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Georgiopoulos G, Makris N, Laina A, Theodorakakou F, Briasoulis A, Trougakos IP, Dimopoulos MA, Kastritis E, Stamatelopoulos K. Cardiovascular Toxicity of Proteasome Inhibitors: Underlying Mechanisms and Management Strategies: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2023; 5:1-21. [PMID: 36875897 PMCID: PMC9982226 DOI: 10.1016/j.jaccao.2022.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 02/24/2023] Open
Abstract
Proteasome inhibitors (PIs) are the backbone of combination treatments for patients with multiple myeloma and AL amyloidosis, while also indicated in Waldenström's macroglobulinemia and other malignancies. PIs act on proteasome peptidases, causing proteome instability due to accumulating aggregated, unfolded, and/or damaged polypeptides; sustained proteome instability then induces cell cycle arrest and/or apoptosis. Carfilzomib, an intravenous irreversible PI, exhibits a more severe cardiovascular toxicity profile as compared with the orally administered ixazomib or intravenous reversible PI such as bortezomib. Cardiovascular toxicity includes heart failure, hypertension, arrhythmias, and acute coronary syndromes. Because PIs are critical components of the treatment of hematological malignancies and amyloidosis, managing their cardiovascular toxicity involves identifying patients at risk, diagnosing toxicity early at the preclinical level, and offering cardioprotection if needed. Future research is required to elucidate underlying mechanisms, improve risk stratification, define the optimal management strategy, and develop new PIs with safe cardiovascular profiles.
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Key Words
- ACE, angiotensin-converting enzyme
- ACS, acute coronary syndrome
- AE, adverse event
- AF, atrial fibrillation
- ARB, angiotensin receptor blocker
- ASCT, autologous stem cell transplantation
- BP, blood pressure
- CVAE, cardiovascular adverse event
- ESC, European Society of Cardiology
- FMD, flow-mediated dilatation
- GLS, global longitudinal strain
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- IHD, ischemic heart disease
- IMiD, immunomodulatory drug
- Kd, carfilzomib and dexamethasone
- LA, left atrial
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MM, multiple myeloma
- NO, nitric oxide
- NP, natriuretic peptide
- OS, overall survival
- PBMC, peripheral blood mononuclear cell
- PFS, progression-free survival
- PH, pulmonary hypertension
- PI, proteasome inhibitor
- PWV, pulse wave velocity
- PrA, proteasome activity
- RRMM, relapse or refractory multiple myeloma
- SBP, systolic blood pressure
- TMA, thrombotic microangiopathy
- UPP, ubiquitin proteasome pathway
- VTE, venous thromboembolism
- Vd, bortezomib and dexamethasone
- WM, Waldenström’s macroglobulinemia
- bortezomib
- cardiovascular toxicity
- carfilzomib
- eNOS, endothelial nitric oxide synthase
- ixazomib
- proteasome inhibition
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Affiliation(s)
- Georgios Georgiopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Nikolaos Makris
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ageliki Laina
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Briasoulis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis P Trougakos
- Department of Cell Biology and Biophysics, Faculty of Biology, National and Kapodistrian University of Athens, Greece
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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2
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Fraser DD, Patel MA, Van Nynatten LR, Martin C, Seney SL, Miller MR, Daley M, Slessarev M, Cepinskas G, Juneja GK, Sabourin V, Fox-Robichaud A, Yeh CH, Kim PY, Badrnya S, Oehler S, Miholits M, Webb B. Cross-immunity against SARS-COV-2 variants of concern in naturally infected critically ill COVID-19 patients. Heliyon 2023; 9:e12704. [PMID: 36594041 PMCID: PMC9797417 DOI: 10.1016/j.heliyon.2022.e12704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/21/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Critically ill patients infected with SARS-CoV-2 display adaptive immunity, but it is unknown if they develop cross-reactivity to variants of concern (VOCs). We profiled cross-immunity against SARS-CoV-2 VOCs in naturally infected, non-vaccinated, critically ill COVID-19 patients. Wave-1 patients (wild-type infection) were similar in demographics to Wave-3 patients (wild-type/alpha infection), but Wave-3 patients had higher illness severity. Wave-1 patients developed increasing neutralizing antibodies to all variants, as did patients during Wave-3. Wave-3 patients, when compared to Wave-1, developed more robust antibody responses, particularly for wild-type, alpha, beta and delta variants. Within Wave-3, neutralizing antibodies were significantly less to beta and gamma VOCs, as compared to wild-type, alpha and delta. Patients previously diagnosed with cancer or chronic obstructive pulmonary disease had significantly fewer neutralizing antibodies. Naturally infected ICU patients developed adaptive responses to all VOCs, with greater responses in those patients more likely to be infected with the alpha variant, versus wild-type.
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Key Words
- ACE2, angiotensin-converting enzyme
- AUC, area-under-the-curve
- Adaptive immunity
- Antibodies
- COPD, chronic obstructive pulmonary disease
- COVID-19
- COVID-19, coronavirus disease 2019
- ICU, intensive care unit
- IQR, interquartile range
- Intensive care units
- MFI, median fluorescence intensity
- MODS, multi-organ dysfunction score
- Neutralizing
- P/F, arterial partial pressure to inspired oxygen
- RBD, receptor binding domain
- REB, research ethics board
- ROC, receiver operating characteristic
- SARS-CoV-2
- SARS-CoV-2 alpha variant
- SARS-CoV-2 beta variant
- SARS-CoV-2 delta variant
- SARS-CoV-2 gamma variant
- SOFA, sequential organ failure assessment
- VOC, variants of concern
- VTE, venous thromboembolism
- WT, wild-type
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Affiliation(s)
- Douglas D. Fraser
- Lawson Health Research Institute, London, ON, N6C 2R5, Canada,Pediatrics, Western University, London, ON, N6A 3K7, Canada,Clinical Neurological Sciences, Western University, London, ON, N6A 3K7, Canada,Physiology & Pharmacology, Western University, London, ON, N6A 3K7, Canada,Corresponding author. Lawson Health Research Institute, London, ON, N6C 2R5, Canada
| | | | | | - Claudio Martin
- Lawson Health Research Institute, London, ON, N6C 2R5, Canada,Medicine, Western University, London, ON, N6A 3K7, Canada
| | | | - Michael R. Miller
- Lawson Health Research Institute, London, ON, N6C 2R5, Canada,Pediatrics, Western University, London, ON, N6A 3K7, Canada
| | - Mark Daley
- Epidemiology, Western University, London, ON, N6A 3K7, Canada
| | - Marat Slessarev
- Lawson Health Research Institute, London, ON, N6C 2R5, Canada,Medicine, Western University, London, ON, N6A 3K7, Canada
| | - Gediminas Cepinskas
- Lawson Health Research Institute, London, ON, N6C 2R5, Canada,Medical Biophysics, Western University, London, ON, N6A 3K7, Canada
| | - Ganeem K. Juneja
- Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, L8L 2X2, Canada
| | - Vanessa Sabourin
- Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, L8L 2X2, Canada
| | - Alison Fox-Robichaud
- Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, L8L 2X2, Canada
| | - Calvin H. Yeh
- Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, L8L 2X2, Canada
| | - Paul Y. Kim
- Medicine, McMaster University, Hamilton, ON, L8S 4L8, Canada,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, L8L 2X2, Canada
| | | | | | | | - Brian Webb
- Thermo Fisher Scientific, Rockford, IL, USA
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Hayashi H, Izumiya Y, Fukuda D, Wakita F, Mizobata Y, Fujii H, Yachi S, Takeyama M, Nishimoto Y, Tsujino I, Nakamura J, Yamamoto N, Nakata H, Ikeda S, Umetsu M, Aikawa S, Satokawa H, Okuno Y, Iwata E, Ogihara Y, Ikeda N, Kondo A, Iwai T, Yamada N, Ogawa T, Kobayashi T, Mo M, Yamashita Y. Real-World Management of Pharmacological Thromboprophylactic Strategies for COVID-19 Patients in Japan: From the CLOT-COVID Study. JACC Asia 2022; 2:897-907. [PMID: 36536621 PMCID: PMC9753959 DOI: 10.1016/j.jacasi.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 12/23/2022]
Abstract
Background Data on prophylactic anticoagulation are important in understanding the current issues, unmet needs, and optimal management of Japanese COVID-19 patients. Objectives This study aimed to investigate the clinical management strategies for prophylactic anticoagulation of COVID-19 patients in Japan. Methods The CLOT-COVID study was a multicenter observational study that enrolled 2,894 consecutive hospitalized patients with COVID-19. The study population consisted of 2,889 patients (after excluding 5 patients with missing data); it was divided into 2 groups: patients with pharmacological thromboprophylaxis (n = 1,240) and those without (n = 1,649). Furthermore, we evaluated the 1,233 patients who received prophylactic anticoagulation-excluding 7 patients who could not be classified based on the intensity of their anticoagulants-who were then divided into 2 groups: patients receiving prophylactic anticoagulant doses (n = 889) and therapeutic anticoagulant doses (n = 344). Results The most common pharmacological thromboprophylaxis anticoagulant was unfractionated heparin (68.2%). The severity of COVID-19 at admission was a predictor of the implementation of pharmacological thromboprophylaxis in the multivariable analysis (moderate vs mild: OR: 16.6; 95% CI:13.2-21.0; P < 0.001, severe vs mild: OR: 342.6, 95% CI: 107.7-1090.2; P < 0.001). It was also a predictor of the usage of anticoagulants of therapeutic doses in the multivariable analysis (moderate vs mild: OR: 2.10; 95% CI: 1.46-3.02; P < 0.001, severe vs mild: OR: 5.96; 95% CI: 3.91-9.09; P < 0.001). Conclusions In the current real-world Japanese registry, pharmacological thromboprophylaxis, especially anticoagulants at therapeutic doses, was selectively implemented in COVID-19 patients with comorbidities and severe COVID-19 status at admission.
