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Eikelboom JW, Kruger PC. Urinary thromboxane and risk of cardiovascular events: role of aspirin. Eur Heart J 2024; 45:1368-1370. [PMID: 38445763 DOI: 10.1093/eurheartj/ehae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Thrombosis and Atherosclerosis Research Institute, Hamilton Health Sciences Corporation and McMaster University, Hamilton, L8L 2X2 Ontario, Canada
| | - Paul C Kruger
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [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] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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3
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Patel SM, Braunwald E, Steffel J, Boriani G, Palazzolo MG, Antman EM, Bohula EA, Carnicelli AP, Connolly SJ, Eikelboom JW, Gencer B, Granger CB, Morrow DA, Patel MR, Wallentin L, Ruff CT, Giugliano RP. Efficacy and Safety of Non-Vitamin-K Antagonist Oral Anticoagulants Versus Warfarin Across the Spectrum of Body Mass Index and Body Weight: An Individual Patient Data Meta-Analysis of 4 Randomized Clinical Trials of Patients With Atrial Fibrillation. Circulation 2024; 149:932-943. [PMID: 38264923 DOI: 10.1161/circulationaha.123.066279] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND The efficacy and safety of non-vitamin-K antagonist oral anticoagulants (NOACs) across the spectrum of body mass index (BMI) and body weight (BW) remain uncertain. METHODS We analyzed data from COMBINE AF (A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in Atrial Fibrillation), which pooled patient-level data from the 4 pivotal randomized trials of NOAC versus warfarin in patients with atrial fibrillation. The primary efficacy and safety outcomes were stroke or systemic embolic events (stroke/SEE) and major bleeding, respectively; secondary outcomes were ischemic stroke/SEE, intracranial hemorrhage, death, and the net clinical outcome (stroke/SEE, major bleeding, or death). Each outcome was examined across BMI and BW. Because few patients had a BMI <18.5 kg/m2 (n=598), the primary analyses were restricted to those with a BMI ≥18.5 kg/m2. RESULTS Among 58 464 patients, the median BMI was 28.3 (interquartile range, 25.2-32.2) kg/m2, and the median BW was 81.0 (interquartile range, 70.0-94.3) kg. The event probability of stroke/SEE was lower at a higher BMI irrespective of treatment, whereas the probability of major bleeding was lower at a higher BMI with warfarin but relatively unchanged across BMI with NOACs. NOACs reduced stroke/SEE overall (adjusted hazard ratio [HRadj], 0.80 [95% CI, 0.73-0.88]; P<0.001), with a generally consistent effect across BMI (Ptrend across HRs, 0.48). NOACs also reduced major bleeding overall (HRadj, 0.88 [95% CI, 0.82-0.94]; P<0.001), but with attenuation of the benefit at a higher BMI (trend test across BMI [Ptrend], 0.003). The overall treatment effects of NOACs versus warfarin for secondary outcomes were consistent across BMI, with the exception of the net clinical outcome and death. While these outcomes were overall reduced with NOACs (net clinical outcome, HRadj, 0.91 [95% CI, 0.87-0.95]; P<0.001; death, HRadj, 0.91 [95% CI, 0.86-0.97]; P=0.003), these benefits were attenuated at higher BMI (Ptrend, 0.001 and 0.08, respectively). All findings were qualitatively similar when analyzed across BW. CONCLUSIONS The treatment effect of NOACs versus warfarin in atrial fibrillation is generally consistent for stroke/SEE across the spectrum of BMI and BW, whereas the reduction in major bleeding is attenuated in those with higher BMI or BW. Death and the net clinical outcome are overall reduced with NOACs over warfarin, although there remain uncertainties for these outcomes at a very high BMI and BW.
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Affiliation(s)
- Siddharth M Patel
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Jan Steffel
- Hirslanden Clinic, Zurich, Switzerland and University of Zurich, Switzerland (J.S.)
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Italy (G.B.)
| | - Michael G Palazzolo
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Elliott M Antman
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Erin A Bohula
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Anthony P Carnicelli
- Cardiology Division, Department of Internal Medicine, Medical University of South Carolina, Charleston (A.P.C.)
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, Canada (S.J.C., J.W.E.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Canada (S.J.C., J.W.E.)
| | - Baris Gencer
- Division of Cardiology, Geneva University Hospitals, Switzerland (B.G.)
- University of Bern Institute of Primary Health Care (BIHAM), Switzerland (B.G.)
| | - Christopher B Granger
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (C.B.G., M.R.P.)
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Division of Cardiology, Duke University, Durham, NC (C.B.G., M.R.P.)
| | - Lars Wallentin
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Sweden (L.W.)
| | - Christian T Ruff
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
| | - Robert P Giugliano
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (S.M.P., E.B., M.G.P., E.M.A., E.A.B., D.A.M., C.T.R., R.P.G.)
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Würtz M, Olesen KKW, Bhatt DL, Yusuf S, Muehlhofer E, Eikelboom JW, Maeng M. Net clinical benefit of extended dual pathway inhibition according to Baseline risk in patients with chronic coronary syndrome: a COMPASS substudy. Eur Heart J Cardiovasc Pharmacother 2024:pvae017. [PMID: 38453426 DOI: 10.1093/ehjcvp/pvae017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
AIMS Guidelines recommend extended dual pathway inhibition (DPI) with aspirin and rivaroxaban in patients with chronic coronary syndrome (CCS) at high ischemic risk. The CHADS-P2A2RC score improves risk prediction and enables antithrombotic treatment allocation in these patients. This study evaluated the net clinical benefit of DPI treatment according to baseline risk as classified by the CHADS-P2A2RC score in patients with CCS included in the COMPASS trial. METHODS COMPASS patients with CCS (n = 14 670), randomized to aspirin alone or DPI, were stratified according to cardiovascular risk using the CHADS-P2A2RC score. Endpoints were major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month risk difference of MACE and bleeding. RESULTS 30-month incidences of MACE (7.9% vs 3.9%, HR 2.01, 95% CI 1.83-2.18) and fatal/critical organ bleeding (1.2% vs 0.8%, HR 1.49 [1.06-1.92]) were higher in high-risk (CHADS-P2A2RC ≥ 4) than low/moderate-risk (CHADS-P2A2RC < 4) patients. DPI reduced MACE (low/moderate-risk: HR 0.62 [0.47-0.82]; high-risk: HR 0.82 [0.68-0.99], p for interaction 0.09) and all-cause death (low/moderate-risk: HR 0.65 [0.46-0.91]; high-risk: HR 0.81 [0.65-1.00], p for interaction 0.29), without substantially increasing fatal/critical organ bleeding (low/moderate-risk: HR 1.35 [0.72-2.53]; high-risk: HR 1.18 [0.73-1.90], p for interaction 0.73). DPI provided net clinical benefit of similar magnitude in low/moderate-risk (-1.81% [-3.00 to -0.62]) and high-risk CCS patients (-1.96% [-3.60 to -0.33]). CONCLUSIONS As classified by the CHADS-P2A2RC score, low/moderate- and high-risk patients with CCS derived similar net clinical benefit and reduction in all-cause death from DPI treatment.
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Affiliation(s)
- Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, Regional Hospital Gødstrup, Herning, Denmark
| | - Kevin Kris Warnakula Olesen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, Regional Hospital Gødstrup, Herning, Denmark
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada
| | - Eva Muehlhofer
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
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Eikelboom JW, Mundl H, Alexander JH, Caso V, Connolly SJ, Coppolecchia R, Gebel M, Hart RG, Holberg G, Keller L, Patel MR, Piccini JP, Rao SV, Shoamanesh A, Tamm M, Viethen T, Yassen A, Bonaca MP. Bleeding Outcomes in Patients Treated With Asundexian in Phase II Trials. J Am Coll Cardiol 2024; 83:669-678. [PMID: 38325992 DOI: 10.1016/j.jacc.2023.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 08/16/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Phase II trials of asundexian were underpowered to detect important differences in bleeding. OBJECTIVES The goal of this study was to obtain best estimates of effects of asundexian vs active control/placebo on major and clinically relevant nonmajor (CRNM) and all bleeding, describe most common sites of bleeding, and explore association between asundexian exposure and bleeding. METHODS We performed a pooled analysis of 3 phase II trials of asundexian in patients with atrial fibrillation (AF), recent acute myocardial infarction (AMI), or stroke. Bleeding was defined according to the International Society on Thrombosis and Hemostasis (ISTH) criteria. RESULTS In patients with AF (n = 755), both asundexian 20 mg and 50 mg once daily vs apixaban had fewer major/CRNM events (3 of 249; incidence rate [IR] per 100 patient-years 5.47 vs 1 of 254 [IR: not calculable] vs 6 of 250 [IR: 11.10]) and all bleeding (12 of 249 [IR: 22.26] vs 10 of 254 [IR: 18.21] vs 26 of 250 [IR: 50.56]). In patients with recent AMI or stroke (n = 3,409), asundexian 10 mg, 20 mg, and 50 mg once daily compared with placebo had similar rates of major/CRNM events (44 of 840 [IR: 7.55] vs 42 of 843 [IR: 7.04] vs 56 of 845 [IR: 9.63] vs 41 of 851 [IR: 6.99]) and all bleeding (107 of 840 [IR: 19.57] vs 123 of 843 [IR: 22.45] vs 130 of 845 [IR: 24.19] vs 129 of 851 [IR: 23.84]). Most common sites of major/CRNM bleeding with asundexian were gastrointestinal, respiratory, urogenital, and skin. There was no significant association between asundexian exposure and major/CRNM bleeding. CONCLUSIONS Analyses of phase II trials involving >500 bleeds highlight the potential for improved safety of asundexian compared with apixaban and similar safety compared with placebo. Further evidence on the efficacy of asundexian awaits the results of ongoing phase III trials.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | | | - John H Alexander
- Duke Clinical Research Institute and Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Valeria Caso
- Santa Maria della Misericordia Hospital, University of Perugia Stroke Unit, Perugia, Italy
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Robert G Hart
- Population Health Research Institute, Hamilton, Ontario, Canada
| | | | | | - Manesh R Patel
- Duke Clinical Research Institute and Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Duke Clinical Research Institute and Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Sunil V Rao
- New York University Langone Health System, New York, New York, USA
| | - Ashkan Shoamanesh
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Marc P Bonaca
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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6
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Chen P, Eikelboom JW, Tan C, Zhang W, Xu Y, Bai J, Wang J, Wang T, Gong X, Liu K, Chen X, Wang X, Zhu L, Zhao X, Yang N, Jiang J, Pu J, Zhao B, Chen Z, Li B, Wang G, Lu C, Ying L, Jiang M, Zhu X, Ma J, Dong Z, Li C, Zong J, Zhang F, Zhu J, Huang J, Kong X, Yu H, Li C. Single Bolus r-SAK Before Primary PCI for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2024; 17:e013455. [PMID: 38258563 DOI: 10.1161/circinterventions.123.013455] [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: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND It is uncertain whether adjunctive thrombolysis is beneficial for patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) within 120 minutes of presentation. This study was to determine whether in patients presenting with ST-segment-elevation myocardial infarction a single bolus recombinant staphylokinase (r-SAK) before timely PCI leads to improved patency of the infarct-related artery and reduces the infarct size. METHODS This is an open-label, prospective, multicenter, randomized study. We enrolled patients aged 18 to 75 years who were within 12 hours of symptom onset of ST-segment-elevation myocardial infarction and expected to undergo PCI within 120 minutes. Patients were administered loading doses of aspirin and ticagrelor and intravenous heparin and were randomized to receive 5 mg bolus of r-SAK or normal saline intravenously before PCI. The primary end point was Thrombolysis in Myocardial Infarction flow grade 2 to 3 or grade 3 in the infarct-related artery 60 minutes after thrombolysis. The infarct size was detected by cardiac magnetic resonance 5 days after randomization. The safety end point was major bleeding (Bleeding Academic Research Consortium ≥3) during 30-day follow-up. RESULTS A total of 283 patients were screened from 8 centers and 200 were randomized (median age, 58.5 years; 14% female). The median symptom to thrombolysis time was 252.5 (interquartile range, 142.8-423.8) minutes and thrombolysis to coronary arteriography was 50.0 (interquartile range, 37.0-66.0) minutes. Patients randomized to r-SAK compared with normal saline more often had Thrombolysis in Myocardial Infarction flow grade 2 to 3 (69.0% versus 29.0%; P<0.001) and Thrombolysis in Myocardial Infarction flow grade 3 (51.0% versus 18.0%; P<0.001) and had smaller infarct size (21.91±10.84% versus 26.85±12.37%; P=0.016). There was no increase in major bleeding (r-SAK, 1.0% versus control, 3.0%; P=0.616). CONCLUSIONS A single bolus r-SAK before primary PCI for ST-segment-elevation myocardial infarction improves infarct-related artery patency and reduces infarct size without increasing major bleeding. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05023681.
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Affiliation(s)
- Pengsheng Chen
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, Xuzhou Central Hospital, Jiangsu, China (P.C.)
| | - John W Eikelboom
- Department of Medicine, McMaster University or Thrombosis Service, Hamilton General Hospital, ON, Canada (J.W.E.)
| | - Chunyue Tan
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Wenhao Zhang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Yi Xu
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jianling Bai
- Department of Biostatistics, Nanjing Medical University, Jiangsu, China (J.B., H.Y.)
| | - Jun Wang
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Tong Wang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, the First People's Hospital of Yancheng, Jiangsu, China (T.W.)
| | - Xiaoxuan Gong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Kun Liu
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, the First People's Hospital of Lianyungang, Jiangsu, China (K.L., B.Z.)
| | - Xin Chen
- Department of Cardiology, the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Jiangsu, China (X.C., Z.C.)
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.W., B.L.)
