1
|
Bernardini A, Bindini L, Antonucci E, Berteotti M, Giusti B, Testa S, Palareti G, Poli D, Frasconi P, Marcucci R. Machine learning approach for prediction of outcomes in anticoagulated patients with atrial fibrillation. Int J Cardiol 2024; 407:132088. [PMID: 38657869 DOI: 10.1016/j.ijcard.2024.132088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND The accuracy of available prediction tools for clinical outcomes in patients with atrial fibrillation (AF) remains modest. Machine Learning (ML) has been used to predict outcomes in the AF population, but not in a population entirely on anticoagulant therapy. METHODS AND AIMS Different supervised ML models were applied to predict all-cause death, cardiovascular (CV) death, major bleeding and stroke in anticoagulated patients with AF, processing data from the multicenter START-2 Register. RESULTS 11078 AF patients (male n = 6029, 54.3%) were enrolled with a median follow-up period of 1.5 years [IQR 1.0-2.6]. Patients on Vitamin K Antagonists (VKA) were 5135 (46.4%) and 5943 (53.6%) were on Direct Oral Anticoagulants (DOAC). Using Multi-Gate Mixture of Experts, a cross-validated AUC of 0.779 ± 0.016 and 0.745 ± 0.022 were obtained, respectively, for the prediction of all-cause death and CV-death in the overall population. The best ML model outperformed CHA2DSVA2SC and HAS-BLED for all-cause death prediction (p < 0.001 for both). When compared to HAS-BLED, Gradient Boosting improved major bleeding prediction in DOACs patients (0.711 vs. 0.586, p < 0.001). A very low number of events during follow-up (52) resulted in a suboptimal ischemic stroke prediction (best AUC of 0.606 ± 0.117 in overall population). Body mass index, age, renal function, platelet count and hemoglobin levels resulted the most important variables for ML prediction. CONCLUSIONS In AF patients, ML models showed good discriminative ability to predict all-cause death, regardless of the type of anticoagulation strategy, and major bleeding on DOAC therapy, outperforming CHA2DS2VASC and the HAS-BLED scores for risk prediction in these populations.
Collapse
Affiliation(s)
- Andrea Bernardini
- Cardiology and Electrophysiology Unit, Santa Maria Nuova Hospital, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Italy.
| | - Luca Bindini
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | | | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Sophie Testa
- Hemostasis and Thrombosis Center, Laboratory Medicine Department, Azienda Socio-Sanitaria Territoriale, Cremona, Italy
| | | | - Daniela Poli
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Paolo Frasconi
- Department of Information Engineering, University of Florence, 50139 Florence, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| |
Collapse
|
2
|
Palareti G, Legnani C, Tosetto A, Poli D, Testa S, Ageno W, Pengo V, Cosmi B, Prandoni P. D-dimer and risk of venous thromboembolism recurrence: Comparison of two studies with similar designs but different laboratory and clinical results. Thromb Res 2024; 238:52-59. [PMID: 38669963 DOI: 10.1016/j.thromres.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 04/03/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND D-dimer testing may help deciding the duration of anticoagulation in subjects at high risk of venous thromboembolism (VTE) recurrence. Two management studies on this issue have been published (DULCIS in 2014 and APIDULCIS in 2022). They had similar designs but had important different results. Aim of this article is to compare their results. METHODS Both studies were finalized to extend anticoagulation [with vitamin K anticoagulants (VKAs) in DULCIS or apixaban 2.5 mg BID (kindly provided by BMS-Pfizer Collaboration) in APIDULCIS] only in patients with positive D-dimer results. RESULTS More D-dimer assays resulted positive in APIDULCIS than in DULCIS (61.1 % vs 47.7 %, respectively; p < 0.0001). While only 4 (0.5 %) refused low dose apixaban in APIDULCIS, the 22.6 % of patients with positive D-dimer refused to resume VKAs in DULCIS; their rates of recurrence were 187 and 8.8 per 100 person-years, respectively (incidence rate ratio [IRR]: 21.2). The incidence of bleeding was low in those receiving apixaban vs those who resumed VKAs (0.4 vs 2.3 per 100 person-years, respectively; IRR 0.17;). While the recurrence rate was low and similar in the studies in subjects who resumed anticoagulation, it was significantly higher in APIDULCIS than in DULCIS in those who stopped anticoagulation for negative D-dimer (5.6 vs 3.0 per 100 person-years, respectively; IRR 1.9). CONCLUSION The low dose Apixaban for extended VTE treatment is effective and safe, and well accepted by patients. Why subjects who stopped anticoagulation for negative D-dimer had a higher recurrence rate in APIDULCIS than in DULCIS remains to be explained.