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Affiliation(s)
- Hiroya Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan,Address for correspondence: Dr Hiroya Hayashi, Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, 1-4-3 Asahimachi, Abenoku, Osaka 545-8585, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Fumiaki Wakita
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiromichi Fujii
- Department of Intensive Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Sen Yachi
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Makoto Takeyama
- Japan Community Health Care Organization Tokyo Shinjuku Medical Center, Tokyo, Japan
| | - Yuji Nishimoto
- Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | | | | | | | | | - Satoshi Ikeda
- Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | | | | | | | | | - Eriko Iwata
- Nankai Medical Center Japan Community Health Care Organization, Saiki, Japan
| | | | | | - Akane Kondo
- Shikoku Medical Center for Children and Adults, Zentsuji, Japan
| | | | | | | | | | - Makoto Mo
- Yokohama Minami Kyosai Hospital, Yokohama, Japan
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Rubini-Costa R, Bermúdez-Jiménez F, Rivera-López R, Sola-García E, Nagib-Raya H, Moreno-Escobar E, López-Zúñiga MÁ, Briones-Través A, Sanz-Herrera F, Sequí-Sabater JM, Romero-Cabrera JL, Maíllo-Seco J, Fernández-Vázquez F, Rivadeneira-Ruiz M, López-Valero L, Gómez-Navarro C, Aparicio-Gómez JA, López MÁ, Tercedor L, Molina-Jiménez M, Macías-Ruiz R, Jiménez-Jáimez J. Prevalence of bleeding secondary to anticoagulation and mortality in patients with atrial fibrillation admitted with SARS-CoV-2 infection. Med Clin (Engl Ed) 2022; 158:569-575. [PMID: 35761979 PMCID: PMC9219541 DOI: 10.1016/j.medcle.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/21/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION AND PURPOSE Atrial fibrillation (AF) is common in patients admitted with severe COVID-19. However, there is limited data about the management of chronic anticoagulation therapy in these patients. We assessed the anticoagulation and incidence of major cardiovascular events in hospitalized patients with AF and COVID-19. METHODS We retrospectively investigated all consecutive patients with AF admitted with COVID-19 between March and May 2020 in 9 Spanish hospitals. We selected a control group of non-AF patients consecutively admitted with COVID-19. We compared baseline characteristics, incidence of major bleeding, thrombotic events and mortality. We used propensity score matching (PSM) to minimize potential confounding variables, as well as a multivariate analysis to predict major bleeding and death. RESULTS 305 patients admitted with AF and COVID-19 were included. After PSM, 151 AF patients were matched with 151 control group patients. During admission, low-molecular-weight heparin was the principal anticoagulant and the incidence of major bleeding and mortality were higher in the AF group [16 (10.6%) vs 3 (2%), p = 0.003; 52 (34.4%) vs 35 (23.2%), p = 0.03, respectively]. The multivariate analysis showed the presence of AF as independent predictor of in-hospital major bleeding and mortality in COVID-19 patients. In AF group, a secondary multivariate analysis identified high levels of D-dimer as independent predictor of in-hospital major bleeding. CONCLUSIONS AF patients admitted with COVID-19 represent a population at high risk for bleeding and mortality during admission. It seems advisable to individualize anticoagulation therapy during admission, considering patient specific bleeding and thrombotic risk.
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Affiliation(s)
- Ricardo Rubini-Costa
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Francisco Bermúdez-Jiménez
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Melchor Fernández Almagro, 3, 28029 Madrid, Spain
| | - Ricardo Rivera-López
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Elena Sola-García
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Hadi Nagib-Raya
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
- Servicio de Cardiología, Hospital Clínico San Cecilio, Av. del Conocimiento, s/n, 18016 Granada, Spain
| | - Eduardo Moreno-Escobar
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
- Servicio de Cardiología, Hospital Clínico San Cecilio, Av. del Conocimiento, s/n, 18016 Granada, Spain
| | - Miguel Ángel López-Zúñiga
- Servicio de Medicina Interna, Hospital Universitario de Jaén, Av. del Ejército Español, 10, 23007 Jaén, Spain
| | - Adela Briones-Través
- Servicio de Urgencias, Consorcio Hospital General Universitario de Valencia, Av. de les Tres Creus, 2, 46014 Valencia, Spain
| | - Francisco Sanz-Herrera
- Servicio de Neumología, Consorcio Hospital General Universitario de Valencia, Av. de les Tres Creus, 2, 46014 Valencia, Spain
| | - Jose Miguel Sequí-Sabater
- Servicio de Reumatología, Hospital Universitario Reina Sofía, Av. Menendez Pidal, s/n, 14004 Córdoba, Spain
| | - Juan Luis Romero-Cabrera
- Servicio de Medicina Interna, Hospital Universitario Reina Sofía, Av. Menendez Pidal, s/n, 14004 Córdoba, Spain
| | - Javier Maíllo-Seco
- Servicio de Cardiología, Hospital Universitario de León, Altos de nava, s/n, 24071 León, Spain
| | | | - María Rivadeneira-Ruiz
- Servicio de Cardiología, Hospital Universitario Virgen Macarena, Dr. Fedriani, 3, 41009 Sevilla, Spain
| | - Lucas López-Valero
- Hospital Universitario de Castellón, Avinguda de Benicàssim, 128, 12004 Castellón, Spain
| | - Carlos Gómez-Navarro
- Servicio de Cardiología, Hospital Universitario Torrecárdenas, Hermandad de Donantes de Sangre, s/n, 04009 Almería, Spain
| | - Jose Antonio Aparicio-Gómez
- Servicio de Cardiología, Hospital Universitario Torrecárdenas, Hermandad de Donantes de Sangre, s/n, 04009 Almería, Spain
| | - Miguel Álvarez López
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Luis Tercedor
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - María Molina-Jiménez
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Rosa Macías-Ruiz
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
| | - Juan Jiménez-Jáimez
- Servicio de Cardiología, Hospital General Universitario Virgen de las Nieves, Avda. de las Fuerzas Armadas 2, 18014 Granada, Spain
- Instituto de Investigación Biosanitaria IBS, Universidad de Granada, Hospital Real, Avenida del Hospicio, s/n, 18010 Granada, Spain
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Elseidy SA, Awad AK, Vorla M, Fatima A, Elbadawy MA, Mandal D, Mohamad T. Cardiovascular complications in the Post-Acute COVID-19 syndrome (PACS). Int J Cardiol Heart Vasc 2022; 40:101012. [PMID: 35355927 PMCID: PMC8958273 DOI: 10.1016/j.ijcha.2022.101012] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/11/2022] [Accepted: 03/17/2022] [Indexed: 01/08/2023]
Abstract
The presence of stress-related (Takotsubo) cardiomyopathy has also been demonstrated in COVID-19. The proposed mechanisms of cardiac damage during the acute phase of COVID-19 include both direct -viral penetration- and indirect routes -hypoxic injury and systemic inflammation. SARS-CoV-2 infection, especially in its severe form, is associated with an increased risk for venous thromboembolism (VTE). Unfractionated heparin (UFH) is the first-line treatment for hemodynamic instability and emergency reperfusion for PASC. Further studies are needed to offer current screening for the occurrence of cardiovascular problems especially myocardial infarction and heart failure in COVID-19 patients.
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) or coronavirus disease 2019 (COVID-19) initially surfaced in December 2019 from Wuhan, China, sweeping the world with various strains, forcing the WHO to declare a pandemic epidemic in March 2020. Furthermore, COVID-19 manifests with a wide array of presentations from fever and fatigue to severe respiratory and cardiovascular complications. Post-COVID-19 syndrome is poorly understood affecting COVID-19 survivors at all levels of disease severity. The disease is most associated with post-discharge dyspnea and fatigue. However, other persistent symptoms as chest pains, palpitations, smell, and taste dysfunctions. Patients with high concentrations of CRP and creatinine in the acute phase of Covid-19 are more prone to cardiac sequelae. Therefore, high levels of cardiac-sensitive troponin and hypokalaemia can also be used for risk stratification. Furthermore, Cardiac damage can manifest as myocarditis, pericarditis, rhythm abnormalities. The use of different diagnostic modalities like electrocardiogram (ECG), echocardiogram, and cardiac magnetic resonance imaging (MRI)(CMR) to evaluate the myocardial damage were studied. However, Cardiovascular complications are a common manifestation of PASC, classification of severity of cardiac symptoms and the emergence of CMR as a diagnostic tool needs more evidence.