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Jiangsu, China (L.Z., G.W.)
| | - Xin Zhao
- Department of Cardiology, the Second Hospital of Dalian Medical University, Liaoning, China (X. Zhao, C. Lu)
| | - Naiquan Yang
- Department of Cardiology, Huai'an Second People's Hospital Affiliated to Xuzhou Medical University, Jiangsu, China (N.Y., L.Y.)
| | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, China (J.J.)
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China (J.P., M.J.)
| | - Bo Zhao
- Department of Cardiology, the First People's Hospital of Lianyungang, Jiangsu, China (K.L., B.Z.)
| | - Zengguang Chen
- Department of Cardiology, the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Jiangsu, China (X.C., Z.C.)
| | - Baihong Li
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.W., B.L.)
| | - Guoyu Wang
- Department of Cardiology, Taizhou People's Hospital, Jiangsu, China (L.Z., G.W.)
| | - Chuan Lu
- Department of Cardiology, the Second Hospital of Dalian Medical University, Liaoning, China (X. Zhao, C. Lu)
| | - Lianghong Ying
- Department of Cardiology, Huai'an Second People's Hospital Affiliated to Xuzhou Medical University, Jiangsu, China (N.Y., L.Y.)
| | - Meng Jiang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China (J.P., M.J.)
| | - Xiaomei Zhu
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jiazheng Ma
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Zhou Dong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Chen Li
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jiaxin Zong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Fumin Zhang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jun Zhu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, China (J. Zhu)
| | - Jun Huang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Xiangqing Kong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Hao Yu
- Department of Biostatistics, Nanjing Medical University, Jiangsu, China (J.B., H.Y.)
| | - Chunjian Li
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
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7
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Bejjani A, Khairani CD, Assi A, Piazza G, Sadeghipour P, Talasaz AH, Fanikos J, Connors JM, Siegal DM, Barnes GD, Martin KA, Angiolillo DJ, Kleindorfer D, Monreal M, Jimenez D, Middeldorp S, Elkind MSV, Ruff CT, Goldhaber SZ, Krumholz HM, Mehran R, Cushman M, Eikelboom JW, Lip GYH, Weitz JI, Lopes RD, Bikdeli B. When Direct Oral Anticoagulants Should Not Be Standard Treatment: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:444-465. [PMID: 38233019 DOI: 10.1016/j.jacc.2023.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 01/19/2024]
Abstract
For most patients, direct oral anticoagulants (DOACs) are preferred over vitamin K antagonists for stroke prevention in atrial fibrillation and for venous thromboembolism treatment. However, randomized controlled trials suggest that DOACs may not be as efficacious or as safe as the current standard of care in conditions such as mechanical heart valves, thrombotic antiphospholipid syndrome, and atrial fibrillation associated with rheumatic heart disease. DOACs do not provide a net benefit in conditions such as embolic stroke of undetermined source. Their efficacy is uncertain for conditions such as left ventricular thrombus, catheter-associated deep vein thrombosis, cerebral venous sinus thrombosis, and for patients with atrial fibrillation or venous thrombosis who have end-stage renal disease. This paper provides an evidence-based review of randomized controlled trials on DOACs, detailing when they have demonstrated efficacy and safety, when DOACs should not be the standard of care, where their safety and efficacy are uncertain, and areas requiring further research.
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Affiliation(s)
- Antoine Bejjani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Candrika D Khairani
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Assi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory Piazza
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran; Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Azita H Talasaz
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran; Virginia Commonwealth University, Richmond, Virginia, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Manuel Monreal
- Cátedra de Enfermedad Tromboembólica, Universidad Católica San Antonio de Murcia, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, New York, New York, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Christian T Ruff
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Z Goldhaber
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, Connecticut, USA; Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA; Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA; Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Behnood Bikdeli
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Cardiovascular Research Foundation, New York, New York, USA.
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8
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Wang MK, Razeghi G, Eikelboom JW, Devereaux PJ, Budgeon CA, Jacka MJ, Wright DJ, Latini R, Conen D. Colchicine and Risk of Venous Thromboembolism: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Can J Cardiol 2024:S0828-282X(24)00018-7. [PMID: 38215967 DOI: 10.1016/j.cjca.2023.12.036] [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] [Received: 11/09/2023] [Revised: 12/01/2023] [Accepted: 12/21/2023] [Indexed: 01/14/2024] Open
Affiliation(s)
- Michael K Wang
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Ghazal Razeghi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Charley A Budgeon
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | | | - David J Wright
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Roberto Latini
- Department of Cardiovascular Research, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - David Conen
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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9
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Godoy A, Chan NC, Bhagirath V, Eikelboom JW, Hirsh J. FRAIL-AF Study: More Bleeding With DOACs Compared With VKAs in Patients With Frailty? Can J Cardiol 2024:S0828-282X(23)02046-9. [PMID: 38176536 DOI: 10.1016/j.cjca.2023.12.030] [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] [Received: 12/11/2023] [Revised: 12/22/2023] [Accepted: 12/28/2023] [Indexed: 01/06/2024] Open
Affiliation(s)
- Alejandro Godoy
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - Noel C Chan
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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10
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Johansson I, Benz AP, Kovalova T, Balasubramanian K, Fukakusa B, Lynn MJ, Nair N, Sikder O, Patel K, Gayathri S, Robinson M, Hardy C, Tyrwhitt J, Schulman S, Eikelboom JW, Connolly SJ. Outcomes of Patients with a Mechanical Heart Valve and Poor Anticoagulation Control on Warfarin. Thromb Haemost 2023. [PMID: 38158198 DOI: 10.1055/s-0043-1777827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with a mechanical heart valve (MHV) require oral anticoagulation. Poor anticoagulation control is thought to be associated with adverse outcomes, but data are limited. OBJECTIVE To assess the risks of clinical outcomes in patients with a MHV and poor anticoagulation control on warfarin. PATIENTS/METHODS We conducted a retrospective study of consecutive patients undergoing MHV implantation at a tertiary care center (2010-2019). Primary outcome was a composite of ischemic stroke, systemic embolism, or prosthetic valve thrombosis. Major bleeding and death were key secondary outcomes. We constructed multivariable regression models to assess the association between time in therapeutic range (TTR) on warfarin beyond 90 days after surgery with outcomes. RESULTS We included 671 patients with a MHV (80.6% in aortic, 14.6% in mitral position; mean age 61 years, 30.3% female). Median follow-up was 4.9 years, mean TTR was 62.5% (14.5% TTR <40%, 24.6% TTR 40-60%, and 61.0% TTR >60%). Overall rates of the primary outcome, major bleeding, and death were 0.73, 1.41, and 1.44 per 100 patient-years. Corresponding rates for patients with TTR <40% were 1.31, 2.77, and 3.22 per 100 patient-years. In adjusted analyses, every 10% decrement in TTR was associated with a 31% increase in hazard for the primary outcome (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.13-1.52), 34% increase in major bleeding (HR: 1.34, 95% CI: 1.17-1.52), and 32% increase in death (HR: 1.32, 95% CI: 1.11-1.57). CONCLUSION In contemporary patients with a MHV, poor anticoagulation control on warfarin was associated with increased risks of thrombotic events, bleeding, and death.
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Affiliation(s)
- Isabelle Johansson
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Division of Cardiology, Department of Medicine K2, Karolinska University Hospital Solna, Karolinska Institutet, Stockholm, Sweden
| | - Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Tanya Kovalova
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Kumar Balasubramanian
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Bianca Fukakusa
- Division of Cardiology, Department of Pediatrics, The University of British Columbia, Vancouver, Canada
| | - Matthew J Lynn
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Nikhil Nair
- Division of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Omaike Sikder
- Division of Medicine, School of Nursing, McMaster University, Hamilton, Canada
| | - Kashyap Patel
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sai Gayathri
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Marlene Robinson
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - Colin Hardy
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Jessica Tyrwhitt
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Ontario, Canada
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11
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Burger PM, Dorresteijn JAN, Fiolet ATL, Koudstaal S, Eikelboom JW, Nidorf SM, Thompson PL, Cornel JH, Budgeon CA, Westendorp ICD, Beelen DPW, Martens FMAC, Steg PG, Asselbergs FW, Cramer MJ, Teraa M, Bhatt DL, Visseren FLJ, Mosterd A. Individual lifetime benefit from low-dose colchicine in patients with chronic coronary artery disease. Eur J Prev Cardiol 2023; 30:1950-1962. [PMID: 37409348 DOI: 10.1093/eurjpc/zwad221] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/30/2023] [Accepted: 07/04/2023] [Indexed: 07/07/2023]
Abstract
AIMS Low-dose colchicine reduces cardiovascular risk in patients with coronary artery disease (CAD), but absolute benefits may vary between individuals. This study aimed to assess the range of individual absolute benefits from low-dose colchicine according to patient risk profile. METHODS AND RESULTS The European Society of Cardiology (ESC) guideline-recommended SMART-REACH model was combined with the relative treatment effect of low-dose colchicine and applied to patients with CAD from the Low-Dose Colchicine 2 (LoDoCo2) trial and the Utrecht Cardiovascular Cohort-Second Manifestations of ARTerial disease (UCC-SMART) study (n = 10 830). Individual treatment benefits were expressed as 10-year absolute risk reductions (ARRs) for myocardial infarction, stroke, or cardiovascular death (MACE), and MACE-free life-years gained. Predictions were also performed for MACE plus coronary revascularization (MACE+), using a new lifetime model derived in the REduction of Atherothrombosis for Continued Health (REACH) registry. Colchicine was compared with other ESC guideline-recommended intensified (Step 2) prevention strategies, i.e. LDL cholesterol (LDL-c) reduction to 1.4 mmol/L and systolic blood pressure (SBP) reduction to 130 mmHg. The generalizability to other populations was assessed in patients with CAD from REACH North America and Western Europe (n = 25 812). The median 10-year ARR from low-dose colchicine was 4.6% [interquartile range (IQR) 3.6-6.0%] for MACE and 8.6% (IQR 7.6-9.8%) for MACE+. Lifetime benefit was 2.0 (IQR 1.6-2.5) MACE-free years, and 3.4 (IQR 2.6-4.2) MACE+-free life-years gained. For LDL-c and SBP reduction, respectively, the median 10-year ARR for MACE was 3.0% (IQR 1.5-5.1%) and 1.7% (IQR 0.0-5.7%), and the lifetime benefit was 1.2 (IQR 0.6-2.1) and 0.7 (IQR 0.0-2.3) MACE-free life-years gained. Similar results were obtained for MACE+ and in American and European patients from REACH. CONCLUSION The absolute benefits of low-dose colchicine vary between individual patients with chronic CAD. They may be expected to be of at least similar magnitude to those of intensified LDL-c and SBP reduction in a majority of patients already on conventional lipid-lowering and blood pressure-lowering therapy.
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Affiliation(s)
- Pascal M Burger
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Aernoud T L Fiolet
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Dutch Cardiovascular Research Network (WCN), Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Stefan Koudstaal
- Dutch Cardiovascular Research Network (WCN), Moreelsepark 1, 3511 EP Utrecht, The Netherlands
- Department of Cardiology, Green Heart Hospital, Gouda, The Netherlands
| | | | - Stefan M Nidorf
- Department of Cardiology, GenesisCare Western Australia, Perth, Australia
- Heart Research Institute of Western Australia, Perth, Australia
| | - Peter L Thompson
- Department of Cardiology, GenesisCare Western Australia, Perth, Australia
- Heart Research Institute of Western Australia, Perth, Australia
| | - Jan H Cornel
- Dutch Cardiovascular Research Network (WCN), Moreelsepark 1, 3511 EP Utrecht, The Netherlands
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Charley A Budgeon
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | | | - Driek P W Beelen
- Department of Cardiology, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Fabrice M A C Martens
- Dutch Cardiovascular Research Network (WCN), Moreelsepark 1, 3511 EP Utrecht, The Netherlands
- Department of Cardiology, Deventer Hospital, Deventer, The Netherlands
| | - Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Université de Paris, Paris, France
| | - Folkert W Asselbergs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Martin Teraa
- Department of Vascular Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, USA
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Arend Mosterd
- Dutch Cardiovascular Research Network (WCN), Moreelsepark 1, 3511 EP Utrecht, The Netherlands
- Department of Cardiology, Meander Medical Centre, Maatweg 3, 3813 TZ Amersfoort, The Netherlands
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12
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Scheier TC, Youssouf N, Mosepele M, Kanyama C, Adekanmbi O, Lakoh S, Muzoora CK, Meintjes G, Mertz D, Eikelboom JW, Wasserman S. Standard of care in advanced HIV disease: review of HIV treatment guidelines in six sub-Saharan African countries. AIDS Res Ther 2023; 20:83. [PMID: 37996881 PMCID: PMC10668471 DOI: 10.1186/s12981-023-00581-5] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends an evidence-based package of care to reduce mortality and morbidity among people with advanced HIV disease (AHD). Adoption of these recommendations by national guidelines in sub-Saharan Africa is poorly documented. We aimed to review national guidelines for AHD management across six selected countries in sub-Saharan Africa for benchmarking against the 2021 WHO recommendations. METHODS We reviewed national guidelines from six countries participating in an ongoing randomized controlled trial recruiting people with AHD. We extracted information addressing 18 items of AHD diagnosis and management across the following domains: [1] Definition of AHD, [2] Screening, [3] Prophylaxis, [4] Supportive care, and [5] HIV treatment. Data from national guideline documents were compared to the 2021 WHO consolidated guidelines on HIV and an agreement score was produced to evaluate extent of guideline adoption. RESULTS The distribution of categories of agreement varied for the national documents. Four of the six countries addressed all 18 items (Malawi, Nigeria, Sierra Leone, Uganda). Overall agreement with the WHO 2021 guidelines ranged from 9 to 15.5 out of 18 possible points: Malawi 15.5 points, Nigeria, and Sierra Leone 14.5 points, South Africa 13.5 points, Uganda 13.0 points and Botswana with 9.0 points. Most inconsistencies were reported for the delay of antiretroviral therapy (ART) in presence of opportunistic diseases. None of the six national guidelines aligned with WHO recommendations around ART timing in patients with tuberculosis. Agreement correlated with the year of publication of the national guideline. CONCLUSION National guidelines addressing the care of advanced HIV disease in sub-Saharan Africa are available. Besides optimal timing for start of ART in presence of tuberculosis, most national recommendations are in line with the 2021 WHO standards.