Collapse
Affiliation(s)
| | | | - Alberto Tosetto
- UOC Ematologia, Centro Malattie Emorragiche e Trombotiche (CMET), AULSS 8 Berica Ospedale S. Bortolo, Vicenza, Italy
| | - Daniela Poli
- Malattie Aterotrombotiche, AOU Careggi, Firenze, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche, ASST Cremona, Cremona, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, Università degli Studi dell'Insubria, UOC Pronto Soccorso, Medicina d'Urgenza e Centro Trombosi ed Emostasi, ASST dei Sette Laghi, Varese, Italy
| | - Vittorio Pengo
- Clinica Cardiologica, Azienda Ospedaliera di Padova, Padova, Italy
| | - Benilde Cosmi
- UO di Angiologia e Malattie della Coagulazione, Dipartimento Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Azienda Ospedaliero Universitaria S. Orsola-Malpighi, I.R.C.C.S., Bologna, Italy
| | | |
Collapse
|
3
|
Testa S, Palareti G, Legnani C, Dellanoce C, Cini M, Paoletti O, Ciampa A, Antonucci E, Poli D, Morandini R, Tala M, Chiarugi P, Santoro RC, Iannone AM, De Candia E, Pignatelli P, Faioni EM, Chistolini A, Esteban MDP, Marietta M, Tripodi A, Tosetto A. Thrombotic events associated with low baseline direct oral anticoagulant levels in atrial fibrillation: the MAS study. Blood Adv 2024; 8:1846-1856. [PMID: 38394387 PMCID: PMC11007438 DOI: 10.1182/bloodadvances.2023012408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/26/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024] Open
Abstract
ABSTRACT Although effective and safe, treatment with direct oral anticoagulants (DOAC) in atrial fibrillation (AF) is still associated with thrombotic complications. Whether the measurement of DOAC levels may improve treatment efficacy is an open issue. We carried out the observational, prospective, multicenter Measure and See (MAS) study. Blood was collected 15 to 30 days after starting DOAC treatment in patients with AF who were followed-up for 1 year. Plasma samples were centralized for DOAC level measurement. Patients' DOAC levels were converted into drug/dosage standardized values to allow a pooled analysis in a time-dependent, competitive-risk model. The measured values were transformed into standardized values (representing the distance of each value from the overall mean) by subtracting the DOAC-specific mean value from the original values and dividing by the standard deviation. Trough and peak DOAC levels were assessed in 1657 and 1303 patients, respectively. In total, 21 thrombotic complications were recorded during 1606 years of follow-up (incidence of 1.31% of patients per year). Of 21 thrombotic events, 17 occurred in patients whose standardized activity levels were below the mean of each DOAC (0); the incidence was the highest (4.82% of patients per year) in patients whose standardized values were in the lowest class (-1.00 or less). Early measurement of DOAC levels in patients with AF allowed us to identify most of the patients who, having low baseline DOAC levels, subsequently developed thrombotic complications. Further studies are warranted to assess whether thrombotic complications may be reduced by measuring baseline DOAC levels and modifying treatment when indicated. This trial was registered at www.ClinicalTrials.gov as #NCT03803579.
Collapse
Affiliation(s)
- Sophie Testa
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | | | | | - Claudia Dellanoce
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Michela Cini
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Oriana Paoletti
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Antonio Ciampa
- Centro Emostasi, UOC Laboratorio Analisi, Ospedale S.G. Moscati, Avellino, Italy
| | | | - Daniela Poli
- Malattie Aterotrombotiche, AOU Careggi, Florence, Italy
| | - Rossella Morandini
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Maurizio Tala
- Centro Emostasi e Trombosi, UO Laboratorio Analisi Chimico-Cliniche e Microbiologiche, ASST Cremona, Cremona, Italy
| | - Paolo Chiarugi
- UO di Analisi chimico cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rita Carlotta Santoro
- Centro Emostasi e Trombosi, UO Emofilia e Patologie della Coagulazione, Dipartimento di Ematologia, Oncologia e Medicina Trasfusionale, Azienda Ospedaliero Universitaria Dulbecco, Catanzaro, Italy
| | | | - Erica De Candia
- UOSD Malattie Emorragiche e Trombotiche, Dipartimento Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Pasquale Pignatelli
- UOC Medicina Interna e Prevenzione dell’Aterosclerosi, Dipartimento di Medicina Interna e Specialità Mediche, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Elena Maria Faioni
- Servizio Immunologia e Medicina Trasfusionale, Ospedale San Paolo, ASST Santi Paolo e Carlo, Milan, Italy
| | - Antonio Chistolini
- UO Medicina Traslazionale e di Precisione, Dipartimento Medicina Interna e Specialità Mediche, Azienda Ospedaliero-Universitaria Policlinico Umberto I, Rome, Italy
| | - Maria del Pilar Esteban
- UO Laboratorio Analisi, Dipartimento dei Servizi Diagnostici, Ospedale Oglio Po, ASST Cremona, Cremona, Italy
| | - Marco Marietta
