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Goldhaber SZ, Bassand JP, Camm AJ, Virdone S, Pieper K, Cools F, Corbalan R, Gersh BJ, Goto S, Haas S, Misselwitz F, Parkhomenko A, Steffel J, Stepinska J, Turpie AGG, Verheugt FWA, Kayani G, Kakkar AK. Clinical Outcomes in Older Patients with Atrial Fibrillation: Insights from the GARFIELD-AF Registry. Am J Med 2024; 137:128-136.e13. [PMID: 37918777 DOI: 10.1016/j.amjmed.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/11/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Oral anticoagulants (OAC) are underutilized in older patients with atrial fibrillation, despite proven clinical benefits. Our objective was to investigate baseline characteristics, treatment patterns, and impact of anticoagulation upon clinical outcomes with respect to age. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed up for 24 months. Adjusted hazard ratios (HR) were obtained via Cox proportional-hazards models with applied weights, to quantify the association of age with clinical outcomes. Comparative effectiveness of OAC vs No OAC and non-vitamin K oral anticoagulants (NOAC) vs vitamin K antagonists (VKA) were assessed using a propensity score with an overlap weighting scheme. RESULTS Of 52,018 patients, 32.6% were 65-74 years of age, 29.3% were 75-84 years, and 7.9% were ≥85 years. OAC treatment was associated with a numerical reduction in all-cause mortality among those aged 65-74 years (HR; 95% confidence interval) (0.86; 0.69-1.06) and aged 75-84 years (0.89; 0.75-1.05) and a significant reduction in patients ≥85 years (0.77; 0.63-0.95) vs no OAC. Similarly, OACs were associated with a decrease in stroke: 65-74 (0.51; 0.35-0.76) and ≥85 years (0.58; 0.34-0.99) and a numerical decrease in 75-84 years (0.84; 0.59-1.18). No increase in major bleeding was observed in patients aged ≥85 treated with OACs. Compared with VKA, NOACs were associated with a significant reduction in all-cause mortality in patients aged <65 and 65-74, with numerical reductions in those aged 75-84 and ≥85 years. CONCLUSIONS Older patients using OACs saw lower all-cause mortality and stroke risk; NOACs had less mortality and major bleeding compared with VKAs.
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Affiliation(s)
| | | | - A John Camm
- Molecular and Clinical Sciences Research Institute, Cardiology Clinical Academic Group, St George's University of London, London, UK
| | | | | | - Frank Cools
- AZ Klina, General Hospital Klina, Brasschaat, Belgium
| | - Ramon Corbalan
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Technical University of Munich, Germany
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Verheugt FWA, Fox KAA, Virdone S, Ambrosio G, Gersh BJ, Haas S, Pieper KS, Kayani G, Camm AJ, Parkhomenko A, Misselwitz F, Ragy H, Ten Cate H, Keltai M, Kakkar AK. Outcomes of Oral Anticoagulation in Atrial Fibrillation Patients With or Without Comorbid Vascular Disease: Insights From the GARFIELD-AF Registry. Am J Med 2023; 136:1187-1195.e15. [PMID: 37704071 DOI: 10.1016/j.amjmed.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/07/2023] [Accepted: 08/11/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Many patients with atrial fibrillation suffer from comorbid vascular disease. The comparative efficacy and safety of different types of oral anticoagulation (OAC) in this patient group have not been widely studied. METHODS Adults with newly diagnosed atrial fibrillation were recruited into the prospective observational registry, GARFIELD-AF, and followed for 24 months. Associations of vascular disease with clinical outcomes were analyzed using adjusted hazard ratios (HR) obtained via Cox proportional-hazard modeling. Outcomes of OAC vs no OAC, and of non-vitamin K antagonist OAC (NOAC) vs vitamin K antagonist (VKA) treatment, were compared by overlap propensity-weighted Cox proportional-hazard models. RESULTS Of 51,574 atrial fibrillation patients, 25.9% had vascular disease. Among eligible atrial fibrillation patients, those with vascular disease received OAC less frequently than those without (63% vs 73%). Over 2-year follow-up, patients with vascular disease showed a higher risk of all-cause mortality (HR 1.30; 95% confidence interval [CI], 1.16-1.47) and cardiovascular mortality (HR 1.59; 95% CI, 1.28-1.97). OAC was associated with a significant decrease in all-cause mortality and non-hemorrhagic stroke, and increased risk of major bleeding in non-vascular disease. In vascular disease, similar but non-significant trends existed for stroke and major bleeding. A significantly lower risk of all-cause mortality (HR 0.74; 95% CI, 0.61-0.90) and major bleeding (HR 0.45; 95% CI, 0.29-0.70) was observed in vascular disease patients treated with NOACs, compared with VKAs. CONCLUSIONS Atrial fibrillation patients with a history of vascular disease have worse long-term outcomes than those without. The association of NOACs vs VKA with clinical outcomes was more evident in atrial fibrillation patients with vascular disease.
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Affiliation(s)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | | | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia School of Medicine Cardiology, Italy
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minn, USA
| | - Sylvia Haas
- [Formerly] Department of Medicine, Technical University of Munich, Germany
| | | | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, UK
| | - Alexandr Parkhomenko
- National Scientific Centre "MD Strazhesko Institute of Cardiology", Kyiv, Ukraine
| | | | - Hany Ragy
- Department of Cardiology, National Heart Institute, Cairo, Egypt
| | - Hugo Ten Cate
- Maastricht University Medical Center (MUMC+) and Cardiovascular Research Institute (CARIM), Maastricht University, Netherlands; Center for Thrombosis and Hemostasis (CTH), Gutenberg University Medical Center, Mainz, Germany
| | - Matyas Keltai
- Semmelweis University, Hungarian Cardiovascular Institute, Budapest, Hungary
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Bassand JP, Virdone S, Camm AJ, Fox KAA, Goldhaber SZ, Goto S, Haas S, Hacke W, Kayani G, Keltai M, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Oral anticoagulation across diabetic subtypes in patients with newly diagnosed atrial fibrillation: A report from the GARFIELD-AF registry. Diabetes Obes Metab 2023; 25:3040-3053. [PMID: 37435777 DOI: 10.1111/dom.15202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 06/16/2023] [Accepted: 06/16/2023] [Indexed: 07/13/2023]
Abstract
AIMS This study aims to describe both management and prognosis of patients with diabetes mellitus (DM) and newly diagnosed atrial fibrillation (AF), overall as well as by antidiabetic treatment, and to assess the influence of oral anticoagulation (OAC) on outcomes by DM status. METHODS The study population comprised 52 010 newly diagnosed patients with AF, 11 542 DM and 40 468 non-DM, enrolled in the GARFIELD-AF registry. Follow-up was truncated at 2 years after enrolment. Comparative effectiveness of OAC versus no OAC was assessed by DM status using a propensity score overlap weighting scheme and weights were applied to Cox models. RESULTS Patients with DM [39.3% oral antidiabetic drug (OAD), 13.4% insulin ± OAD, 47.2% on no antidiabetic drug] had higher risk profile, OAC use, and rates of clinical outcomes compared with patients without DM. OAC use was associated in patients without DM and patients with DM with lower risk of all-cause mortality [hazard ratio 0.75 (0.69-0.83), 0.74 (0.64-0.86), respectively] and stroke/systemic embolism (SE) [0.69 (0.58-0.83), 0.70 (0.53-0.93), respectively]. The risk of major bleeding with OAC was similarly increased in patients without DM and those with DM [1.40 (1.14-1.71), 1.37 (0.99-1.89), respectively]. Patients with insulin-requiring DM had a higher risk of all-cause mortality and stroke/SE [1.91 (1.63-2.24)], [1.57 (1.06-2.35), respectively] compared with patients without DM, and experienced significant risk reductions of all-cause mortality and stroke/SE with OAC [0.73 (0.53-0.99); 0.50 (0.26-0.97), respectively]. CONCLUSIONS In both patients with DM and patients without DM with AF, OAC was associated with lower risk of all-cause mortality and stroke/SE. Patients with insulin-requiring DM derived significant benefit from OAC.
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Affiliation(s)
- Jean-Pierre Bassand
- University of Besançon Franche-Comté, Besançon, France
- Thrombosis Research Institute, London, UK
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
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van Campen C(LMC, Rowe PC, Verheugt FWA, Visser FC. Influence of end-tidal CO 2 on cerebral blood flow during orthostatic stress in controls and adults with myalgic encephalomyelitis/chronic fatigue syndrome. Physiol Rep 2023; 11:e15639. [PMID: 37688420 PMCID: PMC10492011 DOI: 10.14814/phy2.15639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 09/10/2023] Open
Abstract
Brain perfusion is sensitive to changes in CO2 levels (CO2 reactivity). Previously, we showed a pathological cerebral blood flow (CBF) reduction in the majority of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) patients during orthostatic stress. Limited data are available on the relation between CO2 and CBF changes in ME/CFS patients. Therefore, we studied this relation between ME/CFS patients and healthy controls (HC) during tilt testing. In this retrospective study, supine and end-tilt CBF, as measured by extracranial Doppler flow, were compared with PET CO2 data in female patients either with a normal heart rate and blood pressure (HR/BP) response or with postural orthostatic tachycardia syndrome (POTS), and in HC. Five hundred thirty-five female ME/CFS patients and 34 HC were included. Both in supine position and at end-tilt, there was a significant relation between CBF and PET CO2 in patients (p < 0.0001), without differences between patients with a normal HR/BP response and with POTS. The relations between the %CBF change and the PET CO2 reduction were both significant in patients and HC (p < 0.0001 and p = 0.0012, respectively). In a multiple regression analysis, the patient/HC status and PET CO2 predicted CBF. The contribution of the PET CO2 to CBF changes was limited, with low adjusted R2 values. In female ME/CFS patients, CO2 reactivity, as measured during orthostatic stress testing, is similar to that of HC and is independent of the type of hemodynamic abnormality. However, the influence of CO2 changes on CBF changes is modest in female ME/CFS patients.
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Affiliation(s)
| | - Peter C. Rowe
- Department of PaediatricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Camm AJ, Steffel J, Virdone S, Bassand JP, Fox KAA, Goldhaber SZ, Goto S, Haas S, Turpie AGG, Verheugt FWA, Misselwitz F, Herreros RC, Kayani G, Pieper KS, Kakkar AK. Guideline-directed medical therapies for comorbidities among patients with atrial fibrillation: results from GARFIELD-AF. Eur Heart J Open 2023; 3:oead051. [PMID: 37293139 PMCID: PMC10246824 DOI: 10.1093/ehjopen/oead051] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/10/2023] [Accepted: 04/20/2023] [Indexed: 06/10/2023]
Abstract
Aims This study aimed to identify relationships in recently diagnosed atrial fibrillation (AF) patients with respect to anticoagulation status, use of guideline-directed medical therapy (GDMT) for comorbid cardiovascular conditions (co-GDMT), and clinical outcomes. The Global Anticoagulant Registry in the FIELD (GARFIELD)-AF is a prospective, international registry of patients with recently diagnosed non-valvular AF at risk of stroke (NCT01090362). Methods and results Guideline-directed medical therapy was defined according to the European Society of Cardiology guidelines. This study explored co-GDMT use in patients enrolled in GARFIELD-AF (March 2013-August 2016) with CHA2DS2-VASc ≥ 2 (excluding sex) and ≥1 of five comorbidities-coronary artery disease, diabetes mellitus, heart failure, hypertension, and peripheral vascular disease (n = 23 165). Association between co-GDMT and outcome events was evaluated with Cox proportional hazards models, with stratification by all possible combinations of the five comorbidities. Most patients (73.8%) received oral anticoagulants (OACs) as recommended; 15.0% received no recommended co-GDMT, 40.4% received some, and 44.5% received all co-GDMT. At 2 years, comprehensive co-GDMT was associated with a lower risk of all-cause mortality [hazard ratio (HR) 0.89 (0.81-0.99)] and non-cardiovascular mortality [HR 0.85 (0.73-0.99)] compared with inadequate/no GDMT, but cardiovascular mortality was not significantly reduced. Treatment with OACs was beneficial for all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use; only in patients receiving all co-GDMT was OAC associated with a lower risk of non-haemorrhagic stroke/systemic embolism. Conclusion In this large prospective, international registry on AF, comprehensive co-GDMT was associated with a lower risk of mortality in patients with AF and CHA2DS2-VASc ≥ 2 (excluding sex); OAC therapy was associated with reduced all-cause mortality and non-cardiovascular mortality, irrespective of co-GDMT use. Clinical Trial Registration Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01090362.
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Affiliation(s)
- Alan John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Institute, St. George's University of London, London, UK
| | | | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- University of Besançon, Besançon, France
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Samuel Z Goldhaber
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Sylvia Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
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Verheugt FWA. MASTER-DAPT: A Further Step Toward Long-Term P2Y 12 Blocker Monotherapy After PCI. JACC Cardiovasc Interv 2023; 16:813-815. [PMID: 37045501 DOI: 10.1016/j.jcin.2023.02.016] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/14/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands.
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Verheugt FWA, Huber K. Continuous Improvement of Antiplatelet Therapy in Cardiovascular Disease. Thromb Haemost 2023; 123:133-134. [PMID: 36603836 DOI: 10.1055/s-0042-1760129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
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Schrör K, Verheugt FWA, Trenk D. Drug-Drug Interaction between Antiplatelet Therapy and Lipid-Lowering Agents (Statins and PCSK9 Inhibitors). Thromb Haemost 2023; 123:166-176. [PMID: 36522182 DOI: 10.1055/s-0042-1758654] [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: 12/23/2022]
Abstract
Lipid-lowering agents and antiplatelet drugs are guideline-recommended standard treatment for secondary prevention of acute thrombotic events in patients with increased cardiovascular risk. Aspirin is the most frequently used antiplatelet drug, either alone or in combination with other antiplatelet agents (P2Y12 inhibitors), while statins are first-line treatment of hypercholesterolemia. The well-established mode of action of aspirin is inhibition of platelet-dependent thromboxane formation. In addition, aspirin also improves endothelial oxygen defense via enhanced NO formation and inhibits thrombin formation. Low-dose aspirin exerts in addition anti-inflammatory effects, mainly via inhibition of platelet-initiated activation of white cells.Statins inhibit platelet function via reduction of circulating low-density lipoprotein-cholesterol (LDL-C) levels and a more direct inhibition of platelet function. This comprises inhibition of thromboxane formation via inhibition of platelet phospholipase A2 and inhibition of (ox)LDL-C-mediated increases in platelet reactivity via the (ox)LDL-C receptor (CD36). Furthermore, statins upregulate endothelial NO-synthase and improve endothelial oxygen defense by inhibition of NADPH-oxidase. PCSK9 antibodies target a serine protease (PCSK9), which promotes the degradation of the LDL-C receptor impacting on LDL-C plasma levels and (ox)LDL-C-receptor-mediated signaling in platelets similar to but more potent than statins.These functionally synergistic actions are the basis for numerous interactions between antiplatelet and these lipid-lowering drugs, which may, in summary, reduce the incidence of atherothrombotic vascular events.