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Affiliation(s)
- Thomas C Scheier
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Nabila Youssouf
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Cecilia Kanyama
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Olukemi Adekanmbi
- Department of Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Sulaiman Lakoh
- College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Conrad K Muzoora
- Department of Internal Medicine Faculty of Medicine Mbarara, University of Science and Technology Mbarara, Mbarara, Uganda
| | - Graeme Meintjes
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Dominik Mertz
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
- Division of Infectious Diseases, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sean Wasserman
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
- Institute for Infection and Immunity, St George's, University of London, London, UK.
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13
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Conen D, Ke Wang M, Popova E, Chan MTV, Landoni G, Cata JP, Reimer C, McLean SR, Srinathan SK, Reyes JCT, Grande AM, Tallada AG, Sessler DI, Fleischmann E, Kabon B, Voltolini L, Cruz P, Maziak DE, Gutiérrez-Soriano L, McIntyre WF, Tandon V, Martínez-Téllez E, Guerra-Londono JJ, DuMerton D, Wong RHL, McGuire AL, Kidane B, Roux DP, Shargall Y, Wells JR, Ofori SN, Vincent J, Xu L, Li Z, Eikelboom JW, Jolly SS, Healey JS, Devereaux PJ. Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial. Lancet 2023; 402:1627-1635. [PMID: 37640035 DOI: 10.1016/s0140-6736(23)01689-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications. METHODS COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125. FINDINGS Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22). INTERPRETATION In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea. FUNDING Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.
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Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ekaterine Popova
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute University San Raffaele, Milan, Italy
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cara Reimer
- Department of Anesthesiology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sean R McLean
- Vancouver Acute Department of Anesthesia and Perioperative Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Patrícia Cruz
- Service of Anesthesiology and Reanimation, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Laura Gutiérrez-Soriano
- Anesthesiology Department, Anesthesiology Research Group, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - William F McIntyre
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Juan Jose Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anna L McGuire
- Division of Thoracic Surgery, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sandra N Ofori
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Lizhen Xu
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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14
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Eikelboom JW, Weitz JI. Warfarin faring better: vitamin K antagonists beat rivaroxaban and apixaban in the INVICTUS and PROACT Xa trials. J Thromb Haemost 2023; 21:3067-3071. [PMID: 37429508 DOI: 10.1016/j.jtha.2023.06.036] [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: 05/12/2023] [Revised: 06/23/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
Although guidelines give preference to direct oral anticoagulants (DOACs) over vitamin K antagonists (VKAs) for stroke prevention in most patients with atrial fibrillation (AF), DOACs are not recommended in those with rheumatic heart disease or mechanical heart valves. The results of the INVICTUS trial (Investigation of Rheumatic AF Treatment Using Vitamin K Antagonists, Rivaroxaban or Aspirin Studies), which compared rivaroxaban with a VKA in patients with rheumatic heart disease-associated AF, and the PROACT Xa trial (A Trial to Determine if Participants with an On-X Aortic Valve Can be Maintained Safely on Apixaban), which compared apixaban with warfarin in patients with an On-X valve in the aortic position, support the use of VKAs for these indications. In this paper, we review the results of these trials, provide perspective on why VKAs were superior to DOACs, and discuss future directions for anticoagulation in these disorders.
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Affiliation(s)
- John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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15
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Li C, Eikelboom JW, Zhong Z, Zhang X, Liu K, Zhu L, Yang N, Chen X, Wang X, Zhao X, Jiang J, Pu J, Zhao B, Zhang F, Zhu J, Huang J, Kong X, Yu H, Tan C, Zhang W, Wang Q, Gong X, Bai J, Li C. Efficacy and safety of a bolus of half-dose r-SAK prior to primary PCI in ST-elevation myocardial infarction: Rationale and design of the OPTIMA-6 trial. Am Heart J 2023; 265:31-39. [PMID: 37369268 DOI: 10.1016/j.ahj.2023.06.012] [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] [Received: 05/07/2023] [Revised: 06/22/2023] [Accepted: 06/22/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Time to reperfusion is the key to the treatment of patients with ST-elevation myocardial infarction (STEMI). It is uncertain whether adjunctive thrombolytic therapy combined with contemporary antiplatelet agent ticagrelor improves outcomes as administered prior to primary percutaneous coronary intervention (PCI) expected to be performed within 120 minutes. METHODS OPTIMA-6 is a multicenter, randomized, double-blind, placebo-controlled, and superiority trial to evaluate the efficacy of a bolus of half-dose recombinant staphylokinase (r-SAK) vs placebo prior to timely primary PCI in patients with STEMI. Enrollment began in April 2023 and is expected to enroll 2,260 patients at approximately 50 centers. Patients with acute STEMI presenting ≤12 hours of symptom onset and expected to undergo primary PCI within 120 minutes but more than 30 minutes are to be randomized to a bolus of half-dose r-SAK or placebo. All recruited patients will be mandatory to take aspirin and ticagrelor and receive a bolus of loading dose heparin before the thrombolytic therapy. The primary efficacy endpoint is major adverse cardiovascular events (MACE) within 90 days, and the MACE is defined as a composite of all-cause death, reinfarction, unplanned target vessel revascularization, heart failure or cardiogenic shock, and major ventricular arrhythmia. The primary safety endpoints are major bleeding events (BARC 3, 5) within 90 days. CONCLUSIONS OPTIMA-6 will reveal the efficacy and safety of a contemporary facilitated PCI with a bolus of half-dose r-SAK in combination with ticagrelor in patients with STEMI.
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Affiliation(s)
- Chen Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - John W Eikelboom
- Department of Medicine, McMaster University or Thrombosis Service, Hamilton General Hospital, Hamilton Ontario, Hamilton, Canada
| | - Zihang Zhong
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiwen Zhang
- Department of Cardiology, the Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Kun Liu
- Department of Cardiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Taizhou, Jiangsu, China
| | - Naiquan Yang
- Department of Cardiology, Huai'an Second People's Hospital Affiliated to Xuzhou Medical University, Huai'an, Jiangsu, China
| | - Xin Chen
- Department of Cardiology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China
| | - Xin Zhao
- Department of Cardiology, The Second Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jun Jiang
- Department of Cardiology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jun Pu
- Department of Cardiology, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
| | - Bo Zhao
- Department of Cardiology, The First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
| | - Fumin Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jun Zhu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, China
| | - Jun Huang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiangqing Kong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hao Yu
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chunyue Tan
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Wenhao Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qin Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoxuan Gong
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jianling Bai
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Chunjian Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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16
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Scheier TC, Carlin S, Wills NK, Wasserman S, Mertz D, Eikelboom JW. Efficacy and Safety of Intensified vs Standard Prophylactic Anticoagulation Therapy in Patients Hospitalized With Coronavirus Disease 2019: Updated Systematic Review and Meta-analysis. Open Forum Infect Dis 2023; 10:ofad506. [PMID: 37953813 PMCID: PMC10633781 DOI: 10.1093/ofid/ofad506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/06/2023] [Indexed: 11/14/2023] Open
Affiliation(s)
| | - Stephanie Carlin
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicola K Wills
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Dominik Mertz
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methodology, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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17
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Mohammadnia N, Los J, Opstal TSJ, Fiolet ATL, Eikelboom JW, Mosterd A, Nidorf SM, Budgeon CA, Tijssen JGP, Thompson PL, Tack CJ, Simsek S, Bax WA, Cornel JH, El Messaoudi S. Colchicine and diabetes in patients with chronic coronary artery disease: insights from the LoDoCo2 randomized controlled trial. Front Cardiovasc Med 2023; 10:1244529. [PMID: 37868776 PMCID: PMC10587438 DOI: 10.3389/fcvm.2023.1244529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/12/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Despite optimal treatment, patients with chronic coronary artery disease (CAD) and diabetes mellitus (DM) are at high risk of cardiovascular events, emphasizing the need for new treatment options. The Low-Dose Colchicine 2 (LoDoCo2) trial demonstrated that colchicine reduces cardiovascular risk in patients with chronic CAD. This analysis determines the efficacy of colchicine in patients with chronic CAD and DM as well as the effect of colchicine on the development of new-onset type 2 diabetes mellitus (T2DM). Methods The LoDoCo2 trial randomized 5,522 patients to placebo or colchicine 0.5 mg once daily, with a median follow-up of 28.6 months. The primary composite endpoint was cardiovascular death, spontaneous myocardial infarction, ischemic stroke, or ischemia-driven revascularization. The effect of its treatment in patients with and without DM was evaluated by including an interaction term in the model. Results A total of 1,007 participants (18.2%) had T2DM at baseline. The adjusted hazard ratio (HR) [(95% confidence interval (CI)] for the primary endpoint in the T2DM group was 1.52 (1.15-2.01, p < 0.01) compared with the group without T2DM. The HR for the treatment effect on the primary endpoint was 0.87 (0.61-1.25) in participants with T2DM and 0.64 (0.51-0.80) in participants without diabetes (pinteraction = 0.14). The incidence of new-onset T2DM was 1.5% (34 out of 2,270) in the colchicine group and 2.2% (49 out of 2,245) in the placebo group (p = 0.10). Discussion In conclusion, based on the current evidence, the beneficial effects of colchicine on cardiovascular endpoints are consistent regardless of DM status. The potential benefits of colchicine in preventing new-onset DM need further investigation. These findings are only hypothesis-generating and require larger prospective trials to confirm the results.
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Affiliation(s)
| | - Jan Los
- Department of Cardiology, Radboudumc, Nijmegen, Netherlands
| | - Tjerk S. J. Opstal
- Department of Cardiology, Radboudumc, Nijmegen, Netherlands
- Department of Cardiology, Northwest Clinics, Alkmaar, Netherlands
| | - Aernoud T. L. Fiolet
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
- Dutch Network for Cardiovascular Research (WCN), Utrecht, Netherlands
| | | | - Arend Mosterd
- Dutch Network for Cardiovascular Research (WCN), Utrecht, Netherlands
- Department of Cardiology, Meander Medical Center, Amersfoort, Netherlands
| | - Stefan M. Nidorf
- Heart and Vascular Research Institute of Western Australia, Perth, WA, Australia
- GenesisCare Western Australia, Perth, WA, Australia
| | - Charley A. Budgeon
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Jan G. P. Tijssen
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Cardialysis BV, Rotterdam, Netherlands
| | - Peter L. Thompson
- Heart and Vascular Research Institute of Western Australia, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
- Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Cees J. Tack
- Department of Internal Medicine, Radboudumc, Nijmegen, Netherlands
| | - Suat Simsek
- Department of Internal Medicine, Northwest Clinics, Alkmaar, Netherlands
- Department of Internal Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Willem A. Bax
- Department of Internal Medicine, Northwest Clinics, Alkmaar, Netherlands
| | - Jan H. Cornel
- Department of Cardiology, Radboudumc, Nijmegen, Netherlands
- Department of Cardiology, Northwest Clinics, Alkmaar, Netherlands
- Dutch Network for Cardiovascular Research (WCN), Utrecht, Netherlands
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18
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Carlin S, Eikelboom JW. In healthy older adults, low-dose aspirin increased incident anemia at a median 4.7 y. Ann Intern Med 2023; 176:JC115. [PMID: 37782929 DOI: 10.7326/j23-0075] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
SOURCE CITATION McQuilten ZK, Thao LT, Pasricha SR, et al. Effect of low-dose aspirin versus placebo on incidence of anemia in the elderly: a secondary analysis of the Aspirin in Reducing Events in the Elderly trial. Ann Intern Med. 2023;176:913-921. 37335992.
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Affiliation(s)
| | - John W Eikelboom
- Population Health Research Institute and McMaster University, Hamilton, Ontario, Canada (J.W.E.)
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19
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Kpagoi SST, Aimone A, Ansumana R, Swaray I, Gelband H, Eikelboom JW, Jha P, Bogoch II. Adult malaria mortality during 2019 at Bo Government Hospital, Sierra Leone. Gates Open Res 2023; 7:48. [PMID: 37655048 PMCID: PMC10465729 DOI: 10.12688/gatesopenres.14396.2] [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] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
It is uncertain whether malaria is an important cause of death among adults in endemic areas. We performed a chart review of adults admitted to Bo Government Hospital during 2019. Of 893 admissions, 149 (59% female, mean age 58.5 years) had a laboratory diagnosis of malaria and 22 (14.8%) died. Mortality was significantly higher among patients with severe malaria compared with those who had non-severe malaria (6/20 [30%] versus 16/129 [12.4%], p=0.031). Our results suggest that malaria is a common cause of death in hospitalized Sierra Leonian adults.