- Struttura Complessa di Ematologia, Policlinico di Modena, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Armando Tripodi
- Centro Emofila e Trombosi Angelo Bianchi Bonomi, presso la Fondazione IRCCS Ca’ Granda Ospedale Maggiore, Milan, Italy
| | - Alberto Tosetto
- UOC Ematologia, Centro Malattie Emorragiche e Trombotiche, AULSS 8 Berica Ospedale S. Bortolo, Vicenza, Italy
| |
Collapse
|
4
|
Pengo V, Sarti L, Antonucci E, Bison E, Pontara E, Cattini MG, Denas G, Poli D, Palareti G. Patients with antiphospholipid syndrome and a first venous or arterial thrombotic event: clinical characteristics, antibody profiles and estimate of the risk of recurrence. Clin Chem Lab Med 2024; 0:cclm-2024-0114. [PMID: 38557303 DOI: 10.1515/cclm-2024-0114] [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] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVES Thrombosis in antiphospholipid syndrome (APS) involves in most cases the venous circulation. Why in some patients thrombotic APS affects the arterial circulation and in particular cerebral circulation is unknown. In previous studies, both patient characteristics and antiphospholipid antibody types and titers have been associated with arterial thrombosis. Aim of this study was to compare the clinical characteristics and laboratory findings of venous and arterial thrombotic APS from a large series of patients. METHODS Data were retrieved from the Start 2 antiphospholipid, a multicenter prospective register of long-term collected data from Thrombosis Centers in Italy. RESULTS Of 167 patients with thrombotic APS, 114 (68 %) had a venous and 53 (32 %) had an arterial event as first clinical manifestation. Several clinical characteristics and risk factors were different among groups in univariate analysis. Using logistic regression analysis, reduced creatinine clearance and hyperlipidemia were independent variable for the occurrence of arterial APS. Notably, no difference in antiphospholipid antibody profiles and aβ2-Glycoprotein I levels were found between groups. A higher adjusted global antiphospholipid syndrome score (aGAPSS) was found in arterial group indicating a possible high recurrence rate in arterial APS. CONCLUSIONS These data have pathophysiological and clinical implication since associated conditions might predispose patients to arterial rather than venous events and call to a close monitoring and treatment of arterial APS due to their increased tendency to recurrence.
Collapse
Affiliation(s)
- Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
- Arianna Anticoagulation Foundation, Bologna, Italy
| | - Luca Sarti
- Thrombosis Center, Medicina Interna d'Urgenza, Ospedale Civile Baggiovara, Modena, Italy
| | | | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Daniela Poli
- Thrombosis Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | |
Collapse
|
5
|
Poli D, Antonucci E, Ageno W, Berteotti M, Falanga A, Pengo V, Chiarugi P, Cosmi B, Paparo C, Chistolini A, Insana A, Lione D, Malcangi G, Martini G, Masciocco L, Pedrini S, Bucherini E, Pastori D, Pignatelli P, Toma A, Testa S, Palareti G. Inappropriate Underdosing of Direct Oral Anticoagulants in Atrial Fibrillation Patients: Results from the START2-AF Registry. J Clin Med 2024; 13:2009. [PMID: 38610775 PMCID: PMC11012240 DOI: 10.3390/jcm13072009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/12/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Direct oral anticoagulants (DOACs) are recommended for stroke prevention in non-valvular atrial fibrillation (NVAF) patients. We aimed to describe the prevalence of inappropriate DOACs dose prescription in the START2-AF Registry, the outcomes according to the appropriateness of the dosage, and the factors associated with inappropriate dose prescription. Methods: Patients' demographics and clinical data were prospectively collected as electronic files in an anonymous form on the website of the START2-Registry; DOACs dosage was determined to be appropriate when prescribed according to the European Heart Rhythm Association Guidelines. Results: We included 5943 NVAF patients on DOACs; 2572 (46.3%) were female patients. The standard dose (SD) was prescribed to 56.9% of patients and the low dose (LD) was prescribed to 43.1% of patients; 38.9% of all NVAF patients received an inappropriate LD DOAC and 0.3% received inappropriate SD. Patients treated with LD DOAC had a significantly higher rate of all bleedings (RR 1.5; 95% CI 1.2-2.0), major bleedings (RR 1.8; 95% CI 1.3-1.7), and mortality (RR 2.8; 95% CI 1.9-4.1) with respect to patients treated with SD DOAC. No difference was found among patients treated with appropriate and inappropriate LD regarding bleeding, thrombotic, and mortality rates. Age, body weight <60 kg, and renal failure were significantly associated with inappropriate LD DOAC prescription. Conclusions: Inappropriate LD DOACs in NVAF patients is not associated with a reduction in bleeding risk, nor with an increased thrombotic risk. Instead, it is associated with higher mortality rate, suggesting that, in clinical practice, underdosing is preferred for patients at particularly high risk for adverse events.
