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Lemesle G, Lamblin N, Schurtz G, Labreuche J, Duhamel A, Verdier B, Steg PG, Bauters C. Comparison of Incidence and Prognostic Impact of Ischemic Major Bleeding and Heart Failure Events in Patients With Chronic Coronary Syndrome: Insights From the CORONOR Registry. Circulation 2024. [PMID: 38660793 DOI: 10.1161/circulationaha.123.067938] [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: 11/13/2023] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Evaluation of the residual risk in patient with chronic coronary syndrome is challenging in daily practice. Several types of events (myocardial infarction, ischemic stroke, bleeding, and heart failure [HF]) may occur, and their impact on subsequent mortality is unclear in the era of modern evidence-based pharmacotherapy. METHODS CORONOR (Suivi d'une cohorte de patients Coronariens stables en région Nord-pas-de-Calais) is a prospective multicenter cohort that enrolled 4184 consecutive unselected outpatients with chronic coronary syndrome. We analyzed the incidence, correlates, and impact of ischemic events (a composite of myocardial infarction and ischemic stroke), major bleeding (Bleeding Academic Research Consortium 3 or higher), and hospitalization for HF on subsequent patient mortality. RESULTS During follow-up (median, 4.9 years), 677 patients (16.5%) died. The 5-year cumulative incidences (death as competing event) of ischemic events, major bleeding, and HF hospitalization were 6.3% (5.6%-7.1%), 3.1% (2.5%-3.6%), and 8.1% (7.3%-9%), respectively. Ischemic events, major bleeding, and HF hospitalization were each associated with all-cause mortality. Major bleeding and hospitalization for HF were associated with the highest mortality rates in the postevent period (42.4%/y and 34.7%/y, respectively) compared with incident ischemic events (13.1%/y). The age- and sex-adjusted hazard ratios for all-cause mortality were 3.57 (95% CI, 2.77-4.61), 9.88 (95% CI, 7.55-12.93), and 8.60 (95% CI, 7.15-10.35) for ischemic events, major bleeding, and hospitalization for HF, respectively (all P<0.001). CONCLUSIONS Hospitalization for HF has become both the most frequent and one of the most ominous events among patients with chronic coronary syndrome. Although less frequent, major bleeding is strongly associated with worse patient survival. Secondary prevention should not be limited to preventing ischemic events. Minimizing bleeding and preventing HF may be at least as important.
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Affiliation(s)
- Gilles Lemesle
- Heart and Lung Institute, University Hospital of Lille, France (G.L.)
- Université de Lille, France (G.L.)
- Institut Pasteur of Lille, Inserm U1011, Lille, France (G.L.)
- FACT (French Alliance for Cardiovascular Trials), Paris, France (G.L.)
| | - Nicolas Lamblin
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, France (N.L., C.B.)
| | | | - Julien Labreuche
- Department of Biostatistics, CHU Lille, Lille, France (J.L., A.D.)
| | - Alain Duhamel
- Department of Biostatistics, CHU Lille, Lille, France (J.L., A.D.)
| | | | - Philippe Gabriel Steg
- Université Paris-Diderot, France (P.G.S.)
- AP-HP, Hopital Bichat, and INSERM U1148, FACT (French Alliance for Cardiovascular Trials), an F-CRIN network, Paris, France (P.G.S.)
| | - Christophe Bauters
- Université de Lille, Inserm, CHU Lille, Institut Pasteur de Lille, France (N.L., C.B.)
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Goodman SG, Steg PG, Szarek M, Bhatt DL, Bittner VA, Diaz R, Harrington RA, Jukema JW, White HD, Zeiher AM, Manvelian G, Pordy R, Poulouin Y, Stipek W, Garon G, Schwartz GG. Safety Of The Pcsk9 Inhibitor Alirocumab: insights From 47,296 Patient-Years Of Observation. Eur Heart J Cardiovasc Pharmacother 2024:pvae025. [PMID: 38658193 DOI: 10.1093/ehjcvp/pvae025] [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: 04/26/2024]
Abstract
The ODYSSEY OUTCOMES trial, comprising over 47 000 patient-years of placebo-controlled observation, demonstrated important reductions in the risk of recurrent ischaemic cardiovascular events with the monoclonal antibody to proprotein convertase subtilisin/kexin type 9 alirocumab, as well as lower all-cause death. These benefits were observed in the context of substantial and persistent lowering of low-density lipoprotein cholesterol with alirocumab compared to that achieved with placebo. The safety profile of alirocumab was indistinguishable from matching placebo except for a ∼1.7% absolute increase in local injection-site reactions. Further, the safety of alirocumab compared to placebo was evident in vulnerable groups identified before randomization, such as the elderly and those with diabetes mellitus, previous ischaemic stroke, or chronic kidney disease. The frequency of adverse events and laboratory-based abnormalities was generally similar to that in placebo-treated patients. Thus, alirocumab appears to be a safe and effective lipid-modifying treatment over a duration of at least 5 years.
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Affiliation(s)
- Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philippe Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), and INSERM U1148, Paris, France
| | - Michael Szarek
- CPC Clinical Research and Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
- State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, NY, NY, USA
| | - Vera A Bittner
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - J Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Harvey D White
- Green Lane Cardiovascular Research Unit, Te Whatu Ora-Health New Zealand, Te Toka Tumai, and University of Auckland, Auckland, New Zealand
| | - Andreas M Zeiher
- Department of Medicine III, Goethe University, Frankfurt am Main, Germany
| | | | - Robert Pordy
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
| | | | - Wanda Stipek
- Regeneron Pharmaceuticals Inc., Tarrytown, NY, USA
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Holtrop J, Bhatt DL, Ray KK, Mach F, Smulders YM, Carballo D, Steg PG, Visseren FLJ, Dorresteijn JAN. Impact of the 2021 European Society for Cardiology prevention guideline's stepwise approach for cardiovascular risk factor treatment in patients with established atherosclerotic cardiovascular disease. Eur J Prev Cardiol 2024; 31:754-762. [PMID: 38324720 DOI: 10.1093/eurjpc/zwae038] [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: 11/16/2023] [Revised: 01/24/2024] [Accepted: 01/27/2024] [Indexed: 02/09/2024]
Abstract
AIMS This study aimed to evaluate the stepwise approach for cardiovascular (CV) risk factor treatment as outlined by the European Society for Cardiology 2021 guidelines on CV disease (CVD) prevention in patients with established atherosclerotic CVD (ASCVD). METHODS AND RESULTS In patients with ASCVD, included in UCC-SMART (n = 8730) and European parts of the REACH registry (n = 18 364), the 10-year CV risk was estimated using SMART2. Treatment effects were derived from meta-analyses and trials. Step 1 recommendations were LDL cholesterol (LDLc) < 1.8 mmol/L, systolic blood pressure (SBP) < 140 mmHg, using any antithrombotic medication, sodium-glucose co-transporter 2 (SGLT2) inhibition, and smoking cessation. Step 2 recommendations were LDLc < 1.4 mmol/L, SBP < 130 mmHg, dual-pathway inhibition (DPI, aspirin plus low-dose rivaroxaban), colchicine, glucagon-like peptide (GLP)-1 receptor agonists, and eicosapentaenoic acid. Step 2 was modelled accounting for Step 1 non-attainment. With current treatment, residual CV risk was 22%, 32%, and 60% in the low, moderate, and pooled (very) high European risk regions, respectively. Step 2 could prevent up to 198, 223 and 245 events per 1000 patients treated, respectively. Intensified LDLc reduction, colchicine, and DPI could be applied to most patients, preventing up to 57, 74, and 59 events per 1000 patients treated, respectively. Following Step 2, the number of patients with a CV risk of <10% could increase from 20%, 6.4%, and 0.5%, following Step 1, to 63%, 48%, and 12%, in the respective risk regions. CONCLUSION With current treatment, residual CV risk in patients with ASCVD remains high across all European risk regions. The intensified Step 2 treatment options result in marked further reduction of residual CV risk in patients with established ASCVD. KEY FINDINGS Guideline-recommended intensive treatment of patients with cardiovascular disease could prevent additional 198-245 new cardiovascular events for every 1000 patients treated.
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Affiliation(s)
- Joris Holtrop
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Kausik K Ray
- Imperial Centre for Cardiovascular Disease Prevention, ICTU-Global, Imperial College London, London, UK
| | - François Mach
- Division of Cardiology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Yvo M Smulders
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
| | - David Carballo
- Division of Cardiology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials) NSERM1148/LVTS, AP-HP, Hôpital Bichat, Paris, France
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
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Hernandez AF, Udell JA, Jones WS, Anker SD, Petrie MC, Harrington J, Mattheus M, Seide S, Zwiener I, Amir O, Bahit MC, Bauersachs J, Bayes-Genis A, Chen Y, Chopra VK, Figtree G, Ge J, Goodman S, Gotcheva N, Goto S, Gasior T, Jamal W, Januzzi JL, Jeong MH, Lopatin Y, Lopes RD, Merkely B, Parikh PB, Parkhomenko A, Ponikowski P, Rossello X, Schou M, Simic D, Steg PG, Szachniewicz J, van der Meer P, Vinereanu D, Zieroth S, Brueckmann M, Sumin M, Bhatt DL, Butler J. Effect of Empagliflozin on Heart Failure Outcomes After Acute Myocardial Infarction: Insights from the EMPACT-MI Trial. Circulation 2024. [PMID: 38581389 DOI: 10.1161/circulationaha.124.069217] [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: 02/12/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Empagliflozin reduces the risk of heart failure events in patients with type 2 diabetes at high cardiovascular risk, chronic kidney disease, and in those with prevalent heart failure irrespective of ejection fraction. While EMPACT-MI showed empagliflozin does not reduce the risk of the composite of hospitalization of heart failure and all-cause mortality, the impact of empagliflozin on first and recurrent heart failure events in patients after myocardial infarction is unknown. METHODS EMPACT-MI was a double-blind, randomized, placebo-controlled, event-driven trial that randomized 6522 patients hospitalized for acute myocardial infarction at risk for heart failure based on newly developed left ventricular ejection fraction of <45% and/or signs or symptoms of congestion to receive empagliflozin 10 mg daily or placebo within 14 days of admission. In prespecified secondary analyses, treatment groups were analyzed for heart failure outcomes. RESULTS Over a median of follow-up of 17.9 months, the risk for first heart failure hospitalization and total heart failure hospitalizations was significantly lower in the empagliflozin compared with the placebo group (118 (3.6%) vs. 153 (4.7%) patients with events, HR 0.77 [95% CI 0.60, 0.98], P=0.031 for first heart failure hospitalization and 148 vs. 207 events, RR 0.67 [95% CI 0.51, 0.89], P=0.006 for total heart failure hospitalizations). Subgroup analysis showed consistency of empagliflozin benefit across clinically relevant patient subgroups for first and total heart failure hospitalizations. Post-discharge need for new use of diuretics, renin-angiotensin modulators, and mineralocorticoid receptor antagonists were less in patients randomized to empagliflozin than placebo (all p<0.05). CONCLUSIONS In patients after acute myocardial infarction with left ventricular dysfunction or congestion, empagliflozin reduced the risk of heart failure.
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Affiliation(s)
- Adrian F Hernandez
- Duke University Department of Medicine, Division of Cardiology, and Duke Clinical Research Institute, Durham, NC
| | - Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - W Schuyler Jones
- Duke University Department of Medicine, Division of Cardiology, and Duke Clinical Research Institute, Durham, NC
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Mark C Petrie
- School of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Josephine Harrington
- Duke University Department of Medicine, Division of Cardiology, and Duke Clinical Research Institute, Durham, NC
| | | | - Svenja Seide
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | | - Offer Amir
- Heart Institute, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, and Department of Medicine, Universitat Autònomoa de Barcelona, Barcelona, Spain
| | - Yundai Chen
- Department of Cardiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shaun Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, St Michael's Hospital, Unity Health Toronto and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nina Gotcheva
- Department of Cardiology, MHAT "National Cardiology Hospital" EAD, Sofia, Bulgaria
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Tomasz Gasior
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; Collegium Medicum, Faculty of Medicine, WSB University, Dabrowa Gornicza, Poland
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA
| | - Myung Ho Jeong
- Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Renato D Lopes
- Duke University Department of Medicine, Division of Cardiology, and Duke Clinical Research Institute, Durham, NC
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| | - Alexander Parkhomenko
- The Ukrainian Institute of Cardiology n. a. M.D. Strazhesko, AMS Ukraine, Kyiv, Ukraine
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Xavier Rossello
- Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Dragan Simic
- Department of Cardiovascular Diseases, University Clinical Center Belgrade, Serbia
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), INSERM U-1148, AP-HP, Hôpital Bichat, Paris, France
| | | | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dragos Vinereanu
- University and Emergency Hospital of Bucharest, Bucharest, Romania
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, and Department of Medicine, University of Mississippi, Jackson, MS
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5
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Udell JA, Petrie MC, Jones WS, Anker SD, Harrington J, Mattheus M, Seide S, Amir O, Bahit MC, Bauersachs J, Bayes-Genis A, Chen Y, Chopra VK, Figtree G, Ge J, Goodman SG, Gotcheva N, Goto S, Gasior T, Jamal W, Januzzi JL, Jeong MH, Lopatin Y, Lopes RD, Merkely B, Martinez-Traba M, Parikh PB, Parkhomenko A, Ponikowski P, Rossello X, Schou M, Simic D, Steg PG, Szachniewicz J, van der Meer P, Vinereanu D, Zieroth S, Brueckmann M, Sumin M, Bhatt DL, Hernandez AF, Butler J. Left Ventricular Function, Congestion, and Effect of Empagliflozin on Heart Failure Risk After Myocardial Infarction. J Am Coll Cardiol 2024:S0735-1097(24)06757-3. [PMID: 38588929 DOI: 10.1016/j.jacc.2024.03.405] [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: 02/22/2024] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Empagliflozin reduces the risk of heart failure (HF) hospitalizations but not all-cause mortality when started within 14 days of acute myocardial infarction (AMI). OBJECTIVE To evaluate the association between left ventricular ejection fraction (LVEF), congestion, or both on outcomes and the impact of empagliflozin in reducing HF risk post-MI. METHODS In the EMPACT-MI trial, patients were randomized within 14 days of an AMI complicated by either newly reduced LVEF<45%, congestion, or both to empagliflozin 10 mg daily or placebo and followed for a median of 17.9 months. RESULTS Among 6522 patients, the mean baseline LVEF was 41%+9%; 2648 patients (40.6%) presented with LVEF<45% alone, 1483 (22.7%) presented with congestion alone, and 2181 (33.4%) presented with both. Among patients in the placebo arm, multivariable adjusted risk for each 10-point reduction in LVEF included all-cause death or HF hospitalization (hazard ratio [HR] 1.49; 95%CI, 1.31-1.69; P<0.0001), first HF hospitalization (HR, 1.64; 95%CI, 1.37-1.96; P<0.0001), and total HF hospitalizations (rate ratio [RR], 1.89; 95%CI, 1.51-2.36; P<0.0001). Presence of congestion was also associated with a significantly higher risk for each of these outcomes (HR 1.52, 1.94, and RR 2.03, respectively). Empagliflozin reduced the risk for first (HR 0.77, 95%CI 0.60-0.98) and total (RR 0.67, 95%CI 0.50-0.89) HF hospitalization, irrespective of LVEF or congestion or both. The safety profile of empagliflozin was consistent across baseline LVEF and irrespective of congestion status. CONCLUSIONS In patients with AMI, severity of LV dysfunction and the presence of congestion was associated with worse outcomes. Empagliflozin reduced first and total HF hospitalizations across the range of LVEF with and without congestion.