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Affiliation(s)
- Karsten Schrör
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität, Düsseldorf, Düsseldorf, Germany
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Dietmar Trenk
- Department Universitäts-Herzzentrum, Klinik für Kardiologie und Angiologie Bad Krozingen, Klinische Pharmakologie, Universitätsklinikum Freiburg, Bad Krozingen, Germany
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9
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Verheugt FWA, Huber K, Clemmensen P, Collet JP, Cuisset T, Andreotti F. Platelet P2Y12 Inhibitor Monotherapy after Percutaneous Coronary Intervention: An Emerging Option for Antiplatelet Therapy De-escalation. Thromb Haemost 2023; 123:159-165. [PMID: 36584699 DOI: 10.1055/s-0042-1755330] [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: 01/01/2023]
Abstract
Antiplatelet therapy is considered essential for secondary prevention of ischemic heart disease. After percutaneous coronary intervention (PCI), temporary dual antiplatelet therapy (DAPT), a combination consisting of aspirin and an oral P2Y12 receptor blocker, is recommended. In the long term, this strategy results in more bleeding than antiplatelet therapy with aspirin alone. Therefore, to reduce bleeding, an increasing trend has been to keep DAPT as short as clinically acceptable, after which aspirin monotherapy is continued. Another option to diminish bleeding is to discontinue aspirin at the moment of DAPT cessation after PCI, and to continue on P2Y12 blocker monotherapy. This survey reviews the evidence on P2Y12 blocker monotherapy. Some clinical guidance will be provided on when and in whom P2Y12 inhibitor monotherapy may be applied after DAPT cessation following PCI.
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Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine, Nykøbing F Hospital, Nykøbing Falster, Denmark
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, HÔpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris, France
| | - Thomas Cuisset
- Department of Cardiology, La Timone Hospital, Marseille, France
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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10
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Andreotti F, Geisler T, Collet JP, Gigante B, Gorog DA, Halvorsen S, Lip GYH, Morais J, Navarese EP, Patrono C, Rocca B, Rubboli A, Sibbing D, Storey RF, Verheugt FWA, Vilahur G. Acute, periprocedural and longterm antithrombotic therapy in older adults: 2022 Update by the ESC Working Group on Thrombosis. Eur Heart J 2023; 44:262-279. [PMID: 36477865 DOI: 10.1093/eurheartj/ehac515] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022] Open
Abstract
The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults.
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Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Largo F Vito 1, 00168 Rome, Italy.,Department of Cardiovascular and Pneumological Sciences, Catholic University, Rome, Italy
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Otfried-Müller-Straße 10, 72076 Tuebingen, Germany
| | - Jean-Philippe Collet
- Paris Sorbonne Université (UPMC), ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Joao Morais
- Serviço de Cardiologia, Centro Hospitalar de Leiria and Center for Innovative Care and Health Technology (ciTechCare), Leiria Polytechnic Institute, Leiria, Portugal
| | - Eliano Pio Navarese
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,SIRIO MEDICINE Network and Faculty of Medicine University of Alberta, Edmonton, Canada
| | - Carlo Patrono
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Seeshaupt, Germany & Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, Research Institute-Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV, Instituto Salud Carlos III, Madrid, Spain
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11
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Muthspiel M, Kaufmann CC, Burger AL, Panzer B, Verheugt FWA, Huber K. Short dual antiplatelet therapy and dual antiplatelet therapy de-escalation after primary percutaneous intervention: For whom and how. Front Cardiovasc Med 2022; 9:1008194. [PMID: 36440022 PMCID: PMC9684463 DOI: 10.3389/fcvm.2022.1008194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/25/2022] [Indexed: 03/14/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) for 6-12 months, followed by lifelong aspirin monotherapy is considered an effective standard therapy for the prevention of thrombo-ischemic events in patients with acute and chronic coronary syndrome (ACS, CCS) undergoing percutaneous coronary intervention (PCI) or after a primarily conservative treatment decision. In ACS patients, the stronger P2Y12-inhibitors ticagrelor or prasugrel are recommended in combination with aspirin unless the individual bleeding risk is high and shortening of DAPT is warranted or clopidogrel is preferred. However, also in patients at low individual bleeding risk, DAPT is associated with a higher risk of bleeding. In recent years, new antithrombotic treatment strategies, such as shortening DAPT followed by early P2Y12-inhibitor monotherapy and de-escalating DAPT from potent P2Y12-inhibitors to clopidogrel by maintaining DAPT duration time, have been investigated in clinical trials and shown to reduce bleeding complications in cardiovascular high-risk patients without negative effects on ischemic events. In this review, we summarize the current knowledge and discuss its implication on future antithrombotic strategies in terms of a personalized medicine.
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Affiliation(s)
- Marie Muthspiel
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Christoph C. Kaufmann
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Achim Leo Burger
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | - Benjamin Panzer
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
| | | | - Kurt Huber
- Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Vienna, Austria
- Medical Faculty, Sigmund Freud University, Vienna, Austria
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Verheugt FWA, Fox KAA, Virdone S, Gersh BJ, Haas S, Pieper K, Kayani G, Camm AJ, Parkhomenko A, Kakkar AK. Differential efficacy and safety of oral anticoagulation in atrial fibrillation patients with or without comorbid vascular disease: insights from the GARFIELD-AF registry. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Many patients with atrial fibrillation (AF) have comorbid vascular disease. The effects of oral anticoagulation (OAC) in AF patients with vascular disease, however, have not been widely studied.
Purpose
To investigate the impact of OAC in AF patients with (Vasc) or without (nVasc) concomitant vascular disease.
Methods
GARFIELD-AF is the largest multinational, prospective AF registry. The study comprised 51,574 GARFIELD-AF patients with newly diagnosed AF, 13,365 Vasc and 38,209 nVasc patients. All patients who reported coronary artery disease, aortic or peripheral artery disease, acute coronary syndromes, myocardial infarction, stenting, or coronary artery bypass graft were classified as having vascular disease. Adjusted hazard ratios were obtained via Cox proportional-hazards models to quantify the association of vascular disease with selected endpoints. Comparative effectiveness analyses were restricted to patients enrolled from April 2013-September 2016 (when NOACs became widely available) and who were eligible for anticoagulation (CHA2DS2-VASc ≥2 excl. gender). To evaluate the safety and efficacy of different anticoagulation strategies in Vasc and nVasc patients, propensity score using an overlap weighting scheme was applied. Weights were applied to Cox proportional-hazards models to estimate the effects of OAC vs No OAC and NOAC vs VKA.
Results
Vasc patients were older (median (Q1; Q3): 72.0 (65.0; 79.0) vs 70.0 (62.0; 78.0) and more often male (62.0 vs 53.6%). Vasc patients had a higher rate of comorbidities including heart failure, hypertension, and diabetes. Vasc patients received less OAC (62.8 vs 68.3%). NOACs were less common compared with nVasc patients (23.8% vs 28.7%) but a similar proportion of VKAs was observed in both (39.0% vs 39.6%). Antiplatelet monotherapy was more common in Vasc (31%) than nVasc (18%) patients.
At 2-years, Vasc was associated with a higher risk of all-cause (HR [95% CI]: 1.30 [1.16–1.47]) and cardiovascular mortality (1.59 [1.28–1.97]). OACs significantly lowered the risk of all-cause mortality and stroke in nVasc patients (0.72 [0.63–0.82] and 0.64 [0.49–0.84], respectively), but not in nVasc patients. OACs led to a numerical increase in major bleeding in Vasc patients (1.32 [0.90–1.93]) and a significant increase in major bleeding in nVasc patients (1.40 [1.03–1.90]) (Figure 1). Compared with VKAs, NOACs did not significantly improve the risk of outcomes in nVasc patients. In Vasc patients however, NOACs significantly lowered the risk of all-cause mortality (0.74 [0.61–0.90]) and major bleeding (0.45 [0.29–0.70]) compared with VKAs (Figure 2).
Conclusion
AF patients with vascular disease have worse long-term outcomes than those without. They receive less often OAC, specifically NOAC, and more antiplatelet agents. The beneficial effects of NOAC over VKA are much more pronounced in patients with than in those without vascular disease.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This work was supported by the Thrombosis Research Institute (London, UK).
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Affiliation(s)
- F W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG) , Amsterdam , The Netherlands
| | - K A A Fox
- University of Edinburgh, Centre for Cardiovascular Science , Edinburgh , United Kingdom
| | - S Virdone
- Thrombosis Research Institute , London , United Kingdom
| | - B J Gersh
- Mayo Clinic College of Medicine and Science , Rochester , United States of America
| | - S Haas
- Vascular Centre Munich , Munich , Germany
| | - K Pieper
- Thrombosis Research Institute , London , United Kingdom
| | - G Kayani
- Thrombosis Research Institute , London , United Kingdom
| | - A J Camm
- St George's University of London, Cardiology Clinical Academic Group Molecular and Clinical Sciences Research Institute , London , United Kingdom
| | - A Parkhomenko
- National Scientific Center of Ukraine, MD Strazhesko Institute of Cardiology , Kiev , Ukraine
| | - A K Kakkar
- Thrombosis Research Institute , London , United Kingdom
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13
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Fox KAA, Virdone S, Bassand JP, Camm AJ, Goto S, Goldhaber SZ, Haas S, Kayani G, Koretsune Y, Misselwitz F, Oh S, Piccini JP, Parkhomenko A, Sawhney JPS, Stepinska J, Turpie AGG, Verheugt FWA, Kakkar AK. Do baseline characteristics and treatments account for geographical disparities in the outcomes of patients with newly diagnosed atrial fibrillation? The prospective GARFIELD-AF registry. BMJ Open 2022; 12:e049933. [PMID: 34996784 PMCID: PMC8744109 DOI: 10.1136/bmjopen-2021-049933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE In patients with newly diagnosed atrial fibrillation (AF), do baseline risk factors and stroke prevention strategies account for the geographically diverse outcomes. DESIGN Global Anticoagulant Registry in the FIELD-Atrial Fibrillation is a prospective multinational non-interventional registry of patients with newly diagnosed AF (n=52 018 patients). SETTING Investigator sites (n=1317) were representative of the care settings/locations in each of the 35 participating countries. Treatment decisions were all determined by the local responsible clinicians. PARTICIPANTS The patients (18 years and over) with newly diagnosed AF had at least 1 investigator-determined stroke risk factor and patients were not required to meet specific thresholds of risk score for anticoagulant treatment. MAIN OUTCOMES AND MEASURES Observed 1-year event rates and risk-standardised rates were derived. RESULTS Rates of death, non-haemorrhagic stroke/systemic embolism and major bleeding varied more than three-to-four fold across countries even after adjustment for baseline factors and antithrombotic treatments. Rates of anticoagulation and antithrombotic treatment varied widely. Patients from countries with the highest rates of cardiovascular mortality and stroke were among the least likely to receive oral anticoagulants. Beyond anticoagulant treatment, variations in the treatment of comorbidities and lifestyle factors may have contributed to the variations in outcomes. Countries with the lowest healthcare Access and Quality indices (India, Ukraine, Argentina, Brazil) had the highest risk-standardised mortality. CONCLUSION The variability in outcomes across countries for patients with newly diagnosed AF is not accounted for by baseline characteristics and antithrombotic treatments. Residual mortality rates were correlated with Healthcare Access and Quality indices. The findings suggest the management of patients with AF needs to not only address guideline indicated and sustained anticoagulation, but also the treatment of comorbidities and lifestyle factors. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- Department of Cardiology, University of Besançon, Besancon, France
| | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine Graduate School of Medicine, Isehara, Japan
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munchen, Germany
| | | | | | | | - Seil Oh
- Department of Internal Medicine, Seoul National University Hospital, Jongno-gu, Korea (the Republic of)
| | | | - Alex Parkhomenko
- National Scientific Center M D Strazhesko Institute of Cardiology, The National Academy of Medical Sciences of Ukraine, Kiiv, Ukraine
| | | | - Janina Stepinska
- Institute of Cardiology, Intensive Cardiac therapy clinic, Warsaw, Poland
| | | | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
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14
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Cools F, Johnson D, Camm AJ, Bassand J, Verheugt FWA, Yang S, Tsiatis A, Fitzmaurice DA, Goldhaber SZ, Kayani G, Goto S, Haas S, Misselwitz F, Turpie AGG, Fox KAA, Pieper KS, Kakkar AK. Risks associated with discontinuation of oral anticoagulation in newly diagnosed patients with atrial fibrillation: Results from the GARFIELD-AF Registry. J Thromb Haemost 2021; 19:2322-2334. [PMID: 34060704 PMCID: PMC8390436 DOI: 10.1111/jth.15415] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/06/2021] [Accepted: 05/19/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Oral anticoagulation (OAC) in atrial fibrillation (AF) reduces the risk of stroke/systemic embolism (SE). The impact of OAC discontinuation is less well documented. OBJECTIVE Investigate outcomes of patients prospectively enrolled in the Global Anticoagulant Registry in the Field-Atrial Fibrillation study who discontinued OAC. METHODS Oral anticoagulation discontinuation was defined as cessation of treatment for ≥7 consecutive days. Adjusted outcome risks were assessed in 23 882 patients with 511 days of median follow-up after discontinuation. RESULTS Patients who discontinued (n = 3114, 13.0%) had a higher risk (hazard ratio [95% CI]) of all-cause death (1.62 [1.25-2.09]), stroke/systemic embolism (SE) (2.21 [1.42-3.44]) and myocardial infarction (MI) (1.85 [1.09-3.13]) than patients who did not, whether OAC was restarted or not. This higher risk of outcomes after discontinuation was similar for patients treated with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) (p for interactions range = 0.145-0.778). Bleeding history (1.43 [1.14-1.80]), paroxysmal vs. persistent AF (1.15 [1.02-1.29]), emergency room care setting vs. office (1.37 [1.18-1.59]), major, clinically relevant nonmajor, and minor bleeding (10.02 [7.19-13.98], 2.70 [2.24-3.25] and 1.90 [1.61-2.23]), stroke/SE (4.09 [2.55-6.56]), MI (2.74 [1.69-4.43]), and left atrial appendage procedures (4.99 [1.82-13.70]) were predictors of discontinuation. Age (0.84 [0.81-0.88], per 10-year increase), history of stroke/transient ischemic attack (0.81 [0.71-0.93]), diabetes (0.88 [0.80-0.97]), weeks from AF onset to treatment (0.96 [0.93-0.99] per week), and permanent vs. persistent AF (0.73 [0.63-0.86]) were predictors of lower discontinuation rates. CONCLUSIONS In GARFIELD-AF, the rate of discontinuation was 13.0%. Discontinuation for ≥7 consecutive days was associated with significantly higher all-cause mortality, stroke/SE, and MI risk. Caution should be exerted when considering any OAC discontinuation beyond 7 days.