Collapse
Affiliation(s)
- Daniela Poli
- Center of Atherothrombotic Disease, Azienda Ospedaliero-Universitaria Careggi, 50134 Firenze, Italy;
| | - Emilia Antonucci
- Fondazione Arianna Anticoagulazione, 40138 Bologna, Italy; (E.A.); (G.P.)
| | - Walter Ageno
- SSD Degenza Breve Internistica, Dipartimento di Medicina Interna, Ospedale di Circolo e Fondazione Macchi, ASST Sette Laghi, 21100 Varese, Italy;
| | - Martina Berteotti
- Center of Atherothrombotic Disease, Azienda Ospedaliero-Universitaria Careggi, 50134 Firenze, Italy;
| | - Anna Falanga
- School of Medicine, Università di Milano Bicocca, 20126 Milano, Italy;
- Immunoematologia e Medicina Trasfusionale ASST Papa Giovanni XXIIIo, 24127 Bergamo, Italy
| | - Vittorio Pengo
- Dipartimento di Scienze Cardio-Toraco-Vascolari, AOU Padova, 35121 Padova, Italy;
| | - Paolo Chiarugi
- UO di Analisi Chimico Cliniche, Azienda Ospedaliero Universitaria Pisana, 56100 Pisa, Italy;
| | - Benilde Cosmi
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria S. Orsola-Malpighi Bologna, 40138 Bologna, Italy;
| | - Carmelo Paparo
- Laboratorio Analisi, Ospedale Maggiore, 10023 Chieri, Italy;
| | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione, Sapienza Università di Roma, 00185 Roma, Italy;
| | - Antonio Insana
- SC Laboratorio Analisi Chimico-Cliniche e Microbiologia, A.O. Ordine Mauriziano, 10128 Torino, Italy;
| | - Domenico Lione
- UOC di Patologia Clinica, Ospedale A Perrino, 72100 Brindisi, Italy;
| | - Giuseppe Malcangi
- U.O. Medicina Trasfusionale, Azienda Ospedaliero-Universitaria Policlinico di Bari, 70124 Bari, Italy;
| | - Giuliana Martini
- Centro Emostasi, Spedali Civili Di Brescia, 25123 Brescia, Italy;
| | | | - Simona Pedrini
- Servizio di Laboratorio, Istituto Ospedaliero Fondazione Poliambulanza, 25124 Brescia, Italy;
| | - Eugenio Bucherini
- Medicina Interna, Ambulatorio Emostasi Trombosi, Faenza (Ra) AUSL Romagna, 48018 Faenza, Italy;
| | - Daniele Pastori
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (D.P.); (P.P.)
| | - Pasquale Pignatelli
- Emergency Medicine Unit, Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, 00185 Roma, Italy; (D.P.); (P.P.)
| | - Andrea Toma
- UOC di Patologia Clinica, Ambulatorio Terapia Anticoagulante Orale, O.C. “L. Cazzavillan”, 36071 Arzignano, Italy;
| | - Sophie Testa
- Haemostasis and Thrombosis Centre, Laboratory Medicine Department, ASST Cremona, 26100 Cremona, Italy;
| | - Gualtiero Palareti
- Fondazione Arianna Anticoagulazione, 40138 Bologna, Italy; (E.A.); (G.P.)