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Affiliation(s)
- Jacob A Udell
- Women's College Hospital and Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada;.
| | - Mark C Petrie
- School of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - W Schuyler Jones
- Division of Cardiology, Duke University Department of Medicine, Durham, NC, USA, and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Josephine Harrington
- Division of Cardiology, Duke University Department of Medicine, Durham, NC, USA, and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | | | - Svenja Seide
- Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Offer Amir
- Heart Institute, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Santa Fe, Argentina
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain, and Department of Medicine, Universitat Autònomoa de Barcelona, Barcelona, Spain
| | - Yundai Chen
- Department of Cardiology, the First Medical Center of Chinese PLA General Hospital, Beijing, China
| | | | - Gemma Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta; Division of Cardiology, Department of Medicine, St Michael's Hospital, Unity Health Toronto and Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Nina Gotcheva
- Department of Cardiology, MHAT "National Cardiology Hospital" EAD, Sofia, Bulgaria
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Japan
| | - Tomasz Gasior
- Boehringer Ingelheim International GmbH, Ingelheim, Germany, and Collegium Medicum - Faculty of Medicine, WSB University, Dabrowa Gornicza, Poland
| | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Myung Ho Jeong
- Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Renato D Lopes
- Division of Cardiology, Duke University Department of Medicine, Durham, NC, USA, and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Puja B Parikh
- Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Alexander Parkhomenko
- The Ukrainian Institute of Cardiology n. a. M.D. Strazhesko, AMS Ukraine, Kyiv, Ukraine
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Xavier Rossello
- Hospital Universitari Son Espases, Health Research Institute of the Balearic Islands, University of the Balearic Islands, Palma de Mallorca, Spain
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Dragan Simic
- Department of Cardiovascular Diseases, University Clinical Center Belgrade, Serbia
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), INSERM U-1148, AP-HP, Hôpital Bichat, Paris, France
| | | | - Peter van der Meer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Bucharest, Romania
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany, and First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Department of Medicine, Durham, NC, USA, and Duke University Medical Center, Duke Clinical Research Institute, Durham, NC, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA, and Department of Medicine, University of Mississippi, Jackson, MS, USA
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Krucoff M, Spirito A, Baber U, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Ticagrelor with or without aspirin following percutaneous coronary intervention in high-risk patients with concomitant peripheral artery disease: A subgroup analysis of the TWILIGHT randomized clinical trial. Am Heart J 2024; 272:11-22. [PMID: 38458371 DOI: 10.1016/j.ahj.2024.03.002] [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: 11/08/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The optimal antiplatelet regimen after percutaneous coronary intervention (PCI) in patients with peripheral artery disease (PAD) is still debated. This analysis aimed to compare the effect of ticagrelor monotherapy versus ticagrelor plus aspirin in patients with PAD undergoing PCI. METHODS In the TWILIGHT trial, patients at high ischemic or bleeding risk that underwent PCI were randomized after 3 months of dual antiplatelet therapy (DAPT) to aspirin or matching placebo in addition to open-label ticagrelor for 12 additional months. In this post-hoc analysis, patient cohorts were examined according to the presence or absence of PAD. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke. Endpoints were assessed at 12 months after randomization. RESULTS Among 7,119 patients, 489 (7%) had PAD and were older, more likely to have comorbidities, and multivessel disease. PAD patients had more bleeding or ischemic complications than no-PAD patients. Ticagrelor monotherapy compared to ticagrelor plus aspirin was associated with less BARC 2, 3, or 5 bleeding in PAD (4.6% vs 8.7%; HR 0.52; 95%CI 0.25-1.07) and no-PAD patients (4.0% vs 7.0%; HR 0.56; 95%CI 0.45-0.69; interaction P-value .830) and a similar risk of death, MI, or stroke in these 2 groups (interaction P-value .446). CONCLUSIONS Despite their higher ischemic and bleeding risk, patients with PAD undergoing PCI derived a consistent benefit from ticagrelor monotherapy after 3 months of DAPT in terms of bleeding reduction without any relevant increase in ischemic events. CLINICAL TRIAL REGISTRY INFORMATION:: https://www. CLINICALTRIALS gov/study/NCT02270242.
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Affiliation(s)
- Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital, Roslyn, Roslyn, NY
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang 110016, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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7
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Mann DL, Nicolas J, Claggett B, Miao ZM, Granger CB, Kerkar P, Køber L, Lewis EF, McMurray JJV, Maggioni AP, Núñez J, Ntsekhe M, Rouleau JL, Sim D, Solomon SD, Steg PG, van der Meer P, Braunwald E, Pfeffer MA, Mehran R. Angiotensin Receptor-Neprilysin Inhibition in Patients With STEMI vs NSTEMI. J Am Coll Cardiol 2024; 83:904-914. [PMID: 38418004 DOI: 10.1016/j.jacc.2024.01.002] [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: 10/16/2023] [Revised: 12/07/2023] [Accepted: 01/02/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Patients who sustain an acute myocardial infarction (AMI), including ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI), remain at high risk for heart failure (HF), coronary events, and death. Angiotensin-converting enzyme inhibitors have been shown to significantly decrease the risk for cardiovascular events in both STEMI and NSTEMI patients. OBJECTIVES The objectives were to determine whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan, compared with ramipril, has impact on reducing cardiovascular events according to the type of AMI. METHODS The PARADISE-MI (Prospective ARNI versus ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction) trial enrolled patients with AMI complicated by left ventricular dysfunction and/or pulmonary congestion and at least 1 risk-enhancing factor. Patients were randomized to either sacubitril/valsartan or ramipril. The primary endpoint was death from cardiovascular causes or incident HF. In this prespecified analysis, we stratified patients according to AMI type. RESULTS Of 5,661 enrolled patients, 4,291 (75.8%) had STEMI. These patients were younger and had fewer comorbidities and cardiovascular risk factors than NSTEMI patients. After adjustment for potential confounders, the risk for the primary outcome was marginally higher in NSTEMI vs STEMI patients (adjusted HR: 1.19; 95% CI: 1.00-1.41), with borderline statistical significance (P = 0.05). The primary composite outcome occurred at similar rates in patients randomized to sacubitril/valsartan vs ramipril in STEMI (10% vs 12%; HR: 0.87; 95% CI: 0.73-1.04; P = 0.13) and NSTEMI patients (17% vs 17%; HR: 0.97; 95% CI: 0.75-1.25; P = 0.80; P interaction = 0.53). CONCLUSIONS Compared with ramipril, sacubitril/valsartan did not significantly decrease the risk for cardiovascular death and HF in patients with AMI complicated by left ventricular dysfunction, irrespective of the type of AMI. (Prospective ARNI vs ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI; NCT02924727).
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Affiliation(s)
- Douglas L Mann
- Washington University School of Medicine, St Louis, Missouri, USA.
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | | | - Prafulla Kerkar
- Department of Cardiology, KEM Hospital, Mumbai, Maharashtra, India
| | - Lars Køber
- Rigshospitalet, Blegdamsvej, Copenhagen, Denmark
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | | | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
| | - Mpiko Ntsekhe
- Division of Cardiology, University of Cape Town & Groote Schuur Hospital, Cape Town, South Africa
| | | | - David Sim
- National Heart Center Singapore, Singapore, Singapore
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM_U1148, Paris, France
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Wiernik E, Renuy A, Kab S, Steg PG, Goldberg M, Zins M, Caligiuri G, Bouchard P, Carra MC. Prevalence of self-reported severe periodontitis: Data from the population-based CONSTANCES cohort. J Clin Periodontol 2024. [PMID: 38430050 DOI: 10.1111/jcpe.13969] [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] [Received: 06/29/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 03/03/2024]
Abstract
AIM To assess the prevalence of severe periodontitis based on the population-based CONSTANCES cohort using a validated self-reported questionnaire. MATERIALS AND METHODS Individuals were selected from the adult population in France using a random sampling scheme. Analyses were restricted to those invited in 2013-2014 who completed the periodontal health questionnaire at the 2017 follow-up. The risk of severe periodontitis was assessed using the periodontal screening score (PESS) and weighting coefficients were applied to provide representative results in the general French population. RESULTS The study included 19,859 participants (9204 men, mean age: 52.8 ± 12.6 years). Based on a PESS ≥ 5, 7106 participants were at risk of severe periodontitis, corresponding to a weighted prevalence of 31.6% (95% confidence interval: 30.6%-32.7%). This prevalence was higher among participants aged 55 and over, those with lower socio-economic status as well as current smokers, e-cigarette users and heavy drinkers. Among individuals at risk of severe periodontitis, only 18.8% (17.3%-20.4%) thought they had gum disease, although 50.5% (48.6%-52.5%) reported that their last dental visit was less than 6 months. CONCLUSIONS The present survey indicates that (1) self-reported severe periodontitis is highly prevalent with marked disparities between groups in the general French adult population, and (2) periodontitis could frequently be under-diagnosed given the low awareness.
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Affiliation(s)
- Emmanuel Wiernik
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
| | - Adeline Renuy
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
| | - Sofiane Kab
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
| | - Philippe Gabriel Steg
- UFR de Médecine, Université Paris-Cité, Paris, France
- Cardiology Department, AP-HP, Hôpital Bichat, Paris, France
- Laboratory for Vascular Translational Science, INSERM U1148, Paris, France
- Institut Universitaire de France, Paris, France
| | - Marcel Goldberg
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
| | - Marie Zins
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
- UFR de Médecine, Université Paris-Cité, Paris, France
| | - Giuseppina Caligiuri
- UFR de Médecine, Université Paris-Cité, Paris, France
- Cardiology Department, AP-HP, Hôpital Bichat, Paris, France
- Laboratory for Vascular Translational Science, INSERM U1148, Paris, France
| | - Philippe Bouchard
- UFR of Odontology, Université Paris Cité, Paris, France
- URP 2496, Montrouge, France
| | - Maria Clotilde Carra
- UMS 011 Population-based Cohorts Unit, Université Paris Cité, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, INSERM, Paris, France
- UFR of Odontology, Université Paris Cité, Paris, France
- Service of Odontology, Rothschild Hospital (AP-HP) and Department of Periodontology, UFR of Odontology, Université Paris Cité, Paris, France
- INSERM-Sorbonne Paris Cité Epidemiology and Statistics Research Centre, Paris, France
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9
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Ducrocq G, Cachanado M, Simon T, Puymirat E, Lemesle G, Lattuca B, Ariza-Solé A, Silvain J, Ferrari E, Gonzalez-Juanatey JR, Martínez-Sellés M, Lermusier T, Coste P, Vanzetto G, Cottin Y, Dillinger JG, Calvo G, Steg PG. Restrictive vs Liberal Blood Transfusions for Patients with Acute Myocardial Infarction and Anaemia by Heart Failure Status: An RCT Subgroup Analysis. Can J Cardiol 2024:S0828-282X(24)00179-X. [PMID: 38408702 DOI: 10.1016/j.cjca.2024.02.013] [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] [Received: 10/25/2023] [Revised: 02/12/2024] [Accepted: 02/18/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Red blood cell transfusion can cause fluid overload. We evaluated the interaction between heart failure (HF) at baseline and transfusion strategy on outcomes in acute myocardial infarction (AMI). METHODS We used data from the randomized REALITY trial (https://www. CLINICALTRIALS gov/study/NCT02648113), comparing restrictive versus liberal transfusion strategies in patients with AMI and anaemia. HF was defined as history of HF or Killip class > 1 at randomization. Primary outcome was major adverse cardiovascular events (MACE: composite of all-cause death, non-recurrent AMI, stroke, or emergency revascularization prompted by ischaemia) at 30 days. RESULTS Among 658 randomized patients, 311 (47.3%) had HF. HF patients had higher rates of MACE at 30 days and 1 year, and higher rates of non-fatal new-onset HF. There was no interaction between HF and effect of randomized assignment on the primary outcome or non-fatal new-onset HF. A liberal transfusion strategy was associated with increased all-cause death at 30 days and at 1 year in HF patients (Pinteraction = 0.009 and P = 0.049, respectively). The main numerical difference in cause of death between restrictive and liberal strategies was death by HF at 30 days (4 vs 11). CONCLUSIONS HF is frequent in AMI patients with anaemia and is associated with higher risk of MACE (including all-cause death) and non-fatal new-onset HF. While there was no interaction of HF with effect of transfusion strategy on MACE, a liberal transfusion strategy was associated with higher all-cause death that appears driven by a higher risk of early death due to HF.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, Assistance Publique-Hôpitaux de Paris (AP-HP), French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine; Sorbonne-Université; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine; Sorbonne-Université; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Etienne Puymirat
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, French Alliance for Cardiovascular Trials (FACT), Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; Paris, France
| | - Benoit Lattuca
- Cardiology department, Nimes University Hospital, Montpellier University, Nimes, France
| | - Albert Ariza-Solé
- Bellvitge University Hospital. Bioheart. Grup de Malalties Cardiovasculars. Institut d'Investigació Biomèdica de Bellvitge; IDIBELL; L'Hospitalet de Llobregat, Barcelona, Spain
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, AP-HP, Hôpital Pitié-Salpêtrière, INSERM UMRS 1166 Paris, France
| | - Emile Ferrari
- Université Côte d'Azur, and CHU de Nice, Hôpital Pasteur 1, Service de Cardiologie, French Alliance for Cardiovascular Trials (FACT), Nice, France
| | - Jose R Gonzalez-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, and Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | - Pierre Coste
- Cardiology Hospital, University of Bordeaux, Bordeaux, France
| | - Gerald Vanzetto
- Service de Cardiologie, CHU Grenoble Alpes; Université Grenoble Alpes; LRB INSERM U 1039, Grenoble, France
| | - Yves Cottin
- Centre Hospitalier Universitaire de Dijon; Université de Bourgogne, Dijon, France
| | - Jean G Dillinger
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, and INSERM U-942, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Philippe Gabriel Steg
- Université Paris-Cité, INSERM-UMR1148; Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials); and Institut Universitaire de France; all in Paris, France.
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10
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Gautier A, Picard F, Ducrocq G, Elbez Y, Fox KM, Ferrari R, Ford I, Tardif JC, Tendera M, Steg PG. New-onset atrial fibrillation and chronic coronary syndrome in the CLARIFY registry. Eur Heart J 2024; 45:366-375. [PMID: 37634147 PMCID: PMC10834159 DOI: 10.1093/eurheartj/ehad556] [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: 02/05/2023] [Revised: 07/13/2023] [Accepted: 08/20/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Data on new-onset atrial fibrillation (NOAF) in patients with chronic coronary syndromes (CCS) are scarce. This study aims to describe the incidence, predictors, and impact on cardiovascular (CV) outcomes of NOAF in CCS patients. METHODS Data from the international (45 countries) CLARIFY registry (prospeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) were used. Among 29 001 CCS outpatients without previously reported AF at baseline, patients with at least one episode of AF/flutter diagnosed during 5-year follow-up were compared with patients in sinus rhythm throughout the study. RESULTS The incidence rate of NOAF was 1.12 [95% confidence interval (CI) 1.06-1.18] per 100 patient-years (cumulative incidence at 5 years: 5.0%). Independent predictors of NOAF were increasing age, increasing body mass index, low estimated glomerular filtration rate, Caucasian ethnicity, alcohol intake, and low left ventricular ejection fraction, while high triglycerides were associated with lower incidence. New-onset atrial fibrillation was associated with a substantial increase in the risk of adverse outcomes, with adjusted hazard ratios of 2.01 (95% CI 1.61-2.52) for the composite of CV death, non-fatal myocardial infarction, or non-fatal stroke, 2.61 (95% CI 2.04-3.34) for CV death, 1.64 (95% CI 1.07-2.50) for non-fatal myocardial infarction, 2.27 (95% CI 1.85-2.78) for all-cause death, 8.44 (95% CI 7.05-10.10) for hospitalization for heart failure, and 4.46 (95% CI 2.85-6.99) for major bleeding. CONCLUSIONS Among CCS patients, NOAF is common and is strongly associated with worse outcomes. Whether more intensive preventive measures and more systematic screening for AF would improve prognosis in this population deserves further investigation.
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Affiliation(s)
- Alexandre Gautier
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
| | - Fabien Picard
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
- Department of Cardiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, 27 Rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Gregory Ducrocq
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
| | - Yedid Elbez
- Signifience, 35 rue de l'Oasis, 92800 Puteaux, France
| | - Kim M Fox
- NHLI Imperial College, Dovehouse Street, London SW3 6LP, UK
| | - Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Via Aldo Moro 8, 44124 Cona (FE) Italy, Scientific Department of Medical Trial Analysis (MTA), Via Antonio Riva 6, 6900, Lugano, Switzerland
| | - Ian Ford
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montreal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Ziolowa Street 45/47, 40-635 Katowice, Poland
| | - Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
- Université Paris Cité, 85 boulevard Saint-Germain, 75006 Paris, France
- Institut Universitaire de France, 1 Rue Descartes, 75005 Paris, France
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11
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Petrie MC, Rouleau JL, Claggett B, Jering K, van der Meer P, Køber L, Miao ZM, Lewis E, Granger C, De Pasqulae CG, Mann D, Steg PG, Maggioni A, Amir O, Lefkowitz M, Braunwald E, Solomon SD, McMurray JJV, Pfeffer MA. Pulmonary Congestion and Left Ventricular Dysfunction After Myocardial Infarction: Insights From the PARADISE-MI Trial. Circulation 2024; 149:335-338. [PMID: 38252738 DOI: 10.1161/circulationaha.123.066163] [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: 01/24/2024]
Affiliation(s)
- Mark C Petrie
- School of Cardiovascular and Metabolic Health, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (M.C.P., J.J.V.M.)
| | - Jean L Rouleau
- Montréal Heart Institute, University of Montréal, Quebec, Canada (J.L.R.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (P.v.d.M.)
| | - Lars Køber
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Eldrin Lewis
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | | | - Carmine G De Pasqulae
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia, Flinders University (C.G.D.P.)
| | - Douglas Mann
- Washington University Medical Center, St Louis, MO (D.M.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, Assistance Publique-Hôpitaux de Paris, French Alliance for Cardiovascular Trials, INSERM U-1148, France (P.G.S.)
| | | | - Offer Amir
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel (O.A.)
| | - Marty Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L.)
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - John J V McMurray
- School of Cardiovascular and Metabolic Health, British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (M.C.P., J.J.V.M.)
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (B.C., K.J., Z.M.M., E.B., S.D.S., M.A.P.)
