de Medicina, Universidade de Sao Paulo, Av Dr Eneas de Carvalho Aguiar 44, 05403 Sao Paulo, Brazil
| | - Giulia Magnani
- University Hospital of Parma, Via Gramsci, 14, 43126 Parma PR, Italy
| | - Kyungah Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Robert F Storey
- University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - P Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, 3 Avenue Victoria, 75004 Paris, France
| | - Jindrich Spinar
- University Hospital Brno, 20 Jihlavska, Brno, Czech Republic
| | - Andrzej Budaj
- Centre of Postgraduate Medical Education, Grochowski Hospital, Grenadierów 51/59, 04-073 Warsaw, Poland
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Gerd Ragna Bloch Thorsens gate 8, Stavanger, Norway
- Drammen Heart Center, Dronninggata 28, 3004 Drammen, Norway
| | - Ramon Corbalan
- Cardiovascular Division, Faculty of Medicine, Pontificia Universidad Católica de Chile, Lira 40, Santiago, Chile
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Róbert Károly krt., 1134 Budapest, Hungary
| | - Maria Teresa Abola
- College of Medicine, University of the Philippines/Philippine Heart Center, East, Quezon City, Metro Manila, Philippines
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Marc P Bonaca
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
- CPC Clinical Research, University of Colorado School of Medicine, 13199 E Montview Blvd Suite 200, Aurora, CO, USA
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8
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Ueland T, Åkerblom A, Ghukasyan T, Michelsen AE, Becker RC, Bertilsson M, Himmelmann A, James SK, Siegbahn A, Storey RF, Kontny F, Aukrust P, Wallentin L. Admission Levels of DKK1 (Dickkopf-1) Are Associated With Future Cardiovascular Death in Patients With Acute Coronary Syndromes. Arterioscler Thromb Vasc Biol 2019; 39:294-302. [PMID: 30580572 DOI: 10.1161/atvbaha.118.311042] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 01/02/2023]
Abstract
Objective- The Wnt/wingless signaling antagonist DKK1 (dickkopf-1) regulates platelet-mediated inflammation and may contribute to plaque destabilization. We hypothesized that DKK1 would be associated with cardiovascular outcomes. Approach and Results- We determined DKK1 levels in serum samples obtained before randomization, at discharge, and 1 and 6 months in a subset of 5165 patients with acute coronary syndromes in the PLATO trial (Platelet Inhibition and Patient Outcomes; NCT00391872). The median (interquartile range) DKK1 concentrations were 0.61 (0.20-1.27) ng/mL at baseline and increased during follow-up. The hazard ratio (95% CIs) for the composite end point (cardiovascular death, nonprocedural spontaneous myocardial infarction, or stroke) during 1 year of follow-up, per 50% increase in baseline DKK1 concentration, was 1.06 (1.02-1.10), P=0.0011, and remained significant in fully adjusted analysis with 14 conventional clinical and demographic and 6 biochemical variables, including NT-proBNP (N-terminal pro-B-type natriuretic peptide), hs-TnT (high-sensitivity troponin T), and GDF-15 (growth differentiation factor 15; 1.05 [1.00-1.09]; P=0.028). This association was mainly driven by the association with cardiovascular death, where a gradual increase in event rates was observed with increasing quartiles of DKK1 (2.7%, 3.0%, 4.3%, and 5.0%) and remained significant and unmodified in fully adjusted analysis (hazard ratio, 1.10 [1.04-1.17]; P=0.002). Change in DKK1 and levels at 1 month were unrelated to outcomes. A modifying effect of ticagrelor on DKK1 discharge levels was observed but not associated with prognosis. Conclusions- In patients with acute coronary syndromes treated with dual antiplatelet treatment, admission DKK1 levels were independently associated with a composite of cardiovascular death, myocardial infarction, or stroke and with cardiovascular death alone.
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Affiliation(s)
- Thor Ueland
- From the Research Institute of Internal Medicine, National Hospital (T.U., A.E.M., P.A.), University of Oslo, Norway.,K.G. Jebsen Inflammatory Research Center (T.U., P.A.), University of Oslo, Norway.,K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.)
| | - Axel Åkerblom
- Division of Cardiology, Department of Medical Sciences (A.Å, S.K.J., L.W.), Uppsala University, Sweden.,Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden
| | - Tatevik Ghukasyan
- Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden
| | - Annika E Michelsen
- From the Research Institute of Internal Medicine, National Hospital (T.U., A.E.M., P.A.), University of Oslo, Norway
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, OH (R.C.B.)
| | - Maria Bertilsson
- Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden
| | | | - Stefan K James
- Division of Cardiology, Department of Medical Sciences (A.Å, S.K.J., L.W.), Uppsala University, Sweden.,Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Clinical Chemistry (A.S.), Uppsala University, Sweden
| | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Norway (F.K.).,Drammen Heart Center, Norway (F.K.)
| | - Pål Aukrust
- From the Research Institute of Internal Medicine, National Hospital (T.U., A.E.M., P.A.), University of Oslo, Norway.,K.G. Jebsen Inflammatory Research Center (T.U., P.A.), University of Oslo, Norway.,K.G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Norway (T.U., P.A.).,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway (P.A.)
| | - Lars Wallentin
- Division of Cardiology, Department of Medical Sciences (A.Å, S.K.J., L.W.), Uppsala University, Sweden.,Uppsala Clinical Research Center (A.Å, T.G., M.B., S.K.J., A.S., L.W.), Uppsala University, Sweden
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9
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Ueland T, Åkerblom A, Ghukasyan T, Michelsen AE, Becker RC, Bertilsson M, Budaj A, Cornel JH, Himmelmann A, James SK, Siegbahn A, Storey RF, Kontny F, Aukrust P, Wallentin L. ALCAM predicts future cardiovascular death in acute coronary syndromes: Insights from the PLATO trial. Atherosclerosis 2019; 293:35-41. [PMID: 31835039 DOI: 10.1016/j.atherosclerosis.2019.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 06/20/2019] [Revised: 10/24/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIMS Activated leukocyte cell adhesion molecule (ALCAM) is upregulated during inflammation and involved in transmigration of leukocytes and T-cell activation. We hypothesized that ALCAM might be associated with recurrent events in patients with acute coronary syndromes (ACS). METHODS ALCAM was measured in serum obtained on admission, at discharge, 1 month and 6 months in a subgroup of 5165 patients admitted with ACS and included in the PLATelet inhibition and patient Outcomes (PLATO) trial (NCT00391872). The association between ALCAM and the composite endpoint and its components, including cardiovascular (CV) death, non-procedural spontaneous myocardial infarction (MI) or stroke during 1-year follow-up, was assessed by Cox proportional hazards models with incremental addition of clinical risk factors and biomarkers (including high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide and growth differentiation factor-15). RESULTS The median (Q1-Q3) concentration of ALCAM at admission was 97 (80-116) ng/mL. A 50% higher level of ALCAM on admission was associated with a hazard ratio (HR) of 1.16 (95% confidence interval [1.00-1.34] p = 0.043) for the composite endpoint in fully adjusted analysis, mainly driven by the association with CV death (HR 1.45 [1.16-1.82] p = 0.0012). CONCLUSIONS In patients with ACS, admission level of ALCAM was independently associated with adverse outcome including CV death even after adjustment for established inflammatory and cardiac biomarkers.
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Affiliation(s)
- Thor Ueland
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Oslo, Norway; K.G. Jebsen Inflammatory Research Center, University of Oslo, Norway; K.G. Jebsen - Thrombosis Research and Expertise Center (TREC), University of Tromsø, Tromsø, Norway.
| | - Axel Åkerblom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tatevik Ghukasyan
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Annika E Michelsen
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Oslo, Norway
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Maria Bertilsson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | | | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Frederic Kontny
- Stavanger University Hospital, Department of Cardiology, Stavanger, Norway; Drammen Heart Center, Drammen, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Oslo, Norway; K.G. Jebsen Inflammatory Research Center, University of Oslo, Norway; K.G. Jebsen - Thrombosis Research and Expertise Center (TREC), University of Tromsø, Tromsø, Norway; Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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10
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Andersen T, Ueland T, Ghukasyan Lakic T, Åkerblom A, Bertilsson M, Aukrust P, Michelsen AE, James SK, Becker RC, Storey RF, Wallentin L, Siegbahn A, Kontny F. C-X-C Ligand 16 Is an Independent Predictor of Cardiovascular Death and Morbidity in Acute Coronary Syndromes. Arterioscler Thromb Vasc Biol 2019; 39:2402-2410. [PMID: 31554419 DOI: 10.1161/atvbaha.119.312633] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [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: 11/16/2022]
Abstract
OBJECTIVE The chemokine CXCL16 (C-X-C motif ligand 16) is a scavenger receptor for OxLDL (oxidized low-density lipoproteins) and involved in inflammation at sites of atherosclerosis. This study aimed to investigate the association of CXCL16 with clinical outcome in patients with acute coronary syndrome. Approach and Results: Serial measurements of CXCL16 were performed in a subgroup of 5142 patients randomized in the PLATO trial (Platelet Inhibition and Patient Outcome). Associations between CXCL16 and a composite of cardiovascular death, spontaneous myocardial infarction or stroke, and the individual components were assessed by multivariable Cox regression analyses. The hazard ratio per 50% increase in admission levels of CXCL16 analyzed as continuous variable was 1.64 (95% CI, 1.44-1.88), P<0.0001. This association remained statistically significant after adjustment for randomized treatment, clinical variables, CRP (C-reactive protein), leukocytes, cystatin C, NT-proBNP (N-terminal pro-brain natriuretic peptide), troponin T, GDF-15 (growth differentiation factor 15), and other biomarkers; hazard ratio 1.23 (1.05-1.45), P=0.0126. The admission level of CXCL16 was independently associated with cardiovascular death (1.50 [1.17-1.92], P=0.0014) but not with ischemic events alone, in fully adjusted analyses. No statistically independent association was found between CXCL16 measured at 1 month, or change in CXCL16 from admission to 1 month, and clinical outcomes. CONCLUSIONS In patients with acute coronary syndrome, admission level of CXCL16 is independently related to adverse clinical outcomes, mainly driven by an association to cardiovascular death. Thus, CXCL16 measurement may enhance risk stratification in patients with this condition. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00391872.
