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Cavallari I, Patti G, Maddaloni E, Veneziano F, Mangiacapra F, Ricottini E, Ussia GP, Grigioni F. Association between platelet reactivity and long-term bleeding complications following percutaneous coronary intervention in patients with and without diabetes. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The association between diabetes mellitus (DM) and bleeding complications following percutaneous coronary intervention (PCI) is controversial. We hypothesized that on-treatment platelet reactivity may have a role in the bleeding risk stratification of such patients.
Purpose
To investigate the role of low platelet reactivity (LPR) in the long-term bleeding risk stratification among patients with and without diabetes undergoing PCI.
Methods
In this observational, retrospective single-center study, 472 patients undergoing PCI for stable coronary artery disease were included. All patients were treated with dual antiplatelet therapy with aspirin and clopidogrel. Platelet reactivity was assessed using the VerifyNow P2Y(12) assay and LPR was defined by values of platelet reactivity unit (PRU) ≤178. Primary endpoint was the occurrence of all bleeding events at 5 years stratified by DM status and LPR.
Results
Out of the study population included, 30.5% had DM (N=144). LPR was numerically less frequent in patients with DM compared to those without (29.2% vs 37.6%; p=0.077). Overall, 11.9% of patients experienced a bleeding complication at 5-year follow-up; 44.6% of events were classified as major bleedings. The incidence of bleeding events per 1000 patients-year was 34.5 (95% CI 22.3–53.5) in DM and 24.2 (95% CI 17.3–33.8) in no DM (p=0.24). A stepwise increase in the crude rates of bleeding complications was observed across patients with and without DM and LPR (log-rank p=0.004), with those having both conditions being at the highest risk of events (Figure). LPR had a similar value for stratifying the risk of bleeding in patients with and without diabetes (p value for interaction between diabetes and LPR status=0.45).
Conclusions
Approximately 1 out of 3 patients undergoing PCI for stable coronary artery disease on clopidogrel has LPR. The assessment of LPR provides a significant incremental value for the prediction of bleeding events irrespective from DM status. While the presence of DM per se does not increase the risk of bleeding complications, the coexistence of DM and LPR identifies the subgroup at the highest risk of events who could benefit from a short-term and less intensive antiplatelet regimen.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- I Cavallari
- University Campus Bio-Medico of Rome, Rome, Italy
| | - G Patti
- University of Eastern Piedmont, Novara, Italy
| | - E Maddaloni
- University Campus Bio-Medico of Rome, Rome, Italy
| | - F Veneziano
- University Campus Bio-Medico of Rome, Rome, Italy
| | | | - E Ricottini
- University Campus Bio-Medico of Rome, Rome, Italy
| | - G P Ussia
- University Campus Bio-Medico of Rome, Rome, Italy
| | - F Grigioni
- University Campus Bio-Medico of Rome, Rome, Italy
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2
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Cavallari I, Sagazio E, Antonucci E, Calabro' P, Gragnano F, Cirillo P, Gresele P, Palareti G, Pengo V, Pignatelli P, Marcucci R, Patti G. Ischemic and bleeding risk stratification in diabetic patients after acute coronary syndrome based on insulin requirement. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1552] [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
Diabetes is a known risk factor for a first or recurrent cardiovascular event, however, its association with an increased risk of bleeding is controversial. To date, no study has explored the prognostic weight of insulin therapy in the setting of ACS.
Purpose
To investigate the differential role of insulin versus no insulin therapy on ischemic and bleeding risks in patients with diabetes and ACS.
Methods
START-ANTIPLATELET is a prospective, real-world multicenter registry including consecutive patients admitted for ACS. For the purpose of this analysis, patients were stratified according to diabetes status and insulin therapy. We compared 1-year rates of major adverse cardiovascular events, a composite of cardiovascular death, myocardial infarction and stroke, and of any bleeding, according to diabetes status (no diabetes, diabetes not on insulin therapy, diabetes on insulin therapy). In addition, we evaluated the net clinical benefit of dual antiplatelet therapy with the newer P2Y12 inhibitors (ticagrelor or prasugrel) vs dual antiplatelet therapy with clopidogrel according to diabetes status.
Results
In an overall population of 907 patients, 198 had diabetes, 10.6% of whom were on insulin. From non-diabetic patients to diabetic patients not on insulin and diabetic patients on insulin there was a stepwise decrease of MACE-free survival (log-rank p 0.039) with incidence of events at 1 year being 3.8%, 6.8% (adjusted p vs no diabetes 0.49) and 12.5% (adjusted p vs no diabetes 0.047), respectively (Figure, panel A). The rates of any bleeding were higher in patients on insulin (20.8% vs 8.8% in those without diabetes and 5.8% in diabetic patients not receiving insulin; log-rank p 0.028; Figure, panel B). Multivariable analysis demonstrated an almost 5-fold increase of any bleeding in diabetic patients with vs without insulin (OR 4.98, 95% CI 1.46–16.92; p=0.010). In the overall population, the incidence of the net composite endpoint including MACE or major bleeding with the use of ticagrelor/prasugrel on top of aspirin was significantly lower compared to use of clopidogrel (4.7% vs 8.4%; OR 0.54, 95% CI 0.30–0.94, p=0.031). This net clinical benefit in patients receiving a newer P2Y12 inhibitor was regardless of the diabetes status (p for interaction 0.48).