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Affiliation(s)
| | - Dana Johnson
- Department of StatisticsNorth Carolina State UniversityRaleighNCUSA
| | - Alan J. Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research InstituteSt. George’s University of LondonLondonUK
| | | | | | - Shu Yang
- North Carolina State UniversityRaleighNCUSA
| | | | | | | | | | - Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | - Sylvia Haas
- Formerly Department of MedicineTechnical University of MunichMunichGermany
| | | | | | - Keith A. A. Fox
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
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15
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Damen SAJ, Cramer GE, Dieker HJ, Gehlmann H, Ophuis TJMO, Aengevaeren WRM, Fokkert M, Verheugt FWA, Suryapranata H, Wu AH, van Wijk XMR, Brouwer MA. Cardiac Troponin Composition Characterization after Non ST-Elevation Myocardial Infarction: Relation with Culprit Artery, Ischemic Time Window, and Severity of Injury. Clin Chem 2021; 67:227-236. [PMID: 33418572 DOI: 10.1093/clinchem/hvaa231] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 09/10/2020] [Indexed: 11/14/2022]
Abstract
BACKGROUND Troponin composition characterization has been implicated as a next step to differentiate among non-ST elevation myocardial infarction (NSTEMI) patients and improve distinction from other conditions with troponin release. We therefore studied coronary and peripheral troponin compositions in relation to clinical variables of NSTEMI patients. METHODS Samples were obtained from the great cardiac vein (GCV), coronary sinus (CS), and peripheral circulation of 45 patients with NSTEMI. We measured total cTnI concentrations, and assessed both complex cTnI (binary cTnIC + all ternary cTnTIC forms), and large-size cTnTIC (full-size and partially truncated cTnTIC). Troponin compositions were studied in relation to culprit vessel localization (left anterior descending artery [LAD] or non-LAD), ischemic time window, and peak CK-MB value. RESULTS Sampling occurred at a median of 25 hours after symptom onset. Of total peripheral cTnI, a median of 87[78-100]% consisted of complex cTnI; and 9[6-15]% was large-size cTnTIC. All concentrations (total, complex cTnI, and large-size cTnTIC) were significantly higher in the CS than in peripheral samples (P < 0.001). For LAD culprit patients, GCV concentrations were all significantly higher; in non-LAD culprit patients, CS concentrations were higher. Proportionally, more large-size cTnTIC was present in the earliest sampled patients and in those with the highest CK-MB peaks. CONCLUSIONS In coronary veins draining the infarct area, concentrations of both full-size and degraded troponin were higher than in the peripheral circulation. This finding, and the observed associations of troponin composition with the ischemic time window and the extent of sustained injury may contribute to future characterization of different disease states among NSTEMI patients.
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Affiliation(s)
- Sander A J Damen
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gilbert E Cramer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hendrik-Jan Dieker
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ton J M Oude Ophuis
- Department of Cardiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | - Marion Fokkert
- Department of Clinical Chemistry, Isala Clinics, Zwolle, The Netherlands
| | - Freek W A Verheugt
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Harry Suryapranata
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alan H Wu
- Department of Clinical Chemistry, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA
| | - Xander M R van Wijk
- Department of Clinical Chemistry, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA
- Department of Pathology, The University of Chicago, Chicago, IL
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
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16
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Pazan F, Collins R, Gil VM, Hanon O, Hardt R, Hoffmeister M, Monteiro P, Quinn TJ, Ropers D, Sergi G, Verheugt FWA, Wehling M. Correction to: A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019). Drugs Aging 2021; 38:637-638. [PMID: 34125425 PMCID: PMC8266692 DOI: 10.1007/s40266-021-00873-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ronan Collins
- Stroke-Service/Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - Victor M Gil
- Cardiovascular Department, Hospital dos Lusíadas, Rua Abílio Mendes, 1500-458, Lisbon, Portugal
| | - Olivier Hanon
- Service de Gérontologie, Hôpital Broca-Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Equipe d'Accueil (EA) 4468, Paris, France
| | - Roland Hardt
- Department of Geriatrics, University Medical Center, University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Hoffmeister
- Cardiology, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Germany
| | - Pedro Monteiro
- Cardiology Department, Coimbra University Hospital, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G4 0SF, UK
| | - Dieter Ropers
- Department of Internal Medicine 1-Cardiology, St. Theresien-Krankenhaus Nuremberg, Mommsenstrasse 24, 90941, Nuremberg, Germany
| | - Giuseppe Sergi
- Clinica Geriatrica-Ospedale Giustinianeo (2nd piano), University of Padova, via Giustiniani 2, 35128, Padua, Italy
| | | | - Martin Wehling
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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17
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Verheugt FWA, Damman P, Damen SAJ, Wykrzykowska JJ, Woelders ECI, van Geuns RJM. P2Y12 blocker monotherapy after percutaneous coronary intervention. Neth Heart J 2021; 29:566-576. [PMID: 34101134 PMCID: PMC8556441 DOI: 10.1007/s12471-021-01582-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
For secondary prevention of coronary artery disease (CAD) antiplatelet therapy is essential. For patients undergoing a percutaneous coronary intervention (PCI) temporary dual antiplatelet platelet therapy (DAPT: aspirin combined with a P2Y12 blocker) is mandatory, but leads to more bleeding than single antiplatelet therapy with aspirin. Therefore, to reduce bleeding after a PCI the duration of DAPT is usually kept as short as clinically acceptable; thereafter aspirin monotherapy is administered. Another option to reduce bleeding is to discontinue aspirin at the time of DAPT cessation and thereafter to administer P2Y12 blocker monotherapy. To date, five randomised trials have been published comparing DAPT with P2Y12 blocker monotherapy in 32,181 stented patients. Also two meta-analyses addressing this novel therapy have been presented. P2Y12 blocker monotherapy showed a 50-60% reduction in major bleeding when compared to DAPT without a significant increase in ischaemic outcomes, including stent thrombosis. This survey reviews the findings in the current literature concerning P2Y12 blocker monotherapy after PCI.
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Affiliation(s)
- F W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - P Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S A J Damen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J J Wykrzykowska
- Department of Cardiology, University Medical Centre, Groningen, The Netherlands
| | - E C I Woelders
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R -J M van Geuns
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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18
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Camm AJ, Fox KAA, Virdone S, Bassand JP, Fitzmaurice DA, Berchuck SI, Gersh BJ, Goldhaber SZ, Goto S, Haas S, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Cappato R, Kakkar AK. Comparative effectiveness of oral anticoagulants in everyday practice. Heart 2021; 107:962-970. [PMID: 33593994 PMCID: PMC8165153 DOI: 10.1136/heartjnl-2020-318420] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study evaluated the comparative effectiveness of vitamin K antagonists (VKAs), direct thrombin inhibitors (DTIs) and factor Xa inhibitors (FXaI) in patients with atrial fibrillation (AF) at risk of stroke in everyday practice. METHODS Data from patients with AF and Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke, TIA, or thromboembolism, Vascular disease, Age 65-74 years, Sex category (CHA2DS2-VASc) score ≥2 (excluding gender) in the Global Anticoagulant Registry in the FIELD-Atrial Fibrillation registry were analysed using an improved method of propensity weighting, overlap weights and Cox proportional hazards models. RESULTS All-cause mortality, non-haemorrhagic stroke/systemic embolism (SE) and major bleeding over 2 years were compared in 25 551 patients, 7162 (28.0%) not treated with oral anticoagulant (OAC) and 18 389 (72.0%) treated with OAC (FXaI (41.8%), DTI (11.4%) and VKA (46.8%)). OAC treatment compared with no OAC treatment was associated with decreased risk of all-cause mortality (HR 0.82 (95% CI 0.74 to 0.91)) and non-haemorrhagic stroke/SE (HR 0.71 (95% CI 0.57 to 0.88)) but increased risk of major bleeding (HR 1.46 (95% CI 1.15 to 1.86)). Non-vitamin K antagonist oral anticoagulant (NOAC) use compared with no OAC treatment was associated with lower risks of all-cause mortality and non-haemorrhagic stroke/SE (HR 0.67 (95% CI 0.59 to 0.77)) and 0.65 (95% CI 0.50 to 0.86)) respectively, with no increase in major bleeding (HR 1.10 (95% CI 0.82 to 1.47)). NOAC use compared with VKA use was associated with lower risk of all-cause mortality and major bleeding (rates/100 patient-years 3.6 (95% CI 3.3 to 3.9) vs 4.8 (95% CI 4.5 to 5.2) and 1.0 (95% CI 0.9 to 1.1) vs 1.4 (95% CI 1.2 to 1.6); HR 0.79 (95% CI 0.70 to 0.89) and 0.77 (95% CI 0.61 to 0.98) respectively), with similar risk of non-haemorrhagic stroke/SE (rates/100 patient-years 0.8 (95% CI 0.7 to 0.9) versus 1.0 (95% CI 0.8 to 1.1); HR 0.96 (95% CI 0.73 to 1.25). CONCLUSION Important benefits in terms of mortality and major bleeding were observed with NOAC versus VKA with no difference among NOAC subtypes. TRIAL REGISTRATION NUMBER NCT01090362.
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Affiliation(s)
- A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George's University of London, London, UK
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, UK
- Department of Cardiology, University of Besançon, Besançon, France
| | | | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Department of Medicine, Formerly Technical University of Munich, Munich, Germany
| | | | | | | | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Center, IRCCS - MultiMedica Group, Sesto San Giovanni (Milan), Italy
| | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK
- University College London, London, UK
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Renda G, Pecen L, Patti G, Ricci F, Kotecha D, Siller-Matula JM, Schnabel RB, Wachter R, Sellal JM, Rohla M, Lucerna M, Huber K, Verheugt FWA, Zamorano JL, Brüggenjürgen B, Darius H, Duytschaever M, Le Heuzey JY, Schilling RJ, Kirchhof P, De Caterina R. Antithrombotic management and outcomes of patients with atrial fibrillation treated with NOACs early at the time of market introduction: Main results from the PREFER in AF Prolongation Registry. Intern Emerg Med 2021; 16:591-599. [PMID: 32955677 PMCID: PMC8049932 DOI: 10.1007/s11739-020-02442-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/08/2020] [Indexed: 02/01/2023]
Abstract
The management of patients with atrial fibrillation (AF) has rapidly changed with increasing use of non-vitamin K antagonist oral anticoagulants (NOACs) and changes in the use of rhythm control therapy. The prevention of thromboembolic events European Registry in Atrial Fibrillation Prolongation Registry (PREFER Prolongation) enrolled consecutive patients with AF on NOACs between 2014 and 2016 in a multicentre, prospective, observational study with one-year follow-up, focusing on the time of introduction of NOACs. Overall, 3783 patients were enrolled, with follow-up information available in 3223 (85%). Mean age was 72.2 ± 9.4 years, 40% were women, mean CHA2DS2VASc score was 3.4 ± 1.6, and 2587 (88.6%) had a CHA2DS2VASc score ≥ 2. Rivaroxaban was used in half of patients, and dabigatran and apixaban were used in about a quarter of patients each; edoxaban was not available for use in Europe at the time. Major cardiovascular event rate was low: serious events occurred in 74 patients (84 events, 2%), including 24 strokes (1%), 62 major bleeds (2%), of which 30 were life-threatening (1%) and 3 intracranial (0.1%), and 28 acute coronary syndromes (1%). Mortality was 2%. Antiarrhythmic drugs were used in about 50% of patients, catheter ablation in 5%. Adverse events were low in this contemporary European cohort of unselected AF patients treated with NOACs already at the time of their first introduction, despite high thromboembolic risk.
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Affiliation(s)
- Giulia Renda
- Department of Neuroscience, Imaging, and Clinical Science, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Ladislav Pecen
- Institute of Computer Science, Academy of Sciences of the Czech Republic, Prague, Czech Republic
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont and Maggiore Della Carità Hospital, Novara, Italy
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging, and Clinical Science, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, and UHB and SWBH NHS Trusts, Birmingham, UK
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Renate B Schnabel
- Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK) Partner Site Hamburg / Kiel/ Lübeck, Hamburg, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
- DZHK (German Centre for Cardiovascular Research), Partner site, Göttingen, Germany
| | - Jean-Marc Sellal
- Department of Cardiology, University Hospital of Nancy, Nancy, France
| | - Miklos Rohla
- Third Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria
| | | | - Kurt Huber
- Third Medical Department, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical School, Vienna, Austria
| | | | - Jose Luis Zamorano
- Department of Cardiology, University Hospital Ramo´N Y Cajal, Madrid, Spain
| | | | | | | | | | | | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, and UHB and SWBH NHS Trusts, Birmingham, UK
| | - Raffaele De Caterina
- Chair of Cardiology, University Cardiology Division, University of Pisa, Pisa University Hospital, Pisa, and Fondazione VillaSerena Per La Ricerca, Città Sant'Angelo, Pescara, Italy.