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Key Words
- ACE2, Angiotensin-converting enzyme 2
- CAMKII, calmodulin-dependent protein kinase II
- CMR, Cardiac magnetic resonance imaging
- COVID-19
- COVID-19, Coronavirus disease 2019
- CVD, Cardiovascular disease
- Cardiovascular diseases
- DAMPs, damage-associated molecular patterns
- IL, interleukin
- Myocardial infarction
- NOAC, novel oral anticoagulation
- PACS, Post-Acute COVID-19 syndrome
- Post covid sequelae
- RAAS, Renin-Angiotensin Aldosterone System dysregulation
- SARS-CoV 2, severe acute respiratory syndrome coronavirus 2
- TMPRS2, transmembrane protease serine 2
- TNF-Alpha, Tumor necrosis factor-alpha
- TTE, transthoracic echocardiogram
- UFH, Unfractionated heparin
- VTE, venous thromboembolism
- WHO, World health organization
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Affiliation(s)
- Sheref A Elseidy
- Internal medicine department, University of Texas health sciences, Houston, TX
| | - Ahmed K Awad
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Monica Vorla
- Department of internal medicine, University of Louisville School of Medicine, Louisville, Ky
| | - Amina Fatima
- University of Louisville School of Medicine, Louisville, Ky
| | | | | | - Tamam Mohamad
- Cardiovascular Disease Department, Wayne State University, Detroit, MI
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6
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Leucker TM, Osburn WO, Reventun P, Smith K, Claggett B, Kirwan BA, de Brouwer S, Williams MS, Gerstenblith G, Hager DN, Streiff MB, Solomon SD, Lowenstein CJ. Effect of Crizanlizumab, a P-Selectin Inhibitor, in COVID-19: A Placebo-Controlled, Randomized Trial. JACC Basic Transl Sci 2021; 6:935-945. [PMID: 34904132 PMCID: PMC8653991 DOI: 10.1016/j.jacbts.2021.09.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 12/24/2022]
Abstract
Severe COVID-19 is characterized by vascular inflammation and thrombosis, including elevations of P-selectin, a marker released by activated endothelial cells that mediates vascular inflammation. We tested the effect of crizanlizumab, an antibody to P-selectin, on biomarkers of inflammation and thrombosis in patients with COVID-19 in a randomized, placebo-controlled, double-blind clinical trial. Crizanlizumab decreased soluble P-selectin levels in patients with COVID-19. Crizanlizumab increased D-dimer and decreased prothrombin fragment 1.2 in patients with COVID-19. Crizanlizumab may induce endogenous thrombolysis in the setting of COVID-19.
COVID-19 is characterized by vascular inflammation and thrombosis, including elevations in P-selectin, a mediator of inflammation released by endothelial cells. We tested the effect of P-selectin inhibition on biomarkers of thrombosis and inflammation in patients with COVID-19. Hospitalized patients with moderate COVID-19 were randomly assigned to receive either placebo or crizanlizumab, a P-selectin inhibitor, in a double-blind fashion. Crizanlizumab reduced P-selectin levels by 89%. Crizanlizumab increased D-dimer levels by 77% and decreased prothrombin fragment. There were no significant differences between crizanlizumab and placebo for clinical endpoints. Crizanlizumab was well tolerated. Crizanlizumab may induce thrombolysis in the setting of COVID-19. (Crizanlizumab for Treating COVID-19 Vasculopathy [CRITICAL]; NCT04435184)
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Affiliation(s)
- Thorsten M Leucker
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William O Osburn
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Paula Reventun
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kimberley Smith
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget-Anne Kirwan
- SOCAR Research SA, Nyon, Switzerland.,Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, Bloomsbury, London, United Kingdom
| | | | - Marlene S Williams
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary Gerstenblith
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David N Hager
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Charles J Lowenstein
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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7
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Leiva O, AbdelHameid D, Connors JM, Cannon CP, Bhatt DL. Common Pathophysiology in Cancer, Atrial Fibrillation, Atherosclerosis, and Thrombosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:619-634. [PMID: 34988471 PMCID: PMC8702799 DOI: 10.1016/j.jaccao.2021.08.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/06/2021] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease and cancer are the 2 leading causes of death worldwide. Emerging evidence suggests common mechanisms between cancer and cardiovascular disease, including atrial fibrillation and atherosclerosis. With advances in cancer therapies, screening, and diagnostics, cancer-specific survival and outcomes have improved. This increase in survival has led to the coincidence of cardiovascular disease, including atrial fibrillation and atherosclerosis, as patients with cancer live longer. Additionally, cancer and cardiovascular disease share several risk factors and underlying pathophysiologic mechanisms, including inflammation, cancer-related factors including treatment effects, and alterations in platelet function. Patients with cancer are at increased risk for bleeding and thrombosis compared with the general population. Although optimal antithrombotic therapy, including agent choice and duration, has been extensively studied in the general population, this area remains understudied in patients with cancer despite their altered thrombotic and bleeding risk. Future investigation, including incorporation of cancer-specific characteristics to traditional thrombotic and bleeding risk scores, clinical trials in the cancer population, and the development of novel antithrombotic and anti-inflammatory strategies on the basis of shared pathophysiologic mechanisms, is warranted to improve outcomes in this patient population.
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Key Words
- AF, atrial fibrillation
- CAD, coronary artery disease
- CHIP, clonal hematopoiesis of indeterminate potential
- CI, confidence interval
- CLEC-2, C-type lectin-like receptor 2
- HR, hazard ratio
- IL, interleukin
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- ROS, reactive oxygen species
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- arrhythmia
- risk factor
- thrombosis
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Duaa AbdelHameid
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M. Connors
- Division of Hematology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher P. Cannon
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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8
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AlSheef M, Gray J, AlShammari A. Risk of postoperative bleeding following dental extractions in patients on antithrombotic treatment. Saudi Dent J 2021; 33:511-7. [PMID: 34803294 DOI: 10.1016/j.sdentj.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 09/02/2020] [Accepted: 09/13/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The risk of bleeding after dental extractions in patients taking antithrombotic medication is not well known. This study aims to investigate the incidence of postoperative bleeding following dental extractions in adult patients taking antithrombotic medication in Saudi Arabia. Methods This retrospective study included 539 patients aged 18–93 years who attended 840 appointments for dental extractions from January 2012 to June 2016 at a tertiary care hospital in Saudi Arabia. Patients who returned with a complaint of bleeding were treated with local hemostatic measures as outpatients. Results and Conclusion: Only 1.7% of extraction appointments were associated with postoperative bleeding. The highest risk of bleeding was noted in patients receiving warfarin (3.88%), whereas those on clopidogrel had no significant risk of bleeding. Women were found to have the highest rate of bleeding, particularly those on newer oral anticoagulant medications. Dental extractions can be safely done in adults receiving antithrombotic treatment, provided established guidelines are followed; therefore, dental professionals must exercise caution when planning invasive dental treatment for patients on continued antithrombotic therapy.
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Hozayen SM, Zychowski D, Benson S, Lutsey PL, Haslbauer J, Tzankov A, Kaltenborn Z, Usher M, Shah S, Tignanelli CJ, Demmer RT. Outpatient and inpatient anticoagulation therapy and the risk for hospital admission and death among COVID-19 patients. EClinicalMedicine 2021; 41:101139. [PMID: 34585129 PMCID: PMC8461367 DOI: 10.1016/j.eclinm.2021.101139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 08/27/2021] [Accepted: 09/07/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with a hypercoagulable state. Limited data exist informing the relationship between anticoagulation therapy and risk for COVID-19 related hospitalization and mortality. METHODS We evaluated all patients over the age of 18 diagnosed with COVID-19 in a prospective cohort study from March 4th to August 27th, 2020 among 12 hospitals and 60 clinics of M Health Fairview system (USA). We investigated the relationship between (1) 90-day anticoagulation therapy among outpatients before COVID-19 diagnosis and the risk for hospitalization and mortality and (2) Inpatient anticoagulation therapy and mortality risk. FINDINGS Of 6195 patients, 598 were immediately hospitalized and 5597 were treated as outpatients. The overall case-fatality rate was 2•8% (n = 175 deaths). Among the patients who were hospitalized, the inpatient mortality was 13%. Among the 5597 COVID-19 patients initially treated as outpatients, 160 (2.9%) were on anticoagulation and 331 were eventually hospitalized (5.9%). In a multivariable analysis, outpatient anticoagulation use was associated with a 43% reduction in risk for hospital admission, HR (95% CI = 0.57, 0.38-0.86), p = 0.007, but was not associated with mortality, HR (95% CI=0.88, 0.50 - 1.52), p = 0.64. Inpatients who were not on anticoagulation (before or after hospitalization) had an increased risk for mortality, HR (95% CI = 2.26, 1.17-4.37), p = 0.015. INTERPRETATION Outpatients with COVID-19 who were on outpatient anticoagulation at the time of diagnosis experienced a 43% reduced risk of hospitalization. Failure to initiate anticoagulation upon hospitalization or maintaining outpatient anticoagulation in hospitalized COVID-19 patients was associated with increased mortality risk. FUNDING No funding was obtained for this study.