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Affiliation(s)
- Satta Sylvia T.K. Kpagoi
- Department of Medicine, Bo Government Hospital, Ministry of Health and Sanitation, Bo, Sierra Leone
| | - Ashley Aimone
- Centre for Global Health Research, Unity Health Toronto and Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Ibrahim Swaray
- Centre for Global Health Research, Unity Health Toronto and Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Health Sciences, Njala University, Bo, Sierra Leone
| | - Hellen Gelband
- Centre for Global Health Research, Unity Health Toronto and Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | | | - Prabhat Jha
- Centre for Global Health Research, Unity Health Toronto and Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Isaac I. Bogoch
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Benz AP, Eikelboom JW. In DVT, oral DTIs and factor Xa inhibitors reduce major bleeding but not recurrent VTE vs. conventional anticoagulants. Ann Intern Med 2023; 176:JC92. [PMID: 37523702 DOI: 10.7326/j23-0053] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
SOURCE CITATION Wang X, Ma Y, Hui X, et al. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis. Cochrane Database Syst Rev. 2023;4:CD010956. 37058421.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany (A.P.B.)
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada (J.W.E.)
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21
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Bikdeli B, Eikelboom JW. P-Selectin de-ACTIVation in COVID-19: What Have We Learned? Circulation 2023; 148:391-393. [PMID: 37523764 DOI: 10.1161/circulationaha.123.065619] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Affiliation(s)
- Behnood Bikdeli
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, CT (B.B.)
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Canada (J.W.E.)
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22
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Benz AP, Hijazi Z, Lindbäck J, Connolly SJ, Eikelboom JW, Kastner P, Ziegler A, Alexander JH, Granger CB, Lopes RD, Oldgren J, Siegbahn A, Wallentin L. Plasma angiopoietin-2 and its association with heart failure in patients with atrial fibrillation. Europace 2023; 25:euad200. [PMID: 37461214 PMCID: PMC10359110 DOI: 10.1093/europace/euad200] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/24/2023] [Indexed: 07/22/2023] Open
Abstract
AIMS Several biomarkers are associated with clinical outcomes in patients with atrial fibrillation (AF), but a causal relationship has not been established. This study aimed to evaluate angiopoietin-2, a novel candidate biomarker of endothelial inflammation and vascular remodelling, in patients with AF. METHODS AND RESULTS Angiopoietin-2 was measured in plasma obtained from patients with AF treated with aspirin monotherapy (exploration cohort, n = 2987) or with oral anticoagulation (validation cohort, n = 13 079). Regression models were built to assess the associations between angiopoietin-2, clinical characteristics, and outcomes. In both cohorts, plasma angiopoietin-2 was independently associated with AF on the baseline electrocardiogram and persistent/permanent AF, age, history of heart failure, female sex, tobacco use/smoking, body mass index, renal dysfunction, diabetes, and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Angiopoietin-2 was independently associated with subsequent hospitalization for heart failure after adjusting for age, creatinine, and clinical characteristics in the exploration cohort [c-index 0.79, 95% confidence interval (CI) 0.75-0.82; third vs. first quartile, hazard ratio (HR) 1.74, 95% CI 1.26-2.41] and in the validation cohort (c-index 0.76, 95% CI 0.74-0.78; HR 1.58, 95% CI 1.37-1.82). In both cohorts, the association persisted when also adjusting for NT-proBNP (P ≤ 0.001). In full multivariable models also adjusted for NT-proBNP, angiopoietin-2 did not show statistically significant associations with ischaemic stroke, cardiovascular and all-cause death, or major bleeding that were consistent across the two cohorts. CONCLUSIONS In patients with AF, plasma levels of angiopoietin-2 were independently associated with subsequent hospitalization for heart failure and provided incremental prognostic value to clinical risk factors and NT-proBNP.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, Mainz 55131, Germany
| | - Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, Ontario L8L 2X2, Canada
| | | | | | - John H Alexander
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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23
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van Broekhoven A, Eikelboom JW, Nidorf SM, Mosterd A, Cornel JH. Elevations in Creatine Kinase are Not Related to the Choice or Dose of Statins in Patients Taking Colchicine 0.5 mg Daily: Insights from the LoDoCo2 Trial. Clin Drug Investig 2023; 43:575-577. [PMID: 37470947 DOI: 10.1007/s40261-023-01287-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Amber van Broekhoven
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Stefan M Nidorf
- Heart and Vascular Research Institute of Western Australia, Perth, Australia
- GenesisCare Western Australia, Perth, Australia
| | - Arend Mosterd
- Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands
- Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Jan H Cornel
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands.
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands.
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24
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Patel K, Sikder O, Nair N, Wasserman S, Eikelboom JW. Venous Thromboembolism in Patients with Human Immunodeficiency Virus. TH Open 2023; 7:e226-e228. [PMID: 37497427 PMCID: PMC10368489 DOI: 10.1055/a-2110-5884] [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] [Received: 03/30/2023] [Accepted: 06/07/2023] [Indexed: 07/28/2023] Open
Affiliation(s)
- Kashyap Patel
- School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Omaike Sikder
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Nikhil Nair
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Rondebosch, Western Cape, South Africa
| | - John W. Eikelboom
- Thrombosis Service, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Hijazi Z, Lindbäck J, Oldgren J, Benz AP, Alexander JH, Connolly SJ, Eikelboom JW, Granger CB, Lopes RD, Siegbahn A, Wallentin L. Individual net clinical outcome with oral anticoagulation in atrial fibrillation using the ABC-AF risk scores. Am Heart J 2023; 261:55-63. [PMID: 36990261 DOI: 10.1016/j.ahj.2023.03.012] [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] [Received: 12/05/2022] [Revised: 02/15/2023] [Accepted: 03/19/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Decisions on stroke prevention strategies in patients with atrial fibrillation (AF) depend on the perceived risks of stroke and bleeding with different antithrombotic treatment strategies. The study objectives were to evaluate net clinical outcome with oral anticoagulation (OAC) for the individual patient with AF and to identify clinically relevant thresholds for OAC treatment. METHODS Patients with AF receiving OAC treatment in the randomized ARISTOTLE and RE-LY trials, with available biomarkers for calculation of ABC-AF scores at baseline, were included (n = 23,121). Observed 1-year risk on OAC was compared with predicted 1-year risk if the same patients would not have received OAC using the ABC-AF scores calibrated for aspirin. Net clinical outcome was defined as the sum of stroke and major bleeding risks. RESULTS The ratio between the 1-year incidence of major bleeding and stroke/systemic embolism events ranged from 1.4 to 10.6 according to different ABC-AF risk profiles. Net clinical outcome analyses showed that in patients with an ABC-AF-stroke risk >1% per year on OAC (>3% without OAC), treatment with OAC consistently provides larger net clinical benefit than no-OAC treatment. In patients with an ABC-AF-stroke risk <1.0% per year on OAC (<3% without OAC) an individualized balancing of risks regarding OAC or no-OAC treatment is needed. CONCLUSIONS In patients with AF, the ABC-AF risk scores allow an individual and continuous estimate of the balance between benefits and risks with OAC treatment. This precision medicine tool therefore seems useful as decision support and visualizes the net clinical benefit or harm with OAC treatment (http://www.abc-score.com/abcaf/). CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00412984 (ARISTOTLE) and NCT00262600 (RE-LY).
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Affiliation(s)
- Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Alexander P Benz
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, NC
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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26
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Eikelboom JW, Belley-Cote E, Whitlock RP, Jolly SS, Wasserman S, Yusuf S. ACT trials: long-term outcomes. Lancet Respir Med 2023; 11:e50. [PMID: 37263712 DOI: 10.1016/s2213-2600(23)00148-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 06/03/2023]
Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - Emilie Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Surgery, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
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27
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Heijman MWJ, Fiolet ATL, Mosterd A, Tijssen JGP, van den Bemt BJF, Schut A, Eikelboom JW, Thompson PL, van den Ende CHM, Nidorf SM, Popa CD, Cornel JH. Association of Low-Dose Colchicine With Incidence of Knee and Hip Replacements : Exploratory Analyses From a Randomized, Controlled, Double-Blind Trial. Ann Intern Med 2023. [PMID: 37247416 DOI: 10.7326/m23-0289] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 05/31/2023] Open
Abstract
BACKGROUND Osteoarthritis is a major contributor to pain and disability worldwide. Given that inflammation plays an important role in the development of osteoarthritis, anti-inflammatory drugs may slow disease progression. OBJECTIVE To examine whether colchicine, 0.5 mg daily, reduces incident total knee replacements (TKRs) and total hip replacements (THRs). DESIGN Exploratory analysis of the LoDoCo2 (Low-Dose Colchicine 2) randomized, controlled, double-blind trial. (Australian New Zealand Clinical Trials Registry: ACTRN12614000093684). SETTING 43 centers in Australia and the Netherlands. PATIENTS 5522 patients with chronic coronary artery disease. INTERVENTION Colchicine, 0.5 mg, or placebo once daily. MEASUREMENTS The primary outcome was time to first TKR or THR since randomization. All analyses were performed on an intention-to-treat basis. RESULTS A total of 2762 patients received colchicine and 2760 received placebo during a median follow-up of 28.6 months. During the trial, TKR or THR was performed in 68 patients (2.5%) in the colchicine group and 97 (3.5%) in the placebo group (incidence rate, 0.90 vs. 1.30 per 100 person-years; incidence rate difference, -0.40 [95% CI, -0.74 to -0.06] per 100 person-years; hazard ratio, 0.69 [CI, 0.51 to 0.95]). In sensitivity analyses, similar results were obtained when patients with gout at baseline were excluded and when joint replacements that occurred in the first 3 and 6 months of follow-up were omitted. LIMITATION LoDoCo2 was not designed to investigate the effect of colchicine in osteoarthritis of the knee or hip and did not collect information specifically on osteoarthritis. CONCLUSION In this exploratory analysis of the LoDoCo2 trial, use of colchicine, 0.5 mg daily, was associated with a lower incidence of TKR and THR. Further investigation of colchicine therapy to slow disease progression in osteoarthritis is warranted. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Michelle W J Heijman
- Department of Research, Sint Maartenskliniek, and Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands (M.W.J.H., C.H.M.E.)
| | - Aernoud T L Fiolet
- Department of Cardiology, University Medical Center Utrecht, and Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands (A.T.L.F.)
| | - Arend Mosterd
- Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands, and Department of Cardiology, Meander Medical Center, Amersfoort, the Netherlands (A.M.)
| | - Jan G P Tijssen
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands, and Cardialysis BV, Rotterdam, the Netherlands (J.G.P.T.)
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, and Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands (B.J.F.B.)
| | - Astrid Schut
- Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands (A.S.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada (J.W.E.)
| | - Peter L Thompson
- Harry Perkins Institute of Medical Research, Nedlands, Western Australia, Australia, and GenesisCare Western Australia and Heart and Vascular Research Institute of Sir Charles Gairdner Hospital, Perth, Western Australia, Australia (P.L.T.)
| | - Cornelia H M van den Ende
- Department of Research, Sint Maartenskliniek, and Department of Rheumatology, Radboud University Medical Center, Nijmegen, the Netherlands (M.W.J.H., C.H.M.E.)
| | - Stefan M Nidorf
- GenesisCare Western Australia and Heart and Vascular Research Institute of Sir Charles Gairdner Hospital, Perth, Western Australia, Australia (S.M.N.)
| | - Calin D Popa
- Department of Rheumatology, Radboud University Medical Center, and Department of Rheumatology, Sint Maartenskliniek, Nijmegen, the Netherlands (C.D.P.)
| | - Jan H Cornel
- Dutch Network for Cardiovascular Research (WCN), Utrecht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands; and Department of Cardiology, Northwest Clinics, Alkmaar, the Netherlands (J.H.C.)
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28
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Benz AP, Hohnloser SH, Eikelboom JW, Carnicelli AP, Giugliano RP, Granger CB, Harrington J, Hijazi Z, Morrow DA, Patel MR, Seiffge DJ, Shoamanesh A, Wallentin L, Yi Q, Connolly SJ. Outcomes of patients with atrial fibrillation and ischemic stroke while on oral anticoagulation. Eur Heart J 2023; 44:1807-1814. [PMID: 37038327 PMCID: PMC10411934 DOI: 10.1093/eurheartj/ehad200] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/08/2023] [Accepted: 03/20/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The prognosis of patients with atrial fibrillation (AF) and ischemic stroke while taking oral anticoagulation is poorly understood. This study aimed to characterize the outcomes of patients following a stroke event while on oral anticoagulation. METHODS AND RESULTS Individual participant data from five pivotal randomized trials of antithrombotic therapy in AF were used to assess the outcomes of patients with a post-randomization ischemic stroke while on study medication (warfarin, standard-, or lower-dose direct oral anticoagulant regimen) during trial follow-up. The primary outcome was recurrent ischemic stroke after the first post-randomization ischemic stroke. The primary analysis included 1163 patients with a first post-randomization ischemic stroke while on study medication (median age 73 years, 39.3% female, 35.4% history of stroke before trial enrollment). During a median continued follow-up of 337 days, 74 patients had a recurrent ischemic stroke [cumulative incidence at 1 year: 7.0%, 95% confidence interval (CI) 5.2%-8.7%]. The cumulative incidence of mortality at 3 months after stroke was 12.4% (95% CI 10.5%-14.4%). Consistent results for the incidence of recurrent ischemic stroke at 1 year were obtained in an analysis accounting for the competing risk of death (6.2%, 95% CI 4.8%-7.9%) and in a landmark analysis excluding the first 2 weeks after the index stroke and only including patients without permanent study drug discontinuation since then (6.8%, 95% CI 4.6%-8.9%). CONCLUSION Patients with AF and ischemic stroke while on oral anticoagulation are at increased risk of recurrent ischemic stroke and death. These patients currently have an unmet medical need.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg University Mainz, Langenbeckstr. 1, Mainz 55131, Rhineland-Palatinate, Germany
| | | | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Anthony P Carnicelli
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Robert P Giugliano
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | | | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David A Morrow
- TIMI Study Group, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - David J Seiffge
- Department of Neurology, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Qilong Yi
- School of Epidemiology and Public Health, University of Ottawa, ON, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton St. E., Hamilton, ON L8L 2X2, Canada
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29
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Wan D, Dehghan M, de Souza RJ, Ramasundarahettige C, Eikelboom JW, Bosch J, Maggioni AP, Bhatt DL, Yusuf S, Anand SS. Dietary intake and cardiovascular outcomes in patients with chronic vascular disease: insights from the COMPASS trial cohort. Eur J Prev Cardiol 2023:7128320. [PMID: 37080912 DOI: 10.1093/eurjpc/zwad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 04/22/2023]
Abstract
AIMS Patients with coronary artery disease (CAD) and patients with peripheral artery disease (PAD) are at risk for major adverse cardiovascular events (MACE) and major adverse limb events (MALE). There are limited data regarding dietary patterns and the risk of recurrent MACE and MALE in CAD and PAD patients. We aimed to identify dietary patterns associated with MACE and MALE in patients with CAD and/or PAD. METHODS AND RESULTS We analysed data collected from patients enrolled into the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial, in which diet was assessed by a short food frequency questionnaire (FFQ) at baseline. Two dietary pattern scores, the modified Alternate Healthy Eating Index (mAHEI) and Mediterranean Diet Score (mMDS), were calculated. We tested the association between mAHEI and mMDS and the incidence of MACE and/or MALE. The mean mAHEI score was 23.0 ± 7.7 (out of 70) overall and was similar comparing CAD and PAD patients. The incidence of MACE or MALE was 6.3% in the lowest diet quality quartile (as assessed by mAHEI) compared with 4.2% in the highest quartile over 30 months. In the fully adjusted model, the hazard ratio of a low diet quality (Quartile 1) compared with the highest (Quartile 4) for MACE or MALE was 1.27 (95% CI: 1.08-1.49; P = 0.004, Q1 vs. Q4). This excess hazard was primarily driven by higher MACE in both the CAD and PAD cohorts. CONCLUSIONS Poor diet quality as assessed by the mAHEI is independently associated with a higher risk of recurrent MACE and MALE in patients with chronic CAD and/or PAD.