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Affiliation(s)
- Thomas Andersen
- From the Department of Anaesthesiology, Stavanger University Hospital, Norway (T.A.)
| | - Thor Ueland
- Research Institute of Internal Medicine, the National Hospital (T.U., P.A., A.E.M.), University of Oslo, Norway.,K.G. Jebsen Inflammatory Research Centre (T.U., P.A.), University of Oslo, Norway.,Faculty of Medicine (T.U., P.A., A.E.M), University of Oslo, Norway.,K.G. Jebsen - Thrombosis Research and Expertise Centre (TREC), University of Tromsø, Norway (T.U., P.A.)
| | - Tatevik Ghukasyan Lakic
- Uppsala Clinical Research Centre (T.G.L., A.Å., M.B., S.K.J., L.W.), Uppsala University, Sweden
| | - Axel Åkerblom
- Uppsala Clinical Research Centre (T.G.L., A.Å., M.B., S.K.J., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (A.Å., S.K.J., L.W.), Uppsala University, Sweden
| | - Maria Bertilsson
- Uppsala Clinical Research Centre (T.G.L., A.Å., M.B., S.K.J., L.W.), Uppsala University, Sweden
| | - Pål Aukrust
- Research Institute of Internal Medicine, the National Hospital (T.U., P.A., A.E.M.), University of Oslo, Norway.,K.G. Jebsen Inflammatory Research Centre (T.U., P.A.), University of Oslo, Norway.,Faculty of Medicine (T.U., P.A., A.E.M), University of Oslo, Norway.,K.G. Jebsen - Thrombosis Research and Expertise Centre (TREC), University of Tromsø, Norway (T.U., P.A.).,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, Rikshospitalet, Norway (P.A.)
| | - Annika E Michelsen
- Research Institute of Internal Medicine, the National Hospital (T.U., P.A., A.E.M.), University of Oslo, Norway.,Faculty of Medicine (T.U., P.A., A.E.M), University of Oslo, Norway
| | - Stefan K James
- Uppsala Clinical Research Centre (T.G.L., A.Å., M.B., S.K.J., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (A.Å., S.K.J., L.W.), Uppsala University, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, OH (R.C.B.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Lars Wallentin
- Uppsala Clinical Research Centre (T.G.L., A.Å., M.B., S.K.J., L.W.), Uppsala University, Sweden.,Department of Medical Sciences, Cardiology (A.Å., S.K.J., L.W.), Uppsala University, Sweden
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry (A.S.), Uppsala University, Sweden
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Norway (F.K.).,Drammen Heart Centre, Norway (F.K.)
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11
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Bansilal S, Bonaca MP, Cornel JH, Storey RF, Bhatt DL, Steg PG, Im K, Murphy SA, Angiolillo DJ, Kiss RG, Parkhomenko AN, Lopez-Sendon J, Isaza D, Goudev A, Kontny F, Held P, Jensen EC, Braunwald E, Sabatine MS, Oude Ophuis AJ. Ticagrelor for Secondary Prevention of Atherothrombotic Events in Patients With Multivessel Coronary Disease. J Am Coll Cardiol 2019; 71:489-496. [PMID: 29406853 DOI: 10.1016/j.jacc.2017.11.050] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/05/2017] [Accepted: 11/25/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with prior myocardial infarction (MI) and multivessel coronary disease (MVD) are at high risk for recurrent coronary events. OBJECTIVES The authors investigated the efficacy and safety of ticagrelor versus placebo in patients with MVD in the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial. METHODS Patients with a history of MI 1 to 3 years before inclusion in the PEGASUS-TIMI 54 trial were stratified in a pre-specified analysis based on the presence of MVD. The effect of ticagrelor (60 mg and 90 mg) on the composite of cardiovascular death, MI, or stroke (major adverse cardiovascular events [MACE]), as well as the composite of coronary death, MI, or stent thrombosis (coronary events), and on TIMI major bleeding, intracranial hemorrhage (ICH), and fatal bleeding were evaluated over a median of 33 months. RESULTS A total of 12,558 patients (59.4%) had MVD. In the placebo arm, compared with patients without MVD, those with MVD were at higher risk for MACE (9.37% vs. 8.57%, adjusted hazard ratio [HRadj]: 1.24; p = 0.026) and for coronary events (7.67% vs. 5.34%, HRadj: 1.49; p = 0.0005). In patients with MVD, ticagrelor reduced the risk of MACE (7.94% vs. 9.37%, HR: 0.82; p = 0.004) and coronary events (6.02% vs. 7.67%, HR: 0.76; p < 0.0001), including a 36% reduction in coronary death (HR: 0.64; 95% confidence interval: 0.48 to 0.85; p = 0.002). In this subgroup, ticagrelor increased the risk of TIMI major bleeding (2.52% vs. 1.08%, HR: 2.67; p < 0.0001), but not ICH or fatal bleeds. CONCLUSIONS Patients with prior MI and MVD are at increased risk of MACE and coronary events, and experience substantial relative and absolute risk reductions in both outcomes with long-term ticagrelor treatment relative to those without MVD. Ticagrelor increases the risk of TIMI major bleeding, but not ICH or fatal bleeding. For patients with prior MI and MVD, ticagrelor is an effective option for long-term antiplatelet therapy. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).
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Affiliation(s)
- Sameer Bansilal
- Zena and Michael Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marc P Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jan H Cornel
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Deepak L Bhatt
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ph Gabriel Steg
- DHU (Département Hospitalo-Universitaire)-FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP-HP (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F-CRIN network, INSERM U-1148, Paris, France; National Heart and Lung Institute, Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, Imperial College, London, United Kingdom
| | - Kyungah Im
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sabina A Murphy
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | | | | | - Daniel Isaza
- Fundacion Cardioinfantil, Instituto de Cardiología, Bogotá, Cundinamarca, Colombia
| | - Assen Goudev
- Medical University Sofia, Queen Ioanna Hospital, Sofia, Bulgaria
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway; Drammen Heart Center, Drammen, Norway
| | - Peter Held
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eva C Jensen
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - A J Oude Ophuis
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar and Dutch Network for Cardiovascular Research (WCN), the Netherlands; Department of Cardiology, CWZ Hospital, Nijmegen, the Netherland
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12
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Ten Cate H, Kontny F, Nilsen DW. Editorial: Novel and potential markers for prediction of outcome in patients with acute and chronic coronary heart disease. Front Cardiovasc Med 2019; 6:66. [PMID: 31192230 PMCID: PMC6540587 DOI: 10.3389/fcvm.2019.00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/03/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Drammen Heart Center, Drammen, Norway
| | - Dennis W Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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13
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Kontny F, Andersen T, Ueland T, Åkerblom A, Lakic TG, Michelsen AE, Aukrust P, Bertilsson M, Becker RC, Himmelmann A, James SK, Siegbahn A, Storey RF, Wallentin L. Pentraxin-3 vs C-reactive protein and other prognostic biomarkers in acute coronary syndrome: A substudy of the Platelet Inhibition and Patients Outcomes (PLATO) trial. Eur Heart J Acute Cardiovasc Care 2019; 9:313-322. [PMID: 31017470 DOI: 10.1177/2048872619846334] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIMS We investigated the dynamics, associations with patient characteristics, other biomarkers, and clinical outcomes of pentraxin 3 in acute coronary syndrome. METHODS AND RESULTS In multivariate analyses, pentraxin 3 measured in 5154 patients randomised in the Platelet Inhibition and Patients Outcomes (PLATO) trial (NCT00391872) was compared with leukocytes, high-sensitivity C-reactive protein, interleukin-6, cystatin C, N-terminal prohormone brain natriuretic peptide, high-sensitivity troponin T and growth differentiation factor 15 concerning prediction of clinical outcome. Pentraxin 3 peaked earlier than high-sensitivity C-reactive protein and was more strongly correlated with N-terminal prohormone brain natriuretic peptide and high-sensitivity troponin T than with high-sensitivity C-reactive protein. The frequency of cardiovascular death, spontaneous myocardial infarction or stroke by quartiles of pentraxin 3 at admission was 6.1%, 7.3%, 9.7% and 10.7%, respectively (p<0.0001). The hazard ratio per 50% increase of pentraxin 3 was 1.13 (95% confidence interval: 1.07-1.19), p<0.0001. This association remained significant after stepwise adjustments for leukocytes/high-sensitivity C-reactive protein (1.09 (1.02-1.15)), p=0.009, interleukin-6 (1.07 (1.01-1.14)), p=0.026, and cystatin C (1.07 (1.00-1.13)), p=0.044, but not after adjustment for N-terminal prohormone brain natriuretic peptide, high-sensitivity troponin T and growth differentiation factor 15. Admission pentraxin 3 was also associated with several of the individual endpoint components (cardiovascular death/spontaneous myocardial infarction; p=0.008, cardiovascular death; p=0.026, and spontaneous myocardial infarction; p=0.017), but not with stroke. Pentraxin 3 measured in the chronic phase (i.e. at one month) was still predictive of the composite endpoint in univariate analysis (1.12 (1.04-1.20) per 50% increase) p=0.0024, but not after adjustment for the other biomarkers. CONCLUSION Admission level of pentraxin 3 is a modestly stronger predictor than high-sensitivity C-reactive protein and interleukin-6, but not than N-terminal prohormone brain natriuretic peptide or high-sensitivity troponin T, concerning cardiovascular outcome in acute coronary syndrome. Pentraxin 3 is more strongly correlated with N-terminal prohormone brain natriuretic peptide and high-sensitivity troponin T than with high-sensitivity C-reactive protein.