| | | |
Collapse
|
6
|
Cosmi B, Borgese L, Legnani C, Sartori M, Palareti G. Sex Differences in Clinical Presentation of Lower Extremity Deep Vein Thrombosis. J Womens Health (Larchmt) 2024. [PMID: 38529881 DOI: 10.1089/jwh.2023.0450] [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] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
Background: Differences between men and women in the clinical features and extent of lower limb deep vein thrombosis (DVT) may influence DVT diagnostic algorithms involving pretest clinical probability (PTP) assessment, D-dimer, and compression ultrasonography (CUS). Aims: To assess differences in DVT clinical presentation between men and women and their effect on PTP and D-dimer. Methods: We conducted a retrospective study in outpatients referred for suspected DVT of the lower limbs to our vascular emergency department from January 2005 to December 2019. Patients underwent PTP assessment with the Wells score, D-dimer testing, and CUS. Results: More women were referred for suspected DVT than men (M/F: 1,785/2,821; F: 61.4%; p < 0.0001). Women were older than men (median age: 71 vs. 67 years; p = 0.0001), DVT was diagnosed in 436 patients (9.4%) but in more men than women (M: 210 [11.8%] vs. F: 226 [8%]; p = 0.0002), with more proximal DVT in men than women (M: 131 7.3% vs. F: 124 [4.4%]; p = 0.00021). PTP was more likely in men (355 [19.9%]) than women (455 [16.2%]) (p = 0.0011); more men had swelling in the entire limb, increased calf circumference by >3 cm compared with the contralateral limb, and pitting edema, than women. D-dimer levels (available in 65% of patients) were more frequently positive in women with DVT than in men (94.6% vs. 85.7%; p = 0.016). However, a positive D-dimer and/or likely PTP was similarly frequent in men (92%) and women (96%) with DVT. Conclusions: More women than men are referred for suspected DVT, and men have a higher prevalence of proximal DVT. However, current algorithms for DVT diagnosis perform similarly in men and in women.
Collapse
Affiliation(s)
- Benilde Cosmi
- Angiology Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Laura Borgese
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Michelangelo Sartori
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | |
Collapse
|
7
|
Palareti G, Antonucci E, Bucherini E, Caronna A, Chistolini A, Di Giorgio A, Di Giulio R, Falanga A, Fregoni V, Garzia M, Mastroiacovo D, Marzolo M, Pancani R, Pastori D, Podda GM, Rigoni AM, Ria L, Sivera P, Testa S, Visonà A, Parisi R, Poli D, Investigators OBOTSTARTPOSTVTE. Long-Term Outcomes in Two-Year Follow-Up after Primary Treatment in Patients with a Prior Venous Thromboembolic Event: A Prospective, Observational, Real-Life Study. J Clin Med 2024; 13:1343. [PMID: 38592175 PMCID: PMC10931842 DOI: 10.3390/jcm13051343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Patients with acute venous thromboembolism (VTE) need anticoagulation (AC) therapy for at least 3/6 months (primary treatment); after that period, they should receive a decision on the duration of therapy. METHODS This study examined the complications occurring during two years of follow-up (FU) in patients with a first VTE who were recruited in 20 clinical centers and had discontinued or prolonged AC. They were included in the START2-POST-VTE prospective observational study. RESULTS A total of 720 patients (53.5% males) who, after the completion of primary treatment, had received the decision to continue (n = 281, 39%; 76.1% with a DOAC) or discontinue (n = 439, 61%) AC were followed up for 2 years (total FU = 1318 years). The decision to prolong or suspend AC was made in similar proportions in patients with unprovoked or provoked index events. Courses of sulodexide treatment or Aspirin (100 mg daily) were prescribed to 20.3% and 4.5%, respectively, of the patients who discontinued AC. The bleeding rate was significantly higher in patients who extended AC (1.6% pt/y) than in those who stopped AC (0.1% pt/y; p = 0.001) and was higher in patients using standard-dose DOACs (3.1% pt/y) than in those using reduced-dose DOACs (0.4% pt/y). The recurrent VTE rates were similar between the two groups (2.2% pt/y during AC vs. 3% pt/y off AC). CONCLUSION Physicians' decisions about AC duration were independent of the unprovoked/provoked nature of the index event. The bleeding rate was higher in patients who continued AC using standard-dose DOACs. Surprisingly, the rate of thrombotic recurrence was not different between those who continued or discontinued AC. Randomized studies comparing different procedures to decide on the duration of AC after a first VTE are needed.