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Affiliation(s)
- Darryl Wan
- Department of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
| | - Mahshid Dehghan
- Department of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Russell J de Souza
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
| | | | - John W Eikelboom
- Department of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Jackie Bosch
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center (ANMCO), Florence, Italy
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Salim Yusuf
- Department of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Sonia S Anand
- Department of Medicine, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
- Hamilton Health Sciences, Population Health Research Institute, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, 1280 Main St W., Hamilton L8S 4K1, Canada
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30
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Eikelboom JW, Yusuf S. Event Adjudication Is Unnecessary in Blinded Trials and May Be Detrimental. JACC: Heart Failure 2023; 11:422-424. [PMID: 37019558 DOI: 10.1016/j.jchf.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/19/2023] [Indexed: 04/05/2023]
Affiliation(s)
| | - Salim Yusuf
- Population Health Research Institute, Hamilton, Ontario, Canada.
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31
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Hirsh J, de Vries TAC, Eikelboom JW, Bhagirath V, Chan NC. Clinical Studies with Anticoagulants that Have Changed Clinical Practice. Semin Thromb Hemost 2023; 49:242-254. [PMID: 36603813 DOI: 10.1055/s-0042-1760330] [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: 01/07/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment and prevention of arterial and venous thromboembolism. Taking a historical perspective, starting in the 1960s, and progressing through to 2022, we discuss key clinical trials of anticoagulants that have changed clinical practice, and examine obstacles encountered in bringing these anticoagulants to the clinic. The design of some of the early studies that shaped clinical practice was poor by current standards, but their results were influential because nothing better was available. Both heparin and vitamin K antagonists had been in clinical use for several decades before well-designed trials in the 1980s optimized their dosing and enhanced their safety and efficacy. Low-molecular-weight heparin then replaced unfractionated heparin because it had a more predictable dose-response and a longer half-life, thereby allowing it to be used conveniently in out-of-hospital settings. More recently, direct oral anticoagulants became the oral anticoagulants of choice for most indications because they were shown to be at least as safe and effective as vitamin K antagonists when used in fixed doses without the need for laboratory monitoring. The design of the trials that led to the approval of the direct oral anticoagulants was excellent, but further studies are required to optimize their dosing in selected patients who were underrepresented in these trials.
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Affiliation(s)
- Jack Hirsh
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Tim A C de Vries
- Heart Center, Department of Clinical and Experimental Cardiology and Cardiothoracic Surgery, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - John W Eikelboom
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Vinai Bhagirath
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Division of Hematology and Thromboembolism, Department of Medicine, Population Health Research Institute, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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Branch KRH, Probstfield JL, Bosch J, Bhatt DL, Maggioni AP, Muehlhofer E, Avezum A, Widimsky P, Connolly SJ, Yi Q, Shestakovska O, Yusuf S, Eikelboom JW. Total events and net clinical benefit of rivaroxaban and aspirin in patients with chronic coronary or peripheral artery disease: The COMPASS trial. Am Heart J 2023; 258:60-68. [PMID: 36646196 DOI: 10.1016/j.ahj.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Low dose rivaroxaban with aspirin reduced major cardiovascular events (MACE) compared to aspirin alone in patients with cardiovascular disease although effects on total events are unknown. METHODS The COMPASS clinical trial randomized 27,395 participants with chronic coronary and/or peripheral artery disease to rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily, rivaroxaban 5 mg twice daily alone, or aspirin 100 mg daily. We analyzed total (first and recurrent) MACE outcomes of cardiovascular death, stroke, or myocardial infarction, and the primary safety outcome of major bleeding. Exploratory analyses included on-treatment and net clinical benefit. Total MACE and safety events were modeled for each treatment. RESULTS MACE events were lowest in rivaroxaban with aspirin (379 first MACE, 432 total MACE) compared with rivaroxaban (448 first, 508 total) or aspirin alone (496 first, 574 total). Rivaroxaban and aspirin reduced total MACE events compared with aspirin alone [HR 0.75, 95% CI 0.66-0.85, P < .0001, number needed to treat for 2 years (NNT2y) of 63]. Total major bleeding was higher for rivaroxaban with aspirin compared to aspirin, but severe bleeding was not increased. The net clinical benefit of rivaroxaban plus aspirin was 20% higher compared with aspirin alone [HR 0.80 (95% CI 16.3%-31.6%)]. Rivaroxaban alone had no benefit on MACE outcomes compared with aspirin alone. MACE outcomes were similar for those on and off randomized treatment. CONCLUSIONS Low dose rivaroxaban with aspirin significantly reduces first and total cardiovascular events compared with aspirin alone with a NNT2y of 63 and a 20% net clinical benefit. TRIAL REGISTRATION NCT01776424. https://clinicaltrials.gov/ct2/show/NCT01776424.
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Affiliation(s)
| | | | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
| | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center (ANMCO) Research Center, Firenze, Toscano, Italy
| | | | - Alvaro Avezum
- Dante Pazzanese Institute of Cardiology and Hospital Alemão Oswaldo Cruz, São Paulo, São Paulo, Brazil
| | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Quilong Yi
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Olga Shestakovska
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Kpagoi SST, Aimone A, Ansumana R, Swaray I, Gelband H, Eikelboom JW, Jha P, Bogoch II. Adult malaria mortality during 2019 at Bo Government Hospital, Sierra Leone. Gates Open Res 2023. [DOI: 10.12688/gatesopenres.14396.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
It is uncertain whether malaria is an important cause of death among adults in endemic areas. We performed a chart review of adults admitted to Bo Government Hospital during 2019. Of 893 admissions, 149 (59% female, mean age 58.5 years) had a laboratory diagnosis of malaria and 22 (14.8%) died. Mortality was significantly higher among patients with severe malaria compared with those who had non-severe malaria (6/20 [30%] versus 16/129 [12.4%], p=0.031). Our results suggest that malaria is a common cause of death in hospitalized Sierra Leonian adults.
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Milling TJ, Middeldorp S, Xu L, Koch B, Demchuk A, Eikelboom JW, Verhamme P, Cohen AT, Beyer-Westendorf J, Michael Gibson C, Lopez-Sendon J, Crowther M, Shoamanesh A, Coppens M, Schmidt J, Albaladejo P, Connolly SJ, Bastani A, Clark C, Concha M, Cornell J, Dombrowski K, Fermann G, Fulmer J, Goldstein J, Kereiakes D, Milling T, Pallin D, Patel N, Refaai M, Rehman M, Schmaier A, Schwarz E, Shillinglaw W, Spohn M, Takata T, Venkat A, Welker J, Welsby I, Wilson J, Van Keer L, Verschuren F, Blostein M, Eikelboom J, Althaus K, Berrouschot J, Braun G, Doeppner T, Dziewas R, Genth-Zotz S, Greinacher P, Hamann F, Hanses F, Heide W, Kallmuenzer B, Kermer P, Poli S, Royl G, Schellong S, Schnupp S, Schwarze J, Spies C, Thomalla G, von Mering M, Weissenborn K, Wollenweber F, Gumbinger C, Jaschinski U, Maschke M, Mochmann HC, Pfeilschifter W, Pohlmann C, Zahn R, Bouzat P, Schmidt J, Vallejo C, Floccard B, Coppens M, van Wissen S, Arellano-Rodrigo E, Valles E, Alikhan R, Breen K, Hall R, Crowther M, Albaladejo P, Cohen A, Demchuk A, Schmidt J, Wyse D, Garcia D, Prins M, Nakamya J, Büller H, Mahaffey KW, Alexander JH, Cairns J, Hart R, Joyner C, Raskob G, Schulman S, Veltkamp R, Meeks B, Zotova E, Ahmad S, Pinto T, Baker K, Dykstra A, Holadyk-Gris I, Malvaso A, Demchuk A. Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors. Circulation 2023; 147:1026-1038. [PMID: 36802876 DOI: 10.1161/circulationaha.121.057844] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented. METHODS Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society of Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome. RESULTS There were 479 patients enrolled (mean age, 78 years; 54% male, 86% White; 81% anticoagulated for atrial fibrillation at a median time of 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 patients (10%); in 16 patients, this occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors. CONCLUSIONS In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02329327.
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Affiliation(s)
- Truman J Milling
- Seton Dell Medical School Stroke Institute, Dell Medical School, University of Texas at Austin (T.J.M.)
| | - Saskia Middeldorp
- Department of Internal Medicine and Radboud Institute of Health Sciences, Nijmegenthe Netherlands (S.M.)
| | - Lizhen Xu
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Bruce Koch
- Alexion, AstraZeneca Rare Disease, BostonMA (B.K.)
| | - Andrew Demchuk
- Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, AlbertaCanada (A.D.)
| | - John W Eikelboom
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Peter Verhamme
- Center for Molecular and Vascular Biology, University of Leuven, Belgium (P.V.)
| | | | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Hematology and Hemostasis, University Hospital Dresden, Germany (J.B-W.)
| | | | - Jose Lopez-Sendon
- Instituto de Investigación Hospital Universitario, La PazMadridSpain (J. L-S.)
| | - Mark Crowther
- Department of Medicine, McMaster University, HamiltonOntario Canada. (J.W.E., M. Crowther)
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands (M. Coppens)
| | - Jeannot Schmidt
- Centre Hospitalier Universitaire de Clermont-Ferrand, France (J.S.)
| | | | - Stuart J Connolly
- Population Health Research Institute, McMaster University, HamiltonOntario Canada. (L.X., A.S., S.J.C.)
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Abstract
No Abstract.
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Affiliation(s)
| | - Jeffrey Ian Weitz
- Medicine, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada
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36
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De Caterina R, Prisco D, Eikelboom JW. Factor XI inhibitors: cardiovascular perspectives. Eur Heart J 2023; 44:280-292. [PMID: 36263776 DOI: 10.1093/eurheartj/ehac464] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [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: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Anticoagulants are the cornerstone for prevention and treatment of thrombosis but are not completely effective, and concerns about the risk of bleeding continue to limit their uptake. Animal studies and experience from patients with genetic coagulation factor XI deficiency suggesting that this factor is more important for thrombosis than for haemostasis raises the potential for drugs that target factor XI to provide safer anticoagulation. Multiple factor XI inhibitors are currently under evaluation in clinical trials, including parenterally administered antisense oligonucleotides, monoclonal antibodies, and orally active small-molecule inhibitors. Promising results of phase 2 trials in patients undergoing major orthopaedic surgery, and in those with end-stage kidney disease, atrial fibrillation and acute coronary syndromes have led to large phase 3 trials that are currently ongoing. We here review premises for the use of these agents, results so far accrued, ongoing studies, and perspectives for future patient care.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Domenico Prisco
- Chair of Internal Medicine, Department of Experimental and Clinical Medicine, University of Florence and Careggi University Hospital, Florence, Italy
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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Hijazi Z, Benz AP, Lindbäck J, Alexander JH, Connolly SJ, Eikelboom JW, Granger CB, Kastner P, Lopes RD, Ziegler A, Oldgren J, Siegbahn A, Wallentin L. Bone morphogenetic protein 10: a novel risk marker of ischaemic stroke in patients with atrial fibrillation. Eur Heart J 2023; 44:208-218. [PMID: 36380569 PMCID: PMC9839419 DOI: 10.1093/eurheartj/ehac632] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS Biomarkers specifically related to atrial tissue may increase the understanding of the pathophysiology of atrial fibrillation (AF) and further improve risk prediction in this setting. Bone morphogenetic protein 10 (BMP10) is a protein expressed in the atrial myocardium. We evaluated the association between BMP10 and the risk of ischaemic stroke and other cardiovascular events in large cohorts of patients with AF, treated with and without oral anticoagulation (OAC). METHODS AND RESULTS BMP10 was measured in plasma samples collected at randomisation in patients with AF without OAC in the ACTIVE A and AVERROES trials (n = 2974), and with OAC in the ARISTOTLE trial (n = 13 079). BMP10 was analysed with a prototype Elecsys immunoassay. Associations with outcomes were evaluated by Cox-regression models adjusted for clinical characteristics, kidney function, and N-terminal pro-B-type natriuretic peptide (NT-proBNP). Median concentrations of BMP10 were 2.47 and 2.44 ng/mL, in the non-OAC and OAC cohort, respectively. Increasing BMP10 was associated with lower body mass index, older age, female sex, kidney dysfunction, and AF rhythm. BMP10 was consistently associated with ischaemic stroke. In the non-OAC cohort, BMP10 increased the concordance index of the multivariable model from 0.713 to 0.733 (P = 0.004) and in the OAC cohort from 0.673 to 0.694 (P < 0.001). Additionally, BMP10 maintained a significant prognostic value after additionally adjusting for NT-proBNP. BMP10 was not independently associated with bleeding or with death. CONCLUSION The novel atrial biomarker BMP10 was independently associated with ischaemic stroke in patients with AF irrespective of OAC treatment. BMP10 seems to be more specifically related to the risk of ischaemic stroke in AF. ONE-SENTENCE SUMMARY In this study, BMP10 may be a novel specific biomarker of ischaemic stroke in patients with atrial fibrillation, irrespective of oral anticoagulation.