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Key Words
- %, percentage
- (n), number
- ACEi, angiotensin-converting enzyme inhibitors
- ARBs, angiotensin receptor blockers
- Anticoagulation
- CI, confidence intervals
- CKD, chronic kidney disease
- CO2, carbon dioxide
- COPD, chronic obstructive pulmonary disease
- COVID-19
- COVID-19, coronavirus disease 2019
- D-dimer
- DIC, disseminated intravascular coagulation
- DOAC, direct oral anticoagulant
- EHR, electronic health records
- EMR, electronic medical records
- HCT, hematocrit
- HIT, heparin-induced thrombocytopenia
- HR, hazard ratio
- Hospitalization
- IPAC, inpatient anticoagulation therapy
- IRB, institutional review board
- Inpatient
- MI, prior myocardial infarction
- Mortality
- OPAC, outpatient persistent anticoagulation therapy
- Outpatient
- RDW, red blood cell distribution width
- SARS-CoV-2, severe Acute Respiratory Syndrome Coronavirus-2
- SBP, systolic blood pressure
- SBP-min, minimum systolic blood pressure
- SD, standard deviations
- SE, standard errors
- SpO2-min, minimum oxygen saturation
- T1DM, type 1 diabetes mellitus
- T2DM, type 2 diabetes mellitus
- VTE, venous thromboembolism
- WBC, white blood cell
- mg/dl, milligram per deciliter
- rt-PCR, reverse transcriptase-polymerase chain reaction
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Affiliation(s)
- Sameh M. Hozayen
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
- Corresponding author.
| | - Diana Zychowski
- Department of Medical Education, University of Minnesota, United States
| | - Sydney Benson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Pamela L. Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
| | - Jasmin Haslbauer
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Alexandar Tzankov
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Zachary Kaltenborn
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine, Assistant Professor of Medicine, Hospitalist, University of Minnesota, Mayo Building, 420 Delaware Street, SE, 6 Floor, Room D694, Minneapolis, MN 55455, United States
| | - Surbhi Shah
- Department of Hematology and oncology, Mayo Clinic, Arizona, United States
| | - Christopher J. Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, United States
- Department of Surgery, North Memorial Health Hospital, Robbinsdale, MN, United States
| | - Ryan T. Demmer
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
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10
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Deitelzweig S, Keshishian AV, Zhang Y, Kang A, Dhamane AD, Luo X, Klem C, Ferri M, Jiang J, Yuce H, Lip GY. Effectiveness and Safety of Oral Anticoagulants Among Nonvalvular Atrial Fibrillation Patients With Active Cancer. JACC CardioOncol 2021; 3:411-424. [PMID: 34604802 PMCID: PMC8463723 DOI: 10.1016/j.jaccao.2021.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/13/2021] [Indexed: 01/01/2023]
Abstract
Background Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer. Objectives This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin. Methods A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score–matched cohorts. Results A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% CI: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, while consistent treatment effects were seen for all treatment comparisons across key cancer types. Conclusions Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types.
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Key Words
- AF, atrial fibrillation
- GI, gastrointestinal
- GU, genitourinary
- ICH, intracranial hemorrhage
- MB, major bleeding
- NOAC, non–vitamin K antagonist oral anticoagulant
- NVAF, nonvalvular atrial fibrillation
- PSM, propensity score matching
- SE, systemic embolism
- VTE, venous thromboembolism
- active cancer
- anticoagulants
- bleeding
- nonvalvular atrial fibrillation
- stroke
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Affiliation(s)
- Steven Deitelzweig
- Ochsner Clinic Foundation, Department of Hospital Medicine, New Orleans, Louisiana, USA
- University of Queensland School of Medicine—Ochsner Clinical School, New Orleans, Louisiana, USA
- Address for correspondence: Dr Steven Deitelzweig, Ochsner Health 1514 Jefferson Highway, 11th floor, Hospital Medicine, New Orleans, Louisiana 70121, USA. @statinmedresearch
| | - Allison V. Keshishian
- STATinMED Research, Ann Arbor, Michigan, USA
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Yan Zhang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amiee Kang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Amol D. Dhamane
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | | | - Christian Klem
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Mauricio Ferri
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Jenny Jiang
- Bristol Myers Squibb Company, Lawrenceville, New Jersey, USA
| | - Huseyin Yuce
- New York City College of Technology, City University of New York, New York, New York, USA
| | - Gregory Y.H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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11
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Ogunwole SM, Chen X, Mitta S, Minhas A, Sharma G, Zakaria S, Vaught AJ, Toth-Manikowski SM, Smith G. Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities. Mayo Clin Proc Innov Qual Outcomes 2021; 5:872-890. [PMID: 34585084 PMCID: PMC8452893 DOI: 10.1016/j.mayocpiqo.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Severe maternal morbidity and mortality continue to increase in the United States, largely owing to chronic and newly diagnosed medical comorbidities. Interconception care, or care and management of medical conditions between pregnancies, can improve chronic disease control before, during, and after pregnancy. It is a crucial and time-sensitive intervention that can decrease maternal morbidity and mortality and improve overall health. Despite these potential benefits, interconception care has not been well implemented by the primary care community. Furthermore, there is a lack of guidelines for optimizing preconception chronic disease, risk stratifying postpartum chronic diseases, and recommending general collaborative management principles for reproductive-age patients in the period between pregnancies. As a result, many primary care providers, especially those without obstetric training, are unclear about their specific role in interconception care and may be unsure of effective methods for collaborating with obstetric care providers. In particular, internal medicine physicians, the largest group of primary care physicians, may lack sufficient clinical exposure to medical conditions in the obstetric population during their residency training and may feel uncomfortable in caring for these patients in their subsequent practice. The objective of this article is to review concepts around interconception care, focusing specifically on preconception care for patients with chronic medical conditions (eg, chronic hypertension, chronic diabetes mellitus, chronic kidney disease, venous thromboembolism, and obesity) and postpartum care for those with medically complicated pregnancies (eg, hypertensive disorders of pregnancy, gestational diabetes mellitus, excessive gestational weight gain, peripartum cardiomyopathy, and peripartum mood disorders). We also provide a pragmatic checklist for preconception and postpartum management.
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Key Words
- ACE, angiotensin-converting enzyme
- ACOG, American College of Obstetricians and Gynecologists
- ARB, angiotensin receptor blocker
- BMI, body mass index
- CKD, chronic kidney disease
- CVD, cardiovascular disease
- DM, diabetes mellitus
- GDM, gestational diabetes mellitus
- HDP, hypertensive disorder of pregnancy
- HbA1c, hemoglobin A1c
- MFM, maternal-fetal medicine
- NTD, neural tube defect
- OB/GYN, obstetrician/gynecologist
- PCP, primary care provider
- PPCM, peripartum cardiomyopathy
- SMFM, Society for Maternal-Fetal Medicine
- VTE, venous thromboembolism
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Affiliation(s)
- S Michelle Ogunwole
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Xiaolei Chen
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Srilakshmi Mitta
- Division of Obstetric and Consultative Medicine, Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI
| | - Anum Minhas
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Garima Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Ciccarone Center for Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arthur Jason Vaught
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Stephanie M Toth-Manikowski
- Division of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago
| | - Graeme Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Queens University School of Medicine, Kingston, Ontario, Canada
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12
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Augustine MR, Knavel Koepsel EM, Peterson LG, Rupkalvis L, Comstock A, McPhail I, McBane RD, Bjarnason H, Houghton DE. Evaluation of Changing Vena Cava Filter Use and Inpatient Hospital Mortality from 2016-2019: A Single-Institution Quality Improvement Project. Mayo Clin Proc Innov Qual Outcomes 2021; 5:851-858. [PMID: 34514336 PMCID: PMC8424125 DOI: 10.1016/j.mayocpiqo.2021.08.006] [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: 11/18/2022] Open
Abstract
Objective To evaluate the changing trends of vena cava filter (VCF) insertion and determine whether changes in VCF use affected inpatient mortality. Patients and Methods A quality improvement project at Mayo Clinic, Rochester, Minnesota, tracks the type and reason for VCF insertions from January 1, 2016, through December 31, 2019, to facilitate appropriate retrieval. The rate of VCF insertions was compared with inpatient mortality rates, normalized for patient volumes using the number of hospital inpatient discharges. Results A total of 698 VCFs were placed in 695 patients: 2016 (n=243), 2017 (n=156), 2018 (n=156), and 2019 (n=120). The rate of VCF insertions (per 1000 inpatient discharges) was 4.02 in 2016, 2.91 in 2017, 2.54 in 2018, and 1.93 in 2019. Mean ± SD age at placement was 62±16.4 years and 59.2% (413/698) were men. Most VCFs were retrievable (85.1%; 594/698) and were placed for treatment (78.4%; 547/698) indications (acute venous thromboembolism within 3 months). The rate of VCF insertions was compared with the inpatient mortality rate (per 100 inpatient discharges) and remained stable (1.83 in 2016, 1.79 in 2017, 1.83 in 2018, and 1.76 in 2019) despite the significant decline in VCF use. Conclusion Data from this quality improvement study demonstrate a reduction of more than 50% in the use of VCFs from 2016 through 2019 at a large academic hospital. These changes are difficult to attribute to any single change in clinical use and there was no appreciable increase in the inpatient hospital mortality rate associated with this decrease in VCF filter use.
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Affiliation(s)
| | | | | | - Laurie Rupkalvis
- Gonda Vascular Center, Departments of Radiology, Mayo Clinic, Rochester, MN
| | - Ann Comstock
- Gonda Vascular Center, Departments of Radiology, Mayo Clinic, Rochester, MN
| | - Ian McPhail
- Gonda Vascular Center, Departments of Radiology, Mayo Clinic, Rochester, MN
| | | | - Haraldur Bjarnason
- Gonda Vascular Center, Departments of Radiology, Mayo Clinic, Rochester, MN
| | - Damon E. Houghton
- Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Correspondence: Address to Damon E. Houghton, MD, MSc, 200 1st St NW, Rochester, MN 55901.