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20
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van Campen CLMC, Rowe PC, Verheugt FWA, Visser FC. Numeric Rating Scales Show Prolonged Post-exertional Symptoms After Orthostatic Testing of Adults With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Front Med (Lausanne) 2021; 7:602894. [PMID: 33585505 PMCID: PMC7874746 DOI: 10.3389/fmed.2020.602894] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: Muscle pain, fatigue, and concentration problems are common among individuals with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). These symptoms are commonly increased as part of the phenomenon of postexertional malaise (PEM). An increase in the severity of these symptoms is described following physical or mental exercise in ME/CFS patients. Another important symptom of ME/CFS is orthostatic intolerance, which can be detected by head-up tilt testing (HUT). The effect of HUT on PEM has not been studied extensively. For this purpose, we assessed numeric rating scales (NRS) for pain, fatigue, and concentration pre- and post-HUT. As pain is a core symptom in fibromyalgia (FM), we subgrouped ME/CFS patients by the presence or absence of FM. Methods and Results: In eligible ME/CFS patients who underwent HUT, NRS of pain, fatigue, and concentration were obtained pre-HUT, immediately after HUT, at 24 and 48 h, and at 7 days posttest. We studied 174 ME/CFS patients with FM, 104 without FM, and 30 healthy controls (HC). Values for all symptoms were unchanged for HC pre- and post-HUT. Compared with pre-HUT, the three NRS post-HUT were significantly elevated in both ME/CFS patient groups even after 7 days. NRS pain was significantly higher at all time points measured in the ME/CFS patients with FM compared with those without FM. In ME/CFS patients, the maximum fatigue and concentration scores occurred directly post-HUT, whereas pain perception reached the maximum 24 h post-HUT. Conclusion: NRS scores of pain, fatigue, and concentration were significantly increased even at 7 days post-HUT compared with pre-HUT in ME/CFS patients with and without FM, suggesting that orthostatic stress is an important determinant of PEM.
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Affiliation(s)
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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21
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Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP, Granger CB, Verheugt FWA, Li J, Ten Berg JM, Sarafoff N, Vranckx P, Goette A, Gibson CM, Alexander JH. Optimal Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: An Updated Network Meta-analysis. JAMA Cardiol 2021; 5:582-589. [PMID: 32101251 DOI: 10.1001/jamacardio.2019.6175] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Antithrombotic treatment in patients with atrial fibrillation (AF) and percutaneous coronary intervention (PCI) presents a balancing act with regard to bleeding and ischemic risks. Objectives To evaluate the safety and efficacy of 4 antithrombotic regimens by conducting an up-to-date network meta-analysis and to identify the optimal treatment for patients with AF undergoing PCI. Data Sources Online computerized database (MEDLINE). Study Selection Five randomized studies were included (N = 11 542; WOEST, PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, ENTRUST-AF PCI). Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this network meta-analysis, in which bayesian random-effects models were applied. The data were analyzed from September 9 to 29, 2019. Main Outcomes and Measures The primary safety outcome was thrombolysis in myocardial infarction (TIMI) major bleeding and the primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE). Results The total number of participants included in the study was 11 532. The mean age of the participants ranged from 70 to 72 years, 69% to 83% were male, 20% to 26% were female, and the participants were predominantly white (>90%). Compared with vitamin K antagonists (VKA) plus dual antiplatelet therapy (DAPT) (reference), the odds ratios (ORs) (95% credible intervals) for TIMI major bleeding were 0.57 (0.31-1.00) for VKA plus P2Y12 inhibitor, 0.69 (0.40-1.16) for non-VKA oral anticoagulant (NOAC) plus DAPT, and 0.52 (0.35-0.79) for NOAC plus P2Y12 inhibitor. For MACE, using VKA plus DAPT as reference, the ORs (95% credible intervals) were 0.97 (0.64-1.42) for VKA plus P2Y12 inhibitor, 0.95 (0.64-1.39) for NOAC plus DAPT, and 1.03 (0.77-1.38) for NOAC plus P2Y12 inhibitor. Conclusions and Relevance The findings of this study suggest that an antithrombotic regimen of VKA plus DAPT should generally be avoided, because regimens in which aspirin is discontinued may lead to lower bleeding risk and no difference in antithrombotic effectiveness. The use of a NOAC plus a P2Y12 inhibitor without aspirin may be the most favorable treatment option and the preferred antithrombotic regimen for most patients with AF undergoing PCI.
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Affiliation(s)
- Renato D Lopes
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Hwanhee Hong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Department of Biostatistics and Bioinformatics, Duke University of School of Medicine, Durham, North Carolina
| | - Ralf E Harskamp
- Amsterdam UMC-University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands
| | - Deepak L Bhatt
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York.,Associate Editor
| | - Christopher P Cannon
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher B Granger
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Jianghao Li
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Jurriën M Ten Berg
- Department of Cardiology and Platelet Function Research, St Antonius Hospital, Nieuwegein, the Netherlands.,Department of Cardiology, Universitair Medisch Centrum Groningen, Groningen, the Netherlands
| | - Nikolaus Sarafoff
- Deutsches Herzzentrum Munchen, Klinik fur Herz-und Kreislauferkrankungen, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Pascal Vranckx
- Department of Cardiology and Intensive Care, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences at the Hasselt University, Hasselt, Belgium
| | - Andreas Goette
- Cardiology and Intensive Care Medicine, St Vincenz-Hospital, Paderborn, Germany
| | - C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Hospital, Harvard Medical School, Boston, Massachusetts
| | - John H Alexander
- Division of Cardiology, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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22
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Seelig J, Hemels MEW, Xhaët O, Bongaerts MCM, de Wolf A, Groenemeijer BE, Heyse A, Hoogslag P, Voet J, Herrman JR, Vervoort G, Hermans W, Wollaert B, Boersma LVA, Hermans K, Lucassen A, Verstraete S, Adriaansen HJ, Mairesse GH, Terpstra WF, Faes D, Pieterse M, Virdone S, Verheugt FWA, Cools F, ten Cate H. Impact of different anticoagulation management strategies on outcomes in atrial fibrillation: Dutch and Belgian results from the GARFIELD-AF registry. J Thromb Haemost 2020; 18:3280-3288. [PMID: 32886853 PMCID: PMC7756514 DOI: 10.1111/jth.15081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/07/2020] [Accepted: 08/25/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The uptake rate of non-vitamin K oral anticoagulants (NOAC) for the treatment of non-valvular atrial fibrillation (AF) was far lower in the Netherlands (NL) compared to Belgium (BE). Also, patients on VKA in NL were treated with a higher target international normalized ratio (INR) range of 2.5 to 3.5. OBJECTIVES To explore the effect of these differences on thromboembolism (TE) and bleeding. METHODS Data from the GARFIELD-AF registry was used. Patients with new-onset AF and ≥1 investigator-determined risk factor for stroke were included between 2010 and 2016. Event rates from 2 years of follow-up were used. RESULTS In NL and BE, 1186 and 1705 patients were included, respectively. Female sex (42.3% vs 42.2%), mean age (70.7 vs 71.3 years), CHA2 DS2 -VASc (3.1 vs 3.1), and HAS-BLED score (1.4 vs 1.5) were comparable between NL and BE. At diagnosis in NL vs BE, 72.1% vs 14.6% received vitamin K antagonists (VKA) and 17.8% vs 65.5% NOACs, varying greatly across cohorts. Mean INR was 2.9 (±1.0) and 2.4 (±1.0) in NL and BE, respectively. Event rates per 100 patient-years in NL and BE, respectively, of all-cause mortality (3.38 vs 3.90; hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.65-1.15), ischemic stroke/TE (0.82 vs 0.72; HR 1.14, 95% CI 0.62-2.11), and major bleeding (2.06 vs 1.54; HR 1.33, 95% CI 0.89-1.99) did not differ significantly. CONCLUSIONS In GARFIELD-AF, despite similar characteristics, patients on anticoagulants were treated differently in NL and BE. Although the rate of major bleeding was 33% higher in NL, variations in bleeding, mortality, and TE rates were not statistically significant.
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Affiliation(s)
- Jaap Seelig
- RijnstateArnhemthe Netherlands
- Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
| | - Martin E. W. Hemels
- RijnstateArnhemthe Netherlands
- Radboud University Medical CentreNijmegenthe Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | - Lucas V. A. Boersma
- St. Antonius ZiekenhuisNieuwegeinthe Netherlands
- Amsterdam UMCAmsterdamthe Netherlands
| | | | | | | | | | | | | | - Dirk Faes
- Mariaziekenhuis Noord‐LimburgOverpeltBelgium
| | | | | | | | | | - Hugo ten Cate
- Cardiovascular Research Institute MaastrichtMaastrichtthe Netherlands
- Anticoagulation Clinic MaastrichtMaastrichtthe Netherlands
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23
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Goto S, Goto S, Pieper KS, Bassand JP, Camm AJ, Fitzmaurice DA, Goldhaber SZ, Haas S, Parkhomenko A, Oto A, Misselwitz F, Turpie AGG, Verheugt FWA, Fox KAA, Gersh BJ, Kakkar AK. New artificial intelligence prediction model using serial prothrombin time international normalized ratio measurements in atrial fibrillation patients on vitamin K antagonists: GARFIELD-AF. Eur Heart J Cardiovasc Pharmacother 2020; 6:301-309. [PMID: 31821482 PMCID: PMC7556811 DOI: 10.1093/ehjcvp/pvz076] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 10/23/2019] [Revised: 11/14/2019] [Accepted: 12/05/2019] [Indexed: 12/05/2022]
Abstract
Aims Most clinical risk stratification models are based on measurement at a single time-point rather than serial measurements. Artificial intelligence (AI) is able to predict one-dimensional outcomes from multi-dimensional datasets. Using data from Global Anticoagulant Registry in the Field (GARFIELD)-AF registry, a new AI model was developed for predicting clinical outcomes in atrial fibrillation (AF) patients up to 1 year based on sequential measures of prothrombin time international normalized ratio (PT-INR) within 30 days of enrolment. Methods and results Patients with newly diagnosed AF who were treated with vitamin K antagonists (VKAs) and had at least three measurements of PT-INR taken over the first 30 days after prescription were analysed. The AI model was constructed with multilayer neural network including long short-term memory and one-dimensional convolution layers. The neural network was trained using PT-INR measurements within days 0–30 after starting treatment and clinical outcomes over days 31–365 in a derivation cohort (cohorts 1–3; n = 3185). Accuracy of the AI model at predicting major bleed, stroke/systemic embolism (SE), and death was assessed in a validation cohort (cohorts 4–5; n = 1523). The model’s c-statistic for predicting major bleed, stroke/SE, and all-cause death was 0.75, 0.70, and 0.61, respectively. Conclusions Using serial PT-INR values collected within 1 month after starting VKA, the new AI model performed better than time in therapeutic range at predicting clinical outcomes occurring up to 12 months thereafter. Serial PT-INR values contain important information that can be analysed by computer to help predict adverse clinical outcomes.
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Affiliation(s)
- Shinichi Goto
- Department of Cardiology, Keio University School of Medicine, Shinanomachi 35, Shinjuku 160-8582, Tokyo, Japan
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan
| | - Karen S Pieper
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK
| | - Jean-Pierre Bassand
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK.,Department of Cardiology, University of Besançon Boulevard Fleming, 25000 Besançon, France
| | - Alan John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St. George's University of London, Cranmer Terrace, Tooting, London, UK
| | - David A Fitzmaurice
- Department of Cardio-respiratory Primary Care, Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Samuel Z Goldhaber
- Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Normannenstr. 34a, Munich 80333, Germany
| | - Alexander Parkhomenko
- National Scientific Center, Strazhesko Institute of Cardiology, 5 Narodnogo Opolcheniya Street, Kiev 03680, Ukraine
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Sihhiye, 06100, Ankara, Turkey
| | - Frank Misselwitz
- Therapeutic areas Thrombosis & Hematology, Bayer AG, Müllerstraße 178, 13353 Berlin, Germany
| | - Alexander G G Turpie
- Department of Medicine, McMaster University, 237 Barton St E Hamilton, Ontario L8L 2X2, Canada
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, NL-1091-AC Amsterdam, Netherlands
| | - Keith A A Fox
- Edinburgh Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Ajay K Kakkar
- Department of Clinical Research, Thrombosis Research Institute, Emmanuel Kaye Building, Manresa Road, Chelsea, London SW3 6LR, UK.,Department of Surgery, University College London, Gower St, Bloomsbury, London WC1E 6BT, UK
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24
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Affiliation(s)
- Marc A Brouwer
- Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B., S.P.V., J.J.F., S.A.D.)
| | - Stijn P G van Vugt
- Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B., S.P.V., J.J.F., S.A.D.)
| | - Jeroen Jaspers Focks
- Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B., S.P.V., J.J.F., S.A.D.)
| | - Sander A J Damen
- Radboud University Medical Center, Nijmegen, the Netherlands (M.A.B., S.P.V., J.J.F., S.A.D.)