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Affiliation(s)
- Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Norway.,Drammen Heart Center, Norway
| | - Thomas Andersen
- Department of Anaesthesiology, Stavanger University Hospital, Norway
| | - Thor Ueland
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Norway.,K.G. Jebsen Thrombosis Research and Expertise Center (TREC), University of Tromsø, Norway
| | - Axel Åkerblom
- Department of Medical Sciences, Cardiology Uppsala University, Sweden.,Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Tatevik G Lakic
- Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Annika E Michelsen
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Norway.,K.G. Jebsen Thrombosis Research and Expertise Center (TREC), University of Tromsø, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Norway.,K.G. Jebsen Thrombosis Research and Expertise Center (TREC), University of Tromsø, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Norway
| | | | - Richard C Becker
- Division of Cardiovascular Health and Disease, Academic Health Center, Cincinnati, OH, USA
| | | | - Stefan K James
- Department of Medical Sciences, Cardiology Uppsala University, Sweden.,Uppsala Clinical Research Center, Uppsala University, Sweden
| | - Agneta Siegbahn
- Department of Medical Sciences, Cardiology Uppsala University, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, UK
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology Uppsala University, Sweden.,Uppsala Clinical Research Center, Uppsala University, Sweden
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14
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Andersen T, Wallentin L, Åkerblom A, Ueland T, Aukrust P, Kontny F. CXC MOTIF LIGAND 16: A NOVEL, INDEPENDENT PREDICTOR OF CARDIOVASCULAR DEATH AND MORBIDITY IN ACUTE CORONARY SYNDROMES - A SUBSTUDY OF THE PLATELET INHIBITION AND PATIENT OUTCOMES TRIAL. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)30680-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Ueland T, Åkerblom A, Ghukasyan T, Michelsen AE, Aukrust P, Becker RC, Bertilsson M, Himmelmann A, James SK, Siegbahn A, Storey RF, Kontny F, Wallentin L. Osteoprotegerin Is Associated With Major Bleeding But Not With Cardiovascular Outcomes in Patients With Acute Coronary Syndromes: Insights From the PLATO (Platelet Inhibition and Patient Outcomes) Trial. J Am Heart Assoc 2018; 7:JAHA.117.007009. [PMID: 29330256 PMCID: PMC5850148 DOI: 10.1161/jaha.117.007009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Background Elevated levels of osteoprotegerin, a secreted tumor necrosis factor–related molecule, might be associated with adverse outcomes in patients with coronary artery disease. We measured plasma osteoprotegerin concentrations on hospital admission, at discharge, and at 1 and 6 months after discharge in a predefined subset (n=5135) of patients with acute coronary syndromes in the PLATO (Platelet Inhibition and Patient Outcomes) trial. Methods and Results The associations between osteoprotegerin and the composite end point of cardiovascular death, nonprocedural spontaneous myocardial infarction or stroke, and non–coronary artery bypass grafting major bleeding during 1 year of follow‐up were assessed by Cox proportional hazards models. Event rates of the composite end point per increasing quartile groups at baseline were 5.2%, 7.5%, 9.2%, and 11.9%. A 50% increase in osteoprotegerin level was associated with a hazard ratio (HR) of 1.31 (95% confidence interval [CI], 1.21–1.42) for the composite end point but was not significant in adjusted analysis (ie, clinical characteristics and levels of C‐reactive protein, troponin T, NT‐proBNP [N‐terminal pro‐B‐type natriuretic peptide], and growth differentiation factor‐15). The corresponding rates of non–coronary artery bypass grafting major bleeding were 2.4%, 2.2%, 3.8%, and 7.2%, with an unadjusted HR of 1.52 (95% CI, 1.36–1.69), and a fully adjusted HR of 1.26 (95% CI, 1.09–1.46). The multivariable association between the osteoprotegerin concentrations and the primary end point after 1 month resulted in an HR of 1.09 (95% CI, 0.89–1.33); for major bleeding after 1 month, the HR was 1.33 (95% CI, 0.91–1.96). Conclusions In patients with acute coronary syndrome treated with dual antiplatelet therapy, osteoprotegerin was an independent marker of major bleeding but not of ischemic cardiovascular events. Thus, high osteoprotegerin levels may be useful in increasing awareness of increased bleeding risk in patients with acute coronary syndrome receiving antithrombotic therapy. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00391872.
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Affiliation(s)
- Thor Ueland
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Norway .,K. G. Jebsen Inflammatory Research Center, University of Oslo, Norway.,K. G. Jebsen-Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Axel Åkerblom
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tatevik Ghukasyan
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Annika E Michelsen
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Norway
| | - Pål Aukrust
- Research Institute of Internal Medicine, The National Hospital, University of Oslo, Norway.,K. G. Jebsen Inflammatory Research Center, University of Oslo, Norway.,K. G. Jebsen-Thrombosis Research and Expertise Center, University of Tromsø, Norway.,Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Maria Bertilsson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Drammen Heart Center, Drammen, Norway
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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16
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Kontny F, Abildgaard U, Dempfle CE. Predictive Value of Coagulation Markers Concerning Clinical Outcome 90 Days after Anterior Myocardial Infarction. Thromb Haemost 2017. [DOI: 10.1055/s-0037-1614557] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
SummaryTo study the predictive value of coagulation markers concerning clinical outcome, prothrombin fragment F1.2 (F1.2), fibrin monomer antigen (FM), D-Dimer (DD), and fibrinogen were measured in plasma samples drawn 2 and 7 days after acute myocardial infarction (AMI) in 314 consecutive patients randomized in a clinical trial of low molecular weight heparin (Dalteparin) (the FRAMI trial). Placebo-treated patients suffering death or new AMI within 90 days had significantly higher levels at day 2 of FM (Enzymun-Test FM), and DD (TINAquant D-dimer) (p = 0.001 and 0.02, respectively), but not F1.2 (Enzygnost F1.2 micro), relative to those without serious clinical events. At day 7 all three coagulation activation markers were significantly higher in patients with subsequent adverse clinical outcome. The Dalteparin group had significantly lower levels of these markers as compared to the placebo group. Left ventricular (LV) thrombus formation was not associated with changes in coagulation activation. However, patients with thrombus had significantly higher fibrinogen levels than those without thrombus (p = 0.004 day 2), independent of treatment group. Thus, markers of coagulation activation may be useful in stratification of patients when estimating risk for adverse clinical outcome after AMI. Furthermore, elevated fibrinogen levels are associated with increased risk of LV thrombus formation.
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17
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Brügger-Andersen T, Pönitz V, Staines H, Grundt H, Sagara M, Nilsen DW, Kontny F. The long pentraxin 3 (PTX3): a novel prognostic inflammatory marker for mortality in acute chest pain. Thromb Haemost 2017; 102:555-63. [DOI: 10.1160/th09-02-0137] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryThe long pentraxin 3 (PTX3) is a recently identified member of the pentraxin protein family that includes C-reactive protein. PTX3 is produced by the major cell types involved in atherosclerotic lesions in response to inflammatory stimuli, and elevated plasma levels are found in several conditions including acute coronary syndromes (ACS). The aim of this study was to assess the value of PTX3 as a prognostic marker of mortality and recurrent ischaemic events in a consecutive series of patients admitted with acute chest pain and potential ACS.The patients received follow-up for 24 months. Blood samples were taken on admission for measurement of PTX3, high sensitive C-reactive protein (hsCRP), B-type natriuretic peptide (BNP), and troponin T. All-cause mortality at 24 months in the study cohort was 15.2%. Patients in the upper PTX3 quartiles had a significantly higher death risk than those in the lowest quartile (Q3: hazard ratio [HR] 2.36; 95% CI 1.12–4.99; p=0.024, and Q4: HR 3.60; 95% CI 1.68–7.72; p=0.001). Elevated BNP levels were also significantly associated with a fatal outcome (Q3: HR 3.05; 95% CI 1.16–7.99; p=0.024; and Q4: HR 3.90; 95% CI 1.48–10.26; p=0.006). Elevation in hsCRP was not associated with increased death risk. As PTX3 predicted mortality independently of BNP, the combination of these two biomarkers showed an incremental prognostic value.PTX3 is a new biomarker related to inflammation that, independently of BNP, strongly predicts long-term all-cause mortality in patients with acute chest pain. The combination of these two biomarkers enhances the prognostic value over either marker alone.
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18
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Lindholm D, James SK, Bertilsson M, Becker RC, Cannon CP, Giannitsis E, Harrington RA, Himmelmann A, Kontny F, Siegbahn A, Steg PG, Storey RF, Velders MA, Weaver WD, Wallentin L. Biomarkers and Coronary Lesions Predict Outcomes after Revascularization in Non–ST-Elevation Acute Coronary Syndrome. Clin Chem 2017; 63:573-584. [DOI: 10.1373/clinchem.2016.261271] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 08/23/2016] [Indexed: 11/06/2022]
Abstract
Abstract
BACKGROUND
Risk stratification in non–ST-elevation acute coronary syndrome (NSTE-ACS) is currently mainly based on clinical characteristics. With routine invasive management, angiography findings and biomarkers are available and may improve prognostication. We aimed to assess if adding biomarkers [high-sensitivity cardiac troponin T (cTnT-hs), N-terminal probrain-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15)] and extent of coronary artery disease (CAD) might improve prognostication in revascularized patients with NSTE-ACS.
METHODS
In the PLATO (Platelet Inhibition and Patient Outcomes) trial, 5174 NSTE-ACS patients underwent initial angiography and revascularization and had cTnT-hs, NT-proBNP, and GDF-15 measured. Cox models were developed adding extent of CAD and biomarker levels to established clinical risk variables for the composite of cardiovascular death (CVD)/spontaneous myocardial infarction (MI), and CVD alone. Models were compared using c-statistic and net reclassification improvement (NRI).
RESULTS
For the composite end point and CVD, prognostication improved when adding extent of CAD, NT-proBNP, and GDF-15 to clinical variables (c-statistic 0.685 and 0.805, respectively, for full model vs 0.649 and 0.760 for clinical model). cTnT-hs did not contribute to prognostication. In the full model (clinical variables, extent of CAD, all biomarkers), hazard ratios (95% CI) per standard deviation increase were for cTnT-hs 0.93(0.81–1.05), NT-proBNP 1.32(1.13–1.53), GDF-15 1.20(1.07–1.36) for the composite end point, driven by prediction of CVD by NT-proBNP and GDF-15. For spontaneous MI, there was an association with NT-proBNP or GDF-15, but not with cTnT-hs.