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13
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Gervaso L, Dave H, Khorana AA. Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:173-190. [PMID: 34396323 PMCID: PMC8352228 DOI: 10.1016/j.jaccao.2021.03.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.
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Key Words
- ASCO, American Society of Clinical Oncology
- ASH, American Society of Hematology
- AT, antithrombin
- ATE, arterial thromboembolism
- CAT, cancer-associated thrombosis
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- CVA, cerebrovascular event
- DOAC, direct oral anticoagulant
- DVT, deep venous thrombosis
- ESMO, European Society of Medical Oncology
- GI, gastrointestinal
- HR, hazard ratio
- ICH, intracranial hemorrhage
- ISTH, International Society on Thrombosis and Haemostasis
- KS, Khorana score
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- MM, multiple myeloma
- NNT, number needed to treat
- PE, pulmonary embolism
- PPV, positive predictive value
- RAM, risk assessment model
- SPE, segmental pulmonary embolism
- SSC, Scientific and Standardization Committee
- SSPE, subsegmental pulmonary embolism
- UHF, unfractionated heparin
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- VVT, visceral vein thrombosis
- arterial thromboembolism
- cancer-associated thrombosis
- prophylaxis
- risk assessment models
- treatment
- venous thromboembolism
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Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, Istituto Europeo di Oncologia, European Institute of Oncology, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Heloni Dave
- Maharaja Sayajirao University, Medical College, Vadodara, Gujarat, India
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
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14
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Al-Subaie AM. Coagulopathies in novel coronavirus (SARS-CoV-2) pandemic: Emerging evidence for hematologists. Saudi J Biol Sci 2021; 28:956-961. [PMID: 33169062 PMCID: PMC7642728 DOI: 10.1016/j.sjbs.2020.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/30/2020] [Accepted: 11/01/2020] [Indexed: 01/22/2023] Open
Abstract
The coronavirus disease (COVID-19), which is also known as acute respiratory syndrome coronavirus-2 (SARS-CoV2) is a transmissible disease, has phenotypes varying from asymptomatic to Acute Respiratory Distress Syndrome (ARDS) or multiple organ dysfunction syndrome (MODS) and ultimately death in certain cases. Coagulation disorders are being frequently reported amongst these patients and the pathogenesis is still not completely understood. Proposed mechanisms for these coagulopathies comprise a hypercoagulable state with micro- and/or macro-thrombosis in the vessels. A number of changes have been reported or proposed in circulating prothrombotic factors in COVID-19 patients and includes elevation in both factor VIII and fibrinogen, circulating prothrombotic microparticles and hyperviscosity. The COVID-19 patients are showing varied coagulopathies and are at high risk for venous thromboembolism (VTE) which demands an early intervention. This paper reviews the evolving data regarding the evaluation and managing of coagulopathies in patients with COVID-19.
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Affiliation(s)
- Abeer M. Al-Subaie
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Imam AbdulRahman bin Faisal University, P.O. Box: 1982, Dammam 31441, Saudi Arabia
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15
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Tomidokoro D, Hayama H, Bekki N, Hara H, Hiroi Y. Venous Thromboembolism in a Young Man With Fused Renal Ectopia. JACC Case Rep 2020; 2:2479-2483. [PMID: 34317198 PMCID: PMC8305092 DOI: 10.1016/j.jaccas.2020.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 11/29/2022]
Abstract
A 19-year-old man presented with chest pain after a trans-Pacific flight. Venous thromboembolism was diagnosed and treated with catheter-directed thrombolysis. Genetic testing revealed factor V Leiden mutation. In addition to the flight history and genetic hypercoagulability, a renal abnormality causing an external compression over the inferior vena cava was suspected to be a contributing factor. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Daiki Tomidokoro
- Address for correspondence: Dr. Daiki Tomidokoro, Department of Cardiology, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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16
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Tran TT, Bjarnason H, McDonald J, Goss B, Kim B, Houghton DE, Stavem K, Kløw NE. Does prophylactic inferior vena cava filter reduce the hazard of pulmonary embolism and mortality in severe trauma? A single center retrospective comparative study. Eur J Radiol Open 2020; 8:100299. [PMID: 33335953 PMCID: PMC7734225 DOI: 10.1016/j.ejro.2020.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/19/2020] [Accepted: 11/20/2020] [Indexed: 11/27/2022] Open
Abstract
Severely injured trauma patients are at high risk of venous thromboembolism. Use of IVC filters in trauma patients without recent history of venous thromboembolism is controversial. IVC filter placement did not reduce the hazard of pulmonary embolism or mortality but may pose an increased hazard of deep venous thrombosis.
Objectives Use of inferior vena cava (IVC) filters in patients following severe trauma without recent history of venous thromboembolism (VTE) is controversial. Our objective was to determine if IVC filter placement in the setting of severe trauma effects the hazard of in-hospital pulmonary embolism (PE), deep venous thrombosis (DVT) and mortality. Methods This retrospective study recruited patients from a single Level I Trauma Center between 1/2008 and 12/2013. Inclusion criteria were age>15 years, Injury Severity Score (ISS)>15 and survival>24 h after hospital admission. Patients with VTE diagnosed prior to IVC filter placement were excluded. A Cox proportional hazards regression model was used, adjusting for immortal time bias with landmark analysis at predefined time after injury. Differences between IVC filter and non-IVC filter groups were adjusted using propensity score. Results In total 1451 patients were reviewed; 282 patients received an IVC filter and 1169 patients had no IVC filter placed. The mean age was 45.9 vs. 56.9 years and the mean ISS was 29.8 vs. 22.6 in the IVC filter and the non-IVC filter group, respectively. IVC filter placement was not associated with the hazard of PE (HR = 0.46; 95 % CI, 0.12,1.70; P = 0.24) or mortality (HR = 1.02; 95 % CI 0.60,1.75; P = 0.93). However, IVC filter placement was associated with the hazard of DVT (HR = 2.73; 95 % CI, 1.28,5.85; P = 0.01). Conclusions In patients with severe trauma, those with prophylactic IVC filter placement did not have a reduced hazard of PE or mortality, but an increased hazard of DVT was observed.
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Affiliation(s)
- Thien Trung Tran
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.,Department of Diagnostic Imaging and Intervention, Akershus University Hospital, Lørenskog, Norway
| | | | | | - Brian Goss
- Department of Radiology, Kingman Regional Medical Center, AZ, USA
| | - Brian Kim
- Division of Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Knut Stavem
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.,Department of Pulmonary Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Nils Einar Kløw
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Norway.,Division of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
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Sethi SS, Zilinyi R, Green P, Eisenberger A, Brodie D, Agerstrand C, Takeda K, Kirtane AJ, Parikh SA, Rosenzweig EB. Right Ventricular Clot in Transit in COVID-19: Implications for the Pulmonary Embolism Response Team. JACC Case Rep 2020; 2:1391-1396. [PMID: 32835284 PMCID: PMC7259913 DOI: 10.1016/j.jaccas.2020.05.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/14/2020] [Accepted: 05/20/2020] [Indexed: 01/30/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 is associated with a prothrombotic state in infected patients. After presenting a case of right ventricular thrombus in a patient with coronavirus disease-2019 (COVID-19), we discuss the unique challenges in the evaluation and treatment of COVID-19 patients, highlighting our COVID-19-modified pulmonary embolism response team algorithm. (Level of Difficulty: Beginner.).
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Key Words
- ARDS, acute respiratory distress syndrome
- COVID-19, coronavirus disease-2019
- CTA, computed tomography angiography
- ECMO, extracorporeal membrane oxygenation
- ICU, intensive care unit
- PE, pulmonary embolism
- PERT, pulmonary embolism response team
- PPE, personal protective equipment
- Pao2, partial arterial pressure of oxygen
- SARS-CoV-2, severe acute respiratory syndrome-coronavirus-2
- TTE, transthoracic echocardiography
- VTE, venous thromboembolism
- clot in transit
- pulmonary embolism
- right ventricle
- tPA, tissue plasminogen activator
- thrombus
- vascular disease
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Affiliation(s)
- Sanjum S. Sethi
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Robert Zilinyi
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Philip Green
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Andrew Eisenberger
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Daniel Brodie
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Cara Agerstrand
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Koji Takeda
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Ajay J. Kirtane
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Sahil A. Parikh
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
| | - Erika B. Rosenzweig
- Columbia University Irving Medical Center, NewYork-Presbyterian Hospital, New York, New York
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18
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Sabatino J, De Rosa S, Polimeni A, Sorrentino S, Indolfi C. Direct Oral Anticoagulants in Patients With Active Cancer: A Systematic Review and Meta-Analysis. JACC CardioOncol 2020; 2:428-440. [PMID: 34396250 PMCID: PMC8352218 DOI: 10.1016/j.jaccao.2020.06.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 01/08/2023]
Abstract
Background Many patients with cancer have a hypercoagulable state and an increased risk of developing venous thromboembolism (VTE), arterial occlusion, and pulmonary emboli. Patients with cancer may also have an increased risk of bleeding with anticoagulant treatment. Recent trials have reported that direct oral anticoagulants (DOACs) are noninferior to the low-molecular-weight heparin, dalteparin, in preventing VTE, but have a higher bleeding rate. Objectives This study compared the efficacy and risks of DOACs versus dalteparin in patients with cancer-related VTEs across all randomized controlled trials (RCTs). Methods This study performed a systematic analysis of RCTs published in PubMed, SCOPUS, and Google Scholar from September 1, 2007 through March 31, 2020 that reported clinical outcomes of treatment with DOACs versus dalteparin in patients with cancer with acute VTE. Two investigators independently performed study selection and data extraction. Extracted data were recorded and exported to statistical software for all analyses (OpenMetaAnalyst). Results This study included 4 randomized trials (N = 2,907). Compared with DOACs, dalteparin was associated with higher VTE recurrence (risk ratio [RR]: 1.55; 95% confidence interval [CI]: 1.19 to 2.03; p = 0.001), whereas clinically relevant nonmajor bleeding (CRNMB) was significantly less frequent with dalteparin than that with DOACs (RR: 0.68; 95% CI: 0.54 to 0.86; p = 0.001). The risk of CRNMB was largely observed with patients with gastrointestinal malignancies. No significant differences were observed in major bleeding (RR: 0.74; 95% CI: 0.52 to 1.06; p = 0.11). Conclusions DOACs were noninferior to dalteparin in preventing VTE recurrence in patients with cancer without a significantly increased risk of major bleeding. However, DOACs were associated with higher rates of CRNMB compared with dalteparin, primarily in patients with gastrointestinal malignancies.