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25
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Lopes RD, Hong H, Harskamp RE, Bhatt DL, Mehran R, Cannon CP, Granger CB, Verheugt FWA, Li J, Ten Berg JM, Sarafoff N, Gibson CM, Alexander JH. Safety and Efficacy of Antithrombotic Strategies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-analysis of Randomized Controlled Trials. JAMA Cardiol 2020; 4:747-755. [PMID: 31215979 DOI: 10.1001/jamacardio.2019.1880] [Citation(s) in RCA: 165] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance The antithrombotic treatment of patients with atrial fibrillation (AF) and coronary artery disease, in particular with acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI), poses a significant treatment dilemma in clinical practice. Objective To study the safety and efficacy of different antithrombotic regimens using a network meta-analysis of randomized controlled trials in this population. Data Sources PubMed, EMBASE, EBSCO, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens. Study Selection Four randomized studies were included (n = 10 026; WOEST, PIONEER AF-PCI, RE-DUAL PCI, and AUGUSTUS). Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review and network meta-analysis between 4 regimens using a Bayesian random-effects model. A pre hoc statistical analysis plan was written, and the review protocol was registered at PROSPERO. Data were analyzed between November 2018 and February 2019. Main Outcomes and Measures The primary safety outcome was Thrombolysis in Myocardial Infarction (TIMI) major bleeding; secondary safety outcomes were combined TIMI major and minor bleeding, trial-defined primary bleeding events, intracranial hemorrhage, and hospitalization. The primary efficacy outcome was trial-defined major adverse cardiovascular events (MACE); secondary efficacy outcomes were individual components of MACE. Results The overall prevalence of ACS varied from 28% to 61%. The mean age ranged from 70 to 72 years; 20% to 29% of the trial population were women; and most patients were at high risk for thromboembolic and bleeding events. Compared with a regimen of vitamin K antagonist (VKA) plus dual antiplatelet therapy (DAPT; P2Y12 inhibitor plus aspirin), the odds ratios (ORs) for TIMI major bleeding were 0.58 (95% CI, 0.31-1.08) for VKA plus P2Y12 inhibitor, 0.49 (95% CI, 0.30-0.82) for non-VKA oral anticoagulant (NOAC) plus P2Y12 inhibitor, and 0.70 (95% CI, 0.38-1.23) for NOAC plus DAPT. Compared with VKA plus DAPT, the ORs for MACE were 0.96 (95% CI, 0.60-1.46) for VKA plus P2Y12 inhibitor, 1.02 (95% CI, 0.71-1.47) for NOAC plus P2Y12 inhibitor, and 0.94 (95% CI, 0.60-1.45) for NOAC plus DAPT. Conclusions and Relevance A regimen of NOACs plus P2Y12 inhibitor was associated with less bleeding compared with VKAs plus DAPT. Strategies omitting aspirin caused less bleeding, including intracranial bleeding, without significant difference in MACE, compared with strategies including aspirin. Our results support the use of NOAC plus P2Y12 inhibitor as the preferred regimen post-percutaneous coronary intervention for these high-risk patients with AF. A regimen of VKA plus DAPT should generally be avoided.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Hwanhee Hong
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Ralf E Harskamp
- Amsterdam UMC Universiteit van Amsterdam, Amsterdam Public Health, Academisch Medisch Centrum, Amsterdam, the Netherlands
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massaschusetts
| | | | - Christopher P Cannon
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massaschusetts
| | | | | | - Jianghao Li
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
| | - Jurriën M Ten Berg
- St Antonius Ziekenhuis, Nieuwegein, the Netherlands.,Universitair Medisch Centrum Groningen, Groningen, the Netherlands
| | | | - C Michael Gibson
- Beth Israel Hospital, Harvard Medical School, Boston, Massaschusetts
| | - John H Alexander
- Duke Clinical Research Institute, Duke Health, Durham, North Carolina
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26
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Pazan F, Collins R, Gil VM, Hanon O, Hardt R, Hoffmeister M, Monteiro P, Quinn TJ, Ropers D, Sergi G, Verheugt FWA, Wehling M. A Structured Literature Review and International Consensus Validation of FORTA Labels of Oral Anticoagulants for Long-Term Treatment of Atrial Fibrillation in Older Patients (OAC-FORTA 2019). Drugs Aging 2020; 37:539-548. [PMID: 32500503 PMCID: PMC8203545 DOI: 10.1007/s40266-020-00771-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Evidence regarding safety and efficacy of oral anticoagulants for the treatment of atrial fibrillation (AFib) in older adults has been assessed regarding the age appropriateness of oral anticoagulants (OAC) according to the FORTA (Fit fOR The Aged) classification (OAC-FORTA). Three years after its first version (OAC-FORTA 2016), an update was initiated to create OAC-FORTA 2019. METHODS A structured review of randomized controlled clinical trials and summaries of individual product characteristics was performed to detect newly emerged evidence on oral anticoagulants in older patients with AFib. This review was used by an interdisciplinary panel of European experts (N = 10) in a Delphi process to label OACs according to FORTA. RESULTS A total of 202 records were identified and 11 studies finally included. We found four new trials providing relevant data on efficacy and safety of warfarin, apixaban, dabigatran or rivaroxaban in older patients with AFib. In the majority of studies comparing the non-vitamin-K oral anticoagulants (NOACs) with warfarin, NOACs were superior to warfarin regarding at least one relevant clinical endpoint. The mean consensus coefficient significantly increased from 0.867 (OAC-FORTA 2016) to 0.931 (p < 0.05) and the proposed FORTA classes were confirmed in all cases during the first round (consensus coefficient > 0.8). Warfarin, dabigatran, edoxaban and rivaroxaban were assigned to the FORTA B label, acenocoumarol, fluindione and phenprocoumon were labeled FORTA C and only apixaban was rated as FORTA A. CONCLUSION OAC-FORTA 2019 confirms that AFib can be successfully treated with positively labeled antithrombotics at advanced age.
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Affiliation(s)
- Farhad Pazan
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ronan Collins
- Stroke-Service/Age-Related Health Care, Tallaght Hospital, Dublin 24, Ireland
| | - Victor M Gil
- Cardiovascular Department, Hospital dos Lusíadas, Rua Abílio Mendes, 1500-458, Lisbon, Portugal
| | - Olivier Hanon
- Service de Gérontologie, Hôpital Broca-Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Equipe d'Accueil (EA) 4468, Paris, France
| | - Roland Hardt
- Department of Geriatrics, University Medical Center, University of Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Martin Hoffmeister
- Cardiology, Städtisches Klinikum Solingen, Gotenstraße 1, 42653, Solingen, Germany
| | - Pedro Monteiro
- Cardiology Department, Coimbra University Hospital, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, New Lister Building, Glasgow Royal Infirmary, Glasgow, G4 0SF, UK
| | - Dieter Ropers
- Department of Internal Medicine 1-Cardiology, St. Theresien-Krankenhaus Nuremberg, Mommsenstrasse 24, 90941, Nuremberg, Germany
| | - Giuseppe Sergi
- Clinica Geriatrica-Ospedale Giustinianeo (2nd piano), University of Padova, via Giustiniani 2, 35128, Padua, Italy
| | | | - Martin Wehling
- Clinical Pharmacology Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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van Campen CLMC, Rowe PC, Verheugt FWA, Visser FC. Cognitive Function Declines Following Orthostatic Stress in Adults With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Front Neurosci 2020; 14:688. [PMID: 32670016 PMCID: PMC7332734 DOI: 10.3389/fnins.2020.00688] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction Orthostatic intolerance (OI) is common among individuals with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Cognitive dysfunction has been demonstrated during head-up tilt testing (HUT) in those with ME/CFS: worse scores on cognitive tests occur with increasing tilt angles and increasing complexity of the cognitive challenge. The aim of our study was to determine whether cognitive impairment persists after completion of HUT. Methods and Results Eligible participants were consecutive individuals satisfying criteria for ME/CFS who underwent HUT because of OI. The 2- and 3-back tests were performed before the start of HUT and within 5 min after completion of HUT. We measured the percentage of correct responses and raw reaction times before and after HUT for both the 2- and 3-back tests. We studied 128 ME/CFS patients who underwent HUT and had a complete set of N-back data before and after HUT. Compared to pre-tilt responses, the percentage of correct responses on the 2-back test decreased post-HUT from 77(18) to 62(21) and of the 3-back test from 57(17) to 41(17) (both p < 0.0001). The raw reaction time of the 2-back test increased post-HUT from 783(190) to 941(234) m/s and of the 3-back test from 950(170) to 1102(176) (both p < 0.0001). There was no difference in the N-back test data for subgroups dichotomized based on disease severity, the presence of co-morbid fibromyalgia, or the presence of postural orthostatic tachycardia syndrome. Conclusion As measured by the N-back test, working memory remains impaired in adults with ME/CFS following a 30-min head-up tilt test.
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Affiliation(s)
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Corbalan R, Bassand JP, Illingworth L, Ambrosio G, Camm AJ, Fitzmaurice DA, Fox KAA, Goldhaber SZ, Goto S, Haas S, Kayani G, Mantovani LG, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Kakkar AK. Analysis of Outcomes in Ischemic vs Nonischemic Cardiomyopathy in Patients With Atrial Fibrillation: A Report From the GARFIELD-AF Registry. JAMA Cardiol 2020; 4:526-548. [PMID: 31066873 DOI: 10.1001/jamacardio.2018.4729] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Congestive heart failure (CHF) is commonly associated with nonvalvular atrial fibrillation (AF), and their combination may affect treatment strategies and outcomes. Objective To assess the treatment strategies and 1-year clinical outcomes of antithrombotic and CHF therapies for patients with newly diagnosed AF with concomitant CHF stratified by etiology (ischemic cardiomyopathy [ICM] vs nonischemic cardiomyopathy [NICM]). Design, Setting, and Participants The GARFIELD-AF registry is a prospective, noninterventional registry. A total of 52 014 patients with AF were enrolled between March 2010 and August 2016. A total of 11 738 patients 18 years and older with newly diagnosed AF (≤6 weeks' duration) and at least 1 investigator-determined stroke risk factor were included. Data were analyzed from December 2017 to September 2018. Exposures One-year follow-up rates of death, stroke/systemic embolism, and major bleeding were assessed. Main Outcomes and Measures Event rates per 100 person-years were estimated from the Poisson model and Cox hazard ratios (HRs) and 95% confidence intervals. Results The median age of the population was 71.0 years, 22 987 of 52 013 were women (44.2%) and 31 958 of 52 014 were white (61.4%). Of 11 738 patients with CHF, 4717 (40.2%) had ICM and 7021 (59.8%) had NICM. Prescription of oral anticoagulant and antiplatelet drugs was not balanced between groups. Oral anticoagulants with or without antiplatelet drugs were used in 2753 patients with ICM (60.1%) and 5082 patients with NICM (73.7%). Antiplatelets were prescribed alone in 1576 patients with ICM (34.4%) and 1071 patients with NICM (15.5%). Compared with patients with NICM, use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (72.6% [3439] vs 60.3% [4236]) and of β blockers (63.3% [2988] vs 53.2% [3737]) was higher in patients with ICM. Rates of all-cause and cardiovascular death per 100 patient-years were significantly higher in the ICM group (all-cause death: ICM, 10.2; 95% CI, 9.2-11.1; NICM, 7.0; 95% CI, 6.4-7.6; cardiovascular death: ICM, 5.1; 95% CI, 4.5-5.9; NICM, 2.9; 95% CI, 2.5-3.4). Stroke/systemic embolism rates tended to be higher in ICM groups compared with NICM groups (ICM, 2.0; 95% CI, 1.6-2.5; NICM, 1.5; 95% CI, 1.3-1.9). Major bleeding rates were significantly higher in the ICM group (1.1; 95% CI, 0.8-1.4) compared with the NICM group (0.7; 95% CI, 0.5-0.9). Conclusions and Relevance Patients with ICM received oral anticoagulants with or without antiplatelet drugs less frequently and antiplatelets alone more frequently than patients with NICM, but they received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers more often than patients with NICM. All-cause and cardiovascular death rates were higher in patients with ICM than patients with NICM. Trial Registration ClinicalTrials.gov Identifier: NCT01090362.
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Affiliation(s)
- Ramon Corbalan
- Division of Cardiovascular Diseases, Catholic University School of Medicine, Santiago, Chile
| | - Jean-Pierre Bassand
- University of Besançon, Besançon, France.,Thrombosis Research Institute, London, England
| | | | | | - A John Camm
- St George's University of London, London, England
| | | | | | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - Sylvia Haas
- Formerly at Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Lorenzo G Mantovani
- Center for Public Health Research, University of Milan Bicocca, Monza, Italy
| | | | - Karen S Pieper
- Thrombosis Research Institute, London, England.,Duke Clinical Research Institute, Durham, North Carolina
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29
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van Campen CMC, Rowe PC, Verheugt FWA, Visser FC. Physical activity measures in patients with myalgic encephalomyelitis/chronic fatigue syndrome: correlations between peak oxygen consumption, the physical functioning scale of the SF-36 questionnaire, and the number of steps from an activity meter. J Transl Med 2020; 18:228. [PMID: 32513266 PMCID: PMC7282044 DOI: 10.1186/s12967-020-02397-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background Most studies to assess effort intolerance in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) have used questionnaires. Few studies have compared questionnaires with objective measures like an actometer or an exercise test. This study compared three measures of physical activity in ME/CFS patients: the physical functioning scale (PFS) of the SF-36, the number of steps/day (Steps) using an actometer, and the %peak VO2 of a cardiopulmonary stress test. Methods Female ME/CFS patients were selected from a clinical database if the three types of measurements were available, and the interval between measurements was ≤ 3 months. Data from the three measures were compared by linear regression. Results In 99 female patients the three different measures were linearly, significantly, and positively correlated (PFS vs Steps, PFS vs %peak VO2 and Steps vs %peak VO2: all P < 0.001). Subgroup analysis showed that the relations between the three measures were not different in patients with versus without fibromyalgia and with versus without a maximal exercise effort (RER ≥ 1.1). In 20 patients re-evaluated for symptom worsening, the mean of all three measures was significantly lower (P < 0.0001), strengthening the observation of the relations between them. Despite the close correlation, we observed a large variation between the three measures in individual patients. Conclusions Given the large variation in ME/CFS patients, the use of only one type of measurement is inadequate. Integrating the three modalities may be useful for patient care by detecting overt discrepancies in activity and may inform studies that compare methods of improving exercise capacity.
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Affiliation(s)
- C M C van Campen
- Stichting CardioZorg, Planetenweg 5, 2132 HN, Hoofddorp, The Netherlands
| | - Peter C Rowe
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA.
| | - Freek W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
| | - Frans C Visser
- Stichting CardioZorg, Planetenweg 5, 2132 HN, Hoofddorp, The Netherlands
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30
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Seelig J, Verheugt FWA, Hemels MEW, Illingworth L, Lucassen A, Adriaansen H, Bongaerts MCM, Pieterse M, Herrman JPR, Hoogslag P, Hermans W, Groenemeijer BE, Boersma LVA, Pieper K, Ten Cate H. Changes in anticoagulant prescription in Dutch patients with recent-onset atrial fibrillation: observations from the GARFIELD-AF registry. Thromb J 2020; 18:5. [PMID: 32256216 PMCID: PMC7104512 DOI: 10.1186/s12959-020-00218-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/17/2020] [Indexed: 12/13/2022] Open
Abstract
Background For the improvement of AF care, it is important to gain insight into current anticoagulation prescription practices and guideline adherence. This report focuses on the largest Dutch subset of AF-patients, derived from the GARFIELD-AF registry. Methods Across 35 countries worldwide, patients with newly diagnosed ‘non-valvular’ atrial fibrillation (AF) with at least one additional risk factor for stroke were included. Dutch patients were enrolled in five, independent, consecutive cohorts from 2010 until 2016. Results In the Netherlands, 1189 AF-patients were enrolled. The prescription of non-vitamin K antagonist oral anticoagulants (NOAC) has increased sharply, and as per 2016, more patients were initiated on NOACs instead of vitamin K antagonists (VKA). In patients with a class I recommendation for anticoagulation, only 7.5% compared to 30.0% globally received no anticoagulation. Reasons for withholding anticoagulation in these patients were unfortunately often unclear. Conclusions The data from the GARFIELD-AF registry shows the rapidly changing anticoagulation preference of Dutch physicians in newly diagnosed AF. Adherence to European AF guidelines in terms of anticoagulant regimen would appear to be appropriate. In absence of structured follow up of AF patients on NOAC, the impact of these rapid practice changes in anticoagulation prescription in the Netherlands remains to be established.