CONCLUSIONS
In revascularized patients with NSTE-ACS, the extent of CAD and concentrations of NT-proBNP and GDF-15 independently improve prognostication of CVD/spontaneous MI and CVD alone. This information may be useful for selection of patients who might benefit from more intense and/or prolonged antithrombotic treatment. ClinicalTrials.gov Identifier: NCT00391872
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Affiliation(s)
- Daniel Lindholm
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Maria Bertilsson
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, Academic Health Center, Cincinnati, OH
| | - Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Clinical Research Institute, Boston, MA
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, University Hospital Heidelberg, Germany
| | | | | | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Philippe Gabriel Steg
- INSERM-Unité 1148, Paris, France
- Assistance Publique-Hôpitaux de Paris; Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Paris, France
- Université Paris-Diderot, Sorbonne-Paris Cité, Paris, France
- NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Matthijs A Velders
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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19
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Wallentin L, Lindhagen L, Ärnström E, Husted S, Janzon M, Johnsen SP, Kontny F, Kempf T, Levin LÅ, Lindahl B, Stridsberg M, Ståhle E, Venge P, Wollert KC, Swahn E, Lagerqvist B. Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study. Lancet 2016; 388:1903-1911. [PMID: 27585757 DOI: 10.1016/s0140-6736(16)31276-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 07/14/2016] [Accepted: 07/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The FRISC-II trial was the first randomised trial to show a reduction in death or myocardial infarction with an early invasive versus a non-invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome. Here we provide a remaining lifetime perspective on the effects on all cardiovascular events during 15 years' follow-up. METHODS The FRISC-II prospective, randomised, multicentre trial was done at 58 Scandinavian centres in Sweden, Denmark, and Norway. Between June 17, 1996, and Aug 28, 1998, we randomly assigned (1:1) 2457 patients with non-ST-elevation acute coronary syndrome to an early invasive treatment strategy, aiming for revascularisation within 7 days, or a non-invasive strategy, with invasive procedures at recurrent symptoms or severe exercise-induced ischaemia. Plasma for biomarker analyses was obtained at randomisation. For long-term outcomes, we linked data with national health-care registers. The primary endpoint was a composite of death or myocardial infarction. Outcomes were compared as the average postponement of the next event, including recurrent events, calculated as the area between mean cumulative count-of-events curves. Analyses were done by intention to treat. FINDINGS At a minimum of 15 years' follow-up on Dec 31, 2014, data for survival status and death were available for 2421 (99%) of the initially recruited 2457 patients, and for other events after 2 years for 2182 (89%) patients. During follow-up, the invasive strategy postponed death or next myocardial infarction by a mean of 549 days (95% CI 204-888; p=0·0020) compared with the non-invasive strategy. This effect was larger in non-smokers (mean gain 809 days, 95% CI 402-1175; pinteraction=0·0182), patients with elevated troponin T (778 days, 357-1165; pinteraction=0·0241), and patients with high concentrations of growth differentiation factor-15 (1356 days, 507-1650; pinteraction=0·0210). The difference was mainly driven by postponement of new myocardial infarction, whereas the early difference in mortality alone was not sustained over time. The invasive strategy led to a mean of 1128 days (95% CI 830-1366) postponement of death or next readmission to hospital for ischaemic heart disease, which was consistent in all subgroups (p<0·0001). INTERPRETATION During 15 years of follow-up, an early invasive treatment strategy postponed the occurrence of death or next myocardial infarction by an average of 18 months, and the next readmission to hospital for ischaemic heart disease by 37 months, compared with a non-invasive strategy in patients with non-ST-elevation acute coronary syndrome. This remaining lifetime perspective supports that an early invasive treatment strategy should be the preferred option in most patients with non-ST-elevation acute coronary syndrome. FUNDING Swedish Heart-Lung Foundation, Swedish Foundation for Strategic Research, and Uppsala Clinical Research Center.
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Affiliation(s)
- Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Elisabet Ärnström
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Steen Husted
- Medical Department, Hospital Unit West, Herning/Holstebro, Denmark
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Division of Health Care Analysis, Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden
| | - Søren Paaske Johnsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Frederic Kontny
- Stavanger University Hospital, Department of Cardiology, Stavanger, Norway; Drammen Heart Center, Drammen, Norway
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Lars-Åke Levin
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden; Division of Health Care Analysis, Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Mats Stridsberg
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- Department of Surgical Sciences, Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - Per Venge
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Kai C Wollert
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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Bonaca MP, Bhatt DL, Oude Ophuis T, Steg PG, Storey R, Cohen M, Kuder J, Im K, Magnani G, Budaj A, Theroux P, Hamm C, Špinar J, Kiss RG, Dalby AJ, Medina FA, Kontny F, Aylward PE, Jensen EC, Held P, Braunwald E, Sabatine MS. Long-term Tolerability of Ticagrelor for the Secondary Prevention of Major Adverse Cardiovascular Events. JAMA Cardiol 2016; 1:425-32. [DOI: 10.1001/jamacardio.2016.1017] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [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: 11/14/2022]
Affiliation(s)
- Marc P. Bonaca
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Deepak L. Bhatt
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Ton Oude Ophuis
- Department of Cardiology, CWZ Hospital, Nijmegen, the Netherlands
| | - P. Gabriel Steg
- Département Hospitalo Universitaire FIRE, AP-HP, Hôpital Bichat, Paris, France4Université Paris–Diderot, Sorbonne Paris Cité, Paris, France
| | - Robert Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, England
| | - Marc Cohen
- Cardiovascular Division, Newark Beth Israel Medical Center, Rutgers–New Jersey Medical School, Newark, New Jersey
| | - Julia Kuder
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Kyungah Im
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Giulia Magnani
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Andrzej Budaj
- Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
| | - Pierre Theroux
- Montreal Heart Institute, University of Montreal, Montreal, Quebec, Canada
| | - Christian Hamm
- Department of Cardiology, Kerckhoff Heart Center, Bad Nauheim, Germany10University of Giessen, Giessen, Hesse, Germany
| | - Jindrich Špinar
- Internal Cardiology Department, University Hospital and Medical Faculty, Brno, Czech Republic
| | - Robert G. Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | - Anthony J. Dalby
- South African Cardiology Clinical Trials Group, Milpark Hospital, Johannesburg, South Africa
| | - Felix A. Medina
- Departamento de Clínicas Médicas, Hospital Nacional Cayetano Heredia, San Martin de Porres, Lima, Peru
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Philip E. Aylward
- South Australian Health and Medical Research Institute, Flinders University, Adelaide, Australia
| | - Eva C. Jensen
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Peter Held
- AstraZeneca Research and Development, Mölndal, Sweden
| | - Eugene Braunwald
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts
| | - Marc S. Sabatine
- TIMI Study Group, Brigham and Women’s Hospital Heart and Vascular Center, Boston, Massachusetts18Deputy Editor, JAMA Cardiology
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Magnani G, Storey RF, Steg G, Bhatt DL, Cohen M, Kuder J, Im K, Aylward P, Ardissino D, Isaza D, Parkhomenko A, Goudev AR, Dellborg M, Kontny F, Corbalan R, Medina F, Jensen EC, Held P, Braunwald E, Sabatine MS, Bonaca MP. Efficacy and safety of ticagrelor for long-term secondary prevention of atherothrombotic events in relation to renal function: insights from the PEGASUS-TIMI 54 trial. Eur Heart J 2015; 37:400-8. [PMID: 26443023 DOI: 10.1093/eurheartj/ehv482] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 07/24/2015] [Accepted: 08/25/2015] [Indexed: 11/12/2022] Open
Abstract
AIMS We evaluated the relationship of renal function and ischaemic and bleeding risk as well as the efficacy and safety of ticagrelor in stable patients with prior myocardial infarction (MI). METHODS AND RESULTS Patients with a history of MI 1-3 years prior from PEGASUS-TIMI 54 were stratified based on estimated glomerular filtration rate (eGFR), with <60 mL/min/1.73 m(2) pre-specified for analysis of the effect of ticagrelor on the primary efficacy composite of cardiovascular death, MI, or stroke (major adverse cardiovascular events, MACE) and the primary safety endpoint of TIMI major bleeding. Of 20 898 patients, those with eGFR <60 (N = 4849, 23.2%) had a greater risk of MACE at 3 years relative to those without, which remained significant after multivariable adjustment (hazard ratio, HRadj 1.54, 95% confidence interval, CI 1.27-1.85, P < 0.001). The relative risk reduction in MACE with ticagrelor was similar in those with eGFR <60 (ticagrelor pooled vs. placebo: HR 0.81; 95% CI 0.68-0.96) vs. ≥60 (HR 0.88; 95% CI 0.77-1.00, Pinteraction = 0.44). However, due to the greater absolute risk in the former group, the absolute risk reduction with ticagrelor was higher: 2.7 vs. 0.63%. Bleeding tended to occur more frequently in patients with renal dysfunction. The absolute increase in TIMI major bleeding with ticagrelor was similar in those with and without eGFR <60 (1.19 vs. 1.43%), whereas the excess of minor bleeding tended to be more pronounced (1.93 vs. 0.69%). CONCLUSION In patients with a history of MI, patients with renal dysfunction are at increased risk of MACE and consequently experience a particularly robust absolute risk reduction with long-term treatment with ticagrelor.