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Key Words
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- DOAC, direct oral anticoagulant
- DOACs
- DVT, deep vein thrombosis
- GI, gastrointestinal
- LMWH, low-molecular-weight heparin
- PE, pulmonary embolism
- RCT, randomized controlled trial
- RR, risk ratio
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- cancer
- direct oral anticoagulants
- hypercoagulable state
- venous thromboembolism
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Affiliation(s)
- Jolanda Sabatino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Salvatore De Rosa
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Alberto Polimeni
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Sabato Sorrentino
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy.,Cardiovascular Research Center, Magna Graecia University, Catanzaro, Italy
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19
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Cambron JC, Saba ES, McBane RD, Casanegra AI, Villarraga HR, Houghton DE, Vlazny DT, Froehling D, Hodge D, Peterson LG, Bott-Kitslaar DM, Wysokinski WE. Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Mayo Clin Proc Innov Qual Outcomes 2020; 4:249-58. [PMID: 32542216 DOI: 10.1016/j.mayocpiqo.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To determine whether the pulmonary embolism (PE) categories of massive, submassive, PE with no right ventricle dysfunction (NRVD), and subsegmental only (SSO) adequately predict clinical outcome. Methods Patients treated for acute PE (March 1, 2013, through July 31, 2019) were followed forward prospectively to compare venous thromboembolism (VTE) recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) across 4 PE categories. Results Of 2703 patients with VTE, 1188 (44%) had PE, of which 1021 (85.9%) completed at least 3 months of therapy or had clinical outcomes precluding further treatment (27 with massive, 217 submassive, 557 NRVD, and 220 SSO PE). One patient with massive, 8 with submassive, 23 with NRVD, and 5 with SSO PE had recurrent VTE (3.90, 5.33, 5.36, and 3.66 per 100 person-years, respectively; P=.84). There were 3 deaths in massive, 27 in submassive, 140 in NRVD, and 34 in SSO PE groups (11.59, 17.37, 31.74, and 24.74 per 100 person-years, respectively; P=.02); when adjusted for cancer, the relationship was no longer significant (P=.27). One patient with massive, 5 with submassive, 22 with NRVD, and 5 with SSO PE had major bleeding (3.90, 3.31, 5.24, and 3.75 per 100 person-years, respectively; P=.66). Similar cumulative rates for CRNMB were observed (P=.87). Three-month rates of VTE recurrence, death, major bleeding, and CRNMB did not differ by PE category. Conclusion In the setting of anticoagulation therapy with maximal standardization and evidence-based practice, there is no evidence of a difference between PE categories and outcomes. Trial Registration clinicaltrials.gov Identifier: NCT03504007.
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Key Words
- AHA, American Heart Association
- CRNMB, clinically relevant nonmajor bleeding
- CT, computed tomography
- DVT, deep vein thrombosis
- HR, hazard ratio
- NRVD, no right ventricle dysfunction
- PE, pulmonary embolism
- PESI, Pulmonary Embolism Severity Index
- RV, right ventricle
- SSO, subsegmental only
- VTE, venous thromboembolism
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20
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Zermatten MG, Fraga M, Calderara DB, Aliotta A, Moradpour D, Alberio L. Biomarkers of liver dysfunction correlate with a prothrombotic and not with a prohaemorrhagic profile in patients with cirrhosis. JHEP Rep 2020; 2:100120. [PMID: 32715285 PMCID: PMC7369360 DOI: 10.1016/j.jhepr.2020.100120] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/08/2020] [Accepted: 04/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Different liver dysfunction biomarkers are used to assess the bleeding risk of patients with cirrhosis, either as such or included in bleeding risk assessment scores. Since the current model of coagulation in patients with cirrhosis describes a procoagulant tendency with increasing severity according to Child-Pugh stage, we decided to investigate the relation between liver dysfunction biomarkers and thrombin generation. Our aim was to verify their adequacy for bleeding risk assessment. Methods We performed a prospective single-centre study including 260 patients with liver cirrhosis. Thrombin generation was measured using ST Genesia® Thrombin Generation System without and with thrombomodulin in order to assess the role of proteins C and S. Relations between thrombin generation and Child-Pugh/model for end-stage liver disease (MELD) scores, prothrombin time (PT)/international normalised ratio (INR), activated partial thromboplastin time (aPTT), factor V activity, albumin, and total bilirubin were assessed. Results Thrombomodulin-mediated inhibition of thrombin generation was significantly decreased in patients with liver cirrhosis compared with healthy donors (p <0.0001) and in Child-Pugh B and C compared with A (p <0.0001 [A–B], 0.4515 [B–C], <0.0001 [A–C]). Thrombomodulin-mediated inhibition significantly decreased with increasing PT/INR, aPTT, and total bilirubin levels and with decreasing factor V activity and albumin levels. Conclusions Worsening liver dysfunction biomarkers reflect an increasing prothrombotic profile in patients with liver cirrhosis. In particular, prolonged PT/INR and aPTT as well as decreasing factor V activity are related to an increasing thrombotic risk and not to an increasing bleeding risk. These parameters should not be used to assess bleeding risk due to haemostatic anomalies in patients with liver cirrhosis. Alternative biomarkers for bleeding risk assessment in patients with liver cirrhosis need to be developed. Lay summary We demonstrate that the laboratory parameters used to assess bleeding risk of patients with liver disease, e.g. prothrombin time/international normalised ratio (PT/INR) and activated partial thromboplastin time (aPTT), are inadequate for this purpose because they are correlated with a prothrombotic coagulation profile. In this article, we highlight the need for alternative parameters to assess bleeding risk in patients with liver disease. Patients with cirrhosis display a prothrombotic coagulation profile. This is due to a relative decrease of natural anticoagulants compared with procoagulants. In cirrhosis, PT and aPTT correlate with a prothrombotic state, and are inadequate as bleeding risk biomarkers.
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Affiliation(s)
- Maxime G Zermatten
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Montserrat Fraga
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Debora Bertaggia Calderara
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Alessandro Aliotta
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Darius Moradpour
- Division of Gastroenterology and Hepatology, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
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21
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Okano M, Hara T, Nishimori M, Irino Y, Satomi-Kobayashi S, Shinohara M, Toh R, Jaffer FA, Ishida T, Hirata KI. In Vivo Imaging of Venous Thrombus and Pulmonary Embolism Using Novel Murine Venous Thromboembolism Model. ACTA ACUST UNITED AC 2020; 5:344-356. [PMID: 32368694 PMCID: PMC7188875 DOI: 10.1016/j.jacbts.2020.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 01/27/2023]
Abstract
We established a novel clinically relevant murine DVT model at femoral/saphenous vein induced by flow restriction and light illumination. Our model newly succeeded in inducing DVT in a valve pocket and enabled spontaneous pulmonary embolism of fibrin-rich thrombus from lower extremity vein, reproducing the clinical VTE scenario. This model is suitable for motion-free in vivo high-resolution imaging of fibrin-rich DVT development and organization using 2-photon microscopy, enabling the real-time imaging of migration of platelets and leukocytes into the erythrocyte-rich DVT.
This work established a new murine venous thromboembolism (VTE) model. This model has multiple novel features representing clinical VTE that include the following: 1) deep venous thrombosis (DVT) was formed and extended in the long axis of femoral/saphenous vein; 2) thrombus was formed in a venous valve pocket; 3) deligation of suture-induced spontaneous pulmonary emboli of fibrin-rich DVT; and 4) cardiac motion-free femoral/saphenous vein allowed high-resolution intravital microscopic imaging of fibrin-rich DVT. This new model requires only commercially available epifluorescence microscopy. Therefore, this model has significant potential for better understanding of VTE pathophysiology.