Collapse
Affiliation(s)
| | | | - Eugenio Bucherini
- SS Medicina Vascolare e Angiologia, AUSL Romagna, 48121 Ravenna, Italy;
| | - Antonella Caronna
- Centro per la Diagnosi e la Sorveglianza della Malattia Tromboembolica, UO Medicina Interna D’urgenza, Azienda Ospedaliero Universitaria Policlinico di Modena, Ospedale Civile Baggiovara, 41124 Modena, Italy;
| | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione Sapienza Università di Roma, 00197 Roma, Italy;
| | - Angela Di Giorgio
- Angiologia Diagnostica Vascolare Non Invasiva, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy;
| | - Rosella Di Giulio
- U.O. Programma Dipartimentale di Ecografia-AUSL, 40133 Bologna, Italy;
| | - Anna Falanga
- School of Medicine, Università di Milano Bicocca, 20126 Milano, Italy;
- Immunoematologia e Medicina Trasfusionale ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Vittorio Fregoni
- U.O.C. Medicina Generale, Ospedale di Sondalo, ASST della Valtellina e dell’Alto Lario, 23035 Sondalo, Italy;
| | - Mariagrazia Garzia
- UOC Ematologia-Trapianto Cellule Staminali, Azienda Ospedaliera S.Camillo-Forlanini, 00152 Roma, Italy;
| | - Daniela Mastroiacovo
- UOSD Angiologia e Diagnostica Vascolare, Ospedale SS Filippo e Nicola, Avezzano (L’Aquila), 67051 L’Aquila, Italy;
| | - Marco Marzolo
- UOS Angiologia Medica, Ospedale di Rovigo, 45100 Rovigo, Italy;
| | - Roberta Pancani
- U.O. Pneumologia, Dipartimento Cardiotoraco-Vascolare, Azienda Ospedaliero-Universitaria Pisana, Ospedale di Cisanello, 56126 Pisa, Italy;
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, 00197 Roma, Italy;
| | - Gian Marco Podda
- Medicina Generale 2, ASST Santi Paolo e Carlo, Università degli Studi di Milano, 20142 Milano, Italy;
| | - Anna Maria Rigoni
- UOC di Angiologia, Azienda Ospedaliero Universitaria Integrata, 37126 Verona, Italy;
| | - Luigi Ria
- UO Medicina Interna, Presidio Ospedaliero di Gallipoli (Lecce), 73014, Gallipoli, Italy;
| | - Piera Sivera
- S.C.D.U. EMATOLOGIA Azienda Ospedaliera Ordine Mauriziano, 10128 Torino, Italy;
| | - Sophie Testa
- Centro Emostasi e Trombosi, ASST Cremona, 26100 Cremona, Italy;
| | - Adriana Visonà
- UOC Angiologia, Dipartimento di Medicina Clinica, Azienda ULSS 2 Marca Trevigiana, Ospedale San Giacomo Apostolo, 31033 Castelfranco Veneto, Italy;
| | - Roberto Parisi
- UOSD Ipertensione e Patologie Endocrine Metaboliche Angiologiche, Ospedale SS. Giovanni e Paolo, 30122 Venezia, Italy;
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, 50134 Firenze, Italy;
| | | |
Collapse
|
8
|
Menichelli D, Poli D, Antonucci E, Palareti G, Pignatelli P, Pastori D. Renin-angiotensin-aldosterone system inhibitors and mortality risk in elderly patients with atrial fibrillation. Insights from the nationwide START registry. Eur J Intern Med 2024; 119:84-92. [PMID: 37648584 DOI: 10.1016/j.ejim.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/17/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Arterial hypertension is the most common cardiovascular comorbidity in atrial fibrillation (AF). Few studies investigated management strategies of hypertension in AF. MATERIALS AND METHODS We included 5769 AF patients on oral anticoagulants from the nationwide ongoing Italian START registry. We investigated the prescription of antihypertensive drugs and mortality risk. Subgroup analyses according to sex and major cardiovascular comorbidities were performed. RESULTS Mean age was 80.8 years, 46.1% were women; 80.3% of patients were hypertensive. Furosemide (30.1%) was the most frequent diuretic followed by hydrochlorothiazide (15.4%) and potassium canrenoate (7.9%). 61.1% received β-blockers: 34.2% bisoprolol, 6.2% atenolol. Additionally, 36.9% were on angiotensin converting enzyme inhibitors (ACE-I): ramipril (20.9%), enalapril (5.3%) and perindopril (2.8%); 31.7% were on angiotensin receptors blockers (ARBs): valsartan (7.6%) and irbesartan (6.4%). Amlodipine and lercanidipine were prescribed in 14.0% and 2.3%, respectively. ACE-I (p < 0.001), α-blockers (p = 0.020) and Dihydropyridines calcium channel blockers (p = 0.004) were more common in men, while ARBs (p = 0.008), thiazide diuretics (p < 0.001) and β-blockers (p < 0.001) in women. During 22.61 ± 17.1 months, 512 patients died. Multivariable Cox regression analysis showed that ACE-I (Hazard ratio [HR] 0.758, 95% Confidence Interval [95%CI] 0.612-0.940, p = 0.012) and ARBs (HR 0.623, 95%CI 0.487-0.796, p < 0.001) inversely associated with mortality. ACE-I/ARBs inversely associated with mortality in both sexes and in patients with diabetes. This associastion was evident for ACE-I in patients with previous cardiovascular disease, and for ARBs in HF. CONCLUSION A lower mortality risk was found in AF patients on ACE-I/ARBs. Different prescription patterns of antihypertensive drugs between men and women do exist.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | - Daniela Poli
- Thrombosis Center, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | | | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy.