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Steg PG, Feldman LJ, Omerovic E. Observational studies play little role in guiding evidence-based medicine: pros and cons. EUROINTERVENTION 2024; 20:29-31. [PMID: 38165107 PMCID: PMC10756226 DOI: 10.4244/eij-e-23-00023] [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: 01/03/2024]
Affiliation(s)
- Philippe Gabriel Steg
- Université Paris-Cité, INSERM U-1148, French Alliance for Cardiovascular Trials (FACT), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat, Paris, France
- Institut Universitaire de France, Paris, France
| | - Laurent J Feldman
- Université Paris-Cité, INSERM U-1148, French Alliance for Cardiovascular Trials (FACT), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Bichat, Paris, France
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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13
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Schou M, Claggett B, Miao ZM, Fernandez A, Filippatos G, Granger C, Jering K, Maggioni AP, McCausland F, Villota JN, Rouleau JL, Mody FV, van der Meer P, Vinereanu D, McGrath M, Zhou Y, Mann DL, Solomon SD, Steg PG, Braunwald E, McMurray JJV, Pfeffer MA, Køber L. Sacubitril/valsartan compared to ramipril in high-risk post-myocardial infarction patients stratified according to use of mineralocorticoid receptor antagonists: Insight from the PARADISE MI trial. Eur J Heart Fail 2024; 26:130-139. [PMID: 37933184 DOI: 10.1002/ejhf.3079] [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: 06/02/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023] Open
Abstract
AIM It is unknown whether safety and clinical endpoints by use of sacubitril/valsartan (an angiotensin receptor-neprilysin inhibitor [ARNI]) are affected by mineralocorticoid receptor antagonists (MRA) in high-risk myocardial infarction (MI) patients. The aim of this study was to examine whether MRA modifies safety and clinical endpoints by use of sacubitril/valsartan in patients with a MI and left ventricular systolic dysfunction (LVSD) and/or pulmonary congestion. METHODS AND RESULTS Patients (n = 5661) included in the PARADISE MI trial (Prospective ARNI vs. ACE Inhibitor Trial to Determine Superiority in Reducing Heart Failure Events After MI) were stratified according to MRA. Primary outcomes in this substudy were worsening heart failure or cardiovascular death. Safety was defined as symptomatic hypotension, hyperkalaemia >5.5 mmol/L, or permanent drug discontinuation. A total of 2338 patients (41%) were treated with MRA. Safety of ARNI compared to ramipril was not altered significantly by ± MRA, and both groups had similar increase in symptomatic hypotension with ARNI. In patients taking MRA, the risk of hyperkalaemia or permanent drug discontinuation was not significantly altered by ARNI (p > 0.05 for all comparisons). The effect of ARNI compared with ramipril was similar in those who were and were not taking MRA (hazard ratio [HR]MRA 0.96, 95% confidence interval [CI] 0.77-1.19 and HRMRA- 0.87, 95% CI 0.71-1.05, for the primary endpoint; p = 0.51 for interaction [Clinical Endpoint Committee adjudicated]); similar findings were observed if investigator-reported endpoints were evaluated (p = 0.61 for interaction). CONCLUSIONS Use of a MRA did not modify safety or clinical endpoints related to initiation of ARNI compared to ramipril in the post-MI setting in patients with LVSD and/or congestion.
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Affiliation(s)
- Morten Schou
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | | | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | | | - Finnian McCausland
- Renal Division, Department of Medicine (F.R.M.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Freny Vaghaiwalla Mody
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Division of Cardiology, University of California, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | - Martina McGrath
- Renal Division, Department of Medicine (F.R.M.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Douglas L Mann
- Washington University School of Medicine, St Louis, MO, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, Paris, France
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, Boston, MA, USA
| | - Lars Køber
- Rigshospitalet, Blegdamsvej, University of Copenhagen, Copenhagen, Denmark
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14
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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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15
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Baber U, Spirito A, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Clinically Driven Revascularization in High-Risk Patients Treated With Ticagrelor Monotherapy After PCI: Insights from the Randomized TWILIGHT Trial. Am J Cardiol 2023; 208:16-24. [PMID: 37806185 DOI: 10.1016/j.amjcard.2023.09.008] [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: 05/16/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
Repeat coronary revascularization is a common adverse event after successful percutaneous coronary intervention. This analysis aimed to assess the effects of ticagrelor monotherapy on repeat clinically driven revascularization (CDR). In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, high-risk patients were maintained on ticagrelor and randomly allocated to aspirin or placebo for 1 year. The primary end point of this analysis was CDR within 12 months after randomization. The key secondary end points were major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, stroke, or CDR, and net adverse clinical events (NACEs), including the individual components of MACCEs and clinically relevant bleeding. The analysis was performed in the per-protocol population. CDR occurred in 473 of 7,039 patients and was associated with a significantly higher risk of subsequent all-cause death, myocardial infarction, or stroke (adjusted hazard ratios [HRs] 2.92, 95% confidence interval [CI] 1.82 to 4.67). Ticagrelor monotherapy was associated with a similar 12-month risk of CDR (7.1% vs 6.6%; HR 1.09, 95% CI 0.90 to 1.30, p = 0.363) and MACCEs (8.9% vs 8.6%; HR 1.04, 95% CI 0.89 to 1.22, p = 0.619), and a lower risk of NACEs (12.2% vs 14.6%; HR 0.83 95% CI 0.73 to 0.94, p = 0.004) than ticagrelor plus aspirin. In conclusion, among high-risk patients who underwent percutaneous coronary intervention, ticagrelor monotherapy after 3 months of ticagrelor-based dual antiplatelet therapy was associated with a similar risk of CDR and MACCEs and a decrease of NACEs (TWILIGHT: NCT02270242).
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Affiliation(s)
- Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, New York; St. Francis Hospital, Roslyn, New York
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, Shenyang, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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16
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Puymirat E, Soulat G, Fayol A, Mousseaux E, Montalescot G, Cayla G, Steg PG, Berard L, Rousseau A, Drouet É, Simon T, Danchin N. Rationale and design of the direct oral anticoagulants for prevention of left ventricular thrombus after anterior acute myocardial infarction (APERITIF) trial. Am Heart J 2023; 266:98-105. [PMID: 37716448 DOI: 10.1016/j.ahj.2023.09.005] [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] [Received: 06/07/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Anterior acute myocardial infarction (AMI) is associated with an increased risk of left ventricular (LV) thrombus formation. We hypothesized that adding low-dose oral rivaroxaban to the usual antiplatelet regimen would reduce the risk of LV thrombus in patients with large AMI. STUDY DESIGN APERITIF is an investigator-initiated, multicenter randomized open-label, blinded end-point (PROBE) trial, nested in the ongoing "FRENCHIE" registry, a French multicenter prospective observational study, in which all consecutive patients admitted within 48 hours of symptom onset in a cardiac Intensive Care Unit (ICU) for AMI are included (NCT04050956). Among them, patients with anterior ST-elevation-myocardial infarction (STEMI) or very high-risk non- ST-elevation-myocardial infarction (NSTEMI) patients with involvement of the left anterior descending artery are randomized into 2 groups: Dual Antiplatelet Therapy (DAPT) alone or DAPT plus rivaroxaban 2.5mg twice daily for 4 weeks, started as soon as possible after completion of the initial percutaneous coronary intervention/angiography procedure. The primary endpoint is the presence of LV thrombus at 1 month, as detected by contrast enhanced CMR (CE-CMR). Secondary endpoints include LV thrombus dimension (greatest diameter), the rate of major bleedings and major cardiovascular events at 1 month. Based on estimated event rates, a sample size of 560 patients is needed to show superiority of DAPT plus rivaroxaban therapy versus DAPT alone, with 80% power. CONCLUSION The APERITIF trial will determine whether, in patients with large AMIs, the use of rivaroxaban 2.5mg twice daily in addition to DAPT reduces LV thrombus formation, compared with DAPT alone. CLINICALTRIALS gov Identifier: NCT05077683.
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Affiliation(s)
- Etienne Puymirat
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; French Alliance for Cardiovascular Trials (FACT), Paris, France.
| | - Gilles Soulat
- PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; Department of Radiology, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Antoine Fayol
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France
| | - Elie Mousseaux
- PARCC (Paris-Cardiovascular Research Center), INSERM 970, Paris, France; Department of Radiology, AP-HP, Hôpital Européen Georges Pompidou, Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie (APHP), INSERM UMRS 1166, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Université Paris-Cité, INSERM Unité-1148, and Hôpital Bichat, AP-HP, Paris, France
| | - Laurence Berard
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Alexandra Rousseau
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Élodie Drouet
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Tabassome Simon
- French Alliance for Cardiovascular Trials (FACT), Paris, France; Department of Clinical Pharmacology and Clinical Research Platform of East of Paris (URCEST-CRCEST), AP-HP, Hôpital Saint Antoine, Université Pierre et Marie Curie (UPMC-Paris 06), Paris, France
| | - Nicolas Danchin
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
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17
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Aggarwal R, Bhatt DL, Szarek M, Cannon CP, McGuire DK, Inzucchi SE, Lopes RD, Davies MJ, Banks P, Pitt B, Steg PG. Efficacy of Sotagliflozin in Adults With Type 2 Diabetes in Relation to Baseline Hemoglobin A1c. J Am Coll Cardiol 2023; 82:1842-1851. [PMID: 37914514 DOI: 10.1016/j.jacc.2023.08.050] [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: 06/09/2023] [Revised: 08/22/2023] [Accepted: 08/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND The SCORED (Effect of Sotagliflozin on Cardiovascular and Renal Events in Patients with Type 2 Diabetes and Moderate Renal Impairment Who Are at Cardiovascular Risk) and SOLOIST-WHF (Effect of Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure) trials demonstrated that sotagliflozin, an SGLT1 and SGLT2 inhibitor, improves outcomes in individuals with type 2 diabetes who have heart failure (HF) or kidney disease. OBJECTIVES We assessed the efficacy of sotagliflozin on HF clinical outcomes in individuals with differing baseline glycosylated hemoglobin (HbA1c) levels. METHODS We included all adults from SCORED and SOLOIST-WHF. The primary outcome was a composite of cardiovascular death, hospitalizations for HF, and urgent visits for HF. The efficacy of sotagliflozin compared with placebo was evaluated by baseline HbA1c using competing-risk marginal proportional hazards models. RESULTS We identified 11,744 adults. Individuals with HbA1c ≤7.5% experienced the primary outcome at a lower rate in the sotagliflozin group (11.2 per 100 person-years) than the placebo group (15.5 per 100 person-years) (HR: 0.73; 95% CI: 0.57-0.93). Similarly, individuals with HbA1c of 7.6% to 9.0% experienced the primary outcome at a lower rate in the sotagliflozin group (7.3 per 100 person-years) than the placebo group (9.4 per 100 person-years) (HR: 0.77; 95% CI: 0.63-0.96). These findings were also consistent among individuals with HbA1c >9.0%, with a primary outcome rate in the sotagliflozin group (7.8 per 100 person-years) that was lower than the placebo group (11.6 per 100 person-years) (HR: 0.65; 95% CI: 0.50-0.84). The efficacy of sotagliflozin was consistent by baseline HbA1c level (P for interaction = 0.58). CONCLUSIONS In individuals with type 2 diabetes and either HF or kidney disease, sotagliflozin reduced HF outcomes irrespective of baseline HbA1c.
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Affiliation(s)
- Rahul Aggarwal
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Michael Szarek
- CPC Clinical Research and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; State University of New York Downstate School of Public Health, Brooklyn, New York, USA
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Darren K McGuire
- University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas, USA
| | | | - Renato D Lopes
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Phillip Banks
- Lexicon Pharmaceuticals, Inc, the Woodlands, Texas, USA
| | - Bertram Pitt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, INSERMU1148 and AP-HP Hopital Bichat, Paris, France; French Alliance for Cardiovascular Trials, Paris, France
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18
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Silvain J, Lattuca B, Puymirat E, Ducrocq G, Dillinger JG, Lhermusier T, Procopi N, Cachanado M, Drouet E, Abergel H, Danchin N, Montalescot G, Simon T, Steg PG. Impact of transfusion strategy on platelet aggregation and biomarkers in myocardial infarction patients with anemia. Eur Heart J Cardiovasc Pharmacother 2023; 9:647-657. [PMID: 37609995 DOI: 10.1093/ehjcvp/pvad055] [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] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/10/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Higher rates of thrombotic events have been reported in myocardial infarction (MI) patients requiring blood transfusion. The impact of blood transfusion strategy on thrombosis and inflammation is still unknown. OBJECTIVE To compare the impact of a liberal vs. a restrictive transfusion strategy on P2Y12 platelet reactivity and biomarkers in the multicentric randomized REALITY trial. METHODS Patients randomized to a liberal (hemoglobin ≤10 g/dL) or a restrictive (hemoglobin ≤8 g/dL) transfusion strategy had VASP-PRI platelet reactivity measured centrally in a blinded fashion and platelet reactivity unit (PRU) measured locally using encrypted VerifyNow; at baseline and after randomization. Biomarkers of thrombosis (P-selectin, PAI-1, vWF) and inflammation (TNF-α) were also measured. The primary endpoint was the change in the VASP-PRI (difference from baseline and post randomization) between the randomized groups. RESULTS A total of 100 patients randomized were included in this study (n = 50 in each group). Transfused patients received on average 2.4 ± 1.6 units of blood. We found no differences in change of the VASP PRI (difference 1.2% 95% CI (-10.3-12.7%)) or by the PRU (difference 13.0 95% CI (-21.8-47.8)) before and after randomization in both randomized groups. Similar results were found in transfused patients (n = 71) regardless of the randomized group, VASP PRI (difference 1.7%; 95% CI (-9.5-1.7%)) or PRU (difference 27.0; 95% CI (-45.0-0.0)). We did not find an impact of transfusion strategy or transfusion itself in the levels of P-selectin, PAI-1, vWF, and TNF-α. CONCLUSION In this study, we found no impact of a liberal vs. a restrictive transfusion strategy on platelet reactivity and biomarkers in MI patients with anemia. A conclusion that should be tempered due to missing patients with exploitable biological data that has affected our power to show a difference.
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Affiliation(s)
- Johanne Silvain
- Sorbonne Université, ACTION Group, INSERM UMRS1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris 75013, France
| | - Benoit Lattuca
- Cardiology Department, Nîmes University Hospital, Montpellier University, ACTION study group, Nîmes 30900, France
| | - Etienne Puymirat
- Université Paris-Cité, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris 75015, France
| | - Gregory Ducrocq
- Université Paris-Cité, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris 75018, France
| | - Jean-Guillaume Dillinger
- Department of Cardiology, Inserm U942, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, University Paris-Cité, Paris 75010, France
| | | | - Niki Procopi
- Sorbonne Université, ACTION Group, INSERM UMRS1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris 75013, France
| | - Marine Cachanado
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris 75012, France
| | - Elodie Drouet
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris 75012, France
| | - Helene Abergel
- Université Paris-Cité, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris 75018, France
| | - Nicolas Danchin
- Université Paris-Cité, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris 75015, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, INSERM UMRS1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris 75013, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris 75012, France
| | - Philippe Gabriel Steg
- Université Paris-Cité, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris 75018, France
- Institut Universitaire de France, Paris 75005, France
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Patel SM, Bonaca MP, Morrow DA, Palazzolo MG, Jarolim P, Steg PG, Bhatt DL, Storey RF, Sabatine MS, O’Donoghue ML. Lipoprotein(a) and Benefit of Antiplatelet Therapy: Insights from the PEGASUS-TIMI 54 Trial. JACC Adv 2023; 2:100675. [PMID: 38106527 PMCID: PMC10723808 DOI: 10.1016/j.jacadv.2023.100675] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2023]
Affiliation(s)
- Siddharth M. Patel
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Michael G. Palazzolo
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Petr Jarolim
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Philippe Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Michelle L. O’Donoghue
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Lawler PR, Manvelian G, Coppi A, Damask A, Cantor MN, Ferreira MAR, Paulding C, Banerjee N, Li D, Jorgensen S, Attre R, Carey DJ, Krebs K, Milani L, Hveem K, Damås JK, Solligård E, Stender S, Tybjærg-Hansen A, Nordestgaard BG, Hernandez-Beeftink T, Rogne T, Flores C, Villar J, Walley KR, Liu VX, Fohner AE, Lotta LA, Kyratsous CA, Sleeman MW, Scemama M, DelGizzi R, Pordy R, Horowitz JE, Baras A, Martin GS, Steg PG, Schwartz GG, Szarek M, Goodman SG. Pharmacologic and Genetic Downregulation of Proprotein Convertase Subtilisin/Kexin Type 9 and Survival From Sepsis. Crit Care Explor 2023; 5:e0997. [PMID: 37954898 PMCID: PMC10635596 DOI: 10.1097/cce.0000000000000997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES Treatments that prevent sepsis complications are needed. Circulating lipid and protein assemblies-lipoproteins play critical roles in clearing pathogens from the bloodstream. We investigated whether early inhibition of proprotein convertase subtilisin/kexin type 9 (PCSK9) may accelerate bloodstream clearance of immunogenic bacterial lipids and improve sepsis outcomes. DESIGN Genetic and clinical epidemiology, and experimental models. SETTING Human genetics cohorts, secondary analysis of a phase 3 randomized clinical trial enrolling patients with cardiovascular disease (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab [ODYSSEY OUTCOMES]; NCT01663402), and experimental murine models of sepsis. PATIENTS OR SUBJECTS Nine human cohorts with sepsis (total n = 12,514) were assessed for an association between sepsis mortality and PCSK9 loss-of-function (LOF) variants. Incident or fatal sepsis rates were evaluated among 18,884 participants in a post hoc analysis of ODYSSEY OUTCOMES. C57BI/6J mice were used in Pseudomonas aeruginosa and Staphylococcus aureus bacteremia sepsis models, and in lipopolysaccharide-induced animal models. INTERVENTIONS Observational human cohort studies used genetic PCSK9 LOF variants as instrumental variables. ODYSSEY OUTCOMES participants were randomized to alirocumab or placebo. Mice were administered alirocumab, a PCSK9 inhibitor, at 5 mg/kg or 25 mg/kg subcutaneously, or isotype-matched control, 48 hours prior to the induction of bacterial sepsis. Mice did not receive other treatments for sepsis. MEASUREMENTS AND MAIN RESULTS Across human cohort studies, the effect estimate for 28-day mortality after sepsis diagnosis associated with genetic PCSK9 LOF was odds ratio = 0.86 (95% CI, 0.67-1.10; p = 0.24). A significant association was present in antibiotic-treated patients. In ODYSSEY OUTCOMES, sepsis frequency and mortality were infrequent and did not significantly differ by group, although both were numerically lower with alirocumab vs. placebo (relative risk of death from sepsis for alirocumab vs. placebo, 0.62; 95% CI, 0.32-1.20; p = 0.15). Mice treated with alirocumab had lower endotoxin levels and improved survival. CONCLUSIONS PCSK9 inhibition may improve clinical outcomes in sepsis in preventive, pretreatment settings.