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Affiliation(s)
- Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.,Department of Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden
| | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Christopher B Granger
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - Peter Kastner
- Roche Diagnostics GmbH, Nonnenwald 2, DE-82377 Penzberg, Germany
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street Durham, NC 27701, USA
| | - André Ziegler
- Roche Diagnostics GmbH, Nonnenwald 2, DE-82377 Penzberg, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
| | - Lars Wallentin
- Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds väg 38, 751 85 Uppsala, Sweden.,Department of Medical Sciences, Cardiology, Uppsala University, Ingång 40, 751 85 Uppsala, Sweden
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38
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W., J.W.E.).,Departments of Medicine (J.I.W., J.W.E.), McMaster University, Hamilton, Ontario, Canada.,Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W., J.W.E.).,Departments of Medicine (J.I.W., J.W.E.), McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada (J.W.E.)
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39
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.).,Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Germany (A.P.B.)
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Ontario, Canada (A.P.B., J.W.E.)
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40
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Eikelboom JW, Bosch J, Connolly SJ, Tyrwitt J, Fox KAA, Muehlhofer E, Neumann C, Tasto C, Bangdiwala SI, Diaz R, Alings M, Dagenais GR, Leong DP, Lonn EM, Avezum A, Piegas LS, Widimsky P, Parkhomenko AN, Bhatt DL, Branch KRH, Probstfield JL, Lopez-Jaramillo P, Rydén L, Pogosova N, Keltai K, Keltai M, Ertl G, Stoerk S, Dans AL, Lanas F, Liang Y, Zhu J, Torp-Pedersen C, Maggioni AP, Commerford PJ, Guzik TJ, Vanassche T, Verhamme P, O'Donnell M, Tonkin AM, Varigos JD, Vinereanu D, Felix C, Kim JH, Ibrahim KS, Lewis BS, Metsarinne KP, Aboyans V, Steg PG, Hori M, Kakkar A, Anand SS, Lamy A, Sharma M, Yusuf S. Long-Term Treatment with the Combination of Rivaroxaban and Aspirin in Patients with Chronic Coronary or Peripheral Artery Disease: Outcomes During the Open Label Extension of the COMPASS trial. Eur Heart J Cardiovasc Pharmacother 2022; 8:786-795. [PMID: 35383832 DOI: 10.1093/ehjcvp/pvac023] [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] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/13/2022] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
AIMS To describe outcomes of patients with chronic coronary artery disease (CAD) and/or peripheral artery disease (PAD) enrolled in the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) randomized trial who were treated with the combination of rivaroxaban 2.5 mg twice daily and aspirin 100 mg once daily during long-term open-label extension (LTOLE). METHODS AND RESULTS Of the 27 395 patients enrolled in COMPASS, 12 964 (mean age at baseline 67.2 years) from 455 sites in 32 countries were enrolled in LTOLE and treated with the combination of rivaroxaban and aspirin for a median of 374 additional days (range 1-1191 days). During LTOLE, the incident events per 100 patient years were as follows: for the primary outcome [cardiovascular death, stroke, or myocardial infarction (MI)] 2.35 [95% confidence interval (CI) 2.11-2.61], mortality 1.87 (1.65-2.10), stroke 0.62 (0.50-0.76), and MI 1.02 (0.86-1.19), with CIs that overlapped those seen during the randomized treatment phase with the combination of rivaroxaban and aspirin. The incidence rates for major and minor bleeding were 1.01 (0.86-1.19) and 2.49 (2.24-2.75), compared with 1.67 (1.48-1.87) and 5.11 (95% CI 4.77-5.47), respectively, during the randomized treatment phase with the combination. CONCLUSION In patients with chronic CAD and/or PAD, extended combination treatment for a median of 1 year and a maximum of 3 years was associated with incidence rates for efficacy and bleeding that were similar to or lower than those seen during the randomized treatment phase, without any new safety signals.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Jacqueline Bosch
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada.,School of Rehabilitation Science, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Jessica Tyrwitt
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Keith A A Fox
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Eva Muehlhofer
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Christoph Neumann
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Christoph Tasto
- Bayer AG Pharmaceuticals, Research & Development, Wuppertal, Germany
| | - Shrikant I Bangdiwala
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Rafael Diaz
- Estudios Clínicos Latino América and Instituto Cardiovascular de Rosario, Rosaria, Argentina
| | - Marco Alings
- Division of Cardiology, Amphia ziekenhuis, Breda, Netherlands and Werkgroep Cardiologische centra Nederland (WCN), Utrecht, the Netherlands
| | - Gilles R Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - Darryl P Leong
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Eva M Lonn
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | | | - Petr Widimsky
- Cardiocenter, University Hospital Kralovske Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Alexander N Parkhomenko
- Emergency Cardiology Dept., National Scientific Center Institute of Cardiology, Kyiv, Ukraine
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kelley R H Branch
- University of Washington Medical Centre, Division of Cardiology, Seattle, WA, USA
| | - Jeffrey L Probstfield
- University of Washington SOM, Division of Cardiology/Department of Medicine, Seattle WA, USA
| | - Patricio Lopez-Jaramillo
- Research Institute, Fundación Oftalmológica de Santander (FOSCAL)-Bucaramanga, Bucaramanga, Colombia
| | - Lars Rydén
- Department of Medicine K2, Karolinska Institutet, Stockholm, Sweden
| | - Nana Pogosova
- National Medical Research Center of Cardiology, Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - Katalin Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
| | - Matyas Keltai
- Hungarian Cardiovascular Institute, Semmelweis University, Budapest, Hungary
| | - Georg Ertl
- Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Stefan Stoerk
- Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Antonio L Dans
- College of Medicine, University of Philippines, Manila, Philippines
| | - Fernando Lanas
- Universidad de La Frontera, Division of Cardiology, Internal Medicine Department, Temuco, Chile
| | - Yan Liang
- Fuwai Hospital, CAMS & PUMC, Beijing, China
| | - Jun Zhu
- Dept of Clinical Medicine, University of Aalborg, Copenhagen, Denmark
| | | | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Patrick J Commerford
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and the University of Cape Town, Cape Town, South Africa
| | - Tomasz J Guzik
- Department of Medicine, Jagiellonian University Medical College Krakow, Poland.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | | | - Andrew M Tonkin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - John D Varigos
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila; University and Emergency Hospital, Bucharest, Romania
| | - Camillo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Quito, Ecuador
| | - Jae-Hyung Kim
- Catholic University of Korea, Department of Medicine, Seoul, South Korea
| | | | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Kaj P Metsarinne
- Division of Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital & INSERM 1094, Limoges, France
| | - Phillippe Gabriel Steg
- Université de Paris, and Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Masatsugu Hori
- Department of Oncocardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Ajay Kakkar
- Thrombosis Research Institute and University College London, London, UK
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Andre Lamy
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Mukul Sharma
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
| | - Salim Yusuf
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton Canada
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Luz Diaz M, Diaz R, Yusufali A, Kumar Sharma S, Tarhuni WM, Hassany M, Avezum A, Harper W, Wasserman S, Almas A, Drapkina O, Felix C, Lopes RD, Berwanger O, Lopez-Jaramillo P, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and the combination of rivaroxaban and aspirin in patients hospitalised with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1169-1177. [PMID: 36228641 PMCID: PMC9635892 DOI: 10.1016/s2213-2600(22)00298-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND COVID-19 disease is accompanied by a dysregulated immune response and hypercoagulability. The Anti-Coronavirus Therapies (ACT) inpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with the combination of rivaroxaban and aspirin for prevention of disease progression in patients hospitalised with COVID-19. METHODS The ACT inpatient, open-label, 2 × 2 factorial, randomised, controlled trial was done at 62 clinical centres in 11 countries. Patients aged at least 18 years with symptomatic, laboratory confirmed COVID-19 who were within 72 h of hospitalisation or worsening clinically if already hospitalised were randomly assigned (1:1) to receive colchicine 1·2 mg followed by 0·6 mg 2 h later and then 0·6 mg twice daily for 28 days versus usual care; and in a second (1:1) randomisation, to the combination of rivaroxaban 2·5 mg twice daily plus aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome, assessed at 45 days in the intention-to-treat population, for the colchicine randomisation was the composite of the need for high-flow oxygen, mechanical ventilation, or death; and for the rivaroxaban plus aspirin randomisation was the composite of major thrombosis (myocardial infarction, stroke, acute limb ischaemia, or pulmonary embolism), the need for high-flow oxygen, mechanical ventilation, or death. The trial is registered at www. CLINICALTRIALS gov, NCT04324463 and is ongoing. FINDINGS Between Oct 2, 2020, and Feb 10, 2022, at 62 sites in 11 countries, 2749 patients were randomly assigned to colchicine or control and the combination of rivaroxaban and aspirin or to the control. 2611 patients were included in the analysis of colchicine (n=1304) versus control (n=1307); 2119 patients were included in the analysis of rivaroxaban and aspirin (n=1063) versus control (n=1056). Follow-up was more than 98% complete. Overall, 368 (28·2%) of 1304 patients allocated to colchicine and 356 (27·2%) of 1307 allocated to control had a primary outcome (hazard ratio [HR] 1·04, 95% CI 0·90-1·21, p=0·58); and 281 (26·4%) of 1063 patients allocated to the combination of rivaroxaban and aspirin and 300 (28·4%) of 1056 allocated to control had a primary outcome (HR 0·92, 95% CI 0·78-1·09, p=0·32). Results were consistent in subgroups defined by vaccination status, disease severity at baseline, and timing of randomisation in relation to onset of symptoms. There was no increase in the number of patients who had at least one serious adverse event for colchicine versus control groups (87 [6·7%] of 1304 vs 90 [6·9%] of 1307) or with rivaroxaban and aspirin versus control groups (85 [8·0%] vs 91 [8·6%]). Among patients assigned to colchicine, 8 (0·61%) had adverse events that led to discontinuation of study drug, mostly gastrointestinal in nature. 17 (1·6%) patients assigned to the combination of rivaroxaban and aspirin had bleeding compared with seven (0·66%) of those allocated to control (p=0·042); the number of serious bleeding events was two (0·19%) versus six (0·57%), respectively (p=0·18). No patients assigned to rivaroxaban and aspirin had serious adverse events that led to discontinuation of study drug. INTERPRETATION Among patients hospitalised with COVID-19, neither colchicine nor the combination of rivaroxaban and aspirin prevent disease progression or death. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada,Correspondence to: Prof John W Eikelboom, Population Health Research Institute, Hamilton, ON L8L 2X2, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Maria Luz Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | | | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - William Harper
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Aysha Almas
- Section of Internal Medicine, Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Oxana Drapkina
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | | | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
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Eikelboom JW, Jolly SS, Belley-Cote EP, Whitlock RP, Rangarajan S, Xu L, Heenan L, Bangdiwala SI, Tarhuni WM, Hassany M, Kontsevaya A, Harper W, Sharma SK, Lopez-Jaramillo P, Dans AL, Palileo-Villanueva LM, Avezum A, Pais P, Xavier D, Felix C, Yusufali A, Lopes RD, Berwanger O, Ali Z, Wasserman S, Anand SS, Bosch J, Choudhri S, Farkouh ME, Loeb M, Yusuf S. Colchicine and aspirin in community patients with COVID-19 (ACT): an open-label, factorial, randomised, controlled trial. Lancet Respir Med 2022; 10:1160-1168. [PMID: 36228639 PMCID: PMC9635862 DOI: 10.1016/s2213-2600(22)00299-5] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/02/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The large number of patients worldwide infected with the SARS-CoV-2 virus has overwhelmed health-care systems globally. The Anti-Coronavirus Therapies (ACT) outpatient trial aimed to evaluate anti-inflammatory therapy with colchicine and antithrombotic therapy with aspirin for prevention of disease progression in community patients with COVID-19. METHODS The ACT outpatient, open-label, 2 × 2 factorial, randomised, controlled trial, was done at 48 clinical sites in 11 countries. Patients in the community aged 30 years and older with symptomatic, laboratory confirmed COVID-19 who were within 7 days of diagnosis and at high risk of disease progression were randomly assigned (1:1) to receive colchicine 0·6 mg twice daily for 3 days and then 0·6 mg once daily for 25 days versus usual care, and in a second (1:1) randomisation to receive aspirin 100 mg once daily for 28 days versus usual care. Investigators and patients were not masked to treatment allocation. The primary outcome was assessed at 45 days in the intention-to-treat population; for the colchicine randomisation it was hospitalisation or death, and for the aspirin randomisation it was major thrombosis, hospitalisation, or death. The ACT outpatient trial is registered at ClinicalTrials.gov, NCT04324463 and is ongoing. FINDINGS Between Aug 27, 2020, and Feb 10, 2022, 3917 patients were randomly assigned to colchicine or control and to aspirin or control; after excluding 36 patients due to administrative reasons 3881 individuals were included in the analysis (n=1939 colchicine vs n=1942 control; n=1945 aspirin vs 1936 control). Follow-up was more than 99% complete. Overall event rates were 5 (0·1%) of 3881 for major thrombosis, 123 (3·2%) of 3881 for hospitalisation, and 23 (0·6%) of 3881 for death; 66 (3·4%) of 1939 patients allocated to colchicine and 65 (3·3%) of 1942 patients allocated to control experienced hospitalisation or death (hazard ratio [HR] 1·02, 95% CI 0·72-1·43, p=0·93); and 59 (3·0%) of 1945 of patients allocated to aspirin and 73 (3·8%) of 1936 patients allocated to control experienced major thrombosis, hospitalisation, or death (HR 0·80, 95% CI 0·57-1·13, p=0·21). Results for the primary outcome were consistent in all prespecified subgroups, including according to baseline vaccination status, timing of randomisation in relation to onset of symptoms (post-hoc analysis), and timing of enrolment according to the phase of the pandemic (post-hoc analysis). There were more serious adverse events with colchicine than with control (34 patients [1·8%] of 1939 vs 27 [1·4%] of 1942) but none in either group that led to discontinuation of study interventions. There was no increase in serious adverse events with aspirin versus control (31 [1·6%] vs 31 [1·6%]) and none that led to discontinuation of study interventions. INTERPRETATION The results provide no support for the use of colchicine or aspirin to prevent disease progression or death in outpatients with COVID-19. FUNDING Canadian Institutes for Health Research, Bayer, Population Health Research Institute, Hamilton Health Sciences Research Institute, and Thistledown Foundation. TRANSLATIONS For the Portuguese, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard P Whitlock