| |
Collapse
|
9
|
Cosmi B, Legnani C, Libra A, Palareti G. D-Dimers in diagnosis and prevention of venous thrombosis: recent advances and their practical implications. Pol Arch Intern Med 2023; 133:16604. [PMID: 37965939 DOI: 10.20452/pamw.16604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
D‑Dimers derive from degradation of cross‑linked fibrin by plasmin, and thus their level is a marker of coagulation and fibrinolytic system activation. Guidelines recommend that D‑dimers are determined if the pretest probability (PTP) is low or intermediate, to exclude venous thromboembolism (VTE), either deep vein thrombosis or pulmonary embolism, and to avoid imaging tests. If the PTP is high or D‑dimer level is above the suggested thresholds, imaging is recommended. D‑Dimer assays offer high sensitivity and low specificity, as D‑dimer levels can be above the threshold in several other conditions than thrombosis, and they increase with age. As a result, there have been several proposals to improve the diagnostic accuracy of D‑dimer levels by adjusting the cutoffs according to patient characteristics, such as age, PTP, pregnancy, renal function, or cancer. D‑Dimer levels can also predict clinical severity of COVID‑19, and escalated anticoagulation based on D‑dimer levels can be associated with a lower risk of mortality in patients with severe COVID‑19. Finally, D‑dimer levels have been incorporated in prediction models for recurrent VTE to help identify patients who may benefit from prolonged anticoagulation.
Collapse
Affiliation(s)
- Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
| | | | - Alessia Libra
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | |
Collapse
|
10
|
Menichelli D, Antonucci E, Pignatelli P, Violi F, Palareti G, Pastori D. Statins under-treatment and mortality in patients with atrial fibrillation. Insights from the nationwide START registry. Nutr Metab Cardiovasc Dis 2023; 33:2261-2268. [PMID: 37580234 DOI: 10.1016/j.numecd.2023.07.016] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND AND AIMS Statins are mainstream drugs for cardiovascular (CV) prevention, but under-prescription is an important clinical challenge. Data on the use of single statins and on the rate of under-prescription in atrial fibrillation (AF) are lacking. We evaluated the association of statin underuse with mortality risk in a large AF cohort. METHODS AND RESULTS As many as 5477 patients from the Italian nationwide START registry were included. The prevalence of different statins was reported and the association of under prescription with all-cause and CV mortality investigated. Mean age was 80.2 years, and 46.4% were women. Among 2899 patients with a clinical indication to statin, only 1578 (54.4%) were on treatment. In a mean follow-up of 22.5 ± 17.1 months, 491 (4.7%/year) deaths occurred (106 CV deaths, 1.0%/year). Atorvastatin and Simvastatin were inversely associated with all-cause (HR 0.692, 95% CI 0.519-0.923, p = 0.012 and HR 0.598, 95% CI 0.428-0.836, p = 0.003, respectively) and CV death (HR 0.372, 95% CI 0.178-0.776, p = 0.008 and HR 0.306, 95% CI 0.123-0.758, p = 0.010, respectively). The 1321 untreated patients were older, more frequently women and with a higher prevalence of diabetes, previous cerebrovascular disease, peripheral artery disease compared to those on treatment. Statin undertreatment was associated with higher risk of all-cause (HR 1.400, 95% CI 1.078-1.819, p = 0.012) and CV death (HR 2.057, 95% CI 1.188-3.561, p = 0.010). CONCLUSIONS AF patients with an indication to statins but left untreated show a high risk of all-cause and CV mortality. Implementation of statin prescription in the AF population can help reducing the residual mortality risk.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, Rome, Italy
| | | | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.
| |
Collapse
|
11
|
Grandone E, Antonucci E, Colaizzo D, De Laurenzo A, Cosmi B, Cini M, Legnani C, Testa S, Margaglione M, Palareti G. Venous Thromboembolism in Women of Childbearing Age: Insights from the START Registry. Thromb Haemost 2023; 123:1060-1068. [PMID: 37263294 DOI: 10.1055/s-0043-1769592] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Women of childbearing age are exposed to venous thromboembolic risk mainly for pregnancy and use of oral contraceptives. The impact of risk factors (RF) on venous thromboembolism (VTE) in these circumstances is still unclear. AIM In the context of START registry, we aimed to investigate the weight of a series of RF on the occurrence of pregnancy- or combined oral contraceptive (COC)-associated VTE. MATERIALS AND METHODS We selected all women included in the START for VTE occurred between 18-42 years and compared those with a first or recurrent pregnancy/postpartum- (group A) or COC-VTE (group B) with those who had VTE outside these circumstances (group C). Final analysis included a cohort of 532 women. Follow-up data showed that there were no significant differences between the groups in terms of thrombotic and haemorrhagic complications. As for pregnancy-associated VTE, the overall outcome was good in terms of both maternal and fetal prognosis. RESULTS In a binary model of logistic regression, correcting for potential confounders, VTE family history conferred a significant and independent higher risk of COC-VTE compared with group C. Similarly, comparison between group A and C documented that family history significantly affected the risk of pregnancy-associated VTE. VTE in the group C was significantly associated with older age. Lastly, smoke was a significant risk factor for pregnancy/postpartum VTE when group A and group B were compared. CONCLUSION Present data suggest that in the setting of fertile women, family history of VTE has a greater role in predicting COC- and pregnancy/postpartum- VTE than outside these circumstances.