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Affiliation(s)
- Patrick R Lawler
- Department of Medicine, McGill University Health Centre, McGill University, Montreal, QC, Canada
- Department of Medicine, Peter Munk Cardiac Centre at University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Alida Coppi
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | - Amy Damask
- Regeneron Genetics Center, Tarrytown, NY
| | | | | | | | | | - Dadong Li
- Regeneron Genetics Center, Tarrytown, NY
| | | | - Richa Attre
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
| | - David J Carey
- Department of Molecular and Functional Genomics, Geisinger Medical Center, Danville, PA
| | - Kristi Krebs
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Lili Milani
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Kristian Hveem
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway
| | - Jan K Damås
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Infectious Diseases, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Erik Solligård
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Medical Quality, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Stefan Stender
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne Tybjærg-Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Børge G Nordestgaard
- Department of Clinical Biochemistry, Copenhagen University Hospital - Herlev Gentofte, University of Copenhagen, Copenhagen, Denmark
| | - Tamara Hernandez-Beeftink
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
- Research Unit, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
| | - Tormod Rogne
- Gemini Center for Sepsis Research, Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Chronic Disease Epidemiology and Center for Perinatal, Pediatric and Environmental Epidemiology, Yale School of Public Health, New Haven, CT
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Carlos Flores
- Research Unit, Hospital Universitario N.S. de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Genomics Division, Instituto Tecnológico y de Energías Renovables (ITER), Santa Cruz de Tenerife, Spain
- Faculty of Health Sciences, University Fernando Pessoa Canarias, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Jesús Villar
- Research Unit, Hospital Universitario de Gran Canaria Dr. Negrin, Las Palmas de Gran Canaria, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Keith R Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Vincent X Liu
- Kaiser Permanente Northern California, Division of Research, Oakland, CA
| | - Alison E Fohner
- Kaiser Permanente Northern California, Division of Research, Oakland, CA
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | | | | | | | | | | | | | | | - Aris Baras
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY
- Regeneron Genetics Center, Tarrytown, NY
| | - Greg S Martin
- Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Grady Memorial Hospital, Atlanta, GA
| | - Philippe Gabriel Steg
- Université de Paris, INSERM U-1148 F75018 Paris, France and Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Gregory G Schwartz
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CA
| | - Michael Szarek
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CA
- CPC Clinical Research, Aurora, CA
- School of Public Health, Downstate Health Sciences University, Brooklyn, NY
| | - Shaun G Goodman
- Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Division of Cardiology, Department of Medicine, St Michael's Hospital, Toronto, ON, Canada
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, AB, Canada
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21
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Miller M, Bhatt DL, Brinton EA, Jacobson TA, Steg PG, Pineda AL, Ketchum SB, Doyle RT, Tardif JC, Ballantyne CM. Effectiveness of icosapent ethyl on first and total cardiovascular events in patients with metabolic syndrome, but without diabetes: REDUCE-IT MetSyn. Eur Heart J Open 2023; 3:oead114. [PMID: 38035037 PMCID: PMC10684296 DOI: 10.1093/ehjopen/oead114] [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] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/07/2023] [Accepted: 11/08/2023] [Indexed: 12/02/2023]
Abstract
Aims Metabolic syndrome (MetSyn) is associated with high risk of cardiovascular (CV) events, irrespective of statin therapy. In the overall REDUCE-IT study of statin-treated patients, icosapent ethyl (IPE) reduced the risk of the primary composite endpoint (CV death, non-fatal myocardial infarction, non-fatal stroke, coronary revascularization, or unstable angina requiring hospitalization) and the key secondary composite endpoint (CV death, non-fatal myocardial infarction, or non-fatal stroke). Methods and results REDUCE-IT was an international, double-blind trial that randomized 8179 high CV risk statin-treated patients with controlled LDL cholesterol and elevated triglycerides, to IPE 4 g/day or placebo. The current study evaluated the pre-specified patient subgroup with a history of MetSyn, but without diabetes at baseline. Among patients with MetSyn but without diabetes at baseline (n = 2866), the majority (99.8%) of this subgroup was secondary prevention patients. Icosapent ethyl use was associated with a 29% relative risk reduction for the first occurrence of the primary composite endpoint [hazard ratio: 0.71; 95% confidence interval (CI): 0.59-0.84; P < 0.0001, absolute risk reduction (ARR) = 5.9%; number needed to treat = 17] and a 41% reduction in total (first plus subsequent) events [rate ratio: 0.59; (95% CI: 0.48-0.72); P < 0.0001] compared with placebo. The risk for the key secondary composite endpoint was reduced by 20% (P = 0.05) and a 27% reduction in fatal/non-fatal MI (P = 0.03), 47% reduction in urgent/emergent revascularization (P < 0.0001), and 58% reduction in hospitalization for unstable angina (P < 0.0001). Non-statistically significant reductions were observed in cardiac arrest (44%) and sudden cardiac death (34%). Conclusion In statin-treated patients with a history of MetSyn, IPE significantly reduced the risk of first and total CV events in REDUCE-IT. The large relative and ARRs observed supports IPE as a potential therapeutic consideration for patients with MetSyn at high CV risk. Registration REDUCE-IT ClinicalTrials.gov number: NCT01492361.
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Affiliation(s)
- Michael Miller
- Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center and Hospital of the University of Pennsylvania, 3900 Woodland Avenue, Philadelphia, PA 19104-4551, USA
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Terry A Jacobson
- Lipid Clinic and Cardiovascular Risk Reduction Program, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Philippe Gabriel Steg
- Université de Paris, FACT (French Alliance for Cardiovascular Trials), Assistance Publique–Hôpitaux de Paris, Hôpital Bichat, INSERM Unité 1148, Paris, France
| | | | | | | | | | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Texas Heart Institute, Houston, TX, USA
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22
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Lavallée PC, Charles H, Albers GW, Caplan LR, Donnan GA, Ferro JM, Hennerici MG, Labreuche J, Molina C, Rothwell PM, Steg PG, Touboul PJ, Uchiyama S, Vicaut É, Wong LKS, Amarenco P. Underlying Causes of TIA and Minor Ischemic Stroke and Risk of Major Vascular Events. JAMA Neurol 2023; 80:1199-1208. [PMID: 37782494 PMCID: PMC10546292 DOI: 10.1001/jamaneurol.2023.3344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/16/2023] [Indexed: 10/03/2023]
Abstract
Importance The coexistence of underlying causes in patients with transient ischemic attack (TIA) or minor ischemic stroke as well as their associated 5-year risks are not well known. Objective To apply the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other cause, or dissection) grading system to assess coexistence of underlying causes of TIA and minor ischemic stroke and the 5-year risk for major vascular events. Design, Setting, and Participants This international registry cohort (TIAregistry.org) study enrolled 4789 patients from June 1, 2009, to December 31, 2011, with 1- to 5-year follow-up at 61 sites in 21 countries. Eligible patients had a TIA or minor stroke (with modified Rankin Scale score of 0 or 1) within the last 7 days. Among these, 3847 patients completed the 5-year follow-up by December 31, 2016. Data were analyzed from October 1, 2022, to June 15, 2023. Exposure Five-year follow-up. Main Outcomes and Measures Estimated 5-year risk of the composite outcome of stroke, acute coronary syndrome, or cardiovascular death. Results A total of 3847 patients (mean [SD] age, 66.4 [13.2] years; 2295 men [59.7%]) in 42 sites were enrolled and participated in the 5-year follow-up cohort (median percentage of 5-year follow-up per center was 92.3% [IQR, 83.4%-97.8%]). In 998 patients with probable or possible causal atherosclerotic disease, 489 (49.0%) had some form of small vessel disease (SVD), including 110 (11.0%) in whom a lacunar stroke was also probably or possibly causal, and 504 (50.5%) had no SVD; 275 (27.6%) had some cardiac findings, including 225 (22.6%) in whom cardiac pathology was also probably or possibly causal, and 702 (70.3%) had no cardiac findings. Compared with patients with none of the 5 ASCOD categories of disease (n = 484), the 5-year rate of major vascular events was almost 5 times higher (hazard ratio [HR], 4.86 [95% CI, 3.07-7.72]; P < .001) in patients with causal atherosclerosis, 2.5 times higher (HR, 2.57 [95% CI, 1.58-4.20]; P < .001) in patients with causal lacunar stroke or lacunar syndrome, and 4 times higher (HR, 4.01 [95% CI, 2.50-6.44]; P < .001) in patients with causal cardiac pathology. Conclusion and Relevance The findings of this cohort study suggest that in patients with TIA and minor ischemic stroke, the coexistence of atherosclerosis, SVD, cardiac pathology, dissection, or other causes is substantial, and the 5-year risk of a major vascular event varies considerably across the 5 categories of underlying diseases. These findings further suggest the need for secondary prevention strategies based on pathophysiology rather than a one-size-fits-all approach.
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Affiliation(s)
- Philippa C. Lavallée
- Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)–U1148, University Paris-Cité, Paris, France
| | - Hugo Charles
- Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)–U1148, University Paris-Cité, Paris, France
| | - Gregory W. Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, California
| | - Louis R. Caplan
- Cerebrovascular Disease Service, Beth Israel Deaconess Medical Center, Harvard University, Boston, Massachusetts
| | - Geoffrey A. Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, The University of Melbourne, Parkville, Australia
| | - José M. Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Michael G. Hennerici
- Department of Neurology, Universitäts Medizin Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Julien Labreuche
- Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)–U1148, University Paris-Cité, Paris, France
- Department of Biostatistics, Centre Hospitalier Universitaire Lille, Lille, France
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Vall d’Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Peter M. Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
| | - Philippe Gabriel Steg
- Department of Cardiology, Hôpital Bichat, Université Paris Cité, AP-HP, INSERM LVTS-U1148, Institut Universitaire de France, Paris, France
| | - Pierre-Jean Touboul
- Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)–U1148, University Paris-Cité, Paris, France
| | - Shinichiro Uchiyama
- Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, International University of Health and Welfare, Tokyo, Japan
| | - Éric Vicaut
- Department of Biostatistics, Fernand Widal Hospital, AP-HP, Université Paris-Cité, Paris, France
| | - Lawrence K. S. Wong
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, Bichat Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Institut National de la Santé et de la Recherche Médicale (INSERM) Laboratory for Vascular Translational Science (LVTS)–U1148, University Paris-Cité, Paris, France
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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23
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Bikdeli B, Erlinge D, Valgimigli M, Kastrati A, Han Y, Steg PG, Stables RH, Mehran R, James SK, Frigoli E, Goldstein P, Li Y, Shahzad A, Schüpke S, Mehdipoor G, Chen S, Redfors B, Crowley A, Zhou Z, Stone GW. Bivalirudin Versus Heparin During PCI in NSTEMI: Individual Patient Data Meta-Analysis of Large Randomized Trials. Circulation 2023; 148:1207-1219. [PMID: 37746717 DOI: 10.1161/circulationaha.123.063946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
BACKGROUND The benefit:risk profile of bivalirudin versus heparin anticoagulation in patients with non-ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) is uncertain. Study-level meta-analyses lack granularity to provide conclusive answers. We sought to compare the outcomes of bivalirudin and heparin in patients with non-ST-segment-elevation myocardial infarction undergoing PCI. METHODS We performed an individual patient data meta-analysis of patients with non-ST-segment-elevation myocardial infarction in all 5 trials that randomized ≥1000 patients with any myocardial infarction undergoing PCI to bivalirudin versus heparin (MATRIX [Minimizing Adverse Hemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox], VALIDATE-SWEDEHEART [Bivalirudin Versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial], ISAR-REACT 4 [Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 4], ACUITY [Acute Catheterization and Urgent Intervention Triage Strategy], and BRIGHT [Bivalirudin in Acute Myocardial Infarction vs Heparin and GPI Plus Heparin Trial]). The primary effectiveness and safety end points were 30-day all-cause mortality and serious bleeding. RESULTS A total of 12 155 patients were randomized: 6040 to bivalirudin (52.3% with a post-PCI bivalirudin infusion), and 6115 to heparin (53.2% with planned glycoprotein IIb/IIIa inhibitor use). Thirty-day mortality was not significantly different between bivalirudin and heparin (1.2% versus 1.1%; adjusted odds ratio, 1.24 [95% CI, 0.86-1.79]; P=0.25). Cardiac mortality, reinfarction, and stent thrombosis rates were also not significantly different. Bivalirudin reduced serious bleeding (both access site-related and non-access site-related) compared with heparin (3.3% versus 5.5%; adjusted odds ratio, 0.59; 95% CI, 0.48-0.72; P<0.0001). Outcomes were consistent regardless of use of a post-PCI bivalirudin infusion or routine lycoprotein IIb/IIIa inhibitor use with heparin and during 1-year follow-up. CONCLUSIONS In patients with non-ST-segment-elevation myocardial infarction undergoing PCI, procedural anticoagulation with bivalirudin and heparin did not result in significantly different rates of mortality or ischemic events, including stent thrombosis and reinfarction. Bivalirudin reduced serious bleeding compared with heparin arising both from the access site and nonaccess sites.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Thrombosis Research Group (B.B.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Yale-New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT (B.B.)
| | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Yaling Han
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, French Alliance for Cardiovascular Trials, L'Institut national de la santé et de la recherche médicale U-1148, Assistance Publique - Hôpitaux de Paris, Hôpital Bichat, Paris, France (P.G.S.)
- Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Rod H Stables
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | | | - Enrico Frigoli
- Bern University Hospital, University of Bern, Switzerland (M.V., E.F.)
| | | | - Yi Li
- General Hospital of Northern Theater Command, Shenyang, China (Y.H., Y.L.)
| | - Adeel Shahzad
- Liverpool Heart and Chest Hospital, United Kingdom (R.H.S., A.S.)
- University of Liverpool, United Kingdom (R.H.S., A.S.)
| | - Stefanie Schüpke
- Deutsches Herzzentrum München, Technische Universität, Munich, Germany (A.K., S.S.)
- German Center for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (A.K., S.S.)
| | - Ghazaleh Mehdipoor
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center, Bronx, NY (G.M.)
| | - Shmuel Chen
- Weill-Cornell Cornell Medical Center/ New York-Presbyterian Hospital, New York, NY (S.C.)
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden (B.R.)
| | | | - Zhipeng Zhou
- Cardiovascular Research Foundation, New York, NY (R.M., Z.Z.)
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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Mesnier J, Suc G, Sayah N, Abtan J, Steg PG. Relevance of medical information obtained from ChatGPT: Are large language models friends or foes? Arch Cardiovasc Dis 2023; 116:485-486. [PMID: 37718185 DOI: 10.1016/j.acvd.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 09/19/2023]
Affiliation(s)
- Jules Mesnier
- Hôpital Bichat, Assistance publique-Hôpitaux de Paris, Inserm U-1148, université de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Gaspard Suc
- Hôpital Bichat, Assistance publique-Hôpitaux de Paris, Inserm U-1148, université de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Neila Sayah
- Hôpital Bichat, Assistance publique-Hôpitaux de Paris, Inserm U-1148, université de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Jérémie Abtan
- Hôpital Bichat, Assistance publique-Hôpitaux de Paris, Inserm U-1148, université de Paris, 46, rue Henri-Huchard, 75018 Paris, France
| | - Philippe Gabriel Steg
- Hôpital Bichat, Assistance publique-Hôpitaux de Paris, Inserm U-1148, université de Paris, 46, rue Henri-Huchard, 75018 Paris, France.
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25
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Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYAB. Strategies to mitigate emergency department crowding and its impact on cardiovascular patients. Eur Heart J Acute Cardiovasc Care 2023; 12:633-643. [PMID: 37163667 DOI: 10.1093/ehjacc/zuad049] [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] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/12/2023]
Abstract
Emergency department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies-such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade-are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.