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Affiliation(s)
- Mitsumasa Okano
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsuya Hara
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Makoto Nishimori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yasuhiro Irino
- Division of Evidence-based Laboratory Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seimi Satomi-Kobayashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masakazu Shinohara
- Division of Epidemiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ryuji Toh
- Division of Evidence-based Laboratory Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Farouc A Jaffer
- Cardiovascular Research Center, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Tatsuro Ishida
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.,Division of Evidence-based Laboratory Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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22
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Kilinc M, Yaylali YT, Yildizeli B, Tas S. Chronic Thromboembolic Pulmonary Hypertension Secondary to Thrombophilia and Incidentally Diagnosed Atrial Septal Defect. JACC Case Rep 2020; 2:658-661. [PMID: 34317315 PMCID: PMC8298561 DOI: 10.1016/j.jaccas.2020.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/10/2020] [Accepted: 01/16/2020] [Indexed: 11/16/2022]
Abstract
A 46-year-old man developed chronic thromboembolic pulmonary hypertension and atrial fibrillation after acute pulmonary embolism. He was found incidentally to have an isolated secundum atrial septal defect, as well as a homozygous mutation for the plasminogen activator inhibitor-1 gene. He was successfully treated with pulmonary endarterectomy and atrial septal defect repair. He has continued to do well on a regimen of dabigatran. (Level of Difficulty: Beginner.)
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Key Words
- AF, atrial fibrillation
- ASD, atrial septal defect
- CTEPH, chronic thromboembolic pulmonary hypertension
- DOAC, direct oral anticoagulant agent
- HF, heart failure
- PAI, plasminogen activator inhibitor
- PAP, pulmonary arterial pressure
- PE, pulmonary embolism
- PEA, pulmonary endarterectomy
- PH, pulmonary hypertension
- PVR, pulmonary vascular resistance
- RA, right atrial
- RHC, right-sided heart catheterization
- RV, right ventricular
- TAPSE, tricuspid annular excursion
- VTE, venous thromboembolism
- dabigatran
- plasminogen activator inhibitor-1 (PAI-1) mutation
- pulmonary endarterectomy
- t-PA, tissue-type plasminogen activator
- u-PA, urokinase-type plasminogen activator
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Affiliation(s)
- Mehmet Kilinc
- Department of Cardiology, Ceylanpinar State Hospital, Sanliurfa, Turkey
| | - Yalin Tolga Yaylali
- Department of Cardiology, Faculty of Medicine, Pamukkale University, Denizli, Turkey
| | - Bedrettin Yildizeli
- Department of Thoracic Surgery, School of Medicine, Marmara University, Istanbul, Turkey
| | - Serpil Tas
- Department of Cardiovascular Surgery, Kartal Kosuyolu Hospital, University of Health Sciences, Istanbul, Turkey
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23
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Al-Mohrej OA, Aldakhil SS, Al-Rabiah MA, Al-Rabiah AM. Surgical treatment of adolescent idiopathic scoliosis: Complications. Ann Med Surg (Lond) 2020; 52:19-23. [PMID: 32153775 PMCID: PMC7052396 DOI: 10.1016/j.amsu.2020.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/23/2020] [Accepted: 02/18/2020] [Indexed: 12/21/2022] Open
Abstract
Despite the fact that spinal surgeries for adolescent idiopathic scoliosis (AIS) result in good outcomes for most patients, they are not without complications either medically or surgically. Neurologic injury represents the most severe complication and is, as such, the most feared. Further complications include dural tears, peripheral neuropathy, surgical-site infections, implant-related issues, thromboembolic events, visual loss, pseudarthrosis, Crankshaft phenomenon, flatback phenomenon, proximal junctional kyphosis, and mortality. It is vital that all spine surgeons to be fully conversant with the possible complications and the proper responses for each of them. Surgeons should know how to manage complications of surgery for AIS. Patients should know about potential complications prior to surgery. Neurologic injury represents the most severe complication.
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Affiliation(s)
- Omar A Al-Mohrej
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
| | - Sahar S Aldakhil
- Department of Orthopedic Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Anwar M Al-Rabiah
- Department of Orthopedic Surgery, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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24
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Lovely JK, Hickman JA, Johnson MG, Naessens JM, Morgenthaler TI. Impact of a Program to Improve Venous Thromboembolism Prophylaxis on Incidence of Thromboembolism and Bleeding Rates in Hospitalized Patients During Implementation of Programs to Improve Venous Thromboembolism Prophylaxis. Mayo Clin Proc Innov Qual Outcomes 2020; 4:159-169. [PMID: 32280926 PMCID: PMC7140013 DOI: 10.1016/j.mayocpiqo.2019.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 11/17/2022] Open
Abstract
Objective To study the impact of multiphase quality improvement efforts to enhance appropriate use of chemical and mechanical venous thromboembolism (VTE) prophylaxis (VTEP) on the rate of hospital-acquired VTE and determine whether efforts have been associated with increased bleeding complications. Patients and Methods All adult inpatients discharged between January 1, 2005, and December 31, 2015, were included in the study. Retrospective interrupted time series analysis compared VTEP performance, VTE outcomes, and unintended consequences (derived from linked administrative and clinical data) across 5 improvement phases: baseline (January 1, 2005-December 31, 2006), paper order set phase (January 1, 2007-February 9, 2009), electronic order set phase (February 10, 2009-December 16, 2009), active reminder phase (December 17, 2009-May 31, 2012), and maintenance phase (June 1, 2012-September 30, 2015). Results Guideline VTEP plan adherence at the end of the study period (including documenting contraindications) reached 88.8% (654,138 of 736,384 patient days). Delivery of pharmacological VTEP increased from 43.9% (49,155 of 111,906 patients) to 60.8% (75,784 of 124,676 patients); delivery of mechanical or pharmacological VTEP increased less (65.0% [431,791 of 664,087 patient days] to 67.4% [496,625 of 736,384 patient days]). Mean VTE rates decreased from 4.6 per 1000 hospitalizations (21.7 VTEs per month) at baseline to 4.3 per 1000 hospitalizations (18.0 VTEs per month) during the maintenance phase (P<.001). More than 97% of patients who had development of VTE (534 of 548) received VTEP, but 65.7% (360 of 548) experienced gaps of 1 or more days in VTEP delivery. Measured in-hospital bleeding rates were fairly consistent over the study (4.6% [5,198 of 111,906 patients] at baseline to 5.3% [6,662 of 124,676 patients] during the reminder phase). There was little change in rates of 7-day readmission with bleeding or VTE. Conclusion Our VTEP project improved guideline compliance, increased the proportion of patients receiving VTEP, and was associated with a decrease in VTE. Gaps in VTEP delivery occurred despite protocoled order sets and electronic feedback. Further improvements in VTE may require new approaches.
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Affiliation(s)
| | - Joel A Hickman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Matthew G Johnson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - James M Naessens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
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25
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Lenihan DJ, Fradley MG, Dent S, Brezden-Masley C, Carver J, Filho RK, Neilan TG, Blaes A, Melloni C, Herrmann J, Armenian S, Thavendiranathan P, Armstrong GT, Ky B, Hajjar L. Proceedings From the Global Cardio-Oncology Summit: The Top 10 Priorities to Actualize for CardioOncology. JACC CardioOncol 2019; 1:256-272. [PMID: 34396188 PMCID: PMC8352295 DOI: 10.1016/j.jaccao.2019.11.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/04/2019] [Indexed: 12/27/2022] Open
Abstract
The discipline of cardio-oncology has expanded at a remarkable pace. Recent developments and challenges to clinicians who practice cardio-oncology were presented at the Global Cardio-Oncology Summit on October 3 to 4, 2019, in São Paulo, Brazil. Here, we present the top 10 priorities for our field that were discussed at the meeting, and also detail a potential path forward to address these challenges. Defining robust predictors of cardiotoxicity, clarifying the role of cardioprotection, managing and preventing thromboembolism, improving hematopoietic stem cell transplant outcomes, personalizing cardiac interventions, building the cardio-oncology community, detecting and treating cardiovascular events associated with immunotherapy, understanding tyrosine kinase inhibitor cardiotoxicity, and enhancing survivorship care are all priorities for the field. The path forward requires a commitment to research, education, and excellence in clinical care to improve our patients' lives.
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Key Words
- CV, cardiovascular
- CVD, cardiovascular disease
- DOAC, direct oral anticoagulant
- GCOS, Global Cardio-Oncology Summit
- GLS, global longitudinal strain
- HCT, hematopoietic cell transplantation
- ICI, immune checkpoint inhibitor
- LVEF, left ventricular ejection fraction
- PD-1, programmed cell death 1 or its ligand
- PD-L1, programmed cell death ligand 1
- TKI, tyrosine kinase inhibitor
- VTE, venous thromboembolism
- anthracycline
- antiangiogenic therapy
- bone marrow transplantation
- breast cancer
- cancer survivorship
- immunotherapy
- thrombosis
- tyrosine kinase inhibitor
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Affiliation(s)
- Daniel J. Lenihan
- Cardio-Oncology Center of Excellence, Cardiovascular Division, Department of Internal Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Michael G. Fradley
- Cardio-Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Joseph Carver
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roberto Kalil Filho
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joerg Herrmann
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Saro Armenian
- City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Paaladinesh Thavendiranathan
- Division of Cardiology, Peter Munk Cardiac Centre, Ted Rogers Program in Cardiotoxicity Prevention, University Health Network, University of Toronto, Toronto, Canada
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Bonnie Ky
- Cardio-Oncology Center of Excellence at the Abramson Cancer Center, Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ludhmila Hajjar
- Cardio-Oncology Program, Department of Cardiopneumology, Cancer Institute and Heart Institute, University of São Paulo, Brazil
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26
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Nan J, Tan N, Schaff H, Bell MR, Pislaru S, Best PJM. A Dangerous Dilemma: Thrombus in Transit During Pregnancy. JACC Case Rep 2019; 1:369-371. [PMID: 34316828 PMCID: PMC8288568 DOI: 10.1016/j.jaccas.2019.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/23/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022]
Abstract
Pregnancy is associated with venous thromboembolism. Occasionally, thrombus can become entrapped across a patent foramen ovale, with risk of systemic embolism. This report presents a case of a pregnant woman who had thrombus in transit diagnosed by echocardiography, which was successfully removed by surgical thrombectomy. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- John Nan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Nicholas Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Hartzell Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Sorin Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
| | - Patricia J M Best
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester Minnesota
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27
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Eid I, Moran D, Morrison L, HajHussein E, Hill H, Ansari R, Williams T, Manzary M. A quality improvement project decreases incidence of pulmonary embolism following arthroplasty. J Orthop 2018; 15:164-167. [PMID: 29657460 DOI: 10.1016/j.jor.2018.01.009] [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: 09/06/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
Abstract
Objective To develop a quality improvement initiative to reduce the incidence of pulmonary embolism (PE) following elective lower extremity joint replacement surgery. Methods 866 Patients undergoing a total knee or total or partial hip replacement surgery at a from 2014 to 2016 were included in this prospective pre-post interventional study. Results There were 13 PE's before the intervention and 2 after the intervention. The incidence of PE was significantly higher prior to the intervention (2.8% vs. 0.7%; p = 0.044). Conclusions Our results suggest that our bundle of interventions was successfully implemented and helped to reduce the incidence of pulmonary embolism following surgery.