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Affiliation(s)
- J Seelig
- 1Department of Cardiology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands.,16Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - F W A Verheugt
- 2Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - M E W Hemels
- 1Department of Cardiology, Rijnstate, Wagnerlaan 55, 6815 AD Arnhem, the Netherlands.,3Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - A Lucassen
- Department of Cardiology, St. Jans Gasthuis, Weert, the Netherlands
| | - H Adriaansen
- 6Anticoagulation Clinic, Gelre Ziekenhuizen, Apeldoorn-Zutphen, the Netherlands
| | - M C M Bongaerts
- 7Anticoagulation Clinic, Ziekenhuis Rivierenland, Tiel, the Netherlands
| | - M Pieterse
- Stichting Cardiologie Amsterdam, Amsterdam, the Netherlands
| | - J P R Herrman
- 9Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - P Hoogslag
- Department of Cardiology, Isala Diaconessenhuis, Meppel, the Netherlands
| | - W Hermans
- 11Department of Cardiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | - B E Groenemeijer
- 12Department of Cardiology, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - L V A Boersma
- 13Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands.,Department of Cardiology, Amsterdam UMC, Amsterdam, the Netherlands
| | - K Pieper
- 4Thrombosis Research Institute, London, UK.,15Duke Clinical Research Institute, Durham, USA
| | - H Ten Cate
- 16Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Anticoagulation Clinic Maastricht, Maastricht, the Netherlands
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Fox KAA, Velentgas P, Camm AJ, Bassand JP, Fitzmaurice DA, Gersh BJ, Goldhaber SZ, Goto S, Haas S, Misselwitz F, Pieper KS, Turpie AGG, Verheugt FWA, Dabrowski E, Luo K, Gibbs L, Kakkar AK. Outcomes Associated With Oral Anticoagulants Plus Antiplatelets in Patients With Newly Diagnosed Atrial Fibrillation. JAMA Netw Open 2020; 3:e200107. [PMID: 32101311 PMCID: PMC7137686 DOI: 10.1001/jamanetworkopen.2020.0107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Patients with nonvalvular atrial fibrillation at risk of stroke should receive oral anticoagulants (OAC). However, approximately 1 in 8 patients in the Global Anticoagulant Registry in the Field (GARFIELD-AF) registry are treated with antiplatelet (AP) drugs in addition to OAC, with or without documented vascular disease or other indications for AP therapy. OBJECTIVE To investigate baseline characteristics and outcomes of patients who were prescribed OAC plus AP therapy vs OAC alone. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of the GARFIELD-AF registry, an international, multicenter, observational study of adults aged 18 years and older with recently diagnosed nonvalvular atrial fibrillation and at least 1 risk factor for stroke enrolled between March 2010 and August 2016. Data were extracted for analysis in October 2017 and analyzed from April 2018 to June 2019. EXPOSURE Participants received either OAC plus AP or OAC alone. MAIN OUTCOMES AND MEASURES Clinical outcomes were measured over 3 and 12 months. Outcomes were adjusted for 40 covariates, including baseline conditions and medications. RESULTS A total of 24 436 patients (13 438 [55.0%] male; median [interquartile range] age, 71 [64-78] years) were analyzed. Among eligible patients, those receiving OAC plus AP therapy had a greater prevalence of cardiovascular indications for AP, including acute coronary syndromes (22.0% vs 4.3%), coronary artery disease (39.1% vs 9.8%), and carotid occlusive disease (4.8% vs 2.0%). Over 1 year, patients treated with OAC plus AP had significantly higher incidence rates of stroke (adjusted hazard ratio [aHR], 1.49; 95% CI, 1.01-2.20) and any bleeding event (aHR, 1.41; 95% CI, 1.17-1.70) than those treated with OAC alone. These patients did not show evidence of reduced all-cause mortality (aHR, 1.22; 95% CI, 0.98-1.51). Risk of acute coronary syndrome was not reduced in patients taking OAC plus AP compared with OAC alone (aHR, 1.16; 95% CI, 0.70-1.94). Patients treated with OAC plus AP also had higher rates of all clinical outcomes than those treated with OAC alone over the short term (3 months). CONCLUSIONS AND RELEVANCE This study challenges the practice of coprescribing OAC plus AP unless there is a clear indication for adding AP to OAC therapy in newly diagnosed atrial fibrillation.
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Affiliation(s)
- Keith A. A. Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | | | - A. John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
| | - Jean-Pierre Bassand
- Thrombosis Research Institute, London, United Kingdom
- University of Besançon, Besançon, France
| | | | | | - Samuel Z. Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Sylvia Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - Karen S. Pieper
- Thrombosis Research Institute, London, United Kingdom
- Duke University, Durham, North Carolina
| | | | | | | | | | | | - Ajay K. Kakkar
- Thrombosis Research Institute, London, United Kingdom
- University College London, London, United Kingdom
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Guimarães PO, Lopes RD, Alexander JH, Thomas L, Hellkamp AS, Hijazi Z, Hylek EM, Gersh BJ, Garcia DA, Verheugt FWA, Hanna M, Flaker G, Vinereanu D, Granger CB. International normalized ratio control and subsequent clinical outcomes in patients with atrial fibrillation using warfarin. J Thromb Thrombolysis 2019; 48:27-34. [PMID: 30972712 DOI: 10.1007/s11239-019-01858-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We explored associations between INR measures and clinical outcomes in patients with AF using warfarin, and whether INR history predicted future INR measurements. We included patients in ARISTOTLE who were randomized to and received warfarin. Among patients who had events, we included those with ≥ 3 INR values in the 180 days prior to the event, with the most recent ≤ 60 days prior to the event, who were on warfarin at the time of event (n = 545). Non-event patients were included in the control group if they had ≥ 180 days of warfarin exposure with ≥ 3 INR measurements (n = 7259). The median (25th, 75th) number of INR values per patient was 29 (21, 38) over a median follow-up of 1.8 years. A total of 87% had at least one INR value < 1.5; 49% had at least one value > 4.0. The last INRs before events (median 14 [24, 7] days) were < 3.0 for at least 75% of patients with major bleeding and > 2.0 for half of patients with ischemic stroke. Historic time in therapeutic range (TTR) was weakly associated with future TTR (R2 = 0.212). Historic TTR ≥ 80% had limited predictive ability to discriminate future TTR ≥ 80% (C index 0.61). In patients with AF receiving warfarin, most bleeding events may not have been preventable despite careful INR control. Our findings suggest that INRs collected through routine management are not sufficiently predictive to provide reassurance about future time in therapeutic range or to prevent subsequent outcomes, and might be over-interpreted in clinical practice.
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Affiliation(s)
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, NC, 27705, USA.
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, 27705, USA
| | | | - Ziad Hijazi
- Uppsala Clinical Research Center, Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | | | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington, Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Greg Flaker
- University of Missouri School of Medicine, Columbia, MO, USA
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
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33
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Bassand JP, Virdone S, Goldhaber SZ, Camm AJ, Fitzmaurice DA, Fox KAA, Goto S, Haas S, Hacke W, Kayani G, Mantovani LG, Misselwitz F, Pieper KS, Turpie AGG, van Eickels M, Verheugt FWA, Kakkar AK. Early Risks of Death, Stroke/Systemic Embolism, and Major Bleeding in Patients With Newly Diagnosed Atrial Fibrillation. Circulation 2019; 139:787-798. [PMID: 30586740 DOI: 10.1161/circulationaha.118.035012] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Atrial fibrillation is associated with increased risks of death, stroke/systemic embolism, and bleeding (incurred by antithrombotic therapy), which may occur early after diagnosis. METHODS We assessed the risk of early events (death, stroke/systemic embolism, and major bleeding) over 12 months and their relation to the time after diagnosis of atrial fibrillation in 52 014 patients prospectively enrolled in the GARFIELD-AF registry (Global Anticoagulant Registry in the FIELD-Atrial Fibrillation) between March 2010 and August 2016. RESULTS Over 12 months, 2140 patients died (mortality rate, 4.3; 95% CI, 4.2-4.5 per 100 person-years), of whom 288 (13.5%) died in the first month (6.8; 95% CI, 6.1-7.6). Over 12 months, 657 patients had a stroke/systemic embolism (1.3; 95% CI, 1.2-1.4) and 411 had a major bleeding (0.8; 95% CI, 0.8-0.9). During the first month, the rates (per 100 person-years) of stroke/systemic embolism and major bleed were 2.3 (95% CI, 1.9-2.8) and 1.5 (95% CI, 1.2-1.9), respectively. The elevated 1-month mortality rate was mostly attributable to cardiovascular mortality (3.5; 95% CI, 3.0-4.1), in particular, heart failure, sudden death, and acute coronary syndromes (1.0 [95% CI, 0.8-1.4], 0.6 [95% CI, 0.4-0.8], and 0.5 [95% CI, 0.3-0.8], respectively). Age, heart failure, prior stroke, history of cirrhosis, vascular disease, moderate-to-severe kidney disease, diabetes mellitus, and living in North or Latin America were independent predictors of a higher risk of early death, whereas anticoagulation and living in Europe or Asia were independent predictors of a lower risk of early death. A predictive model developed for the 1-month risk of death had a C-statistic of 0.81 (95% CI, 0.78-0.83). CONCLUSIONS The increased hazard of early events, in particular, cardiovascular mortality, in newly diagnosed atrial fibrillation points to the importance of comprehensive care for such patients and should alert clinicians to detect warning signs of possible early mortality. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01090362.
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Affiliation(s)
- Jean-Pierre Bassand
- University of Besançon, France (J.-P.B.).,Thrombosis Research Institute, London, UK (J.-P.B., S.V., G.K., K.S.P., A.K.K.)
| | - Saverio Virdone
- Thrombosis Research Institute, London, UK (J.-P.B., S.V., G.K., K.S.P., A.K.K.)
| | - Samuel Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.Z.G.)
| | - A John Camm
- St George's University of London, UK (A.J.C.)
| | | | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK (K.A.A.F.)
| | - Shinya Goto
- Tokai University School of Medicine, Kanagawa, Japan (S.G.)
| | - Sylvia Haas
- Formerly Klinikum rechts der Isar, Technical University of Munich, Germany (S.H.)
| | | | - Gloria Kayani
- Thrombosis Research Institute, London, UK (J.-P.B., S.V., G.K., K.S.P., A.K.K.)
| | - Lorenzo G Mantovani
- Center for Public Health Research, University of Milan Bicocca, Monza, Italy (L.G.M.)
| | | | - Karen S Pieper
- Thrombosis Research Institute, London, UK (J.-P.B., S.V., G.K., K.S.P., A.K.K.).,Duke Clinical Research Institute, Durham, NC (K.S.P.)
| | | | | | | | - Ajay K Kakkar
- Thrombosis Research Institute, London, UK (J.-P.B., S.V., G.K., K.S.P., A.K.K.).,University College London, UK (A.K.K.)
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Kerneis M, Yee MK, Mehran R, Nafee T, Bode C, Halperin JL, Peterson ED, Verheugt FWA, Wildgoose P, van Eickels M, Lip GYH, Cohen M, Fox KAA, Gibson CM. Novel Oral Anticoagulant Based Versus Vitamin K Antagonist Based Double Therapy Among Stented Patients With Atrial Fibrillation: Insights From the PIONEER AF-PCI Trial. Circ Cardiovasc Interv 2019; 12:e008160. [PMID: 31707805 DOI: 10.1161/circinterventions.119.008160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among stented patients with atrial fibrillation, double therapy with a novel oral anticoagulant plus single antiplatelet therapy (SAPT) reduces bleeding or cardiovascular rehospitalizations compared with a vitamin K antagonist (VKA) based triple therapy regimen. A recent study demonstrated that apixaban based double therapy reduced bleeding compared with VKA based double therapy. However, it remains unknown whether rivaroxaban based double therapy is superior to a VKA based double therapy. METHODS Patient with stented atrial fibrillation (n=2124) were randomized to 3 groups: rivaroxaban 15 mg od plus a P2Y12 inhibitor (Group 1, n=709); rivaroxaban 2.5 mg bid plus dual antiplatelet therapy (DAPT; Group 2, n=709); and warfarin plus DAPT (Group 3, n=706). Before randomization, subjects were stratified according to a prespecified duration of DAPT (1, 6, or 12 months). After the prespecified DAPT duration, subjects in Group 2 were switched to rivaroxaban 15 mg plus low dose aspirin, and those in Group 3 were switched to VKA plus low dose aspirin. The Wei, Lin, and Weissfeld time to multiple events method was used to compare the occurrence of all bleeding and cardiovascular rehospitalizations among subjects on a novel oral anticoagulant versus VKA based double therapy. RESULTS A total of 906 subjects were prespecified to a 1 or 6 months DAPT duration and received at least one dose of study drug. Twenty subjects (3.3%) assigned to novel oral anticoagulant+SAPT, and 15 (5.1%) subjects assigned to VKA+SAPT experienced multiple rehospitalizations. In total, 124 (20.3%) events occurred among subjects on novel oral anticoagulant+SAPT compared with 87 (29.6%) among subjects on VKA+SAPT (hazard ratio=0.65 [95% CI, 0.45-0.93], P=0.008). CONCLUSIONS Among stented patients with atrial fibrillation, rivaroxaban plus SAPT was superior to warfarin plus SAPT in lowering total bleeding and cardiovascular rehospitalization. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01830543.
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Affiliation(s)
- Mathieu Kerneis
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.K., M.K.Y., T.N., C.M.G.)
| | - Megan K Yee
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.K., M.K.Y., T.N., C.M.G.)
| | - Roxana Mehran
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, NY (R.M., J.L.H.)
| | - Tarek Nafee
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.K., M.K.Y., T.N., C.M.G.)
| | - Christoph Bode
- Heart Center, Department for Cardiology and Angiology I, University of Freiburg, Germany (C.B.)
| | - Jonathan L Halperin
- Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, NY (R.M., J.L.H.)
| | | | - Freek W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands (F.W.A.V.)
| | - Peter Wildgoose
- Janssen Pharmaceuticals, Inc, Beerse, Belgium, Inc, Titusville, NJ (P.W.)
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L.)
| | - Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ (M.C.)
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, United Kingdom (K.A.A.F.)
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.K., M.K.Y., T.N., C.M.G.)