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Affiliation(s)
- Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House 2nd Floor, Boston, MA 02115, USA
| | - Yonathan Freund
- Emergency Department Hospital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Gabriel Steg
- Department of Cardiology, Université Paris-Cité, Institut Universitaire de France, FACT, French Alliance for Cardiovascular Trials, INSERM-1148, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- Emergency Department, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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26
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Goodman SG, Steg PG, Poulouin Y, Bhatt DL, Bittner VA, Diaz R, Garon G, Harrington RA, Jukema JW, Manvelian G, Stipek W, Szarek M, White HD, Schwartz GG. Long-Term Efficacy, Safety, and Tolerability of Alirocumab in 8242 Patients Eligible for 3 to 5 Years of Placebo-Controlled Observation in the ODYSSEY OUTCOMES Trial. J Am Heart Assoc 2023; 12:e029216. [PMID: 37702079 PMCID: PMC10547267 DOI: 10.1161/jaha.122.029216] [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] [Received: 12/21/2022] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Shaun G. Goodman
- Canadian VIGOUR CentreUniversity of AlbertaAlbertaEdmontonCanada
- St. Michael’s Hospital, Unity Health Toronto, University of TorontoOntarioTorontoCanada
| | - Philippe Gabriel Steg
- Université Paris‐Cité, INSERM (Institut National de la Santé Et de la Recherche Médicale) U1148, and Assistance Publique–Hôpitaux de Paris, Hôpital BichatParisFrance
- FACT (French Alliance for Cardiovascular Trials), Institut Universitaire de FranceParisFrance
| | | | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount SinaiNYNew YorkUSA
| | - Vera A. Bittner
- Division of Cardiovascular DiseaseUniversity of Alabama at BirminghamALBirminghamUSA
| | - Rafael Diaz
- Estudios Cardiológicos LatinoaméricaInstituto Cardiovascular de RosarioRosarioArgentina
| | | | - Robert A. Harrington
- Stanford Center for Clinical Research, Department of MedicineStanford UniversityCAStanfordUSA
| | - J. Wouter Jukema
- Department of CardiologyLeiden University Medical CenterLeidenthe Netherlands
- Netherlands Heart InstituteUtrechtthe Netherlands
| | | | | | - Michael Szarek
- CPC (Colorado Prevention Center) Clinical Research and Division of CardiologyUniversity of Colorado School of MedicineCOAuroraUSA
- State University of New YorkDownstate Health Sciences UniversityNYBrooklynUSA
| | - Harvey D. White
- Lane Cardiovascular Services Auckland City HospitalAucklandNew Zealand
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Perrichot A, Vaittinada Ayar P, Taboulet P, Choquet C, Gay M, Casalino E, Steg PG, Curac S, Vaittinada Ayar P. Assessment of real-time electrocardiogram effects on interpretation quality by emergency physicians. BMC Med Educ 2023; 23:677. [PMID: 37723508 PMCID: PMC10506301 DOI: 10.1186/s12909-023-04670-x] [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] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 09/12/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Electrocardiogram (ECG) is one of the most commonly performed examinations in emergency medicine. The literature suggests that one-third of ECG interpretations contain errors and can lead to clinical adverse outcomes. The purpose of this study was to assess the quality of real-time ECG interpretation by senior emergency physicians compared to cardiologists and an ECG expert. METHODS This was a prospective study in two university emergency departments and one emergency medical service. All ECGs were performed and interpreted over five weeks by a senior emergency physician (EP) and then by a cardiologist using the same questionnaire. In case of mismatch between EP and the cardiologist our expert had the final word. The ratio of agreement between both interpretations and the kappa (k) coefficient characterizing the identification of major abnormalities defined the reading ability of the emergency physicians. RESULTS A total of 905 ECGs were analyzed, of which 705 (78%) resulted in a similar interpretation between emergency physicians and cardiologists/expert. However, the interpretations of emergency physicians and cardiologists for the identification of major abnormalities coincided in only 66% (k: 0.59 (95% confidence interval (CI): 0.54-0.65); P-value = 1.64e-92). ECGs were correctly classified by emergency physicians according to their emergency level in 82% of cases (k: 0.73 (95% CI: 0.70-0.77); P-value ≈ 0). Emergency physicians correctly recognized normal ECGs (sensitivity = 0.91). CONCLUSION Our study suggested gaps in the identification of major abnormalities among emergency physicians. The initial and ongoing training of emergency physicians in ECG reading deserves to be improved.
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Affiliation(s)
- Alice Perrichot
- Emergency Department, Beaujon Hospital AP-HP, Clichy, France
| | - Pradeebane Vaittinada Ayar
- Laboratoire des Sciences du Climat et l’Environnement (LSCE-IPSL), CNRS/CEA/UVSQ, UMR8212, Université Paris-Saclay, Gif-sur-Yvette, 91190 France
| | - Pierre Taboulet
- Emergency Department, Saint Louis Hospital AP-HP, Clichy, France
| | | | - Matthieu Gay
- Emergency Department, Beaujon Hospital AP-HP, Clichy, France
| | | | | | - Sonja Curac
- Emergency Department, Beaujon Hospital AP-HP, Clichy, France
| | - Prabakar Vaittinada Ayar
- Emergency Department, Beaujon Hospital AP-HP, Clichy, France
- INSERM UMR-S942, MASCOTT, Paris, France
- University of Paris Cité, Paris, France
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28
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Oqab Z, Kunadian V, Wood DA, Storey RF, Rao SV, Mehran R, Pinilla-Echeverri N, Mani T, Boone RH, Kassam S, Bossard M, Mansour S, Ball W, Sibbald M, Valettas N, Moreno R, Steg PG, Cairns JA, Mehta SR. Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial. Circ Cardiovasc Interv 2023; 16:e012867. [PMID: 37725677 DOI: 10.1161/circinterventions.122.012867] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 07/31/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND In the COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI for STEMI), a strategy of complete revascularization reduced the risk of major cardiovascular events compared with culprit-lesion-only percutaneous coronary intervention in patients presenting with ST-segment-elevation myocardial infarction (STEMI) and multivessel coronary artery disease. Patients with diabetes have a worse prognosis following STEMI. We evaluated the consistency of the effects of complete revascularization in patients with and without diabetes. METHODS The COMPLETE trial randomized a strategy of complete revascularization, consisting of angiography-guided percutaneous coronary intervention of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only percutaneous coronary intervention (guideline-directed medical therapy alone). In prespecified analyses, treatment effects were determined in patients with and without diabetes on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Interaction P values were calculated to evaluate whether there was a differential treatment effect in patients with and without diabetes. RESULTS Of the 4041 patients enrolled in the COMPLETE trial, 787 patients (19.5%) had diabetes. The median HbA1c (glycated hemoglobin) was 7.7% in the diabetes group and 5.7% in the nondiabetes group. Complete revascularization consistently reduced the first coprimary outcome in patients with diabetes (hazard ratio, 0.87 [95% CI, 0.59-1.29]) and without diabetes (hazard ratio, 0.70 [95% CI, 0.55-0.90]), with no evidence of a differential treatment effect (interaction P=0.36). Similarly, for the second coprimary outcome, no differential treatment effect (interaction P=0.27) of complete revascularization was found in patients with diabetes (hazard ratio, 0.61 [95% CI, 0.43-0.87]) and without diabetes (hazard ratio, 0.48 [95% CI, 0.39-0.60]). CONCLUSIONS Among patients presenting with STEMI and multivessel disease, the benefit of complete revascularization over a culprit-lesion-only percutaneous coronary intervention strategy was consistent regardless of the presence or absence of diabetes.
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Affiliation(s)
- Zardasht Oqab
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Dalhousie University, Nova Scotia, Halifax, Canada (Z.O.)
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom (V.K.)
| | - David A Wood
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Sunil V Rao
- NYU Langone Health System, New York (S.V.R.)
| | - Roxana Mehran
- Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Thenmozhi Mani
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Robert H Boone
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Saleem Kassam
- Scarborough Health Network Centenary, Toronto, Ontario, Canada (S.K.)
| | | | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada (S.M.)
| | - Warren Ball
- Peterborough Regional Health Centre, Toronto, Ontario, Canada (W.B.)
| | - Matthew Sibbald
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Nicholas Valettas
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
| | - Raul Moreno
- University Hospital La Paz, Madrid, Spain (R.M.)
| | | | - John A Cairns
- Centre for Cardiovascular Innovation, UBC Division of Cardiology, St Paul's and Vancouver General Hospital, Canada (D.A.W., R.H.B., J.A.C.)
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- McMaster University, Hamilton, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
- Hamilton Health Sciences, Ontario, Canada (Z.O., N.P.-E., T.M., M.S., N.V., S.R.M.)
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Zhou XD, Targher G, Byrne CD, Somers V, Kim SU, Chahal CAA, Wong VWS, Cai J, Shapiro MD, Eslam M, Steg PG, Sung KC, Misra A, Li JJ, Brotons C, Huang Y, Papatheodoridis GV, Sun A, Yilmaz Y, Chan WK, Huang H, Méndez-Sánchez N, Alqahtani SA, Cortez-Pinto H, Lip GYH, de Knegt RJ, Ocama P, Romero-Gomez M, Fudim M, Sebastiani G, Son JW, Ryan JD, Ikonomidis I, Treeprasertsuk S, Pastori D, Lupsor-Platon M, Tilg H, Ghazinyan H, Boursier J, Hamaguchi M, Nguyen MH, Fan JG, Goh GBB, Al Mahtab M, Hamid S, Perera N, George J, Zheng MH. An international multidisciplinary consensus statement on MAFLD and the risk of CVD. Hepatol Int 2023; 17:773-791. [PMID: 37204656 PMCID: PMC10198034 DOI: 10.1007/s12072-023-10543-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [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: 03/19/2023] [Accepted: 04/18/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Fatty liver disease in the absence of excessive alcohol consumption is an increasingly common condition with a global prevalence of ~ 25-30% and is also associated with cardiovascular disease (CVD). Since systemic metabolic dysfunction underlies its pathogenesis, the term metabolic (dysfunction)-associated fatty liver disease (MAFLD) has been proposed for this condition. MAFLD is closely intertwined with obesity, type 2 diabetes mellitus and atherogenic dyslipidemia, which are established cardiovascular risk factors. Unlike CVD, which has received attention in the literature on fatty liver disease, the CVD risk associated with MAFLD is often underestimated, especially among Cardiologists. METHODS AND RESULTS A multidisciplinary panel of fifty-two international experts comprising Hepatologists, Endocrinologists, Diabetologists, Cardiologists and Family Physicians from six continents (Asia, Europe, North America, South America, Africa and Oceania) participated in a formal Delphi survey and developed consensus statements on the association between MAFLD and the risk of CVD. Statements were developed on different aspects of CVD risk, ranging from epidemiology to mechanisms, screening, and management. CONCULSIONS The expert panel identified important clinical associations between MAFLD and the risk of CVD that could serve to increase awareness of the adverse metabolic and cardiovascular outcomes of MAFLD. Finally, the expert panel also suggests potential areas for future research.
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Affiliation(s)
- Xiao-Dong Zhou
- Department of Cardiovascular Medicine, The Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Giovanni Targher
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Verona, Verona, Italy
| | - Christopher D Byrne
- Southampton National Institute for Health and Care Research Biomedical Research Centre, University Hospital Southampton, and University of Southampton, Southampton General Hospital, Southampton, UK
| | - Virend Somers
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, USA
| | - Seung Up Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
| | - C Anwar A Chahal
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, USA
- Center for Inherited Cardiovascular Diseases, WellSpan Health, Lancaster, PA, USA
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, EC1A 7BE, West Smithfield, UK
| | - Vincent Wai-Sun Wong
- State Key Laboratory of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Jingjing Cai
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Michael D Shapiro
- Center for Prevention of Cardiovascular Disease, Section on Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Mohammed Eslam
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, NSW, 2145, Australia
| | - Philippe Gabriel Steg
- Université Paris -Cité, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), INSERM U1148, Paris, France
| | - Ki-Chul Sung
- Department of Internal Medicine, Division of Cardiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Anoop Misra
- Fortis C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, National Diabetes Obesity and Cholesterol Foundation and Diabetes Foundation (India), New Delhi, India
| | - Jian-Jun Li
- State Key Laboratory of Cardiovascular Diseases, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Carlos Brotons
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Sardenya Primary Health Care Center, Barcelona, Spain
| | - Yuli Huang
- Department of Cardiology, Shunde Hospital, Southern Medical University, Jiazi Road, Lunjiao Town, Shunde District, Foshan, China
| | - George V Papatheodoridis
- Department of Gastroenterology, Medical School of National and Kapodistrian University of Athens, General Hospital of Athens "Laiko", Athens, Greece
| | - Aijun Sun
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yusuf Yilmaz
- Institute of Gastroenterology, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Wah Kheong Chan
- Gastroenterology and Hepatology Unit, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Hui Huang
- Department of Cardiology, The Eighth Affiliated Hospital of Sun Yat-Sen University, 3025 Shennan Middle Road, Shenzhen, China
| | - Nahum Méndez-Sánchez
- Liver Research Unit, Medica Sur Clinic and Foundation and Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Saleh A Alqahtani
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, 720 Rutland Avenue, Baltimore, MD, USA
| | - Helena Cortez-Pinto
- Laboratório de Nutrição e Metabolismo, Faculdade de Medicina, Clínica Universitária de Gastrenterologia, Universidade de Lisboa, Lisbon, Portugal
| | - 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 Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Robert J de Knegt
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center Rotterdam, Gravendijkwal 230, Room Ha 206, Rotterdam, The Netherlands
| | - Ponsiano Ocama
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Manuel Romero-Gomez
- Department of Digestive and Liver Diseases, Institute of Biomedicine of Seville, University Hospital Virgen del Rocio, University of Seville, Seville, Spain
| | - Marat Fudim
- Department of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Giada Sebastiani
- Division of Gastroenterology and Hepatology, Chronic Viral Illness Service, McGill University Health Centre, Royal Victoria Hospital, 1001 Blvd. Décarie, Montreal, Canada
| | - Jang Won Son
- Division of Endocrinology and Metabolism, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - John D Ryan
- Department of Hepatology, RCSI School of Medicine and Medical Sciences, Dublin/Beaumont Hospital, Dublin, Ireland
| | - Ignatios Ikonomidis
- Preventive Cardiology Laboratory and Cardiometabolic Clinic, Second Cardiology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Sombat Treeprasertsuk
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Monica Lupsor-Platon
- Department of Medical Imaging, "Prof. Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepathology, "Iuliu Hațieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology and Metabolism, Medical University Innsbruck, Innsbruck, Austria
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
| | - Jerome Boursier
- Hepato-Gastroenterology Department, University Hospital, 4 Larrey Street, 49933, Angers Cedex 09, France
- HIFIH Laboratory, UPRES 3859, SFR 4208, LUNAM University, Angers, France
| | - Masahide Hamaguchi
- Department of Endocrinology and Metabolism, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465, Kajii-Cho, Kawaramachi-Hirokoji, Kamigyo-Ku, Kyoto, Japan
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, CA, USA
| | - Jian-Gao Fan
- Center for Fatty Liver, Department of Gastroenterology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - George Boon-Bee Goh
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Saeed Hamid
- Department of Medicine, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan
| | - Nilanka Perera
- Department of Medicine, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - Jacob George
- Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital, University of Sydney, Sydney, NSW, 2145, Australia.
| | - Ming-Hua Zheng
- MAFLD Research Center, Department of Hepatology, The First Affiliated Hospital of Wenzhou Medical University, No. 2 Fuxue Lane, Wenzhou, 325000, China.
- Institute of Hepatology, Wenzhou Medical University, Wenzhou, China.
- Key Laboratory of Diagnosis and Treatment for the Development of Chronic Liver Disease in Zhejiang Province, Wenzhou, China.
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30
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Mohammadi KA, Brackin T, Schwartz GG, Steg PG, Szarek M, Manvelian G, Pordy R, Fazio S, Geba GP. Effect of proprotein convertase subtilisin/kexin type 9 inhibition on cancer events: A pooled, post hoc, competing risk analysis of alirocumab clinical trials. Cancer Med 2023; 12:16859-16868. [PMID: 37458138 PMCID: PMC10501297 DOI: 10.1002/cam4.6310] [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: 05/15/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE Assess the risk of new and worsening cancer events among participants who received the lipid-lowering therapy alirocumab, a proprotein convertase subtilisin/kexin type 9 inhibitor. DESIGN Pooled post hoc analysis. SETTING Six phase 3 or phase 4 placebo-controlled randomised trials with alirocumab. PARTICIPANTS A total of 24,070 patients from the safety population with complete dosing data (alirocumab, n = 12,533; placebo, n = 11,537). INTERVENTION Alirocumab 75 mg, alirocumab 150 mg, alirocumab 75 mg increasing to 150 mg if low-density lipoprotein cholesterol <50 mg/dL not achieved, or placebo, all every 2 weeks. All participants received background high-intensity or maximum-tolerated statin therapy. OUTCOMES AND MEASURES The first new or worsening incident cancer events were assessed during the treatment-emergent adverse event period. Four outcomes were evaluated: any-neoplasm, malignant neoplasms, broad definition of hormone-sensitive cancers, and stricter definition of hormone-sensitive cancers. Sub-distribution hazard ratios and 95% confidence intervals (CIs) were estimated using a competing risk framework, with death as a competing risk. RESULTS Considering both treatment arms in aggregate, 969 (4.03%), 779 (3.24%), 178 (0.74%) and 167 (0.69%) patients developed any neoplasm, malignant neoplasms, broad definition of hormone-sensitive cancer and strict definition of hormone-sensitive cancer events, respectively. There was no significant difference in the risk of having any neoplasm in the alirocumab versus the placebo group (sub-distribution hazards ratio [95% CI], 0.93 [0.82-1.1]; p = 0.28). A nominally lower risk of having any neoplasms with alirocumab was observed among subjects aged ≥64 years (sub-distribution hazards ratio 0.83; 95% CI, 0.70-0.99). CONCLUSIONS Intensive low-density lipoprotein cholesterol lowering with a proprotein convertase subtilisin/kexin type 9 inhibitor combined with statin does not appear to increase the risk of new or worsening cancer events.