Conclusions
In this cohort of ACS patients, the presence of diabetes stratified by insulin therapy was associated with a graded increase in the 1-year rates of MACE. Conversely, insulin therapy significantly contributed to the overall increase of bleeding risk in diabetes.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- I Cavallari
- Campus Bio-Medico University of Rome, Cardiovascular Sciences, Rome, Italy
| | - E Sagazio
- University of Eastern Piedmont, Novara, Italy
| | - E Antonucci
- Azienda Ospedaliero, Universitaria di Bologna, Policlinico S.Orsola-Malpigh, Bologna, Italy
| | - P Calabro'
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - F Gragnano
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P Cirillo
- Parthenope University of Naples, Naples, Italy
| | - P Gresele
- University of Perugia, Perugia, Italy
| | - G Palareti
- Azienda Ospedaliero, Universitaria di Bologna, Policlinico S.Orsola-Malpigh, Bologna, Italy
| | - V Pengo
- University of Padua, Padova, Italy
| | | | | | - G Patti
- University of Eastern Piedmont, Novara, Italy
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Moscarella E, Calabro P, Gragnano F, Cesaro A, Pafundi P, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Sasso F, Pengo V, Gresele P, Marcucci R. Effect of body mass index on ischemic and bleeding events in patients presenting with acute coronary syndromes: insights from the START-ANTIPLATELET registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1720] [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
The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding events as possible explanations to the obesity paradox in ACS patients.
Methods
For the purpose of this sub-study, patients enrolled in the START-ANTIPLATELET registry were stratified according to Body Mass Index (BMI) into three groups: normal, BMI <25kg/m2; overweight, BMI: 25–29.9kg/m2; obese, BMI ≥30kg/m2. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, and major bleeding.
Results
Patients were classified as follows: 410 (33.9%) normal, 538 (44.5%) overweight, 261 (21.6%) obese. Compared to the normal weight group, obese and overweight patients had a higher prevalence of cardiovascular risk factors, but were younger, with a better left ventricular ejection fraction (LVEF) and lower PRECISE-DAPT score. At one-year follow-up NACE was more frequently observed in normal than in overweight and obese patients (15.1%,8.6%,and9.6%, respectively; p=0.004), driven by a significantly higher rate of all-cause death (6.3%,2.6%, and 3.8%, respectively; p=0.008), while no significant differences were noted in terms of MI, stroke, and major bleeding. When correcting for confounding variables, BMI loses its power in independently predicting outcomes, failing to confirm the obesity paradox in a real-world ACS population.
Conclusions
Our study conflicts the obesity paradox in real-world ACS population, and suggest that the reduced mortality rate may be explained by a lower bleeding risk in obese patients allowing a more aggressive medical treatment, and by a better LVEF translating into a higher survival rate.
Funding Acknowledgement
Type of funding source: None
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Affiliation(s)
- E Moscarella
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P Calabro
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - F Gragnano
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - A Cesaro
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P.C Pafundi
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - G Patti
- University of L'Aquila, L'Aquila, Italy
| | | | | | | | | | | | - F.C Sasso
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - V Pengo
- General University Hospital of Alicante, Alicante, Spain
| | - P Gresele
- University of Perugia, Perugia, Italy
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Cavallari I, Verolino G, Patti G. 3054Efficacy and safety of non-vitamin K oral anticoagulants in patients with atrial fibrillation and cancer. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz745.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Anticoagulation in patients with cancer and atrial fibrillation (AF) is particularly challenging given the higher risk of both thrombotic and bleeding complications in this setting. Data regarding the efficacy and safety of non-vitamin K oral anticoagulants (NOACs) in AF patients with malignancy remain unclear.
Purpose
In the present meta-analysis we further investigate the efficacy and safety of NOACs compared to warfarin in patients with AF and cancer assuming that available studies may be individually underpowered for endpoints at low incidence, i.e. stroke, major and intracranial bleeding.
Methods
We performed a systematic review and meta-analysis of studies comparing the use of NOACs vs. warfarin in AF patients with cancer. Efficacy outcome measures included stroke or systemic embolism, venous thromboembolism and mortality. Safety outcome measures were major bleeding and intracranial hemorrhage.