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Affiliation(s)
- Iyad Eid
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia.,Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
| | - Dane Moran
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Lynn Morrison
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | | | - Hanna Hill
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Rasha Ansari
- Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
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28
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Tourinho-Barbosa RR, Tobias-Machado M, Castro-Alfaro A, Ogaya-Pinies G, Cathelineau X, Sanchez-Salas R. Complications in robotic urological surgeries and how to avoid them: A systematic review. Arab J Urol 2017; 16:285-292. [PMID: 30140463 PMCID: PMC6104661 DOI: 10.1016/j.aju.2017.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/26/2017] [Accepted: 11/08/2017] [Indexed: 01/16/2023] Open
Abstract
Objectives To review the main complications related to the robot-assisted laparoscopic (RAL) approach in urology and to suggest measures to avoid such issues. Methods A systematic search for articles of the contemporary literature was performed in PubMed database for complications in RAL urological procedures focused on positioning, access, and operative technique considerations. Each complication topic is followed by recommendations about how to avoid it. Results In all, 40 of 253 articles were included in this analysis. Several complications in RAL procedures can be avoided if the surgical team follows some key steps. Adequate patient positioning must avoid skin, peripheral nerve, and muscles injuries, and ocular and cognitive complications mainly related to steep Trendelenburg positioning in pelvic procedures. Port-site access and closure should not be neglected during minimally invasive procedures as these complications although rare can be troublesome. Technique-related complications depend on surgeon experience and the early learning curve should be monitored. Conclusions Adequate patient selection, surgical positioning, mentorship training, and avoiding long-lasting procedures are essential to prevent RAL-related complications. The robotic surgical team must be careful and work together to avoid possible complications. This review offers several steps in surgical planning to reach this goal.
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Affiliation(s)
- Rafael Rocha Tourinho-Barbosa
- Department of Urology, L'Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France.,Division of Urology, ABC Medical School, Sao Paulo, Brazil
| | | | - Adalberto Castro-Alfaro
- Department of Urology, L'Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France
| | - Gabriel Ogaya-Pinies
- Department of Urology, University of Central Florida College of Medicine and Global Robotics Institute, Florida Hospital-Celebration Health, FL, USA
| | - Xavier Cathelineau
- Department of Urology, L'Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France
| | - Rafael Sanchez-Salas
- Department of Urology, L'Institut Mutualiste Montsouris, Université Paris-Descartes, Paris, France
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29
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Chaudhary R, Damluji A, Batukbhai B, Sanchez M, Feng E, Chandra Serharan M, Moscucci M. Venous Thromboembolism Prophylaxis: Inadequate and Overprophylaxis When Comparing Perceived Versus Calculated Risk. Mayo Clin Proc Innov Qual Outcomes 2017; 1:242-247. [PMID: 30225423 PMCID: PMC6132201 DOI: 10.1016/j.mayocpiqo.2017.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Guidelines for venous thromboembolism (VTE) prophylaxis recommend appropriate risk stratification using risk estimation models as high risk or low risk followed by initiation of chemical or mechanical prophylaxis, respectively. We explored adherence to guidelines on the basis of the documentation of VTE prophylaxis. A retrospective medical record review of 437 consecutive adult patients (≥18 years) admitted to general medical wards under medicine service between January 1, 2015, and March 1, 2015, was performed. The primary outcome was appropriateness of risk stratification using the Padua Prediction Score. Secondary outcomes were appropriateness of type of prophylaxis (chemical vs mechanical) and cost-benefit analysis. We observed appropriate stratification based on the documented risk (compared with the calculated risk) in 54.9% of the patients (40.8% with low risk vs 72.1% with high risk; P<.001). Overall, 182 of 240 low-risk patients received unnecessary chemical prophylaxis, whereas 23 of 197 high-risk patients without contraindications for chemical prophylaxis received mechanical or no prophylaxis. No clinical VTE events were noted in the patients inappropriately assigned to mechanical or no prophylaxis. Also, 67.3% of patients with both low documented and low calculated risk and 74.5% of patients with low documented and high calculated risk received chemical prophylaxis, consistent with a tendency toward overtreatment. A total of 4068 annualized patient-days ($77,652/y) of inappropriate chemical prophylaxis were administered. In conclusion, estimation of the risk of VTE based on clinical impression was not congruent with the risk calculated using risk prediction models and was associated with a tendency toward overtreatment. These data support the inclusion of VTE risk calculators in electronic health record systems.
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Affiliation(s)
- Rahul Chaudhary
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD
| | - Abdulla Damluji
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD.,Division of Cardiology, Johns Hopkins University, Baltimore, MD
| | - Bhavina Batukbhai
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD
| | - Martin Sanchez
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD
| | - Eric Feng
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD
| | | | - Mauro Moscucci
- Sinai Hospital of Baltimore, LifeBridge Health Cardiovascular Institute, Baltimore, MD.,University of Michigan Health System, Ann Arbor, MI
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30
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Shiroyama T, Hayama M, Satoh S, Nasu S, Tanaka A, Morita S, Morishita N, Suzuki H, Okamoto N, Hirashima T. Successful retreatment with osimertinib after osimertinib-induced acute pulmonary embolism in a patient with lung adenocarcinoma: A case report. Respir Med Case Rep 2016; 20:25-27. [PMID: 27896061 PMCID: PMC5121160 DOI: 10.1016/j.rmcr.2016.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 10/31/2016] [Accepted: 11/04/2016] [Indexed: 11/16/2022] Open
Abstract
Pulmonary embolism (PE) can be life-threatening, and it is challenging to diagnose because of its nonspecific signs and symptoms. PE is also an important potential risk of osimertinib treatment, however, clinical courses regarding retreatment after osimertinib-induced acute pulmonary embolism remain unclear. We described a 77-year-old woman with postoperative recurrent lung adenocarcinoma who developed osimertinib-induced acute PE. She received apixaban and was later successfully retreated with osimertinib. This case suggests that retreatment with osimertinib after osimertinib-induced acute PE may be a treatment option when alternative therapeutic options are limited.
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Affiliation(s)
- Takayuki Shiroyama
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Manabu Hayama
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Shingo Satoh
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Shingo Nasu
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Ayako Tanaka
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Satomu Morita
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Naoko Morishita
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Hidekazu Suzuki
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Norio Okamoto
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Tomonori Hirashima
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
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31
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Murray KM, Parker W, Stephany H, Redger K, Mirza M, Lopez-Corona E, Holzbeierlein JM, Lee EK. Venous thromboembolism after radical cystectomy: Experience with screening ultrasonography. Arab J Urol 2016; 14:37-43. [PMID: 26966592 DOI: 10.1016/j.aju.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/13/2015] [Accepted: 11/24/2015] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES To detect the incidence of immediate postoperative deep vein thrombosis (DVT) using screening lower extremity ultrasonography (US) in patients undergoing radical cystectomy (RC) and to determine the rate of symptomatic pulmonary embolism (PE) after RC and identify risk factors for venous thromboembolic (VTE) events in a RC population. PATIENTS AND METHODS We performed a retrospective review of prospective data collected on patients who underwent RC between July 2008 and January 2012. These patients underwent screening US at 2/3 days after RC to determine the rate of asymptomatic DVT. A chart review was completed to identify those who had a symptomatic PE. Univariate and multivariable analysis was used to identify risk factors associated with DVT, PE and total VTE events. RESULTS In all, 221 patients underwent RC and asymptomatic DVT was identified in 21 (9.5%) on screening US. Nine (4.5%) developed symptomatic PE at a median of 9 days, of which no patients had positive lower extremity US postoperatively. Increased length of hospital stay, increased estimated blood loss, and lower body mass index were linked to risk of PE, and only a previous history of DVT was associated with postoperative DVT. CONCLUSION Patients who undergo RC are at high-risk for thromboembolic events and multimodal prophylaxis should be administered. Clinicians should be especially vigilant in those who demonstrate factors associated with higher risk for VTE events.
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