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Affiliation(s)
| | | | | | - Philippe Gabriel Steg
- Université Paris‐CitéParisFrance
- FACT (French Alliance for Cardiovascular Trials) INSERM U1148ParisFrance
- Assistance Publique‐Hôpitaux de ParisHôpital BichatParisFrance
| | - Michael Szarek
- State University of New YorkDownstate School of Public HealthBrooklynNew YorkUSA
- CPC Clinical Research and Division of CardiologyUniversity of Colorado School of MedicineAuroraColoradoUSA
| | | | - Robert Pordy
- Regeneron Pharmaceuticals, Inc.TarrytownNew YorkUSA
| | - Sergio Fazio
- Regeneron Pharmaceuticals, Inc.TarrytownNew YorkUSA
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Gragnano F, Cao D, Pirondini L, Franzone A, Kim HS, von Scheidt M, Pettersen AÅR, Zhao Q, Woodward M, Chiarito M, McFadden EP, Park KW, Kastrati A, Seljeflot I, Zhu Y, Windecker S, Kang J, Schunkert H, Arnesen H, Bhatt DL, Steg PG, Calabrò P, Pocock S, Mehran R, Valgimigli M. P2Y 12 Inhibitor or Aspirin Monotherapy for Secondary Prevention of Coronary Events. J Am Coll Cardiol 2023; 82:89-105. [PMID: 37407118 DOI: 10.1016/j.jacc.2023.04.051] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [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: 02/17/2023] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Aspirin is the only antiplatelet agent with a Class I recommendation for long-term prevention of cardiovascular events in patients with coronary artery disease (CAD). There is inconsistent evidence on how it compares with alternative antiplatelet agents. OBJECTIVES This study compared P2Y12 inhibitor monotherapy vs aspirin in patients with CAD. METHODS We conducted a patient-level meta-analysis of randomized trials comparing P2Y12 inhibitor monotherapy vs aspirin monotherapy for the prevention of cardiovascular events in patients with established CAD. The primary outcome was the composite of cardiovascular death, myocardial infarction, and stroke. Prespecified key secondary outcomes were major bleeding and net adverse clinical events (the composite of the primary outcome and major bleeding). Data were pooled in a 1-step meta-analysis. RESULTS Patient-level data were obtained from 7 trials. Overall, 24,325 participants were available for analysis, including 12,178 patients assigned to receive P2Y12 inhibitor monotherapy (clopidogrel in 7,545 [62.0%], ticagrelor in 4,633 [38.0%]) and 12,147 assigned to receive aspirin. Risk of the primary outcome was lower with P2Y12 inhibitor monotherapy compared with aspirin over 2 years (HR: 0.88; 95% CI: 0.79-0.97; P = 0.012), mainly owing to less myocardial infarction (HR: 0.77; 95% CI: 0.66-0.90; P < 0.001). Major bleeding was similar (HR: 0.87; 95% CI: 0.70-1.09; P = 0.23) and net adverse clinical events were lower (HR: 0.89; 95% CI: 0.81-0.98; P = 0.020) with P2Y12 inhibitors. The treatment effect was consistent across prespecified subgroups and types of P2Y12 inhibitors. CONCLUSIONS Given its superior efficacy and similar overall safety, P2Y12 inhibitor monotherapy might be preferred over aspirin monotherapy for long-term secondary prevention in patients with established CAD. (P2Y12 Inhibitor or Aspirin Monotherapy as Secondary Prevention in Patients With Coronary Artery Disease: An Individual Patient Data Meta-Analysis of Randomized Trials [PANTHER collaborative initiative]; CRD42021290774).
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Affiliation(s)
- Felice Gragnano
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Leah Pirondini
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Franzone
- Department of Advanced Biomedical Sciences Federico II University of Naples, Naples, Italy
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Moritz von Scheidt
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Alf-Åge R Pettersen
- Department of Cardiology, Ringerike Hospital, Vestre Viken HF, Drammen, Norway; Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mark Woodward
- The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Eugene P McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands; Department of Cardiology, Cork University Hospital, Cork, Ireland
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Ingebjørg Seljeflot
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jeehoon Kang
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heribert Schunkert
- Department of Cardiology, Deutsches Herzzentrum München, Technische Universität München and Deutsches Zentrum für Herz-und Kreislauferkrankungen, Partner Site Munich Heart Alliance, Munich, Germany
| | - Harald Arnesen
- Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital Ullevaal, Oslo, Norway; Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Philippe Gabriel Steg
- Université Paris-Cité, FACT (French Alliance for Cardiovascular Trials), Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, INSERM Unité 1148, Paris, France
| | - Paolo Calabrò
- Department of Translational Medical Science, University of Campania Luigi Vanvitelli, Naples, Italy; Division of Cardiology, Sant'Anna and San Sebastiano Hospital, Caserta, Italy
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland.
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Amarenco P, Lavallée PC, Kim JS, Labreuche J, Charles H, Giroud M, Lee BC, Mahagne MH, Meseguer E, Nighoghossian N, Steg PG, Vicaut É, Bruckert E. More Than 50 Percent Reduction in LDL Cholesterol in Patients With Target LDL <70 mg/dL After a Stroke. Stroke 2023. [PMID: 37376989 DOI: 10.1161/strokeaha.123.042621] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/05/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Whether a strategy to target an LDL (low-density lipoprotein) cholesterol <70 mg/dL is more effective when LDL is reduced >50% from baseline rather than <50% from baseline has not been investigated. METHODS The Treat Stroke to Target trial was conducted in France and South Korea in 61 sites between March 2010 and December 2018. Patients with ischemic stroke in the previous 3 months or transient ischemic attack within the previous 15 days and evidence of cerebrovascular or coronary artery atherosclerosis were randomly assigned to a target LDL cholesterol of <70 mg/dL or 100±10 mg/dL, using statin and/or ezetimibe as needed. We used the results of repeated LDL measurements (median, 5 [2-6] per patient) during 3.9 years (interquartile range, 2.1-6.8) of follow-up. The primary outcome was the composite of ischemic stroke, myocardial infarction, new symptoms requiring urgent coronary or carotid revascularization, and vascular death. Cox regression model including lipid-lowering therapy as a time-varying variable, after adjustment for randomization strategy, age, sex, index event (stroke or transient ischemic attack), and time since the index event. RESULTS Among 2860 patients enrolled, patients in the lower target group who had >50% LDL cholesterol reduction from baseline during the trial had a higher baseline LDL cholesterol and a lower LDL cholesterol achieved as compared to patients who had <50% LDL cholesterol reduction (155±32 and 62 mg/dL versus 121±34 and 74 mg/dL, respectively, P<0.001 for both). In the <70 mg/dL target group, patients with >50% LDL reduction had a significant reduction in the primary outcome as compared to the higher target group (hazard ratio, 0.61 [95% CI, 0.43-0.88]; P=0.007) and patients with <50% LDL reduction from baseline had little reduction (hazard ratio, 0.96 [95% CI, 0.73-1.26]; P=0.75). CONCLUSIONS In this post hoc analysis of the TST trial, targeting an LDL cholesterol of <70 mg/dL reduced the risk of primary outcome compared with 100±10 mg/dL provided LDL cholesterol reduction from baseline was superior to 50%, thereby suggesting that the magnitude of LDL cholesterol reduction was as important to consider as the target level to achieve. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01252875; https://clinicaltrialsregister.eu; Unique identifier: EUDRACT2009-A01280-57.
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Affiliation(s)
- Pierre Amarenco
- APHP, Department of Neurology and Stroke Center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris, France (P.A., P.C.L., H.C., E.M.)
- Population Health Research Institute, MacMaster University, Hamilton, Ontario, Canada (P.A.)
| | - Philippa C Lavallée
- APHP, Department of Neurology and Stroke Center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris, France (P.A., P.C.L., H.C., E.M.)
| | - Jong S Kim
- Kangneung Asan Hospital, Kangneung, South Korea (J.S.K.)
| | - Julien Labreuche
- CHU Lille, Department of Biostatistics, F59000-Lille, France (J.L.)
| | - Hugo Charles
- APHP, Department of Neurology and Stroke Center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris, France (P.A., P.C.L., H.C., E.M.)
| | - Maurice Giroud
- Department of Neurology, University Hospital of Dijon, Dijon Stroke Registry, EA 7460, University of Burgundy, UBFC, France (M.G.)
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (B.-C.L.)
| | | | - Elena Meseguer
- APHP, Department of Neurology and Stroke Center, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris, France (P.A., P.C.L., H.C., E.M.)
| | - Norbert Nighoghossian
- Hospices Civils de Lyon, Department of Neurology and Stroke Center, Lyon University, France (N.N.)
| | - Philippe Gabriel Steg
- Université de Paris, INSERM LVTS-U1148, F-75018, Paris, France (P.G.S.)
- AP-HP, Hôpital Bichat, F-765018 Paris, France (P.G.S.)
| | - Éric Vicaut
- APHP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France (É.V.)
| | - Eric Bruckert
- APHP, Department of Endocrinology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France (E.B.)
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Balagny P, Vidal-Petiot E, Renuy A, Matta J, Frija-Masson J, Steg PG, Goldberg M, Zins M, d'Ortho MP, Wiernik E. Prevalence, treatment and determinants of obstructive sleep apnoea and its symptoms in a population-based French cohort. ERJ Open Res 2023; 9:00053-2023. [PMID: 37228279 PMCID: PMC10204811 DOI: 10.1183/23120541.00053-2023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/13/2023] [Indexed: 05/27/2023] Open
Abstract
Background Obstructive sleep apnoea (OSA) is associated with increased morbidity and mortality. Although the disorder has been well studied in selected high-risk populations, few data exist on its prevalence in the general population. We aimed to assess the prevalence and determinants of OSA in France. Methods Data from participants of the French population-based CONSTANCES cohort aged 18-69 years at inclusion and being treated for sleep apnoea or screened for OSA in 2017 using the Berlin Questionnaire were analysed. Weighted analyses were performed to provide recent and representative results in the general population. Results Among 20 151 participants, the prevalence of treated sleep apnoea was 3.5% (95% CI 3.0-3.9%). The prevalence of untreated subjects with a positive Berlin Questionnaire was 18.1% (95% CI 17.3-19.2%) for a total weighted prevalence of treated sleep apnoea or high risk of OSA of 20.9% (95% CI 20.0-21.9%). Regarding prevalence of OSA symptoms, it was 37.2% (95% CI 36.1-38.3%) for severe snoring and 14.6% (95% CI 13.8-15.5%) for hypersomnolence. In multivariable logistic regression analysis, male sex, age, previous cardiovascular events, smoking, low educational level, low physical activity and depressive symptoms were associated with having either treated sleep apnoea or a positive Berlin Questionnaire. Conclusion In this large French population-based cohort, one in five participants had a high likelihood of OSA, whereas only 3.5% were treated for the disorder, suggesting major underdiagnosis in the general population. OSA diagnosis should be considered more often in people with risk factors such as depressive symptoms as well as unhealthy behaviours and socioeconomic conditions.
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Affiliation(s)
- Pauline Balagny
- Université Paris Cité, UFR de Médecine, Paris, France
- Service de Physiologie Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
| | - Emmanuelle Vidal-Petiot
- Université Paris Cité, UFR de Médecine, Paris, France
- Service de Physiologie Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1148, Laboratory for Vascular Translational Science, Paris, France
| | - Adeline Renuy
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
| | - Joane Matta
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
| | - Justine Frija-Masson
- Université Paris Cité, UFR de Médecine, Paris, France
- Service de Physiologie Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1148, Laboratory for Vascular Translational Science, Paris, France
| | - Philippe Gabriel Steg
- Université Paris Cité, UFR de Médecine, Paris, France
- INSERM U1148, Laboratory for Vascular Translational Science, Paris, France
- Département de Cardiologie, AP-HP, Hôpital Bichat, Paris, France
- Institut Universitaire de France, Paris, France
| | - Marcel Goldberg
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
| | - Marie Zins
- Université Paris Cité, UFR de Médecine, Paris, France
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
| | - Marie-Pia d'Ortho
- Université Paris Cité, UFR de Médecine, Paris, France
- Service de Physiologie Explorations Fonctionnelles, AP-HP, Hôpital Bichat, Paris, France
- INSERM U1141, NeuroDiderot, Paris, France
| | - Emmanuel Wiernik
- Université Paris Cité, Population-based Cohorts Unit, INSERM, Paris Saclay University, Université de Versailles Saint-Quentin-en-Yvelines, UMS 011, Paris, France
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Lavallée PC, Charles H, Albers GW, Caplan LR, Donnan GA, Ferro JM, Hennerici MG, Labreuche J, Molina C, Rothwell PM, Steg PG, Touboul PJ, Uchiyama S, Vicaut É, Wong LKS, Amarenco P. Effect of atherosclerosis on 5-year risk of major vascular events in patients with transient ischaemic attack or minor ischaemic stroke: an international prospective cohort study. Lancet Neurol 2023; 22:320-329. [PMID: 36931807 DOI: 10.1016/s1474-4422(23)00067-4] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/02/2023] [Accepted: 02/22/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The prevalence of atherosclerosis and the long-term risk of major vascular events in people who have had a transient ischaemic attack or minor ischaemic stroke, regardless of the causal relationship between the index event and atherosclerosis, are not well known. In this analysis, we applied the ASCOD (atherosclerosis, small vessel disease, cardiac pathology, other causes, and dissection) grading system to estimate the 5-year risk of major vascular events according to whether there was a causal relationship between atherosclerosis and the index event (ASCOD grade A1 and A2), no causal relationship (A3), and with or without a causal relationship (A1, A2, and A3). We also aimed to estimate the prevalence of different grades of atherosclerosis and identify associated risk factors. METHODS We analysed patient data from TIAregistry.org, which is an international, prospective, observational registry of patients with a recent (within the previous 7 days) transient ischaemic attack or minor ischaemic stroke (modified Rankin Scale score of 0-1) from 61 specialised centres in 21 countries in Europe, Asia, the Middle East, and Latin America. Using data from case report forms, we applied the ASCOD grading system to categorise the degree of atherosclerosis in our population (A0: no atherosclerosis; A1 or A2: atherosclerosis with stenosis ipsilateral to the cerebral ischaemic area; A3: atherosclerosis in vascular beds not related to the ischaemic area or ipsilateral plaques without stenosis; and A9: atherosclerosis not assessed). The primary outcome was a composite of non-fatal stroke, non-fatal acute coronary syndrome, or cardiovascular death within 5 years. FINDINGS Between June 1, 2009, and Dec 29, 2011, 4789 patients were enrolled to TIAregistry.org, of whom 3847 people from 42 centres participated in the 5-year follow-up; 3383 (87·9%) patients had a 5-year follow-up visit (median 92·3% [IQR 83·4-97·8] per centre). 1406 (36·5%) of 3847 patients had no atherosclerosis (ASCOD grade A0), 998 (25·9%) had causal atherosclerosis (grade A1 or A2), and 1108 (28·8%) had atherosclerosis that was unlikely to be causal (grade A3); in 335 (8·7%) patients, atherosclerosis was not assessed (grade A9). The 5-year event rate of the primary composite outcome was 7·7% (95% CI 6·3-9·2; 101 events) in patients categorised with grade A0 atherosclerosis, 19·8% (17·4-22·4; 189 events) in those with grade A1 or A2, and 13·8% (11·8-16·0; 144 events) in patients with grade A3. Compared with patients with grade A0 atherosclerosis, patients categorised as grade A1 or A2 had an increased risk of the primary composite outcome (hazard ratio 2·77, 95% CI 2·18-3·53; p<0·0001), as did patients with grade A3 (1·87, 1·45-2·42; p<0·0001). Except for age, male sex, and multiple infarctions on neuroimaging, most of the risk factors that were identified as being associated with grade A1 or A2 atherosclerosis were modifiable risk factors (ie, hypertension, dyslipidaemia, overweight, smoking cigarettes, and low physical activity; all p values <0·025). INTERPRETATION In patients with transient ischaemic attack or minor ischaemic stroke, those with atherosclerosis have a much higher risk of major vascular events within 5 years than do those without atherosclerosis. Preventive strategies addressing complications of atherosclerosis should focus on individuals with atherosclerosis rather than grouping together all people who have had a transient ischaemic attack or minor ischaemic stroke (including those without atherosclerosis). FUNDING AstraZeneca, Sanofi, Bristol Myers Squibb, SOS Attaque Cérébrale Association.