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Sumathy Rangarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Laura Heenan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada
| | - Shrikant I Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wadea M Tarhuni
- Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada,Department of Medicine, Western University, Clinical Skills Building London, ON, Canada,Windsor Cardiac Centre, Windsor, ON, Canada
| | - Mohamed Hassany
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Anna Kontsevaya
- National Medical Research Center for Therapy and Preventive Medicine, Moscow, Russia
| | - William Harper
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | - Antonio L Dans
- UP College of Medicine, University of the Philippines Manila, Manila, Philippines
| | | | - Alvaro Avezum
- International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Prem Pais
- St John's Research Institute, Bangalore, India
| | - Denis Xavier
- St John's Medical College, St John's Research Institute, Bangalore, India
| | - Camilo Felix
- Facultad de Ciencias de la Salud Eugenio Espejo, Universidad UTE, Ecuador
| | - Afzalhussein Yusufali
- Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates
| | - Renato D Lopes
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, NC, USA
| | | | - Zeeshan Ali
- Jinnah Sindh Medical University and Jinnah Postgraduate Medical Center, Karachi, Pakistan
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Sonia S Anand
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | | | - Michael E Farkouh
- Peter Munk Cardiac Centre, University of Toronto, Toronto, ON, Canada
| | - Mark Loeb
- Departments of Pathology and Molecular Medicine and Health Evidence Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences Hamilton, Ontario, Canada,Department of Medicine, McMaster University, Hamilton, ON, Canada
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Smolderen KG, Mena-Hurtado C, Eikelboom JW, Bosch J, Xie F, Ramasundarahettige C, Bhatt DL, Anand SS. Health Status and Cognitive Function for Risk Stratification in Chronic Coronary and Peripheral Artery Disease. Eur J Prev Cardiol 2022; 30:535-545. [PMID: 36444513 DOI: 10.1093/eurjpc/zwac282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS It is unclear whether health status and cognitive function assessments can augment traditional coronary artery disease (CAD) and peripheral artery disease (PAD) biomedical risk prediction frameworks. We examined the association between health status and cognitive function and subsequent adverse cardiovascular and limb events in CAD and PAD. METHODS Stable CAD and PAD patients from the international, multi-center COMPASS trial completed the visual analogue scale, (VAS) of the EQ-5D-3L to assess overall health status, and the Digit Symbol Substitution test (DSST) to assess cognitive function. Main outcomes were incident development of major adverse cardiovascular events, and the combined endpoint major adverse cardiovascular or limb events. The EQ VAS (per 10 unit increase) and DSST (per 5 unit increase) were added to fully adjusted (medications, demographics, cardiovascular history and risk factors) hierarchical Cox regression models. RESULTS A total of 23,433 patients were in the CAD cohort and 6,899 in the PAD cohort. Among both the CAD and PAD groups, higher scores on the EQ VAS (CAD: HR = 0.89, 95%CI 0.88-0.89; PAD HR = 0.89, 95%CI 0.88-0.89) and DSST (CAD HR = 0.95, 95%CI 0.94-0.95) (PAD HR = 0.95, 95%CI 0.94-0.95) were associated with a lower risk of a major adverse cardiovascular or limb events. Population attributable risks associated with the lower two quartiles vs. upper quartiles for the EQ-5D and DSST scores were 7% and 16%, respectively in the CAD cohort; and for PAD, at 14% and 18%, respectively. CONCLUSIONS Adding health status and cognitive functioning information to biomedical evaluations can augment cardiovascular risk-stratification in CAD and PAD.
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Affiliation(s)
- Kim G Smolderen
- Yale University, School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, New Haven, CT @KimGSmolderen.,Yale University, School of Medicine, Department of Psychiatry, New Haven, CT
| | - Carlos Mena-Hurtado
- Yale University, School of Medicine, Department of Internal Medicine, Vascular Medicine Outcomes Program, New Haven, CT @CarlosMenaYale
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University @johneikelboom
| | - Jackie Bosch
- Department of Medicine McMaster University, Hamilton Ontario.,School of Rehabilitation Science, McMaster University, Hamilton, Ontario
| | - Feng Xie
- Population Health Research Institute, Hamilton Health Sciences, McMaster University.,Centre for Health Economics and Policy Analysis, McMaster University, Ontario, Canada
| | - Chinthanie Ramasundarahettige
- Population Health Research Institute, Hamilton Health Sciences, McMaster University.,McMaster University, Department of Health Evidence and Impact, Hamilton, Ontario
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts @DLBhattMD
| | - Sonia S Anand
- Population Health Research Institute, Hamilton Health Sciences, McMaster University @DrSoniaAnand1.,Department of Medicine McMaster University, Hamilton Ontario.,McMaster University, Department of Health Evidence and Impact, Hamilton, Ontario
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Gaba P, Bhatt DL, Dagenais GR, Bosch J, Maggioni AP, Widimsky P, Leong D, Fox KAA, Yusuf S, Eikelboom JW. Comparison of Investigator-Reported vs Centrally Adjudicated Major Adverse Cardiac Events: A Secondary Analysis of the COMPASS Trial. JAMA Netw Open 2022; 5:e2243201. [PMID: 36409491 PMCID: PMC9679876 DOI: 10.1001/jamanetworkopen.2022.43201] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE In the Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) trial, there was a significant reduction in the adjudicated primary outcome among patients with stable atherosclerotic vascular disease randomized to dual pathway inhibition (rivaroxaban 2.5 mg twice daily plus aspirin 100 mg daily) vs aspirin monotherapy, but not with rivaroxaban 5 mg twice daily vs aspirin monotherapy. Whether the results are similar without adjudication is unknown. OBJECTIVE To examine the impact of dual pathway inhibition (with rivaroxaban plus aspirin) or rivaroxaban monotherapy compared with aspirin monotherapy on investigator-reported CV events and to understand the extent of concordance between investigator-reported and centrally adjudicated clinical events. DESIGN, SETTING, AND PARTICIPANTS This is a secondary analysis of the COMPASS trial, an international, double-blind, double-dummy, randomized clinical trial with a 3-by-2 partial factorial design that evaluated participants with stable atherosclerotic vascular disease receiving rivaroxaban plus aspirin, rivaroxaban monotherapy, or aspirin monotherapy. End points were collected by blinded site investigators and adjudicated by a blinded clinical end point committee. Data were analyzed from March 2013 through February 2017. INTERVENTIONS Participants received dual inhibition pathway (2.5 mg rivaroxaban twice daily plus 100 mg aspirin once daily), rivaroxaban monotherapy (5 mg twice daily), or aspirin monotherapy (100 mg once daily). MAIN OUTCOMES AND MEASURES The primary efficacy outcome was a composite of cardiovascular (CV) death, stroke, or myocardial infarction (MI). Adjudicated and investigator-reported end points were compared. RESULTS A total of 27 395 patients (mean [SD] age, 68.2 [7.9] years; 78.0% men) were assessed, including 9152 patients randomized to dual pathway inhibition, 9117 patients randomized to rivaroxaban monotherapy, and 9126 patients randomized to aspirin monotherapy. Adjudication reduced the number of events by 10% to 15% for most end points. Among investigator-reported end points, dual pathway inhibition significantly reduced the rate of the primary efficacy outcome compared with aspirin alone (411 patients [4.5%] vs 542 patients [5.9%]; hazard ratio [HR], 0.75 [95% CI, 0.66-0.85]; P < .001), with similar reduction in adjudicated end points, (379 patients [4.1%] vs 496 patients [5.4%]; HR, 0.76 [95% CI, 0.66-0.86]; P < .001). Likewise, effects on ischemic end points were highly concordant (κ statistic = 0.94 [95% CI, 0.93-0.95] for the primary composite end point). Unlike with adjudicated outcomes, there was a significant reduction in the primary end point with rivaroxaban monotherapy vs aspirin monotherapy using investigator-reported events (477 patients [5.2%] vs 542 patients [5.9%]; HR, 0.88 [95% CI, 0.78-0.99]; P = .04) compared with adjudicated events (448 patients [4.9%] vs 496 patients [5.4%]; HR, 0.90 [95% CI, 0.79-1.03]; P = .12). CONCLUSIONS AND RELEVANCE This secondary analysis of the COMPASS trial found that whether assessed by blinded site investigators or adjudicators, dual pathway inhibition significantly reduced CV events among patients with stable atherosclerotic disease compared with aspirin plus placebo. These findings suggest that using investigator-reported events in blinded clinical trials may be a more efficient alternative to adjudication. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01776424.
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Affiliation(s)
- Prakriti Gaba
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gilles R Dagenais
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | - Jackie Bosch
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - Petr Widimsky
- Cardiocenter, University Hospital "Kralovske Vinohrady," Prague, Czech Republic
| | - Darryl Leong
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - Salim Yusuf
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Canada
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Jensen T, Thrane PG, Olesen KKW, Würtz M, Mortensen MB, Gyldenkerne C, Thim T, Nørgaard BL, Jensen JM, Kristensen SD, Nielsen JC, Eikelboom JW, Maeng M. Antithrombotic treatment beyond one year after percutaneous coronary intervention in patients with atrial fibrillation. European Heart Journal - Cardiovascular Pharmacotherapy 2022; 9:208-219. [PMID: 36269306 DOI: 10.1093/ehjcvp/pvac058] [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] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/26/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022]
Abstract
Abstract
Aims
Beyond 1 year after percutaneous coronary intervention (PCI), guidelines recommend anticoagulant monotherapy in patients with atrial fibrillation (AF) rather than dual therapy with an anticoagulant and an antiplatelet drug. The risks and benefits of this strategy, however, remain uncertain. We examined hospitalization for bleeding and ischemic risk beyond 1 year after PCI in patients with AF treated with monotherapy versus dual therapy. Furthermore, among patients treated with monotherapy, we compared direct oral anticoagulant (DOAC) therapy and vitamin K antagonist (VKA) therapy.
Methods and results
We included all patients with AF undergoing first-time PCI between 2003 and 2017 from the Western Denmark Heart Registry and followed them for up to 4 years. Follow-up started 15 months after PCI to enable assessment of medical treatment after 12 months. Using a Cox regression model, we computed weighted hazard ratios (HRw) of hospitalization for bleeding and major adverse cardiac events (MACE). Analyses comparing monotherapy versus dual therapy included 3331 patients, and analyses comparing DOAC versus VKA monotherapy included 1275 patients. Risks of hospitalization for bleeding (HRw 0.90, 95% confidence interval [CI] 0.75–1.09) and MACE (HRw 1.04, 95% CI 0.90–1.19) were similar with monotherapy and dual therapy. Similarly, risks of hospitalization for bleeding (HRw 1.27, 95% CI 0.84–1.92) and MACE (HRw 1.15, 95% CI 0.87–1.50) were equal with DOAC and VKA monotherapy.
Conclusion
Our results support long-term OAC monotherapy beyond 1 year after PCI in patients with atrial fibrillation and suggest that DOAC monotherapy is as safe and effective as VKA monotherapy.
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Affiliation(s)
- Thomas Jensen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | | | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | - Christine Gyldenkerne
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital , Aarhus , Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
| | | | | | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - John W Eikelboom
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University , Ontario , Canada
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital , Aarhus , Denmark
- Department of Clinical Medicine, Aarhus University , Aarhus , Denmark
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Van Broekhoven A, Mohammadnia N, Silvis MJM, Los J, Fiolet ATL, Opstal TSJ, Mosterd A, Eikelboom JW, Nidorf SM, Bax WA, Tijssen JGP, De Kleijn DPV, Thompson PL, El Messaoudi S, Cornel JH. End-of-trial inflammatory biomarkers, lipid levels, creatine kinase and markers of renal and liver function in the LoDoCo2 trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1266] [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 Low-Dose Colchicine 2 (LoDoCo2) trial demonstrated that colchicine reduced major cardiovascular events in patients with chronic coronary artery disease (CAD). The effect of long-term colchicine treatment on inflammatory biomarkers and markers reflecting renal and liver function have not been investigated yet.