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Affiliation(s)
- Giulia Magnani
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Gabriel Steg
- Cardiology Department, DHU-FIRE, Hôpital Bichat, Paris, France Université Paris-Diderot, Paris, France INSERM U1148, Paris, France
| | - Deepak L Bhatt
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Marc Cohen
- Cardiovascular Division, Department of Medicine, Rutgers-New Jersey Medical School, New York, USA
| | - Julia Kuder
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Kyungah Im
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Philip Aylward
- Division of Medicine, Cardiac & Critical Care Services, Flinders University and Medical Centre, Adelaide, Australia
| | - Diego Ardissino
- Cardiovascular Division, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | - Assen R Goudev
- Department of Cardiology, Queen Giovanna University Hospital, Sofia, Bulgaria
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Ramon Corbalan
- Cardiovascular Division, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felix Medina
- Hospital Nacional Cayetano Heredia, San Martin de Porres, Lima, Peru
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Marc S Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
| | - Marc P Bonaca
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, USA
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Wallentin L, Michelsen AE, Aukrust P, Becker R, Bertilsson M, Budaj A, Cornel J, Himmelmann A, Husted S, Siegbahn A, Storey R, Kontny F, Ueland T. ACTIVATED LEUKOCYTE CELL ADHESION MOLECULE (ALCAM) AND OUTCOMES IN ACUTE CORONARY SYNDROMES: A PLATO BIOMARKER SUBSTUDY. J Am Coll Cardiol 2015. [DOI: 10.1016/s0735-1097(15)60231-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lindholm D, James S, Bertilsson M, Cannon C, Giannitsis E, Harrington R, Himmelmann A, Kontny F, Siegbahn A, Steg P, Velders M, Weaver WD, Wallentin L. BIOMARKERS FOR PREDICTION OF OUTCOMES IN REVASCULARIZED PATIENTS WITH NON-ST-ELEVATION ACUTE CORONARY SYNDROME: A PLATO SUBSTUDY. J Am Coll Cardiol 2014. [DOI: 10.1016/s0735-1097(14)60045-0] [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: 11/25/2022]
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Mjelva ØR, Brügger-Andersen T, Pönitz V, Grundt H, Kontny F, Staines H, Nilsen DW. Long-term prognostic utility of PAPP-A and calprotectin in suspected acute coronary syndrome. SCAND CARDIOVASC J 2013; 47:88-97. [DOI: 10.3109/14017431.2013.764571] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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]
Affiliation(s)
| | | | - Volker Pönitz
- Department of Cardiology, Stavanger University Hospital,
Stavanger, Norway
| | - Heidi Grundt
- Department of Medicine, Stavanger University Hospital,
Stavanger, Norway
- Institute of Medicine, University of Bergen,
Bergen, Norway
| | | | | | - Dennis W.T. Nilsen
- Department of Cardiology, Stavanger University Hospital,
Stavanger, Norway
- Institute of Medicine, University of Bergen,
Bergen, Norway
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James S, Angiolillo DJ, Cornel JH, Erlinge D, Husted S, Kontny F, Maya J, Nicolau JC, Spinar J, Storey RF, Stevens SR, Wallentin L. Ticagrelor vs. clopidogrel in patients with acute coronary syndromes and diabetes: a substudy from the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J 2010; 31:3006-16. [PMID: 20802246 PMCID: PMC3001588 DOI: 10.1093/eurheartj/ehq325] [Citation(s) in RCA: 309] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Aims Patients with diabetes mellitus (DM) have high platelet reactivity and are at increased risk of ischaemic events and bleeding post-acute coronary syndromes (ACS). In the PLATelet inhibition and patient Outcomes (PLATO) trial, ticagrelor reduced the primary composite endpoint of cardiovascular death, myocardial infarction, or stroke, but with similar rates of major bleeding compared with clopidogrel. We aimed to investigate the outcome with ticagrelor vs. clopidogrel in patients with DM or poor glycaemic control. Methods and results We analysed patients with pre-existing DM (n = 4662), including 1036 patients on insulin, those without DM (n = 13 951), and subgroups based on admission levels of haemoglobin A1c (HbA1c; n = 15 150). In patients with DM, the reduction in the primary composite endpoint (HR: 0.88, 95% CI: 0.76–1.03), all-cause mortality (HR: 0.82, 95% CI: 0.66–1.01), and stent thrombosis (HR: 0.65, 95% CI: 0.36–1.17) with no increase in major bleeding (HR: 0.95, 95% CI: 0.81–1.12) with ticagrelor was consistent with the overall cohort and without significant diabetes status-by-treatment interactions. There was no heterogeneity between patients with or without ongoing insulin treatment. Ticagrelor reduced the primary endpoint, all-cause mortality, and stent thrombosis in patients with HbA1c above the median (HR: 0.80, 95% CI: 0.70–0.91; HR: 0.78, 95% CI: 0.65–0.93; and HR: 0.62, 95% CI: 0.39–1.00, respectively) with similar bleeding rates (HR: 0.98, 95% CI: 0.86–1.12). Conclusion Ticagrelor, when compared with clopidogrel, reduced ischaemic events in ACS patients irrespective of diabetic status and glycaemic control, without an increase in major bleeding events.
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Affiliation(s)
- Stefan James
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarsköldsväg 14B, Science Park, Uppsala SE-751 85, Sweden.
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Cannon CP, Harrington RA, James S, Ardissino D, Becker RC, Emanuelsson H, Husted S, Katus H, Keltai M, Khurmi NS, Kontny F, Lewis BS, Steg PG, Storey RF, Wojdyla D, Wallentin L. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet 2010; 375:283-93. [PMID: 20079528 DOI: 10.1016/s0140-6736(09)62191-7] [Citation(s) in RCA: 453] [Impact Index Per Article: 32.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Variation in and irreversibility of platelet inhibition with clopidogrel has led to controversy about its optimum dose and timing of administration in patients with acute coronary syndromes. We compared ticagrelor, a more potent reversible P2Y12 inhibitor with clopidogrel in such patients. METHODS At randomisation, an invasive strategy was planned for 13 408 (72.0%) of 18 624 patients hospitalised for acute coronary syndromes (with or without ST elevation). In a double-blind, double-dummy study, patients were randomly assigned in a one-to-one ratio to ticagrelor and placebo (180 mg loading dose followed by 90 mg twice a day), or to clopidogrel and placebo (300-600 mg loading dose or continuation with maintenance dose followed by 75 mg per day) for 6-12 months. All patients were given aspirin. The primary composite endpoint was cardiovascular death, myocardial infarction, or stroke. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00391872. FINDINGS 6732 patients were assigned to ticagrelor and 6676 to clopidogrel. The primary composite endpoint occurred in fewer patients in the ticagrelor group than in the clopidogrel group (569 [event rate at 360 days 9.0%] vs 668 [10.7%], hazard ratio 0.84, 95% CI 0.75-0.94; p=0.0025). There was no difference between clopidogrel and ticagrelor groups in the rates of total major bleeding (691 [11.6%] vs 689 [11.5%], 0.99 [0.89-1.10]; p=0.8803) or severe bleeding, as defined according to the Global Use of Strategies To Open occluded coronary arteries, (198 [3.2%] vs 185 [2.9%], 0.91 [0.74-1.12]; p=0.3785). INTERPRETATION Ticagrelor seems to be a better option than clopidogrel for patients with acute coronary syndromes for whom an early invasive strategy is planned.
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Kontny F, Risanger T, Bye A, Arnesen Ø, Johansen OE. Effects of telmisartan on office and 24-hour ambulatory blood pressure: an observational study in hypertensive patients managed in primary care. Vasc Health Risk Manag 2010; 6:31-8. [PMID: 20191081 PMCID: PMC2828104 DOI: 10.2147/vhrm.s9122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Indexed: 11/23/2022] Open
Affiliation(s)
| | | | - Arne Bye
- Frosta Health Centre, Frosta, Norway
| | - Øyvind Arnesen
- Medical Department, Boehringer-Ingelheim Norway KS, Asker, Norway
| | - Odd Erik Johansen
- Medical Department, Boehringer-Ingelheim Norway KS, Asker, Norway
- Correspondence: Odd Erik Johansen, Medical Department, Boehringer-Ingelheim, Norway KS, PO Box 405, 1373 Asker, Norway, Tel +47 97817674, Fax +47 66761330, Email
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Chesebro JH, Verheugt FW, Kontny F, Fry ET, Wallentin L, Camm AJ, Bechtold H. Evaluating the place of low-molecular-weight heparin in the management of acute coronary syndromes. A panel discussion with audience participation. Clin Cardiol 2009; 24:I20-2. [PMID: 11286311 PMCID: PMC6655222 DOI: 10.1002/clc.4960241307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- J H Chesebro
- The Cardiovascular Institute, Mount Sinai Hospital, New York, New York 10029, USA
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Abstract
A crucial question in the acute management of the patient with unstable coronary artery disease (UCAD) is whether to carry out early intervention, performing angiography soon after presentation and following this with revascularization where appropriate, or whether to follow a noninvasive medical strategy as far as possible unless symptoms necessitate intervention. The body of literature addressing this question is sparse, but the recent Fast Revascularization during InStability in Coronary artery disease (FRISC II) study has provided new insights into the problem. Using a factorial design to randomize patients to invasive or noninvasive management strategies, and to short- or long-term treatment with the low-molecular-weight heparin (LMWH) dalteparin sodium (Fragmin), it was shown in FRISC II that early invasive treatment (within 7 days), when combined with optimal medical pretreatment with dalteparin sodium, aspirin, and appropriate antianginal medication, is associated with improved clinical outcomes, relative to a "watchful waiting" approach based on noninvasive therapy. Thus, an early invasive approach following aggressive medical pretreatment should be the preferred strategy for patients with UCAD who present with signs of ischemia on the electrocardiogram or raised biochemical markers of myocardial damage at admission.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway.
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Abstract
The FRISC II study addressed two key questions in the management of acute coronary syndromes: is it beneficial to extend low-molecular-weight heparin (LMWH) therapy with dalteparin beyond the initial period of acute treatment; and, is a strategy of early invasive therapy, including angioplasty and surgical revascularization, preferable to a more conservative strategy? The study focused on patients with unstable coronary artery disease (UCAD), that is, angina and non-ST-segment-elevation myocardial infarction (MI). Patients were allocated in a randomized, factorial study design to either an invasive or a conservative management strategy. Within each of these groups, patients were further randomized to receive either 3 months of extended treatment with dalteparin or placebo, following at least 5 days' treatment with open-label dalteparin. After 1 year, patient survival and MI-free survival were significantly higher in the invasive therapy group than in the noninvasive group. Patients who received extended dalteparin treatment had a significantly reduced probability of death or MI after 1 month (relative risk reduction 47%; p = 0.002), a benefit still evident after 60 days, but after 3 months there was no longer any significant clinical advantage compared with placebo. There was, however, a significant reduction in the combined incidence of death, MI, or revascularization at 3 months in the extended dalteparin treatment group (relative risk reduction 13%; p = 0.031). The benefits of extended dalteparin treatment were particularly marked in patients with elevated troponin-T or ST-segment depression. A subgroup analysis of conservatively managed patients who underwent revascularization in the first 45 days revealed that the probability of death or MI at 1 year was significantly lower among patients who received extended dalteparin treatment (relative risk reduction 35%; p = 0.02). Extended dalteparin treatment is, however, associated with a small increase in bleeding risk. In conclusion, early invasive therapy (following combined treatment with aspirin and dalteparin) is recommended in a majority of patients with UCAD. Furthermore, extended dalteparin treatment for up to 45 days is efficacious and well tolerated, and therefore provides a useful "bridge" to revascularization when early revascularization is not immediately available.