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Affiliation(s)
- Philippa C Lavallée
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Hugo Charles
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Louis R Caplan
- Cerebrovascular Disease Service, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Geoffrey A Donnan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - José M Ferro
- Instituto de Medicina Molecular João Lobo Antunes, Universidade de Lisboa, Lisbon, Portugal
| | - Michael G Hennerici
- Department of Neurology, Universitäts Medizin Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julien Labreuche
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France; Department of Biostatistics, CHU Lille, Lille, France
| | - Carlos Molina
- Department of Neurology, Stroke Unit, Vall d'Hebron University Hospital, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Peter M Rothwell
- Nuffield Department of Clinical Neuroscience, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, Oxford, UK
| | - Philippe Gabriel Steg
- Department of Cardiology, APHP, INSERM LVTS-U1148, DHU FIRE, Université Paris-Diderot, Université Paris Cité, Paris, France; Institut Universitaire de France, Paris, France
| | - Pierre-Jean Touboul
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France
| | - Shinichiro Uchiyama
- Center for Brain and Cerebral Vessels, International University of Health and Welfare, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Éric Vicaut
- Department of Biostatistics, APHP, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, Paris, France
| | - Lawrence K S Wong
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region, China
| | - Pierre Amarenco
- Department of Neurology and Stroke Center, APHP, Bichat Hospital, INSERM LVTS-U1148, DHU FIRE, University of Paris-Cité, Paris, France; Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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Costa F, Montalto C, Branca M, Hong SJ, Watanabe H, Franzone A, Vranckx P, Hahn JY, Gwon HC, Feres F, Jang Y, De Luca G, Kedhi E, Cao D, Steg PG, Bhatt DL, Stone GW, Micari A, Windecker S, Kimura T, Hong MK, Mehran R, Valgimigli M. Dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk: a meta-analysis of randomized trials. Eur Heart J 2023; 44:954-968. [PMID: 36477292 DOI: 10.1093/eurheartj/ehac706] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 10/13/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. The current study, using the totality of existing evidence, evaluated the impact of an abbreviated DAPT regimen in HBR patients. METHODS AND RESULTS A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated [i.e. very-short (1 month) or short (3 months)] with standard (≥6 months) DAPT in HBR patients without indication for oral anticoagulation. A total of 11 trials, including 9006 HBR patients, were included. Abbreviated DAPT reduced major or clinically relevant non-major bleeding [risk ratio (RR): 0.76, 95% confidence interval (CI): 0.61-0.94; I2 = 28%], major bleeding (RR: 0.80, 95% CI: 0.64-0.99, I2 = 0%), and cardiovascular mortality (RR: 0.79, 95% CI: 0.65-0.95, I2 = 0%) compared with standard DAPT. No difference in all-cause mortality, major adverse cardiovascular events, myocardial infarction, or stent thrombosis was observed. Results were consistent, irrespective of HBR definition and clinical presentation. CONCLUSION In HBR patients undergoing PCI, a 1- or 3-month abbreviated DAPT regimen was associated with lower bleeding and cardiovascular mortality, without increasing ischaemic events, compared with a ≥6-month DAPT regimen. STUDY REGISTRATION PROSPERO registration number CRD42021284004.
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Affiliation(s)
- Francesco Costa
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Claudio Montalto
- De Gasperis Cardio Center, Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy
| | | | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Fausto Feres
- Istituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil
| | - Yangsoo Jang
- Department of Cardiology, CHA Bundang Medical Center, Seongnam, Korea
| | | | - Elvin Kedhi
- Clinique Hopitaliere Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Davide Cao
- Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, A.O.U. Policlinic 'G. Martino', Messina 98100, Italy
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
| | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera Italiana (USI), Lugano, Switzerland
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Steg PG, Bhatt DL, Miller M, Brinton EA, Jacobson TA, Ketchum S, Jiao L, Pineda AL, Doyle RT, Tardif JC, Ballantyne CM. BENEFITS OF ICOSAPENT ETHYL IN PATIENTS WITH RECENT ACUTE CORONARY SYNDROME (ACS): REDUCE-IT ACS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01557-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Bittner V, Schwartz GG, Bhatt DL, Diaz R, Garon G, Goodman SG, Harrington RA, Jukema JW, Pordy R, Szarek M, White HD, Zeiher AM, Steg PG, Investigators ODYSSEYOUTCOMES. LIPOPROTEIN(A) AND CARDIOVASCULAR OUTCOMES IN WOMEN AND MEN AFTER AN ACUTE CORONARY SYNDROME: A POST HOC ODYSSEY OUTCOMES TRIAL ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02069-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Mesnier J, Bhatt DL, Zheng L, Fox KM, Harrington RA, Leiter LA, Mehta SR, Simon T, Andersson M, Himmelmann A, Steg PG. PREVALENCE AND IMPACT OF ANGINA IN PATIENTS WITH STABLE CORONARY ARTERY DISEASE AND DIABETES. INSIGHTS FROM THE THEMIS TRIAL. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01615-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Carson JL, Brooks MM, Chaitman BR, Alexander JH, Goodman SG, Bertolet M, Abbott JD, Cooper HA, Rao SV, Triulzi DJ, Fergusson DA, Kostis WJ, Noveck H, Simon T, Steg PG, DeFilippis AP, Goldsweig AM, Lopes RD, White H, Alsweiler C, Morton E, Hébert PC. Rationale and design for the myocardial ischemia and transfusion (MINT) randomized clinical trial. Am Heart J 2023; 257:120-129. [PMID: 36417955 PMCID: PMC9928777 DOI: 10.1016/j.ahj.2022.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 09/19/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Accumulating evidence from clinical trials suggests that a lower (restrictive) hemoglobin threshold (<8 g/dL) for red blood cell (RBC) transfusion, compared with a higher (liberal) threshold (≥10 g/dL) is safe. However, in anemic patients with acute myocardial infarction (MI), maintaining a higher hemoglobin level may increase oxygen delivery to vulnerable myocardium resulting in improved clinical outcomes. Conversely, RBC transfusion may result in increased blood viscosity, vascular inflammation, and reduction in available nitric oxide resulting in worse clinical outcomes. We hypothesize that a liberal transfusion strategy would improve clinical outcomes as compared to a more restrictive strategy. METHODS We will enroll 3500 patients with acute MI (type 1, 2, 4b or 4c) as defined by the Third Universal Definition of MI and a hemoglobin <10 g/dL at 144 centers in the United States, Canada, France, Brazil, New Zealand, and Australia. We randomly assign trial participants to a liberal or restrictive transfusion strategy. Participants assigned to the liberal strategy receive transfusion of RBCs sufficient to raise their hemoglobin to at least 10 g/dL. Participants assigned to the restrictive strategy are permitted to receive transfusion of RBCs if the hemoglobin falls below 8 g/dL or for persistent angina despite medical therapy. We will contact each participant at 30 days to assess clinical outcomes and at 180 days to ascertain vital status. The primary end point is a composite of all-cause death or recurrent MI through 30 days following randomization. Secondary end points include all-cause mortality at 30 days, recurrent adjudicated MI, and the composite outcome of all-cause mortality, nonfatal recurrent MI, ischemia driven unscheduled coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting), or readmission to the hospital for ischemic cardiac diagnosis within 30 days. The trial will assess multiple tertiary end points. CONCLUSIONS The MINT trial will inform RBC transfusion practice in patients with acute MI.
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Affiliation(s)
| | | | | | | | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Toronto Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Marnie Bertolet
- University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - J Dawn Abbott
- Warren Alpert Medical School. Brown University, Providence, RI
| | | | - Sunil V Rao
- Durham VA Medical Center, Durham, NC; NYU Langone Health, New York, NY
| | | | | | | | - Helaine Noveck
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | | | | | | | - Renato D Lopes
- Brazilian Clinical Research Institute, São Paulo, Brazil; Duke Clinical Research Institute, Durham, NC
| | - Harvey White
- Green Lane Clinical Coordinating Centre Ltd, Auckland, New Zealand
| | | | | | - Paul C Hébert
- Centre de Recherche du Centre Hosp. Universitaire de Montréal, Montréal, Québec, Canada
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Schwartz GG, Szarek M, Bhatt DL, Bittner V, Bujas-Bobanovic M, Diaz R, Fazio S, Goodman SG, Harrington RA, Jukema JW, Pordy R, Scemama M, White HD, Zeiher AM, Steg PG. SHORT-DURATION, VERY HIGH-INTENSITY LIPID-LOWERING THERAPY RESULTS IN PROLONGED REDUCTION OF CARDIOVASCULAR EVENTS FOLLOWING ACUTE CORONARY SYNDROME. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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41
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Kosiborod M, Bhatt DL, Szarek M, Steg PG, Pitt B. EFFECTS OF SGLT 1-2 INHIBITOR SOTAGLIFLOZIN ON SYMPTOMS, PHYSICAL LIMITATIONS AND QUALITY OF LIFE IN PATIENTS WITH WORSENING HEART FAILURE: RESULTS FROM THE SOLOIST TRIAL. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00723-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Durand-Zaleski I, Ducrocq G, Mimouni M, Frenkiel J, Avendano-Solá C, Gonzalez-Juanatey JR, Ferrari E, Lemesle G, Puymirat E, Berard L, Cachanado M, Arnaiz JA, Martínez-Sellés M, Silvain J, Ariza-Solé A, Calvo G, Danchin N, Paco S, Drouet E, Abergel H, Rousseau A, Simon T, Steg PG. Economic evaluation of restrictive vs. liberal transfusion strategy following acute myocardial infarction (REALITY): trial-based cost-effectiveness and cost-utility analyses. Eur Heart J Qual Care Clin Outcomes 2023; 9:194-202. [PMID: 35612990 DOI: 10.1093/ehjqcco/qcac029] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/09/2022] [Accepted: 05/18/2022] [Indexed: 01/29/2023]
Abstract
AIMS To estimate the cost-effectiveness and cost-utility ratios of a restrictive vs. liberal transfusion strategy in acute myocardial infarction (AMI) patients with anaemia. METHODS AND RESULTS Patients (n = 666) with AMI and haemoglobin between 7-8 and 10 g/dL recruited in 35 hospitals in France and Spain were randomly assigned to a restrictive (n = 342) or a liberal (n = 324) transfusion strategy with 1-year prospective collection of resource utilization and quality of life using the EQ5D3L questionnaire. The economic evaluation was based on 648 patients from the per-protocol population. The outcomes were 30-day and 1-year cost-effectiveness, with major adverse cardiovascular events (MACEs) averted as the effectiveness outcome. and a 1-year cost-utility ratio.The 30-day incremental cost-effectiveness ratio was €33 065 saved per additional MACE averted with the restrictive vs. liberal strategy, with an 84% probability for the restrictive strategy to be cost-saving and MACE-reducing (i.e. dominant). At 1 year, the point estimate of the cost-utility ratio was €191 500 saved per quality-adjusted life year gained; however, the cumulated MACE was outside the pre-specified non-inferiority margin, resulting in a decremental cost-effectiveness ratio with a point estimate of €72 000 saved per additional MACE with the restrictive strategy. CONCLUSION In patients with AMI and anaemia, the restrictive transfusion strategy was dominant (cost-saving and outcome-improving) at 30 days. At 1 year, the restrictive strategy remained cost-saving, but clinical non-inferiority on MACE was no longer maintained. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02648113. ONE SENTENCE SUMMARY The use of a restrictive transfusion strategy in patients with acute myocardial infarction is associated with lower healthcare costs, but more evidence is needed to ascertain its long-term clinical impact.
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Affiliation(s)
- Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, place du parvis de Notre Dame 75004, Paris, France.,INSERM UMR 1153 CRESS, Paris, France
| | - Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, 75018, Paris, France
| | - Maroua Mimouni
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, place du parvis de Notre Dame 75004, Paris, France
| | - Jerome Frenkiel
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, place du parvis de Notre Dame 75004, Paris, France
| | - Cristina Avendano-Solá
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jose R Gonzalez-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Emile Ferrari
- Université Côte d'Azur, and CHU de Nice, Hôpital Pasteur 1, Service de Cardiologie, 06001, Nice, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France
| | - Etienne Puymirat
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), 75015, Paris, France
| | - Laurence Berard
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, and Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), INSERM UMRS 1166, 75013, Paris, France
| | - Albert Ariza-Solé
- University Hospital Bellvitge, Heart Disease Institute, Barcelona, Spain
| | - Gonzalo Calvo
- Àrea del Medicament, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Nicolas Danchin
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), 75015, Paris, France
| | - Sandra Paco
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Elodie Drouet
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Helene Abergel
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, 75018, Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, 75012, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, 75018, Paris, France
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Vidal-Petiot E, Elbez Y, Mesnier J, Ducrocq G, Ford I, Tendera M, Ferrari R, Tardif JC, Fox KM, Steg PG. Optimal or standard control of systolic and diastolic blood pressure across risk factor categories in patients with chronic coronary syndromes. Eur J Prev Cardiol 2023:6974677. [PMID: 36617264 DOI: 10.1093/eurjpc/zwad004] [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: 11/07/2022] [Revised: 12/09/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Abstract
AIMS Guidelines have lowered blood pressure (BP) targets to <130/80 mmHg. We examined the benefit of intensive control for each BP component, versus the burden of other modifiable risk factors, in patients with chronic coronary syndromes (CCS). METHODS AND RESULTS The CLARIFY registry (ISRCTN43070564) enrolled 32 703 CCS patients, from 2009-2010, with a 5-year follow-up. Patients with either BP component below European guideline safety boundaries (120/70 mmHg) were excluded, leaving 19 167 patients (mean age 63.8 ± 10.1 years, 78% men) in the present analysis. A multivariable-adjusted Cox proportional hazards model showed a gradual increase in cardiovascular risk (cardiovascular death, myocardial infarction, or stroke) when the number of uncontrolled risk factors (active smoking, no physical activity, low-density lipoprotein cholesterol ≥100 mg/dL, and diabetes with glycated haemoglobin ≥7%) increased [adjusted hazard ratio (HR): 1.34; 95% confidence interval (CI): 1.17-1.52, 1.65 (1.40-1.94), and 2.47 (1.90-3.21) for 1, 2, and 3 or 4 uncontrolled risk factors, respectively, versus 0], without significant interaction with BP. Although uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) BP were both associated with higher risk than standard BP, standard BP was associated with higher risk than optimal control for only the diastolic component (adjusted HR: 1.08; 95% CI: 0.94-1.25 for systolic BP 130-139 versus 120-129 mmHg and 1.43; 95% CI: 1.27-1.62 for diastolic BP 80-89 versus 70-79 mmHg). CONCLUSIONS Our results suggest that optimal BP target in CCS may be ≤139/79 mmHg, and that optimizing the burden of other risk factors should be prioritized over further reduction of systolic BP.
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Affiliation(s)
- Emmanuelle Vidal-Petiot
- Physiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat and INSERM U1149, Centre for Research in Inflammation, 46 rue Henri Huchard, 75018 Paris, France.,Université Paris-Cité, Paris, France
| | - Yedid Elbez
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France.,FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, 75018 Paris, France.,Biostat Signifience, 35 rue de l'Oasis, 92800 Puteaux, France
| | - Jules Mesnier
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France.,FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, 75018 Paris, France
| | - Gregory Ducrocq
- Université Paris-Cité, Paris, France.,Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France.,FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, 75018 Paris, France
| | - Ian Ford
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Michal Tendera
- Medical University of Silesia, School of Medicine in Katowice, Department of Cardiology and Structural Heart Disease, Katowice, Poland
| | - Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Italy and Scientific Department of Medical Trial Analysis (MTA), Lugano, Switzerland
| | - Jean-Claude Tardif
- Department of Medicine, Montreal Heart Institute, Université de Montreal, 5000 Belanger Street, Montreal H1T1C8, PQ, Canada
| | - Kim M Fox
- NHLI Imperial College, Dovehouse Street, London SW3 6LP ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Philippe Gabriel Steg
- Université Paris-Cité, Paris, France.,Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France.,FACT (French Alliance for Cardiovascular Trials) and INSERM U1148, Laboratory for Vascular Translational Science, 46, rue Henri Huchard, 75018 Paris, France.,Institut Universitaire de France
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Affiliation(s)
- Philippe Gabriel Steg
- Université Paris-Cité, France (P.G.S., J.K.).,Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France (P.G.S., J.K.).,French Alliance for Cardiovascular Trials, Institut National de la Santé et de la Recherche Médicale U-1148, Paris (P.G.S.).,Institut Universitaire de France, Paris (P.G.S.)
| | - John Kikoïne
- Université Paris-Cité, France (P.G.S., J.K.).,Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France (P.G.S., J.K.)
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Abtan J, Bhatt DL, Elbez Y, Ducrocq G, Goto S, Smith SC, Ohman EM, Eagle KA, Fox K, Harrington RA, Leiter LA, Mehta SR, Simon T, Petrov I, Sinnaeve PR, Pais P, Lev E, Bueno H, Wilson P, Steg PG. External applicability of the Effect of ticagrelor on Health Outcomes in diabEtes Mellitus patients Intervention Study (THEMIS) trial: An analysis of patients with diabetes and coronary artery disease in the REduction of Atherothrombosis for Continued Health (REACH) registry. Int J Cardiol 2023; 370:51-57. [PMID: 36270493 DOI: 10.1016/j.ijcard.2022.10.132] [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: 09/13/2021] [Revised: 08/05/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
AIMS THEMIS is a double-blind, randomized trial of 19,220 patients with diabetes mellitus and stable coronary artery disease (CAD) comparing ticagrelor to placebo, in addition to aspirin. The present study aimed to describe the proportion of patients eligible and reasons for ineligibility for THEMIS within a population of patients with diabetes and CAD included in the Reduction of Atherothrombosis for Continued Health (REACH) registry. METHODS AND RESULTS The THEMIS eligibility criteria were applied to REACH patients. THEMIS included patients ≥50 years with type 2 diabetes and stable CAD as determined by either a history of previous percutaneous coronary intervention, coronary artery bypass grafting, or documentation of angiographic stenosis of ≥50% of at least one coronary artery. Patients with prior myocardial infarction or stroke were excluded. In REACH, 10,156 patients had stable CAD and diabetes. Of these, 6515 (64.1%) patients had at least one exclusion criteria. From the remaining population, 784 patients did not meet inclusion criteria (7.7%) mainly due to absence of aspirin treatment (7.2%), yielding a 'THEMIS-eligible population' of 2857 patients (28.1% of patients with diabetes and stable CAD). The main reasons for exclusion were a history of myocardial infarction (53.1%), use of oral anticoagulation (14.5%), or history of stroke (12.9%). Among the 4208 patients with diabetes and a previous PCI, 1196 patients (28.4%) were eligible for inclusion in the THEMIS-PCI substudy. CONCLUSIONS In a population of patients with diabetes and stable coronary artery disease, a sizeable proportion appear to be 'THEMIS eligible.' CLINICAL TRIAL REGISTRATION http://www. CLINICALTRIALS gov identifier: NCT01991795.