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Sullivan AE, Nanna MG, Rao SV, Cantrell S, Gibson CM, Verheugt FWA, Peterson ED, Lopes RD, Alexander JH, Granger CB, Yee MK, Kong DF. A systematic review of randomized trials comparing double versus triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 96:E102-E109. [PMID: 31713326 DOI: 10.1002/ccd.28535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prior randomized controlled trials (RCT) evaluating the optimal antithrombotic therapies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been powered to evaluate ischemic outcomes. We compared double therapy with oral anticoagulation (OAC) and a P2Y12 inhibitor to triple therapy with an OAC + dual antiplatelet therapy in patients with AF requiring PCI. METHODS Using PRISMA guidelines, we searched for RCTs including patients with AF as an indication for OAC and undergoing PCI or medical management of acute coronary syndrome. The results were pooled using fixed-effects and random-effects models to estimate the overall effect of double therapy versus triple therapy on ischemic and bleeding outcomes. RESULTS We identified four RCTs, comprising 10,238 patients (5,498 double therapy, 4,740 triple therapy). Trial-reported major adverse cardiovascular events were similar between double therapy and triple therapy (fixed effect model OR 1.09, 95% CI 0.94-1.26). However, stent thrombosis (61/5,496 double therapy vs. 33/4738 triple therapy; fixed effect model OR 1.57, 95% CI 1.02-2.40; number needed to treat with triple therapy = 242) favored triple therapy. Bleeding outcomes were less frequent with double therapy (746/5470 vs. 950/4710; fixed effect model OR 0.59, 95% CI 0.53-0.65; number needed to harm with triple therapy = 16), but with significant heterogeneity (Q = 8.33, p = .04; I2 = 64%), as were intracranial hemorrhages (19/5470 vs. 30/4710; fixed effect model OR 0.54, 95% CI 0.31-0.96). CONCLUSIONS Double therapy in patients with AF requiring OAC following PCI or Acute coronary syndrome has a significantly better safety profile than triple therapy but may be associated with a modest increased risk of stent thrombosis.
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Affiliation(s)
- Alexander E Sullivan
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sunil V Rao
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sarah Cantrell
- Duke University School of Medicine, Durham, North Carolina
| | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Eric D Peterson
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John H Alexander
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher B Granger
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Megan K Yee
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David F Kong
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Cramer GE, Damen SAJ, Vroemen WHM, Mezger STP, Suryapranata H, Van Royen N, Bekers O, Meex SJR, Wodzig WKWH, Verheugt FWA, De Boer D, Brouwer MA, Mingels AMA. P4503A multi-site coronary vein sampling study on cardiac troponin T degradation in non-ST-elevation myocardial infarction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
High-sensitivity cardiac troponin (hs-cTn) assays have reduced specificity for myocardial infarction (MI). In conditions other than MI, cardiac troponin T (cTnT) elevations have been attributed to small cTnT fragments. In search of improved cTnT assay specificity for MI, determination of the in-vivo molecular appearance of cTnT during MI is pivotal.
Purpose
To determine cTnT composition close to its site of release and during the course of MI by multi-site coronary venous system (CVS) and peripheral sampling.
Methods
Lithium-heparinized (LH) plasma and serum samples were obtained from multiple CVS locations in NSTEMI patients. Additionally, samples were drawn from a peripheral artery and vein followed by collections at 6- and 12 hours post-catheterization. cTnT concentrations were measured using the hs-cTnT immunoassay (Roche). The molecular cTnT composition was determined by gel filtration chromatography and Western blotting in an early and late presenting patient.
Results
CVS hs-cTnT concentrations were 28% higher than in the peripheral artery sample (n=71, p<0.001). In contrast to LH plasma, serum caused pre-analytical cTn T-I-C complex disintegration and cTnT degradation. CVS samples demonstrated presence of cTn T-I-C complex, free intact cTnT, and 29 kDa and 15–18 kDa cTnT fragments in higher absolute concentrations than measured peripherally. While the proportion of cTn T-I-C complex decreased and disappeared over time, 15–18 kDa cTnT fragments increased. Moreover, cTn T-I-C complex was more prominent in the early versus the late presenting patient.
Central illustration
Conclusions
In NSTEMI, cTnT is released as a combination of cTn T-I-C complex, free intact cTnT and multiple cTnT fragments. Over time, the composition of observed cTnT forms changes due to in-vivo degradation. These findings serve as a stepping stone to improve diagnostic accuracy of the hs-cTnT assay for MI.
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Affiliation(s)
- G E Cramer
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - S A J Damen
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - W H M Vroemen
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - S T P Mezger
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - H Suryapranata
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - N Van Royen
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - O Bekers
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - S J R Meex
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - W K W H Wodzig
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - F W A Verheugt
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - D De Boer
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
| | - M A Brouwer
- Radboud University Medical Centre, Nijmegen, Netherlands (The)
| | - A M A Mingels
- Maastricht University Medical Centre (MUMC), Maastricht, Netherlands (The)
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Affiliation(s)
- Freek W. A. Verheugt
- Department of Cardiology Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
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38
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Affiliation(s)
- Freek W A Verheugt
- Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
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39
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Schrör K, Kristensen SD, Storey RF, Verheugt FWA. Aspirin and Primary Prevention in Patients with Diabetes—A Critical Evaluation of Available Randomized Trials and Meta-Analyses. Thromb Haemost 2019; 119:1573-1582. [DOI: 10.1055/s-0039-1694774] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AbstractPrimary prevention of cardiovascular events with aspirin in patients with elevated cardiovascular risk, including diabetics, is currently under intense discussion. Data from meta-analyses suggests that the efficacy of aspirin in these patients is low, whereas there is a significantly increased bleeding tendency. However, meta-analyses are based on trials that differ in many important aspects, including study selection. Fresh insights were expected from the ASCEND trial, by far the largest primary, randomized, placebo-controlled prevention trial in diabetics without known cardiovascular disease. There was a small but significant reduction in serious cardiovascular events by aspirin (8.6% vs. 9.6%) but also a significant increase in major bleeding: 4.1% versus 3.2%. Unfortunately, this trial did not meet the desired annual rate of elevated vascular risk of ≥ 2%. It was only 1.2 to 1.3%, and thus in the range of other primary prevention trials in low-risk patients. Apart from potential compliance problems, possible explanations for the small cardioprotective effect of antiplatelet treatment include a healthy lifestyle as well as improved vascular protection by comedication with vasoactive and anti-inflammatory drugs, such as statins or antihypertensive agents, as well as proton-pump inhibitors that might modify bleeding, specifically in the upper gastrointestinal tract—the most frequently affected site. Also, the introduction of new antidiabetic drugs with more favorable cardiovascular effects may in part explain the low event rate. ASCEND, similar to ARRIVE, did not study patients at elevated (as planned) but only at low vascular risk and, therefore, was largely confirmatory of earlier primary prevention trials.
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Affiliation(s)
- Karsten Schrör
- Institut für Pharmakologie und Klinische Pharmakologie, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany
| | | | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Freek W. A. Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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40
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Halvorsen S, Storey RF, Rocca B, Sibbing D, Ten Berg J, Grove EL, Weiss TW, Collet JP, Andreotti F, Gulba DC, Lip GYH, Husted S, Vilahur G, Morais J, Verheugt FWA, Lanas A, Al-Shahi Salman R, Steg PG, Huber K. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2019; 38:1455-1462. [PMID: 27789570 DOI: 10.1093/eurheartj/ehw454] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 09/11/2016] [Indexed: 01/09/2023] Open
Affiliation(s)
- Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität, Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas W Weiss
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna, A-1160, Austria
| | - Jean-Philippe Collet
- Univ Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, ICAN, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Felicita Andreotti
- Institute of Cardiology, Catholic University Medical School, Rome, Italy
| | - Dietrich C Gulba
- Clinic for Internal Medicine and Pneumology, Katholisches Klinikum Oberhausen GmbH, St. Marien Hospital, Oberhausen, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom; and Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
| | - Steen Husted
- Medical Department, Region Hospital West, Herning/Holstebro
| | - Gemma Vilahur
- Cardiovascular Research Center, CSIC-ICCC, HSCSP-Barcelona, Spain
| | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Portugal
| | - Freek W A Verheugt
- Emeritus Professor of Cardiology, P.C. Hooftstraat 188, CH Amsterdam, 1071, Netherlands
| | - Angel Lanas
- Service of Digestive Diseases. University Hospital. University of Zaragoza. CIBERehd. IIS Aragón. Zaragoza, Spain
| | | | - Philippe Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris Cité, DHU FIRE, AP-HP and INSERM U-1148, all in Paris, France. NHLI, Imperial College, Royal Brompton Hospital, London, UK
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna, A-1160, Austria
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41
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Damen SAJ, Vroemen WHM, Brouwer MA, Mezger STP, Suryapranata H, van Royen N, Bekers O, Meex SJR, Wodzig WKWH, Verheugt FWA, de Boer D, Cramer GE, Mingels AMA. Multi-Site Coronary Vein Sampling Study on Cardiac Troponin T Degradation in Non-ST-Segment-Elevation Myocardial Infarction: Toward a More Specific Cardiac Troponin T Assay. J Am Heart Assoc 2019; 8:e012602. [PMID: 31269858 PMCID: PMC6662151 DOI: 10.1161/jaha.119.012602] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/17/2019] [Indexed: 01/24/2023]
Abstract
Background Cardiac troponin T ( cTnT ) is seen in many other conditions besides myocardial infarction, and recent studies demonstrated distinct forms of cTnT . At present, the in vivo formation of these different cTnT forms is incompletely understood. We therefore performed a study on the composition of cTnT during the course of myocardial infarction, including coronary venous system sampling, close to its site of release. Methods and Results Baseline samples were obtained from multiple coronary venous system locations, and a peripheral artery and vein in 71 non- ST -segment-elevation myocardial infarction patients. Additionally, peripheral blood was drawn at 6- and 12-hours postcatheterization. cTnT concentrations were measured using the high-sensitivity- cTnT immunoassay. The cTnT composition was determined via gel filtration chromatography and Western blotting in an early and late presenting patient. High-sensitivity - cTnT concentrations were 28% higher in the coronary venous system than peripherally (n=71, P<0.001). Coronary venous system samples demonstrated cT n T-I-C complex, free intact cTnT , and 29 kD a and 15 to 18 kD a cTnT fragments, all in higher concentrations than in simultaneously obtained peripheral samples. While cT n T-I-C complex proportionally decreased, and disappeared over time, 15 to 18 kD a cTnT fragments increased. Moreover, cT n T-I-C complex was more prominent in the early than in the late presenting patient. Conclusions This explorative study in non- ST -segment-elevation myocardial infarction shows that cTnT is released from cardiomyocytes as a combination of cT n T-I-C complex, free intact cTnT , and multiple cTnT fragments indicating intracellular cTnT degradation. Over time, the cT n T-I-C complex disappeared because of in vivo degradation. These insights might serve as a stepping stone toward a high-sensitivity- cTnT immunoassay more specific for myocardial infarction.
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Affiliation(s)
- Sander A. J. Damen
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Wim H. M. Vroemen
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Marc A. Brouwer
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Stephanie T. P. Mezger
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Harry Suryapranata
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Niels van Royen
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Otto Bekers
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Steven J. R. Meex
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Will K. W. H. Wodzig
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Freek W. A. Verheugt
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Douwe de Boer
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - G. Etienne Cramer
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | - Alma M. A. Mingels
- Central Diagnostic LaboratoryMaastricht University Medical CenterMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
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42
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Hein R, Verheugt FWA, Sibbing D. Risk Evaluation Tools for Prediction and Possible Guidance of DAPT: Is Scoring a Hit in East Asians Patients undergoing PCI? Thromb Haemost 2019; 119:1033-1035. [PMID: 31183843 DOI: 10.1055/s-0039-1692169] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ralph Hein
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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43
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Aengevaeren VL, Gommans DHF, Dieker HJ, Timmermans J, Verheugt FWA, Bakker J, Hopman MTE, DE Boer MJ, Brouwer MA, Thompson PD, Kofflard MJM, Cramer GE, Eijsvogels TMH. Association between Lifelong Physical Activity and Disease Characteristics in HCM. Med Sci Sports Exerc 2019; 51:1995-2002. [PMID: 31033902 PMCID: PMC6798742 DOI: 10.1249/mss.0000000000002015] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
PURPOSE Hypertrophic cardiomyopathy (HCM) is characterized by inappropriate left ventricular (LV) wall thickness. Adaptations to exercise can occasionally mimic certain HCM characteristics. However, it is unclear whether physical activity affects HCM genotype expression and disease characteristics. Consequently, we compared lifelong physical activity volumes between HCM gene carriers with and without HCM phenotype, and compared disease characteristics among tertiles of physical activity in phenotypic HCM patients. METHODS We enrolled n = 22 genotype positive/phenotype negative (G+/P-) HCM gene carriers, n = 44 genotype positive/phenotype positive (G+/P+) HCM patients, and n = 36 genotype negative/phenotype positive (G-/P+) HCM patients. Lifelong physical activity was recorded using a questionnaire and quantified as metabolic equivalent of task hours per week. RESULTS We included 102 participants (51 ± 16 yr, 49% male). Lifelong physical activity volumes were not different between G+/P+ and G+/P- subjects (16 [10-29] vs 14 [6-26] metabolic equivalent of task-hours per week, P = 0.33). Among phenotypic HCM patients, there was no difference in LV wall thickness, mass, and late gadolinium enhancement across physical activity tertiles. Patients with the highest reported physical activity volumes were younger at the time of diagnosis (tertile 1: 52 ± 14 yr, tertile 2: 49 ± 15 yr, tertile 3: 41 ± 18 yr; P = 0.03), and more often had a history of nonsustained ventricular tachycardia (4% vs 30% vs 30%, P = 0.03). CONCLUSIONS Lifelong physical activity volumes are not associated with genotype-to-phenotype transition in HCM gene carriers. We also found no difference in LV wall thickness across physical activity tertiles. However, the most active HCM patients were younger at the time of diagnosis and had a higher arrhythmic burden. These observations warrant further exploration of the role of exercise in HCM disease development.
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Affiliation(s)
- Vincent L Aengevaeren
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS.,Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - D H Frank Gommans
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Hendrik-Jan Dieker
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Janneke Timmermans
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Freek W A Verheugt
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Jeannette Bakker
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, the NETHERLANDS
| | - Maria T E Hopman
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Menko-Jan DE Boer
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Marc A Brouwer
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | | | - Marcel J M Kofflard
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, the NETHERLANDS
| | - G Etienne Cramer
- Radboud Institute for Health Sciences, Department of Cardiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS
| | - Thijs M H Eijsvogels
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the NETHERLANDS.,Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, England, UNITED KINGDOM
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44
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Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands.