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Affiliation(s)
- F Kontny
- Department of Cardiology, The Heart and Lung Centre, Ullevål University Hospital, Oslo, Norway
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García-Pavía P, Segovia J, Molano J, Mora R, Kontny F, Erik Berge K, Lerend TP, Alonso-Pulpóna L. Miocardiopatía hipertrófica de alto riesgo asociada con una nueva mutación en la proteína C fijadora de miosina. Rev Esp Cardiol 2007. [DOI: 10.1157/13100284] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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García-Pavía P, Segovia J, Molano J, Mora R, Kontny F, Erik Berge K, Leren TP, Alonso-Pulpón L. [High-risk hypertrophic cardiomyopathy associated with a novel mutation in cardiac Myosin-binding protein C]. Rev Esp Cardiol 2007; 60:311-4. [PMID: 17394878] [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: 05/14/2023]
Abstract
Hypertrophic cardiomyopathy is an autosomal dominant inherited disease characterized by ventricular hypertrophy and myofibril disarray. Mutations responsible for hypertrophic cardiomyopathy have been identified in 11 genes that encode for cardiac sarcomere proteins. Traditionally, hypertrophic cardiomyopathy due to mutation of the myosin-binding protein C gene (MYBPC3) has been thought to follow a benign course. We report a family with several members affected by hypertrophic cardiomyopathy in which there was a high incidence of sudden death. Disease was presumably caused by the substitution of cytosine by guanine at nucleotide 269 of MYBPC3 mRNA. This mutation, which has not previously been described, modifies codon 79, which encodes for the incorporation of a tyrosine, and gives rise to a stop codon. The mutation described here appears to confer a higher risk than that previously associated with hypertrophic cardiomyopathy due to MYBPC3 gene mutation.
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Affiliation(s)
- Pablo García-Pavía
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain.
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Lagerqvist B, Diderholm E, Lindahl B, Husted S, Kontny F, Ståhle E, Swahn E, Venge P, Siegbahn A, Wallentin L. FRISC score for selection of patients for an early invasive treatment strategy in unstable coronary artery disease. Heart 2005; 91:1047-52. [PMID: 16020594 PMCID: PMC1769057 DOI: 10.1136/hrt.2003.031369] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To develop a scoring system for risk stratification and evaluation of the effect of an early invasive strategy for treatment of unstable coronary artery disease (CAD). DESIGN Retrospective analysis of a randomised study (FRISC II; fast revascularisation in instability in coronary disease). SETTING 58 Scandinavian hospitals. PATIENTS 2457 patients with unstable CAD from the FRISC II study. MAIN OUTCOME MEASURES One year rates of mortality and death/myocardial infarction (MI). METHODS Patients were randomly assigned to an early invasive or a non-invasive strategy. From the non-invasive cohort independent variables of death or death/MI were identified. RESULTS Seven factors, age > 70 years, male sex, diabetes, previous MI, ST depression, and increased concentrations of troponins and markers of inflammation (interleukin 6 or C reactive protein), were associated with an independent increased risk for death or death/MI. In patients with > or = 5 of these factors the invasive strategy reduced mortality from 15.4% (20 of 130) to 5.2% (7 of 134) (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.15 to 0.78, p = 0.006). Death/MI was also reduced in patients with 3-4 factors from 15.7% (80 of 511) to 10.8% (58 of 538) (RR 0.69, 95% CI 0.50 to 0.94, p = 0.02). Neither death nor death/MI was reduced in patients with 0-2 risk factors. CONCLUSION In unstable CAD, this scoring system based on factors independently associated with an adverse outcome can be used shortly after admission to the hospital for risk stratification and for selection of patients to an early invasive treatment strategy.
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Affiliation(s)
- B Lagerqvist
- Department of Medical Sciences, Cardiology, University Hospital, Uppsala, Sweden.
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Jacobsen MD, Wagner GS, Holmvang L, Kontny F, Wallentin L, Husted S, Swahn E, Ståhle E, Steffensen R, Clemmensen P. Quantitative T-wave analysis predicts 1 year prognosis and benefit from early invasive treatment in the FRISC II study population. Eur Heart J 2004; 26:112-8. [PMID: 15618066 DOI: 10.1093/eurheartj/ehi026] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS To investigate the prognostic value of T-wave abnormalities in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), and whether such ECG changes may predict benefit from an early coronary angiography. Although ST-segment changes are considered the most important ECG feature in NSTE-ACS, T-wave abnormalities are the most common ECG finding. We hypothesize that a new quantitative approach to T-wave analysis could improve the prognostic value of this ECG abnormality. METHODS AND RESULTS Quantitative T-wave analysis was performed on the admission ECG in 1609 patients with NSTE-ACS. Nine different categories of T-wave abnormality were analysed for their prognostic value concerning clinical outcome in patients not randomized to early coronary angiography. Also, the presence of one category (i.e. T-wave abnormality in > or =6 leads) was analysed for its predictive value concerning benefit from early coronary angiography. The combined study endpoint was death or myocardial infarction at 1 year follow-up. Patients with > or =6 leads with abnormal T-waves and concomitant ST-segment depression had a higher risk when not receiving early coronary angiography (24 vs. 12%, respectively; P=0.003), but could be brought to the same level of risk as the remaining patients with this treatment. For non-invasively treated patients five different categories of T-wave abnormality were significantly associated with an adverse outcome. CONCLUSION New quantitative T-wave analysis of the admission ECG gives additional predictive information concerning clinical outcome and identifies patients who benefit from early coronary angiography.
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Affiliation(s)
- Michael D Jacobsen
- The Heart Center, Department of Medicine B, H:S Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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Lagerqvist B, Husted S, Kontny F. A long-term perspective on the protective effects of an early invasive strategy in unstable coronary artery disease: two-year follow-up of the FRISC-II invasive study. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1062-1458(03)00082-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Olesen M, Kwong E, Meztli A, Kontny F, Seljeflot I, Arnesen H, Lyngdorf L, Falk E. No effect of cyclooxygenase inhibition on plaque size in atherosclerosis-prone mice. SCAND CARDIOVASC J 2002; 36:362-7. [PMID: 12626204 DOI: 10.1080/140174302762659094] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To study the role of cyclooxygenase (COX) inhibition on the development of advanced atherosclerosis in apolipoprotein E-deficient (apoE(-/-)) mice. DESIGN Sixty apoE(-/-) mice were divided into three groups: a control group, a group fed standard mouse chow supplemented with 0.0067% (wt/wt) MF Tricyclic (selective COX-2 inhibitor), and a group fed the diet supplemented with 0.0134% (wt/wt) sulindac (non-selective COX inhibitor). Four months later, the mice were killed and the atherosclerotic plaque area in the aortic root was measured. RESULTS Mean body weights did not differ at any time. The MF Tricyclic and sulindac groups had drug plasma levels of 1.31 +/- 0.11 and 0.84 +/- 0.23 micro g/ml, respectively. Plasma total cholesterol and triglyceride values were similar in all three groups. A small difference in plasma levels of high-density lipoprotein cholesterol was found between the groups (p = 0.03). Advanced atherosclerotic plaques were present in mice from all three groups, but there was no difference in mean plaque size between the groups (p = 0.9). CONCLUSION Neither selective COX-2 nor non-selective COX inhibition influenced the development of advanced atherosclerosis in apoE(-/-) mice.
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Affiliation(s)
- Mette Olesen
- Department of Cardiology, Institute of Experimental Clinical Research, Aarhus University Hospital (Skejby), DK-8200 Aarhus N, Denmark
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James S, Armstrong P, Califf R, Husted S, Kontny F, Niemminen M, Pfisterer M, Simoons ML, Wallentin L. Safety and efficacy of abciximab combined with dalteparin in treatment of acute coronary syndromes. Eur Heart J 2002; 23:1538-45. [PMID: 12242074 DOI: 10.1053/euhj.2002.3257] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS The safety and efficacy of abciximab in addition to low-molecular-weight-heparin as the primary medical treatment of acute coronary syndromes has not previously been investigated. METHODS AND RESULTS The GUSTO IV-ACS trial included 7800 patients with chest pain and either ST-segment depression or a positive troponin test. They were randomized to abciximab for 24 h, 48 h or placebo. In the dalteparin substudy, 974 patients received 5 days of s.c. dalteparin, instead of a 48 h infusion of unfractionated heparin (UFH). Major and minor bleedings were more frequent for abciximab (24 and 48 h combined) than placebo both in the dalteparin (abciximab 5.0% vs placebo 1.8% P<0.05) and in the UFH cohort (3.8% vs 1.8% P<0.001). However, stroke rates were low, < or = 0.6%. At 30 days there were no significant differences in the rate of death or MI, either in the dalteparin (abciximab 9.6% vs placebo 11.3%: O.R. 0.85; 95% C.I. 0.58-1.25) or in the UFH cohort (8.5% vs 7.6%: O.R.; 1.12: 0.95-1.34). CONCLUSION Treatment with abciximab, aspirin and s.c. dalteparin is associated with a low risk of major side effects and is as safe as the combination of abciximab and UFH. Without early coronary intervention there is no indication for abciximab treatment.
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Affiliation(s)
- S James
- Department of Cardiology, Thoraxcenter, Academic Hospital, Uppsala, Sweden
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Husted SE, Wallentin L, Lagerqvist B, Kontny F, Ståhle E, Swahn E. Benefits of extended treatment with dalteparin in patients with unstable coronary artery disease eligible for revascularization. Eur Heart J 2002; 23:1213-8. [PMID: 12127923 DOI: 10.1053/euhj.2001.3077] [Citation(s) in RCA: 7] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS The FRISC II trial demonstrated that, for patients with unstable coronary artery disease, an early invasive strategy following acute treatment with dalteparin and aspirin, was superior to a more conservative approach. We evaluated whether it is beneficial to extend treatment with dalteparin to patients eligible for revascularization but for whom these procedures are performed after the initial hospital stay. METHODS AND RESULTS As a subanalysis of FRISC II, the efficacy and clinical safety of extended dalteparin treatment (5000 or 7500 IU.12h(-1) to day 90) compared with placebo was assessed in 1601 patients randomized to a non-invasive group who underwent revascularization only when necessary because of recurring symptoms, (re)infarction, or severe ischaemia. By day 90, 440 patients had undergone revascularization: 267 of these procedures occurred during the double-blind period. All patients initially received acute treatment (5-7 days from day 1) with dalteparin (120 IU/kg(-1) 12h(-1)). The incidence of death and/or myocardial infarction was monitored until revascularization or day 45 and until revascularization or day 90. There was a significant difference in the estimated probability of death and/or myocardial infarction until revascularization or day 90 in favour of dalteparin (log-rank test, P=0.0415) and there was a significant reduction in death and/or myocardial infarction in favour of extended dalteparin treatment at day 45, with a 57% relative risk reduction (P=0.0004). At day 90 the relative risk reduction was 29%. The safety profile of extended dalteparin treatment was similar to that of acute usage. CONCLUSION Extended dalteparin treatment for up to 45 days is effective and safe as a bridging therapy for patients with unstable coronary artery disease awaiting revascularization.