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Affiliation(s)
- Jeremie Abtan
- FACT (French Alliance for Cardiovascular clinical Trials), Université de Paris, Hôpital Bichat (Assistance Publique - Hôpitaux de Paris) and INSERM U-1148, all in Paris, France; Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA.
| | - Yedid Elbez
- FACT (French Alliance for Cardiovascular clinical Trials), Université de Paris, Hôpital Bichat (Assistance Publique - Hôpitaux de Paris) and INSERM U-1148, all in Paris, France
| | - Gregory Ducrocq
- FACT (French Alliance for Cardiovascular clinical Trials), Université de Paris, Hôpital Bichat (Assistance Publique - Hôpitaux de Paris) and INSERM U-1148, all in Paris, France
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Sidney C Smith
- Division of Cardiology, Department of Medicine, University of North Carolina, Chapel Hill, USA
| | - E Magnus Ohman
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, NC, USA
| | - Kim A Eagle
- University of Michigan Cardiovascular Center, Ann Arbor, USA
| | - Kim Fox
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Institute of Cardiovascular Medicine and Science, Royal Brompton Hospital, London, United Kingdom
| | - Robert A Harrington
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, California, USA
| | - Lawrence A Leiter
- Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute, St Michael's Hospital, University ot Toronto, Ontario, Canada
| | - Shamir R Mehta
- Population Health Research Institute and Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tabassome Simon
- Plateforme de Recherche Clinique de l'Est Parisien (URCEST-CRCEST-CRB), Saint-Antoine Hospital, AP-HP, Paris, France
| | - Ivo Petrov
- University Hospital Acibadem City Clinic Sofia, Sofia University St. Kliment Ohridski, Bulgaria
| | - Peter R Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium
| | - Prem Pais
- Division of Clinical Research and Training, St. John's Research Institute, Bangalore, India
| | - Eli Lev
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Department of Cardiology, Assuta Ashdod University Hospital, Ashdod, Faculty of Medicine, Ben Gurion University, Be'er Sheva, all in, Israel
| | - Héctor Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre, Centro Nacional de Investigaciones Cardiovasculares, and CIBER de enfermedades CardioVasculares (CIBERCV), Madrid, Spain
| | | | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular clinical Trials), Université de Paris, Hôpital Bichat (Assistance Publique - Hôpitaux de Paris) and INSERM U-1148, all in Paris, France; National Heart and Lung Institute, Imperial College, London, United Kingdom
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Mehran R, Steg PG, Pfeffer MA, Jering K, Claggett B, Lewis EF, Granger C, Køber L, Maggioni A, Mann DL, McMurray JJV, Rouleau JL, Solomon SD, Ducrocq G, Berwanger O, De Pasquale CG, Landmesser U, Petrie M, Leng DSK, van der Meer P, Lefkowitz M, Zhou Y, Braunwald E. The Effects of Angiotensin Receptor-Neprilysin Inhibition on Major Coronary Events in Patients With Acute Myocardial Infarction: Insights From the PARADISE-MI Trial. Circulation 2022; 146:1749-1757. [PMID: 36321459 DOI: 10.1161/circulationaha.122.060841] [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] [Indexed: 11/06/2022]
Abstract
BACKGROUND In patients who survive an acute myocardial infarction (AMI), angiotensin-converting enzyme inhibitors decrease the risk of subsequent major cardiovascular events. Whether angiotensin-receptor blockade and neprilysin inhibition with sacubitril/valsartan reduce major coronary events more effectively than angiotensin-converting enzyme inhibitors in high-risk patients with recent AMI remains unknown. We aimed to compare the effects of sacubitril/valsartan on coronary outcomes in patients with AMI. METHODS We conducted a prespecified analysis of the PARADISE-MI trial (Prospective ARNI vs ACE Inhibitors Trial to Determine Superiority in Reducing Heart Failure Events After MI), which compared sacubitril/valsartan (97/103 mg twice daily) with ramipril (5 mg twice daily) for reducing heart failure events after myocardial infarction in 5661 patients with AMI complicated by left ventricular systolic dysfunction, pulmonary congestion, or both. In the present analysis, the prespecified composite coronary outcome was the first occurrence of death from coronary heart disease, nonfatal myocardial infarction, hospitalization for angina, or postrandomization coronary revascularization. RESULTS Patients were randomly assigned at a median of 4.4 [3.0-5.8] days after index AMI (ST-segment-elevation myocardial infarction 76%, non-ST-segment-elevation myocardial infarction 24%), by which time 89% of patients had undergone coronary reperfusion. Compared with ramipril, sacubitril/valsartan decreased the risk of coronary outcomes (hazard ratio, 0.86 [95% CI, 0.74-0.99], P=0.04) over a median follow-up of 22 months. Rates of the components of the composite outcomes were lower in patients on sacubitril/valsartan but were not individually significantly different. CONCLUSIONS In survivors of an AMI with left ventricular systolic dysfunction and pulmonary congestion, sacubitril/valsartan-compared with ramipril-reduced the risk of a prespecified major coronary composite outcome. Dedicated studies are necessary to confirm this finding and elucidate its mechanism. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02924727.
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Affiliation(s)
- Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - Philippe Gabriel Steg
- Université Paris-Cité, AP-HP (Assistance Publique-Hôpitaux de Paris), FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148, France (P.G.S.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Karola Jering
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, CA (E.F.L.)
| | | | - Lars Køber
- Professor of Cardiology, Department of Clinical Medicine, University of Copenhagen, Denmark (L.K.)
| | - Aldo Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy (A.M.)
| | - Douglas L Mann
- Washington University Medical Center, St Louis, MO (D.L.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
| | - Gregory Ducrocq
- Département de Cardiologie, Hôpital Bichat Assistance Publique Hôpitaux de Paris. France (G.D.)
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, São Paulo-SP, Brazil (O.B.)
| | - Carmine G De Pasquale
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, South Australia (C.G.D.P.)
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany (U.L.)
| | - Mark Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Scotland (J.J.V.M., M.P.)
| | | | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (P.v.d.M.)
| | - Martin Lefkowitz
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Yinong Zhou
- Novartis Pharmaceutical Corporation, East Hanover, NJ (M.L., Y.Z.)
| | - Eugene Braunwald
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.A.P., K.J., B.C., S.D.S., E.B.)
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47
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Mehta SR, Wang J, Wood DA, Spertus JA, Cohen DJ, Mehran R, Storey RF, Steg PG, Pinilla-Echeverri N, Sheth T, Bainey KR, Bangalore S, Cantor WJ, Faxon DP, Feldman LJ, Jolly SS, Kunadian V, Lavi S, Lopez-Sendon J, Madan M, Moreno R, Rao SV, Rodés-Cabau J, Stanković G, Bangdiwala SI, Cairns JA. Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction: Results From the COMPLETE Randomized Clinical Trial. JAMA Cardiol 2022; 7:1091-1099. [PMID: 36129696 PMCID: PMC9494273 DOI: 10.1001/jamacardio.2022.3032] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/25/2022] [Indexed: 01/09/2023]
Abstract
Importance In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown. Objective To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD. Design, Setting, and Participants This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021. Interventions Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization. Main Outcomes and Measures Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end. Results Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02). Conclusions and Relevance In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.
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Affiliation(s)
- Shamir R. Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - David A. Wood
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri–Kansas City, Kansas City
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital, Roslyn, New York
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Philippe Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - David P. Faxon
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laurent J. Feldman
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Sanjit S. Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Shahar Lavi
- Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jose Lopez-Sendon
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Raul Moreno
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | | | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Quebec, Canada
| | - Goran Stanković
- Serbia to Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Shrikant I. Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John A. Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
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48
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Batra G, Lindbäck J, Becker RC, Harrington RA, Held C, James SK, Kempf T, Lopes RD, Mahaffey KW, Steg PG, Storey RF, Swahn E, Wollert KC, Siegbahn A, Wallentin L. Biomarker-Based Prediction of Recurrent Ischemic Events in Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2022; 80:1735-1747. [PMID: 36302586 DOI: 10.1016/j.jacc.2022.08.767] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/15/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute coronary syndrome (ACS), there is residual and variable risk of recurrent ischemic events. OBJECTIVES This study aimed to develop biomarker-based prediction models for 1-year risk of cardiovascular (CV) death and myocardial infarction (MI) in patients with ACS undergoing percutaneous coronary intervention. METHODS We included 10,713 patients from the PLATO (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome) trial in the development cohort and externally validated in 3,508 patients from the TRACER (Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome) trial. Variables contributing to risk of CV death/MI were assessed using Cox regression models, and a score was derived using subsets of variables approximating the full model. RESULTS There were 632 and 190 episodes of CV death/MI in the development and validation cohorts. The most important predictors of CV death/MI were the biomarkers, growth differentiation factor 15, and N-terminal pro-B-type natriuretic peptide, which had greater prognostic value than all candidate variables. The final model included 8 items: age (A), biomarkers (B) (growth differentiation factor 15 and N-terminal pro-B-type natriuretic peptide), and clinical variables (C) (extent of coronary artery disease, previous vascular disease, Killip class, ACS type, P2Y12 inhibitor). The model, named ABC-ACS ischemia, was well calibrated and showed good discriminatory ability for 1-year risk of CV death/MI with C-indices of 0.71 and 0.72 in the development and validation cohorts, respectively. For CV death, the score performed better, with C-indices of 0.80 and 0.84 in the development and validation cohorts, respectively. CONCLUSIONS An 8-item score for the prediction of CV death/MI was developed and validated for patients with ACS undergoing percutaneous coronary intervention. The ABC-ACS ischemia score showed good calibration and discrimination and might be useful for risk prediction and decision support in patients with ACS. (A Comparison of Ticagrelor [AZD6140] and Clopidogrel in Patients With Acute Coronary Syndrome [PLATO]; NCT00391872; Trial to Assess the Effects of Vorapaxar [SCH 530348; MK-5348] in Preventing Heart Attack and Stroke in Participants With Acute Coronary Syndrome [TRACER]; NCT00527943).
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Affiliation(s)
- Gorav Batra
- 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
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, Heart, Lung and Vascular Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Tibor Kempf
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Renato D Lopes
- Department of Medicine, Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, California, USA
| | - Philippe Gabriel Steg
- Université de Paris, Institut National de la Santé et de la Recherche Médicale-Unité 1148, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Eva Swahn
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Kai C Wollert
- Division of Molecular and Translational Cardiology, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - 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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49
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Raskob GE, Ageno W, Albers G, Elliott CG, Halperin J, Maynard G, Steg PG, Weitz JI, Albanese J, Yuan Z, Levitan B, Lu W, Suh EY, Spiro T, Lipardi C, Barnathan ES, Spyropoulos AC. Benefit-Risk Assessment of Rivaroxaban for Extended Thromboprophylaxis After Hospitalization for Medical Illness. J Am Heart Assoc 2022; 11:e026229. [PMID: 36205248 DOI: 10.1161/jaha.122.026229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Venous thromboembolism (VTE) often occurs after hospitalization in medically ill patients, but the population benefit-risk of extended thromboprophylaxis remains uncertain. Methods and Results The MARINER (Medically Ill Patient Assessment of Rivaroxaban Versus Placebo in Reducing Post-Discharge Venous Thrombo-Embolism Risk) study (NCT02111564) was a randomized double-blind trial that compared thromboprophylaxis with rivaroxaban 10 mg daily versus placebo for 45 days after hospital discharge in medically ill patients with a creatinine clearance ≥50 mL/min. The benefit-risk balance in this population was quantified by calculating the between-treatment rate differences in efficacy and safety end points per 10 000 patients treated. Clinical characteristics of the study population were consistent with a hospitalized medical population at risk for VTE. Treating 10 000 patients with rivaroxaban resulted in 32.5 fewer symptomatic VTE and VTE-related deaths but was associated with 8 additional major bleeding events. The treatment benefit was driven by the prevention of nonfatal symptomatic VTE (26 fewer events). There was no between-treatment difference in the composite of critical site or fatal bleeding. Conclusions Extending thromboprophylaxis with rivaroxaban for 45 days after hospitalization provides a positive benefit-risk balance in medically ill patients at risk for VTE who are not at high risk for bleeding. Registration URL: https://clinicaltrials.gov/; Unique identifier: NCT02111564.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public Health University of Oklahoma Health Sciences Center Oklahoma City OK
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | - Gregory Albers
- Stanford Stroke Center Stanford University Medical Center Stanford CA
| | - C Gregory Elliott
- Department of Medicine Intermountain Medical Center and the University of Utah Salt Lake City UT
| | | | | | - Philippe Gabriel Steg
- Universite Paris-Cite Assistance Publique-Hôpitauxde Paris, and INSERM U-1148 Paris France.,Imperial College, Royal Brompton Hospital London United Kingdom
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | | | - Zhong Yuan
- Janssen Research & Development, LLC Titusville NJ
| | | | - Wentao Lu
- Janssen Research & Development, LLC Raritan NJ
| | | | - Theodore Spiro
- Clinical Development Pharmaceuticals, Bayer U.S. LLC Whippany NJ
| | | | | | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell The Feinstein Institute for Medical Research, and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lennox Hill Hospital New York NY
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50
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Mehran R, Spirito A, Cao D, Sartori S, Baber U, Dangas G, Gibson CM, Steg PG, Pocock SJ, Valgimigli M. Safety and efficacy of biodegradable polymer biolimus-eluting stents in patients with non-ST-elevation acute coronary syndrome: a pooled analysis of GLASSY and TWILIGHT. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2060] [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
Biodegradable polymer (BP) drug-eluting stents (DES) have shown similar safety and efficacy compared with second-generation durable polymer (DP)-DES in several randomized trials and meta-analyses. However, study participants were generally maintained on a standard dual antiplatelet therapy (DAPT) for at least 6 months after percutaneous coronary intervention (PCI). Therefore, the differences in thrombogenicity between these two stent technologies may have been unappreciated, especially among patients with acute coronary syndrome (ACS).
Purpose
We aimed to compare the safety and efficacy of BP Biolimus-Eluting Stent (BP-BES) versus 2nd generation DP-DES among ACS patients undergoing PCI and receiving ticagrelor alone or in combination with aspirin.
Methods
We pooled individual patient-level data from two randomized controlled trials, the Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention (TWILIGHT, n=9,006) (1) and the GLOBAL LEADERS Adjudication Sub-Study (GLASSY, n=7,585) (2). In order to reduce biases related to trial design differences, only NST-ACS patients not fulfilling any exclusion criterion of both studies were included and 2 separate analysis for short (0 to 3 months after PCI) and long-term (3 to 12 months after PCI) outcomes were performed. Patients were stratified according to the stent used at index PCI (BP-BES vs 2nd generation DP-DES). In both analysis, the primary outcome was major adverse cardiovascular events (MACE, a composite of cardiovascular death, myocardial infarction and definite or probable stent thrombosis); the key secondary outcomes were target-vessel failure (TVF) and BARC 2, 3 or 5 bleeding. Events rate and risk were assessed separately for the two study periods and subsequently 12-months risk estimates were derived by pooling the results of the two analysis.
Results
Out of 7,729 and 6,572 NST-ACS patients included in the two analysis, 2,321 (30%) and 2,211 (33.6%) received a BP-BES, respectively. Among patients treated with BP-BES versus DP-DES, the occurrence of MACE was similar at 3 months after PCI (1.1% vs 1.4%, adjusted HR 0.81, 95% CI 0.51–1.29), while it was significantly lower in the former group between 3 and 12 months (1.7% vs 3.1%, adj. HR 0.46, 95% CI 0.32–0.67) and in the overall period (pooled adjusted HR estimate 0.58, 95% CI 0.43–0.77).
Similarly, significant differences were observed for TVF and BARC 2, 3, or 5 bleeding, whose risk at 12 months was lower among BP-BES than DP-DES patients (pooled adj. HR estimate 0.49, 95% CI 0.38–0.63 and 0.79, 95% CI 0.79, 95% CI 0.65–0.97, respectively).
Conclusion
As compared to 2nd generation DP-DES, BP-BES was associated with a lower risk of MACE, TVF and bleeding among NST-ACS patients undergoing PCI and treated with ticagrelor with or without aspirin. The findings of this analysis are exploratory and need further confirmation.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Biosensors (Singapore)
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Affiliation(s)
- R Mehran
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - A Spirito
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - D Cao
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - S Sartori
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - U Baber
- University of Oklahoma Health Sciences Center , Oklahoma City , United States of America
| | - G Dangas
- Icahn School of Medicine at Mount Sinai , New York , United States of America
| | - C M Gibson
- Beth Israel Deaconess Medical Center , Boston , United States of America
| | - P G Steg
- Bichat APHP Site of Paris Nord University Hospital , Paris , France
| | - S J Pocock
- London School of Hygiene and Tropical Medicine, Department of Medical Statistics , London , United Kingdom
| | - M Valgimigli
- Cardiocentro Ticino Institute , Lugano , Switzerland
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