Results
We pooled data from 6 identified studies enrolling a total of 31,756 AF patients with cancer. Mean follow-up was 1.7 years. Patients with cancer had significantly increased annualized rates of venous thromboembolism (1.38% vs. 0.74%), major bleeding (9.01% vs. 5.13%), in particular major gastrointestinal bleeding (2.38% vs. 1.60%), and all-cause mortality (17.73% vs. 8.50%) vs. those without (all P values <0.001), whereas the incidence of stroke or systemic embolism and intracranial hemorrhage did not differ. Compared with warfarin, treatment with NOACs nominally decreased the risk of stroke or systemic embolism (5.41% vs. 2.70%; odds ratio, OR; 95% confidence intervals, CI 0.51, 0.26–1.01; P=0.05; Figure), mainly of ischemic stroke (OR 0.56; 95% CI 0.35–0.89; P=0.01), and the risk of venous thromboembolism (OR 0.51; 95% CI 0.42–0.61; P<0.001). In cancer patients receiving NOACs there was a significant reduction of major bleeding (3.95% vs. 4.66%; OR 0.66, 95% CI 0.46–0.94; P=0.02; Figure) and intracranial hemorrhage (0.26% vs. 0.66%; OR 0.25, 95% CI 0.08–0.82; P=0.02) vs. warfarin, with no difference in gastrointestinal major bleeding rates.
Conclusion
AF patients on oral anticoagulation and concomitant cancer are at higher risk of venous thromboembolism, major bleeding and all-cause mortality. NOACs may represent a safer and more effective alternative to warfarin also in this setting of patients.
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Affiliation(s)
- I Cavallari
- University Campus Bio-Medico of Rome, Rome, Italy
| | - G Verolino
- University Campus Bio-Medico of Rome, Rome, Italy
| | - G Patti
- University of L'Aquila, L'Aquila, Italy
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Cavallari I, Patti G, Pecen L, Lucerna M, Huber K, Rohla M, Renda G, Siller-Matula J, Ricci F, Kirkhhof P, De Caterina R. P3837Net clinical benefit of NOACs vs. VKAs in elderly patients with atrial fibrillation: a pooled analysis from the real-world PREFER in AF and PREFER in AF PROLONGATION registries. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3837] [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)
- I Cavallari
- University Campus Bio-Medico of Rome, Rome, Italy
| | - G Patti
- University Campus Bio-Medico of Rome, Rome, Italy
| | - L Pecen
- Charles University of Pilsen, Pilsen, Czech Republic
| | - M Lucerna
- Daiichi Sankyo Europe, Munich, Germany
| | - K Huber
- Wilhelminen Hospital, Vienna, Austria
| | - M Rohla
- Wilhelminen Hospital, Vienna, Austria
| | - G Renda
- G. d'Annunzio University, Chieti, Italy
| | | | - F Ricci
- G. d'Annunzio University, Chieti, Italy
| | - P Kirkhhof
- University of Birmingham, Birmingham, United Kingdom
| | - R De Caterina
- University of Birmingham, Birmingham, United Kingdom
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Cavallari I, Patti G, Lucerna M, Pecen L, Siller-Matula J, Kirchhof P, De Caterina R. P5153Net clinical benefit of oral anticoagulation in very elderly patients with atrial fibrillation: a sub-analysis from the PREFER in AF registry. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.p5153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Turillazzi S, Cervo R, Cavallari I. Invasion of the Nest of Polistes dominulus by the Social Parasite Sulcopolistes sulcifer (Hymenoptera, Vespidae)1. Ethology 2010. [DOI: 10.1111/j.1439-0310.1990.tb00784.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lorenzo J, Platon O, Cavallari I. 421 Correction de la myopie forte : StickLens, résultats après 6 ans de recul. J Fr Ophtalmol 2005. [DOI: 10.1016/s0181-5512(05)73541-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Theodoropoulou M, Cavallari I, Barzon L, D'Agostino DM, Ferro T, Arzberger T, Grübler Y, Schaaf L, Losa M, Fallo F, Ciminale V, Stalla GK, Pagotto U. Differential expression of menin in sporadic pituitary adenomas. Endocr Relat Cancer 2004; 11:333-44. [PMID: 15163308 DOI: 10.1677/erc.0.0110333] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pituitary adenomas represent one of the key features of multiple endocrine neoplasia type 1. The gene involved in this syndrome (MEN1) is a putative tumor suppressor, that codes for a 610-amino acid nuclear protein termed 'menin'. Analyses of sporadic pituitary adenomas have so far failed to reveal MEN1 mutations or defects in MEN1 transcription in these tumors. In the present study we detected menin protein expression in a panel of normal and tumoral pituitary tissues, using a monoclonal antibody against the carboxy-terminus of menin. In the normal human pituitary gland, strong nuclear staining for menin was detectable in the majority of the endocrine cells of the anterior lobe, without a clear association with a particular hormone-producing type. In sporadic pituitary adenomas, menin expression was variable, with a high percentage of cases demonstrating a significant decrease in menin immunoreactivity when compared with the normal pituitary. Interestingly, metastatic tissues derived from one pituitary carcinoma had no detectable menin levels. Altogether, our data provide the first information regarding the status of menin expression in human normal and neoplastic pituitary as determined by immunohistochemistry (IHC).
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Affiliation(s)
- M Theodoropoulou
- Max Planck Institute of Psychiatry, Neuroendocrinology Group, 80804 Munich, Germany.
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