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Affiliation(s)
- S E Husted
- Department of Medicine and Cardiology, Aarhus University Hospital, Denmark
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Pedersen TR, Jahnsen KE, Vatn S, Semb AG, Kontny F, Zalmai A, Nerdrum T. Benefits of early lipid-lowering intervention in high-risk patients: the lipid intervention strategies for coronary patients study. Clin Ther 2000; 22:949-60. [PMID: 10972631 DOI: 10.1016/s0149-2918(00)80066-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is controversy about whether lipid-lowering pharmacotherapy should be initiated immediately after an acute coronary event or only after diet and lifestyle changes have proved inadequate. OBJECTIVE This study, known as the Lipid Intervention Strategies for Coronary Patients Study, compared the efficacy of immediate versus deferred simvastatin treatment in conjunction with dietary advice about reducing lipid levels in hypercholesterolemic patients with acute coronary syndromes. METHODS This randomized, open-label, parallel-group study included 151 hypercholesterolemic (low-density lipoprotein cholesterol [LDL-C] >3.0 mmol/L) men and women aged 35 to 75 years. Within 4 days of diagnosis of acute myocardial infarction (MI) or unstable angina pectoris, all patients received dietary advice from a specially trained nurse. Subsequently, patients were randomized to 2 treatment groups: 1 group received immediate treatment with simvastatin 40 mg/d; patients in the other group received simvastatin 40 mg/d after 3 months only if their LDL-C remained >3.0 mmol/L. RESULTS The immediate-simvastatin group (n = 73) and the deferred-simvastatin group (n = 78) were balanced with respect to baseline characteristics. Of the 151 patients, 25% were women, 25% had concomitant hypertension, and 75% had a diagnosis of MI on enrollment. At 3 months, 90% of the patients receiving dietary advice plus immediate simvastatin treatment had achieved the recommended European target LDL-C level of <3.0 mmol/L, compared with 7% of those treated with diet alone. By 6 months, when 92% of the study participants were receiving simvastatin 40 mg/d, the proportion of patients achieving target LDL-C levels was 92% in the group that received immediate simvastatin therapy and 81% in the group that received deferred simvastatin therapy. The reductions in LDL-C (42%-48%) were considered to be clinically comparable between the 2 groups at 12 months. CONCLUSIONS On the basis of these results, we concluded that few patients with hypercholesterolemia and acute coronary syndromes reach the recommended European target LDL-C level of <3.0 mmol/L with dietary advice alone. However, early treatment with simvastatin 40 mg/d combined with dietary advice and follow-up at a dedicated outpatient clinic specializing in coronary heart disease resulted in 9 out of 10 patients reaching a recommended target LDL-C level of <3.0 mmol/L. Initiation of simvastatin therapy while a patient is hospitalized may increase the likelihood of the patient's lipid levels being managed according to current recommendations after he or she is discharged.
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Affiliation(s)
- T R Pedersen
- Cardiology Department, Aker University Hospital, Oslo, Norway.
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Wallentin L, Lagerqvist B, Husted S, Kontny F, Ståhle E, Swahn E. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during Instability in Coronary artery disease. Lancet 2000; 356:9-16. [PMID: 10892758 DOI: 10.1016/s0140-6736(00)02427-2] [Citation(s) in RCA: 459] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The Fragmin and Fast Revascularisation during Instability in Coronary artery disease II trial (FRISC II) compared an early invasive with an early non-invasive strategy in unstable coronary-artery disease. We report outcome at 1 year. METHODS 2457 patients were randomly assigned invasive or non-invasive treatment and 3 months of dalteparin or placebo. Complete information at 1 year was available for 1222 in the invasive group and 1234 in the non-invasive group. Analyses were by intention to treat. FINDINGS Revascularisation was done within the first 10 days in 71% of the invasive group and 9% of the non-invasive group and within the first year in 78% and 43%. During the first year, 27 (2.2%) patients in the invasive group and 48 (3.9%) in the non-invasive group died (risk ratio 0.57 [95% CI 0.36-0.90], p=0.016). 105 (8.6%) versus 143 (11.6%) had myocardial infarction (0.74 [0.59-0.94], p=0.015). The composite of death or myocardial infarction occurred in 127 (10.4%) versus 174 (14.1%) patients (0.74 [0.60-0.92], p=0.005). There were also reductions in readmission (451 [37%] vs 704 [57%]; 0.67 [0.62-0.72]), and revascularisation after the initial admission (92 [7.5%] vs 383 [31%]; 0.24 [0.20-0.30]). The results did not interact with the dalteparin/placebo allocation. INTERPRETATION After 1 year in 100 patients, an invasive strategy saves 1.7 lives, prevents 2.0 non-fatal myocardial infarctions and 20 readmissions, and provides earlier and better symptom relief at the cost of 15 more patients with coronary-artery bypass grafting and 21 more with percutaneous transluminal angioplasty. Therefore, an invasive approach should be the preferred strategy in patients with unstable coronary-artery disease and signs of ischaemia on electrocardiography or raised levels of biochemical markers of myocardial damage.
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Affiliation(s)
- L Wallentin
- Department of Cardiology, University Hospital, Uppsala, Sweden.
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Härdig L, Daae C, Dellborg M, Kontny F, Bohmer T. Reduced thiamine phosphate, but not thiamine diphosphate, in erythrocytes in elderly patients with congestive heart failure treated with furosemide. J Intern Med 2000; 247:597-600. [PMID: 10809999 DOI: 10.1046/j.1365-2796.2000.00649.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To measure the concentrations of thiamine and thiamine esters by high-pressure liquid chromatography (HPLC) in elderly patients treated with furosemide for heart failure and in a control group. DESIGN A cross-sectional study of blood thiamine and thiamine ester concentrations. SUBJECTS Forty-one patients admitted to hospital for heart failure and 34 elderly living at home. No vitamin supplementation was allowed. RESULTS Compared with the healthy controls, furosemide-treated patients had significantly reduced whole blood thiamine phosphate (TP; 4.4 +/- 2.2 vs. 7.6 +/- 2.0 nmol L-1) and thiamine diphosphate (TPP; 76 +/- 21.5 vs. 91 +/- 19.8 nmol L-1) (mean +/- SD). When the thiamine concentrations were related to the haemoglobin concentrations, which were reduced in the heart failure patients, the levels of TP (nmol g-1 Hb) were 0.38 +/- 0.26 vs. 0.54 +/- 0.17 (P < 0.0001), and of TPP were 6.35 +/- 1.76 vs. 6.37 +/- 1.29 (P = 0.95). There were no differences in T and TP concentrations in plasma between the two groups. CONCLUSIONS The elderly patients with heart failure treated with furosemide have not reduced the storage form of thiamine, TPP, but only TP. This change is most likely not an expression of a thiamine deficiency, but rather of an altered metabolism of thiamine, which is not understood at present.
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Affiliation(s)
- L Härdig
- Department of Medicine, Section of Cardiology, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden
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Dahl T, Kontny F, Slagsvold CE, Christophersen B, Abildgaard U, Odegaard OR, Morkrid L, Dale J. Lipoprotein(a), other lipoproteins and hemostatic profiles in patients with ischemic stroke: the relation to cardiogenic embolism. Cerebrovasc Dis 2000; 10:110-7. [PMID: 10686449 DOI: 10.1159/000016039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Lipoprotein and hemostatic profiles including coagulation inhibitors were determined in 136 patients with acute ischemic stroke. Based on clinical examination, cerebral computed tomography, Doppler ultrasonography of precerebral arteries and transthoracic echocardiography, the strokes were classified as cardioembolic (n = 38), non-cardioembolic (n = 92), and mixed cardioembolic/hypertensive (n = 6). Patients with cardioembolic stroke were older than patients with non-cardioembolic stroke. Lipoprotein(a) was higher in the cardioembolic than in the non-cardioembolic group. Lipoprotein(a) was not significantly correlated to the other lipid levels and may represent an independent lipid risk factor. The non-cardioembolic group had higher levels of total cholesterol, triglycerides, total cholesterol/high-density lipoprotein cholesterol ratio, low-density lipoprotein cholesterol, apolipoprotein A1, and apolipoprotein B. The cardioembolic group had higher concentrations of fibrinogen and D-dimer, and lower levels of antithrombin, protein C, protein S and heparin cofactor 2 than the non-cardioembolic group. The differences in the hemostatic profile are consistent with thrombosis due to activated coagulation being more involved in the pathogenesis of cardioembolic than of non-cardioembolic stroke. Lipoprotein(a) seems to be more associated with coagulation markers of thrombosis than with atherosclerosis, whereas the other lipids mainly seem to be risk factors for atherosclerosis.