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45
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Goto S, Angchaisuksiri P, Bassand J, Camm AJ, Dominguez H, Illingworth L, Gibbs H, Goldhaber SZ, Goto S, Jing Z, Haas S, Kayani G, Koretsune Y, Lim TW, Oh S, Sawhney JPS, Turpie AGG, van Eickels M, Verheugt FWA, Kakkar AK. Management and 1-Year Outcomes of Patients With Newly Diagnosed Atrial Fibrillation and Chronic Kidney Disease: Results From the Prospective GARFIELD - AF Registry. J Am Heart Assoc 2019; 8:e010510. [PMID: 30717616 PMCID: PMC6405596 DOI: 10.1161/jaha.118.010510] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 12/24/2018] [Indexed: 01/11/2023]
Abstract
Background Using data from the GARFIELD - AF (Global Anticoagulant Registry in the FIELD -Atrial Fibrillation), we evaluated the impact of chronic kidney disease ( CKD ) stage on clinical outcomes in patients with newly diagnosed atrial fibrillation ( AF ). Methods and Results GARFIELD - AF is a prospective registry of patients from 35 countries, including patients from Asia (China, India, Japan, Singapore, South Korea, and Thailand). Consecutive patients enrolled (2013-2016) were classified with no, mild, or moderate-to-severe CKD , based on the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative guidelines. Data on CKD status and outcomes were available for 33 024 of 34 854 patients (including 9491 patients from Asia); 10.9% (n=3613) had moderate-to-severe CKD , 16.9% (n=5595) mild CKD , and 72.1% (n=23 816) no CKD . The use of oral anticoagulants was influenced by stroke risk (ie, post hoc assessment of CHA 2 DS 2- VAS c score), but not by CKD stage. The quality of anticoagulant control with vitamin K antagonists did not differ with CKD stage. After adjusting for baseline characteristics and antithrombotic use, both mild and moderate-to-severe CKD were independent risk factors for all-cause mortality. Moderate-to-severe CKD was independently associated with a higher risk of stroke/systemic embolism, major bleeding, new-onset acute coronary syndrome, and new or worsening heart failure. The impact of moderate-to-severe CKD on mortality was significantly greater in patients from Asia than the rest of the world ( P=0.001). Conclusions In GARFIELD - AF , moderate-to-severe CKD was independently associated with stroke/systemic embolism, major bleeding, and mortality. The effect of moderate-to-severe CKD on mortality was even greater in patients from Asia than the rest of the world. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01090362.
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Affiliation(s)
- Shinya Goto
- Tokai University School of MedicineKanagawaJapan
| | | | - Jean‐Pierre Bassand
- University of BesançonFrance
- Thrombosis Research InstituteLondonUnited Kingdom
| | - A. John Camm
- St. George's University of LondonLondonUnited Kingdom
| | - Helena Dominguez
- Bispebjerg‐Frederiksberg HospitalCopenhagenDenmark
- Faculty of Health SciencesUniversity of CopenhagenCopenhagenDenmark
| | | | | | | | | | - Zhi‐Cheng Jing
- Fu Wai HospitalState Key Lab of Cardiovascular DiseaseNational Center for Cardiovascular DiseasePUMC & CAMSBeijingChina
| | - Sylvia Haas
- Formerly Klinikum rechts der IsarTechnical University of MunichGermany
| | | | | | | | - Seil Oh
- Seoul National University HospitalSeoulKorea
| | | | | | | | | | - Ajay K. Kakkar
- Thrombosis Research InstituteLondonUnited Kingdom
- University College LondonLondonUnited Kingdom
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46
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Korjian S, Daaboul Y, Laliberté F, Zhao Q, Mehran R, Bode C, Halperin J, Verheugt FWA, Lip GYH, Cohen M, Peterson ED, Fox KAA, Gibson CM, Pinto DS. Cost Implications of Anticoagulation Strategies After Percutaneous Coronary Intervention Among Patients With Atrial Fibrillation (A PIONEER-AF PCI Analysis). Am J Cardiol 2019; 123:355-360. [PMID: 30502047 DOI: 10.1016/j.amjcard.2018.10.033] [Citation(s) in RCA: 6] [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] [Received: 07/23/2018] [Revised: 10/15/2018] [Accepted: 10/22/2018] [Indexed: 11/19/2022]
Abstract
The PIONEER AF-PCI trial demonstrated that in atrial fibrillation patients who underwent intracoronary stenting, either rivaroxaban 15 mg daily plus P2Y12 inhibitor monotherapy (Group 1) or 2.5 mg rivaroxaban twice daily plus dual antiplatelet therapy (DAPT) (Group 2) was associated with fewer recurrent hospitalizations, primarily for bleeding and cardiovascular events, compared with standard-of-care vitamin K antagonist and DAPT (Group 3). Associated costs are unknown. This study estimates costs associated with rivaroxaban strategies compared with vitamin K antagonist and DAPT. Medication costs were estimated using wholesale acquisition costs, medication discontinuation rates, and costs of monitoring. Using a large US healthcare claims database, the mean adjusted increase in 1-year cost of care for individuals with atrial fibrillation and percutaneous coronary intervention (PCI) rehospitalized for bleeding, cardiovascular, and other events was compared with those not rehospitalized. Using adjudicated rehospitalization rates from PIONEER AF-PCI, cost differences were estimated. Rates of rehospitalization for bleeding were 6.5%, 5.4%, 10.5%, and 20.3%, 20.3%, 28.4% for cardiovascular events in Groups 1, 2, and 3. Medication and monitoring costs were $3,942, $4,115, and $1,703. One-year costs for all recurrent hospitalization costs and/or patient for the groups were $24,535, $20,205, and $29,756. One-year cost increase associated with bleeding rehospitalizations and/or patient was $4,160, $3,212, and $6,876 and was $13,264, $11,545, and $17,220 for cardiovascular rehospitalizations and/or patient. Overall estimated cost per patient was $28,476, $24,320, and $31,458. Compared with warfarin, both rivaroxaban treatment strategies had higher medication costs, but these were more than accounted for by fewer hospitalizations.
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Affiliation(s)
- Serge Korjian
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts
| | | | | | - Qi Zhao
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Roxana Mehran
- The Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York
| | - Christoph Bode
- Department for Cardiology and Angiology I, Heart Center, University of Freiburg, Freiburg, Germany
| | - Jonathan Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, Icahn School of Medicine at Mount Sinai, New York
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | | | - Marc Cohen
- The Division of Cardiology, Newark Beth Israel Medical Center, Newark, New Jersey
| | | | - Keith A A Fox
- The Centre for Cardiovascular Science, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts
| | - Duane S Pinto
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Massachusetts.
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47
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Alexander KP, Brouwer MA, Mulder H, Vinereanu D, Lopes RD, Proietti M, Al-Khatib SM, Hijazi Z, Halvorsen S, Hylek EM, Verheugt FWA, Alexander JH, Wallentin L, Granger CB. Outcomes of apixaban versus warfarin in patients with atrial fibrillation and multi-morbidity: Insights from the ARISTOTLE trial. Am Heart J 2019; 208:123-131. [PMID: 30579505 DOI: 10.1016/j.ahj.2018.09.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [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] [Received: 05/17/2018] [Accepted: 09/05/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) often have multi-morbidity, defined as ≥3 comorbid conditions. Multi-morbidity is associated with polypharmacy, adverse events, and frailty potentially altering response to anticoagulation. We sought to describe the prevalence of multi-morbidity among older patients with AF and determine the association between multi-morbidity, clinical outcomes, and the efficacy and safety of apixaban compared with warfarin. METHODS In this post-hoc subgroup analysis of the ARISTOTLE trial, we studied enrolled patients age ≥ 55 years (n = 16,800). Patients were categorized by the number of comorbid conditions at baseline: no multi-morbidity (0-2 comorbid conditions), moderate multi-morbidity (3-5 comorbid conditions), and high multi-morbidity (≥6 comorbid conditions). Association between multi-morbidity and clinical outcomes were analyzed by treatment with a median follow-up of 1.8 (1.3-2.3) years. RESULTS Multi-morbidity was present in 64% (n = 10,713) of patients; 51% (n = 8491) had moderate multi-morbidity, 13% (n = 2222) had high multi-morbidity, and 36% (n = 6087) had no multi-morbidity. Compared with the no multi-morbidity group, the high multi-morbidity group was older (74 vs 69 years), took twice as many medications (10 vs 5), and had higher CHA2DS2-VASc scores (4.9 vs 2.7) (all P < .001). Adjusted rates per 100 patient-years for stroke/systemic embolism, death, and major bleeding increased with multi-morbidity (Reference no multi-morbidity; moderate multi-morbidity 1.42 [1.24-1.64] and high multi-morbidity 1.92 [1.59-2.31]), with no interaction in relation to efficacy or safety of apixaban. CONCLUSIONS Multi-morbidity is prevalent among the population with AF; efficacy and safety of apixaban is preserved in this subgroup supporting extension of trial results to the most complex AF patients.
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Affiliation(s)
- Karen P Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Marc A Brouwer
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marco Proietti
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | | | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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48
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Damen SAJ, Cramer GE, Dieker HJ, Gehlmann H, Aengevaeren WRM, Oude Ophuis TJM, Fokkert MJ, Dikkeschei LD, Vroemen WHM, Verheugt FWA, Brouwer MA, Suryapranata H. A multi-site coronary sampling study on CRP in non-STEMI: Novel insights into the inflammatory process in acute coronary syndromes. Atherosclerosis 2018; 278:117-123. [PMID: 30268067 DOI: 10.1016/j.atherosclerosis.2018.09.024] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/14/2018] [Accepted: 09/18/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Inflammation has become a key element in cardiovascular disease, and recently, new anti-inflammatory interventions have shown promising results. In this context, CRP levels have been thoroughly studied in vitro and in animals, but studies in humans are scarce and insights into its release, site(s) of production and uptake are not uniform. METHODS We performed a biomarker study with multi-site sampling in the coronary circulation, in non-ST elevation MI (NSTEMI) patients with coronary angiography and right-sided catheterisation. Trans-lesional gradients were obtained by sampling distal to the culprit lesion, in patients with a suitable anatomy. To asses trans-cardiac gradients, blood was sampled from the systemic circulation, coronary sinus (CS) and great cardiac vein. Concentrations of CRP were measured with a high-sensitivity assay. RESULTS In 42 patients, a median systemic venous CRP concentration of 4.97 mg/L was observed. There was no evidence of a trans-lesional gradient (4.59 mg/L versus 4.56 mg/L, p = 0.278; n = 14). A significant decrease in CRP concentration was observed between systemic arterial and CS samples (4.88 mg/L versus 4.44 mg/L; p < 0.001; n = 42). This trans-cardiac gradient was irrespective of time of presentation, infarct size and culprit lesion location. The gradient was not only driven by blood that ran through the injured myocardium, but also by lower CRP concentrations in the coronary veins that drain non-infarcted myocardium. CONCLUSIONS In the context of NSTEMI, we observed a trans-cardiac decrease in CRP, which may indicate the first human in vivo proof of a net CRP uptake by the myocardium, with a role for CRP both in the injured and adjacent myocardium.
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Affiliation(s)
- Sander A J Damen
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Gilbert E Cramer
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Hendrik-Jan Dieker
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Helmut Gehlmann
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Wim R M Aengevaeren
- Department of Cardiology, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, the Netherlands
| | - Ton J M Oude Ophuis
- Department of Cardiology, Canisius Wilhelmina Hospital, Weg Door Jonkerbos 100, 6532 SZ, Nijmegen, the Netherlands
| | - Marion J Fokkert
- Department of Clinical Chemistry, Isala Clinics, Dr. van Heesweg 2, 8025 AB, Zwolle, the Netherlands
| | - Lambert D Dikkeschei
- Department of Clinical Chemistry, Isala Clinics, Dr. van Heesweg 2, 8025 AB, Zwolle, the Netherlands
| | - Wim H M Vroemen
- Central Diagnostic Laboratory, Maastricht University Medical Center, P. Debyelaan 25, 6202 AZ, Maastricht, the Netherlands
| | - Freek W A Verheugt
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Marc A Brouwer
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Harry Suryapranata
- Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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49
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Camm AJ, Cools F, Virdone S, Bassand JP, Fitzmaurice DA, Fox KAA, Goldhaber SZ, Goto S, Haas S, Mantovani LG, Pieper K, Turpie AGG, Verheugt FWA, Kakkar AK. 1354The effect of non-recommended dosing of non-vitamin K antagonist oral anticoagulants (NOACs) on 1-year mortality in patients with newly diagnosed AF? Results from the GARFIELD-AF registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.1354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A J Camm
- St. George's University of London and Imperial College, London, United Kingdom
| | - F Cools
- AZ KLINA Cardiology, Brasschaat, Belgium
| | - S Virdone
- Thrombosis Research Institute, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK and University of Besançon, Besançon, France
| | - D A Fitzmaurice
- University of Warwick Medical School, Coventry, United Kingdom
| | - K A A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - S Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - K Pieper
- Duke Clinical Research Institute, Durham, NC, USA & Thrombosis Research Institute, London, United Kingdom
| | | | - F W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands
| | - A K Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
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50
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Fox KAA, Berchuck S, Camm AJ, Bassand JP, Fitzmaurice DA, Gersh BJ, Goldhaber SZ, Goto S, Haas S, Misselwitz F, Pieper K, Turpie AGG, Verheugt FWA, Kakkar AK. P2895Evaluation of the effect of oral anticoagulants on all-cause mortality within 3 months of the diagnosis of atrial fibrillation: results from the GARFIELD-AF prospective registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p2895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- K A A Fox
- University of Edinburgh, Edinburgh, United Kingdom
| | - S Berchuck
- Duke Clinical Research Institute, Durham, United States of America
| | - A J Camm
- St. George's University of London and Imperial College, London, United Kingdom
| | - J.-P Bassand
- Thrombosis Research Institute, London, UK & University of Besançon, Besancon, France
| | - D A Fitzmaurice
- University of Warwick Medical School, Coventry, United Kingdom
| | - B J Gersh
- Mayo Clinic, Rochester, United States of America
| | - S Z Goldhaber
- Brigham and Women's Hospital and Harvard Medical School, Boston, United States of America
| | - S Goto
- Tokai University School of Medicine, Kanagawa, Japan
| | - S Haas
- Formerly Department of Medicine, Technical University of Munich, Munich, Germany
| | | | - K Pieper
- Duke Clinical Research Institute, Durham, NC, USA & Thrombosis Research Institute, London, United Kingdom
| | | | - F W A Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, Netherlands
| | - A K Kakkar
- Thrombosis Research Institute & University College London, London, United Kingdom
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