Purpose
This substudy examines levels of inflammatory biomarkers, lipid fractions, creatine kinase (CK) and markers of renal and liver function at close-out of the trial.
Methods
The LoDoCo2 trial randomly assigned patients with chronic CAD to colchicine 0.5 mg once daily or placebo. Blood samples were drawn during close-out visits after a median follow-up of 32.7 (interquartile range [IQR] 24.0–48.6) months.
Results
Assignment to colchicine was associated with lower levels of high-sensitivity C-Reactive Protein (0.94 mg/L [0.53–1.93] vs. 1.24 mg/L [0.73–2.55]; −24.2%; p<0.01) and interleukin-6 (2.70 ng/L [1.79–4.18] vs. 3.16 ng/L [2.07–4.95]; −14.9%; p<0.01), but was not associated with any differences in lipid fractions or markers of renal function. Although CK levels were higher after colchicine (123.0 U/L, [84.0–184.0] vs. 110.0 U/L, [77.0–164.0], p<0.01), the number of participants with marked elevations of CK (>5 times upper limit of normal [ULN]) was low and not different between treatment groups. Levels of alanine aminotransferase (ULN 40 U/L) and albumin (ULN 50 U/L) were higher (p<0.01) in the colchicine group compared to placebo (30.0 U/L [22.0–40.0] vs. 26.0 U/L [19.0–34.0] and 43.01 g/L±2.39 vs. 42.64 g/L±2.48, respectively). There were no differences in gamma-glutamyl transferase or bilirubin.
Conclusion
Long-term low-dose colchicine in patients with chronic CAD was associated with lower levels of hs-CRP and IL-6 but was not associated with clinically important differences in lipid fractions, CK, renal or liver function.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): The National Health Medical Research Council of AustraliaThe Netherlands Organization for Health Research and Development
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Affiliation(s)
- A Van Broekhoven
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - N Mohammadnia
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - M J M Silvis
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - J Los
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - A T L Fiolet
- University Medical Center Utrecht, Cardiology , Utrecht , The Netherlands
| | - T S J Opstal
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - A Mosterd
- Meander Medical Center, Cardiology , Amersfoort , The Netherlands
| | | | - S M Nidorf
- Heart and Vascular Research Institute of Western Australia , Perth , Australia
| | - W A Bax
- Northwest Clinics, Internal Medicine , Alkmaar , The Netherlands
| | - J G P Tijssen
- Amsterdam UMC, Cardiology , Amsterdam , The Netherlands
| | - D P V De Kleijn
- University Medical Center Utrecht, Vascular Surgery , Utrecht , The Netherlands
| | - P L Thompson
- University of Western Australia, School of Population and Global Health , Perth , Australia
| | - S El Messaoudi
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - J H Cornel
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
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Mohammadnia N, Los J, Opstal TSJ, Fiolet ATL, Eikelboom JW, Mosterd A, Nidorf SM, Budgeon CA, Tijssen JGP, Thompson PL, Tack CJ, Simsek S, Bax WA, Cornel JH, El Messaoudi S. The effects of colchicine in patients with diabetes mellitus and chronic coronary artery disease: a post-hoc analysis of the LoDoCo2-trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2401] [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
Atherosclerosis is an inflammatory disease and is accelerated by diabetes mellitus (DM). Patients with chronic coronary artery disease (CAD) who also have DM are at high risk of recurrent cardiovascular events. The role of inflammation in atherosclerosis is well established, whereas the role of inflammation on incident and progression of DM has been hypothesized. The nucleotide-binding oligomerization domain-, leucine-rich repeat-, and pyrin domain-containing protein 3 (NLRP3) inflammasome in particular, may play an important role in the onset and progression of T2DM. The anti-inflammatory drug colchicine attenuates the NLRP3-inflammasome. The Low-Dose Colchicine 2 (LoDoCo2) trial showed that colchicine reduces cardiovascular risk in patients with chronic CAD.
Purpose
The purpose of this study was to assess the effects of colchicine in patients with chronic CAD and DM on cardiovascular events as well as the effect of colchicine on the development of new-onset DM.
Methods
The LoDoCo2 trial randomized 5522 to placebo or colchicine, with a median follow-up of 28.6 months (interquartile range 20.5–44.4). The primary endpoint was a composite of cardiovascular death, spontaneous myocardial infarction, ischaemic stroke, or ischaemia-driven revascularization. Secondary outcomes consisted of the aforementioned events, separately. Cox proportional hazards models were used to investigate univariable associations between DM status for all endpoints in the placebo group. The interactions between treatment group and DM status were evaluated with the addition of treatment and the treatment-by-DM variable interaction.
Results
In total, 1007 participants (18.2%) had DM at baseline. The hazard ratio for the primary endpoint was 0.87 (95% CI, 0.61–1.25) in those with DM and 0.64 (95% CI, 0.51–0.80) in those without DM (p for interaction>0.05). Treatment effects of colchicine were consistent over all secondary endpoints (p for interaction>0.05). The incidence of new-onset DM was 1.5% (34/2270) in the colchicine group and 2.2% (49/2245) in the placebo group (p=0.10). Participants with DM were at higher risk for all endpoints. The primary composite end point in the placebo group occurred in 13.0% (67/515) patients with DM and in 8.8% (197/2245) of the patients without DM (unadjusted hazard ratio 1.54 [95% CI 1.16–2.03, p<0.01]) compared to the group without DM. DM was also strongly associated with the occurrence of all secondary end points.
Conclusion
This study shows that the beneficial effects of colchicine on cardiovascular endpoints are consistent regardless of DM status. The data indicate that larger trials are needed to assess whether colchicine reduces the incidence of new-onset DM.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): National Health Medical Research Council of Australia and the Netherlands Organization for Health Research and Development
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Affiliation(s)
- N Mohammadnia
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - J Los
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - T S J Opstal
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - A T L Fiolet
- University Medical Center Utrecht, Cardiology , Utrecht , The Netherlands
| | | | - A Mosterd
- Meander Medical Center, Cardiology , Amersfoort , The Netherlands
| | - S M Nidorf
- Heart and Vascular Research Institute of Western Australia , Perth , Australia
| | - C A Budgeon
- University of Western Australia , Perth , Australia
| | - J G P Tijssen
- Amsterdam UMC, Cardiology , Amsterdam , The Netherlands
| | - P L Thompson
- University of Western Australia , Perth , Australia
| | - C J Tack
- Radboud University Medical Center, Internal Medicine , Nijmegen , The Netherlands
| | - S Simsek
- Northwest Clinics, Internal Medicine , Alkmaar , The Netherlands
| | - W A Bax
- Northwest Clinics, Internal Medicine , Alkmaar , The Netherlands
| | - J H Cornel
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
| | - S El Messaoudi
- Radboud University Medical Center, Cardiology , Nijmegen , The Netherlands
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Zong J, Tang Y, Wang T, Ullah I, Xu K, Wang J, Chen P, Chen Z, Zhu T, Chen J, Li J, Wang F, Yang L, Fan Y, Shi L, Gong X, Eikelboom JW, Zhao Y, Li C. Impact of Insulin Receptor Substrate-1 rs956115 and CYP2C19 rs4244285 Genotypes on Clinical Outcome of Patients Undergoing Percutaneous Coronary Intervention. J Am Heart Assoc 2022; 11:e025058. [PMID: 35929455 PMCID: PMC9496289 DOI: 10.1161/jaha.121.025058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Insulin receptor substrate‐1 (IRS‐1) rs956115 is associated with vascular risk in patients with coronary artery disease and concomitant diabetes. CYP2C19*2 (rs4244285) modulates clopidogrel response and predicts the outcome of coronary artery disease. This study was designed to explore the association between IRS‐1, CYP2C19*2 genotypes, platelet reactivity, and 1‐year outcome in patients with coronary artery disease undergoing percutaneous coronary intervention. Methods and Results Genotyping was performed using an improved multiplex ligation detection reaction technique. Platelet aggregation was assessed by light transmission aggregometry. Major adverse cardiovascular events were defined as a composite of cardiovascular death, myocardial infarction, and ischemic stroke. A total of 2213 consecutive patients were screened and 1614 were recruited. At 1 month, patients with IRS‐1 CG genotype had significantly lower levels of ADP‐induced platelet aggregation compared with patients with CC homozygotes. Patients with IRS‐1 CG or GG genotype had a 2.09‐fold higher risk of major adverse cardiovascular events compared with those with CC homozygotes (95% CI, 1.04–4.19; P=0.0376). By comparison, patients with CYP2C19*2 GA or AA genotype had higher ADP‐induced platelet aggregation compared with patients with GG homozygotes. Although there was no significant difference in risk of major adverse cardiovascular events between patients with GA/AA and GG genotypes, patients with GA genotype had a 2.19‐fold higher risk than those with GG homozygotes (95% CI, 1.13–4.24; P=0.0200). No interaction between IRS‐1 and CYP2C19*2 genotypes was observed. Conclusions In patients following percutaneous coronary intervention, IRS‐1 GG/CG and CYP2C19*2 GA genotypes were associated with 2.09‐ and 2.19‐fold increased cardiovascular risk, respectively, at 1‐year follow‐up. The association between IRS‐1 genotypes and major adverse cardiovascular events appeared to be independent of known clinical predictors. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01968499.
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Affiliation(s)
- Jiaxin Zong
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Yingdan Tang
- Department of Biostatistics School of Public Health Nanjing Medical University Nanjing Jiangsu China
| | - Tong Wang
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China.,Department of Cardiology The First People's Hospital of Yancheng Yancheng Jiangsu China
| | - Inam Ullah
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Ke Xu
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China.,Department of Cardiology Shanghai Chest HospitalShanghai Jiao Tong University School of Medicine Shanghai China
| | - Jing Wang
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Pengsheng Chen
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Zengguang Chen
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Tiantian Zhu
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Jun Chen
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Jimin Li
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Fei Wang
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Lu Yang
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Yuansheng Fan
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Lu Shi
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - Xiaoxuan Gong
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
| | - John W Eikelboom
- Department of Medicine McMaster University or Thrombosis ServiceHamilton General Hospital Hamilton Ontario Canada
| | - Yang Zhao
- Department of Biostatistics School of Public Health Nanjing Medical University Nanjing Jiangsu China
| | - Chunjian Li
- Departments of Cardiology The First Affiliated Hospital of Nanjing Medical University Nanjing Jiangsu China
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Bosch J, Moayyedi P, Alings M, Avezum A, Bangdiwala SI, Barkun A, Cassella F, da Rocha AM, Duzen I, Enns R, Forbes N, Hamilton L, Islam S, Kilickap M, Kruger P, Liang Y, Nicolau JC, Nunes R, O’Donnell M, Oliveira G, Rey A, Sun Y, Vanassche T, Verhamme P, Walsh M, Wang Z, Wu C, Zhao L, Zhu J, Eikelboom JW. INTERBLEED: Design of an international study of risk factors for gastrointestinal bleeding and cardiovascular events after gastrointestinal bleeding. CJC Open 2022; 4:996-1005. [DOI: 10.1016/j.cjco.2022.08.002] [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] [Received: 05/23/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
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Camm CF, Virdone S, Goto S, Bassand JP, van Eickels M, Haas S, Gersh BJ, Pieper K, Fox KAA, Misselwitz F, Turpie AGG, Goldhaber SZ, Verheugt F, Camm J, Kayani G, Panchenko E, Oh S, Luciardi HL, Sawhney JPS, Connolly SJ, Angchaisuksiri P, ten Cate H, Eikelboom JW, Kakkar AK. Association of body mass index with outcomes in patients with newly diagnosed atrial fibrillation: GARFIELD-AF. Open Heart 2022. [PMCID: PMC9362832 DOI: 10.1136/openhrt-2022-002038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objective While greater body mass index (BMI) is associated with increased risk of developing atrial fibrillation (AF), the impact of BMI on outcomes in newly diagnosed AF is unclear. We examine the influence of BMI on outcomes and whether this is modified by sex and evaluate the effect of non-vitamin K oral anticoagulants (NOACs) in patients with high BMI. Methods GARFIELD-AF is a prospective registry of 52 057 newly diagnosed AF patients. The study population comprised 40 482 participants: 703 underweight (BMI <18.5 kg/m2), 13 095 normal (BMI=18.5–24.9 kg/m2), 15 043 overweight (BMI=25.0–29.9 kg/m2), 7560 obese (BMI=30.0–34.9 kg/m2) and 4081 extremely obese (BMI ≥35.0 kg/m2). Restricted cubic splines quantified the association of BMI with outcomes. Comparative effectiveness of NOACs and vitamin K antagonists (VKAs) by BMI was performed using propensity score overlap-weighted Cox models. Results The median age of participants was 71.0 years (Q1; Q3 62.0; 78.0), and 55.6% were male. Those with high BMI were younger, more often had vascular disease, hypertension and diabetes. Within 2-year follow-up, a U-shaped relationship between BMI and all-cause mortality was observed, with BMI of ~30 kg/m2 associated with the lowest risk. The association with new/worsening heart failure was similar. Only low BMI was associated with major bleeding and no association emerged for non-haemorrhagic stroke. BMI was similarly associated with outcomes in men and women. BMI did not impact the lower rate of all-cause mortality of NOACs compared with VKAs. Conclusions In the GARFIELD-AF registry, underweight and extremely obese AF patients have increased risk of mortality and new/worsening heart failure compared with normal or obese patients.
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