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Affiliation(s)
- T Dahl
- Department of Medicine, University of Oslo, Oslo, Norway
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Abstract
AIMS A novel sensitive method for analyses of soluble fibrin monomer antigen was used to assess the predictive value of fibrin monomer when estimating mortality after acute myocardial infarction. METHODS AND RESULTS Fibrin monomer was measured in plasma samples from 293 patients enrolled in a randomized clinical trial of low molecular weight heparin (dalteparin) in acute myocardial infarction (the FRAMI trial). Samples taken on days 2 and 7 were analysed using the Enzymun-Test FM(R)(Boehringer Mannheim, Germany). Non-survivors had significantly higher fibrin monomer levels relative to survivors (day 2, median (min-max): 1.8 mg. l-1(<0.01-73.1) vs 0.4 mg. l-1(<0. 01-103.5), P<0.0001). Fibrin monomer levels were significantly associated with congestive heart failure (P<0.001), enzymatic infarct size (P<0.0001), dalteparin treatment (P<0.001), and thrombolytic therapy (P=0.016). The relationship between fibrin monomer and mortality remained statistically significant after adjustment for these variables. In logistic regression analyses, fibrin monomer levels, age and congestive heart failure were all independent predictors of fatal outcome. CONCLUSIONS Increased fibrin monomer level is an independent predictor of mortality in patients with myocardial infarction. It allows further risk stratification when combined with known risk factors such as age and presence of congestive heart failure.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway
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Dempfle CE, Kontny F, Abildgaard U. Predictive value of coagulation markers concerning clinical outcome 90 days after anterior myocardial infarction. Thromb Haemost 1999; 81:701-4. [PMID: 10365740] [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: 02/12/2023]
Abstract
To study the predictive value of coagulation markers concerning clinical outcome, prothrombin fragment F1.2 (F1.2), fibrin monomer antigen (FM), D-Dimer (DD), and fibrinogen were measured in plasma samples drawn 2 and 7 days after acute myocardial infarction (AMI) in 314 consecutive patients randomized in a clinical trial of low molecular weight heparin (Dalteparin) (the FRAMI trial). Placebo-treated patients suffering death or new AMI within 90 days had significantly higher levels at day 2 of FM (Enzymun-Test FM), and DD (TINAquant D-dimer) (p = 0.001 and 0.02, respectively), but not F1.2 (Enzygnost F1.2 micro), relative to those without serious clinical events. At day 7 all three coagulation activation markers were significantly higher in patients with subsequent adverse clinical outcome. The Dalteparin group had significantly lower levels of these markers as compared to the placebo group. Left ventricular (LV) thrombus formation was not associated with changes in coagulation activation. However, patients with thrombus had significantly higher fibrinogen levels than those without thrombus (p = 0.004 day 2), independent of treatment group. Thus, markers of coagulation activation may be useful in stratification of patients when estimating risk for adverse clinical outcome after AMI. Furthermore, elevated fibrinogen levels are associated with increased risk of LV thrombus formation.
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Affiliation(s)
- C E Dempfle
- University of Heidelberg, Mannheim University Hospital, First Dept. of Medicine, Germany.
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Pedersen T, Jahnsen KE, Vatn S, Semb A, Kontny F, Zalmai A, Nerdrum T. Lipid intervention strategies in acute coronary syndromes: A randomised trial with simvastatin. Atherosclerosis 1999. [DOI: 10.1016/s0021-9150(99)80755-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Left ventricular thrombus formation and resolution were studied by serial echocardiography in 38 patients with acute anterior myocardial infarction. Twenty (52.6%) patients developed thrombus. Cumulative rates were: 12/20 (60%) at 24 h (+/-24 h), 17/20 (85%) at 72 h (+/-24 h), and 19/20 (95%) at 120 h (+/-24 h). Early thrombus formation was associated with worse left ventricular wall motion relative to those with delayed thrombus development (P=0.00016). In patients with initially normal echocardiograms, subsequent thrombus formation was associated with wall motion deterioration (P=0.016). A thrombus occurred in 16/28 (57.1%) patients given streptokinase. Heparin and warfarin were given in case of thrombus formation. Among survivors with thrombus, resolution occurred with a cumulative rate of 1/18 (5.6%) at 72 h (+/-24 h), 2/18 (11.1%) at 120 h (+/-24 h), 10/18 (55.6%) at 3 months (+/-1 week) and 16/18 (88.9%) at 6 months (+/-1 week). No embolic events occurred. Left ventricular thrombus formation occurs often and early after acute anterior myocardial infarction, even when streptokinase is given. Delayed thrombus formation is associated with wall motion deterioration. Thrombus resolution occurs frequently during anticoagulation and seems not associated with increased embolic risk.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway
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Kontny F, Dale J, Abildgaard U, Pedersen TR. Randomized trial of low molecular weight heparin (dalteparin) in prevention of left ventricular thrombus formation and arterial embolism after acute anterior myocardial infarction: the Fragmin in Acute Myocardial Infarction (FRAMI) Study. J Am Coll Cardiol 1997; 30:962-9. [PMID: 9316525 DOI: 10.1016/s0735-1097(97)00258-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The present trial investigated the efficacy and safety of dalteparin in the prevention of arterial thromboembolism after an acute anterior myocardial infarction (MI). BACKGROUND Left ventricular (LV) thrombus formation is associated with increased risk of arterial embolism in patients with an acute MI. Thrombolytic and antiplatelet therapy do not prevent thrombus formation. METHODS A total of 776 patients were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial of subcutaneous dalteparin (150 IU/kg body weight every 12 h during the hospital period). Thrombolytic therapy and aspirin were administered in 91.5% and 97.6% of patients, respectively. The primary study end point was the composite of thrombus formation diagnosed by echocardiography and arterial embolism on day 9 +/- 2. RESULTS Of 517 patients with echocardiographic recordings available for end point analysis, thrombus formation or embolism, or both, was found in 59 (21.9%) of 270 patients (59 with thrombus, none with embolism) in the placebo group and 35 (14.2%) of 247 patients (34 with thrombus, 1 with embolism) in the dalteparin group (p = 0.03). The risk reduction of thrombus formation associated with dalteparin treatment was 0.63 (95% confidence interval 0.43 to 0.92, p = 0.02). Analyses of all randomized patients (388 in each group) revealed no significant difference between the placebo and dalteparin groups with respect to arterial embolism (6 vs. 5 patients), reinfarction (8 vs. 6 patients) and mortality rates (23 vs. 23 patients, p = NS for all). Dalteparin was associated with an increased risk of hemorrhage: major in 11 dalteparin group patients (2.9%) verus 1 placebo group patient (0.3%, p = 0.006); minor in 52 dalteparin group patients (14.8%) versus 8 placebo group patients (1.8%, p < 0.001). CONCLUSIONS Dalteparin treatment significantly reduces LV thrombus formation in acute anterior MI but is associated with increased hemorrhagic risk.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway.
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Abstract
Coronary artery thrombosis superimposed on a disrupted atherosclerotic plaque has emerged as the pivotal pathophysiologic event in acute coronary syndromes (i.e., unstable angina, myocardial infarction, and sudden death). The various clinical manifestations depend on the extent and duration of thrombus deposition, which are determined by several local and systemic thrombogenic risk factors. The thrombotic response to plaque disruption involves both platelet activation and thrombin generation. Accordingly, combined treatment with aspirin and heparin has proved more efficacious than either treatment alone in the risk reduction of serious cardiac events in patients with unstable angina or non-Q-wave infarction. However, withdrawal of heparin is, even after prolonged treatment, associated with an increased short-term risk of serious cardiac events relative to the risk in patients given only aspirin. Furthermore, the long-term relative event rate seems not to be influenced by administration of heparin or direct antithrombins in the acute phase. Both transient hypercoagulability associated with heparin withdrawal and continuous thrombin generation over a longer term related to the underlying disease may explain the rebound in clinical events. Longer duration of combined antiplatelet and anticoagulant treatments, e.g., until healing of the culprit lesion or even until stabilization of vulnerable, yet nondisrupted plaques, may improve long-term clinical outcome.
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Affiliation(s)
- F Kontny
- Department of Cardiology, Aker University Hospital, Oslo, Norway
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Wallentin L, Husted S, Kontny F, Swahn E. Long-term low-molecular-weight heparin (Fragmin) and/or early revascularization during instability in coronary artery disease (the FRISC II Study). Am J Cardiol 1997; 80:61E-63E. [PMID: 9296473 DOI: 10.1016/s0002-9149(97)00493-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The Fragmin and/or Early Revascularisation during Instability in Coronary Artery Disease (FRISC II) trial will, in a prospective multicenter factorially randomized study, compare the efficacy of 3 months continuation of subcutaneous treatment with the low-molecular-weight heparin dalteparin (Fragmin) with that of placebo and will also compare a direct invasive strategy with a stepwise selective approach with regard to the utilization of coronary angiography and revascularization in patients with unstable coronary artery disease. The primary endpoints are death or myocardial infarction after 3 and 6 months respectively. Secondary endpoints are the same events after 12-24 months and also cardiac symptoms, exercise capacity, and/or signs of myocardial ischemia, readmission, and costs. Analyses will also be made of subgroups based on inclusion diagnosis, initial elevation of biochemical markers of myocardial damage, elevation of fibrinogen or C-reactive protein, signs of ischemia in electrocardiography at rest or at continuous 24-hour ischemia monitoring, and left ventricular function at echocardiography. Altogether, 3,100 patients will be recruited in 65-70 Scandinavian centers. Completion of follow-up is anticipated in the second half of 1998. The FRISC II study will further elucidate new alternatives for antithrombotic, invasive, and individually tailored treatment of unstable coronary syndromes.
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Affiliation(s)
- L Wallentin
- Department of Cardiology, University of Uppsala, Sweden
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Kontny F, Dale J, Hegrenaes L, Lem P, Søberg T, Morstøl T. Left ventricular thrombosis and arterial embolism after thrombolysis in acute anterior myocardial infarction: predictors and effects of adjunctive antithrombotic therapy. Eur Heart J 1993; 14:1489-92. [PMID: 8299630 DOI: 10.1093/eurheartj/14.11.1489] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The prevalence of left ventricular (LV) thrombosis and incidence of arterial embolism after acute anterior myocardial infarction (AAMI) treated with streptokinase 1.5 x 10(6) IU intravenously was studied in 136 patients enrolled consecutively in five cardiological centres. Adjunctive antithrombotic therapy was administered according to the routine of each centre. Thrombus formation was studied by two-dimensional echocardiography, and events of arterial embolism recorded. LV thrombosis was found in 37 (27.2%) of the patients. In a subgroup of 53 patients receiving post-thrombolytic therapy with acetylsalicylic acid only, a thrombus developed in 14 (26.4%). The thrombus prevalence among patients given high-dose heparin was significantly lower than among those receiving either low-dose heparin or no heparin (4/30 vs 33/106, P = 0.045). Logistic regression analysis suggested that severe LV wall motion abnormality (P < 0.001) and avoidance of treatment with high-dose heparin (P = 0.023) were independent predictors of LV thrombus formation. Only one patient (0.7%) suffered arterial embolism (ischaemic stroke). In conclusion, LV thrombosis is frequent after thrombolytic therapy for AAMI, and impaired LV wall motion represents an independent predisposing factor. Low-dose heparin and acetylsalicylic acid seem less effective for LV thrombus prophylaxis than high-dose heparin. The incidence of arterial embolism is low.
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Affiliation(s)
- F Kontny
- Medical Department, Aker University Hospital, Oslo, Norway
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