Collapse
Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
- Ob/Gyn Department, University of Foggia, Foggia, Italy
- Ob/Gyn and Perinatal Medicine Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | | | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Antonio De Laurenzo
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza," San Giovanni Rotondo, Italy
| | - Benilde Cosmi
- UO di Angiologia e Malattie della Coagulazione, Dipartimento Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna; Azienda Ospedaliero Universitaria S. Orsola-Malpighi, IRCCS, Bologna, Italy
| | - Michela Cini
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | | | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche, ASST Cremona, Cremona, Italy
| | - Maurizio Margaglione
- Medical Genetics, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | | |
Collapse
|
12
|
Cosmi B, Legnani C, Cini M, Borgese L, Sartori M, Palareti G. Incidence and clinical outcomes of heparin-induced thrombocytopenia: 11 year experience in a tertiary care university hospital. Intern Emerg Med 2023; 18:1971-1980. [PMID: 37568069 DOI: 10.1007/s11739-023-03379-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/12/2023] [Indexed: 08/13/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a rare immuno-mediated adverse reaction with high thrombotic and mortality risk. To evaluate incidence and outcomes of HIT cases diagnosed at a tertiary care hospital from 2007 to 2018. A retrospective study was conducted. Patients with suspected HIT underwent 4Ts score assessment and anti-heparin PF4 IgG antibodies ELISA screening test. If the latter was positive, platelet aggregation test (PAT) was performed. If the latter was positive, any form of heparin was stopped, alternative anticoagulants were started and then overlapped with warfarin. HIT incidence was calculated by dividing HIT cases by the mean yearly number of admitted patients over 11 years. Follow-up was 90 days. Among 2125 screening tests, 96 (4.5%) were positive with confirmatory PAT in 82/90 (3.8% for missing data in 6). Median age was 75; 39 patients were surgical and 51 medical. The median 4Ts score was 5. Unfractionated heparin was employed in 34 (37%). HIT incidence was 0.16/1000/patient/years (95% CI: 0.12-0.23) in surgical and 0.15/1000/patient/years (95%: 0.12-0.20) in medical patients. HIT with thrombosis (HIT-T) was observed in 31 patients (0.05/1000/patient/years 95% CI: 0.04-0.1), with venous thromboses in 25 (80%). HIT without thrombosis was observed in 59 patients (0.1/1000 patient/years; 95% CI: 0.08-0.13, twofold vs HIT-T). All cause mortality was 25.5% (95% CI: 17.6-35.4), major bleeding 7.7% (95% CI:3.2-15.3), and thromboembolic complications 3.3% (95% CI:1.1-9.3). HIT is a rare event with high mortality, despite the use of non heparin anticoagulants.
Collapse
Affiliation(s)
- Benilde Cosmi
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | | | - Laura Borgese
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Michelangelo Sartori
- Angiology and Blood Coagulation Unit , IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | |
Collapse
|
13
|
Rostagno C, Rubbieri G, Zeppa M, Cartei A, Ceccofiglio A, Mannarino GM, Palareti G, Grandone E. Management and 1-Year Outcome in Elderly Patients with Hip Fracture Surgery Receiving Anticoagulation (Warfarin or DOAc) or P2Y12 Antiplatelet Agents. J Clin Med 2023; 12:6178. [PMID: 37834822 PMCID: PMC10573498 DOI: 10.3390/jcm12196178] [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] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
(1) Background: Little prospective data exist regarding the perioperative management and long-term prognosis of elderly patients receiving treatment with antithrombotic drugs and undergoing urgent surgery for a hip fracture. (2) Methods: The study included patients who required hip surgery and were receiving warfarin, DOAc or P2Y12 antiplatelet agents at the moment of trauma. Ongoing antithrombotic treatment was managed according to existing recommendations. The endpoints of the study were the time to surgery, perioperative bleeding, the need for transfusion and, finally, mortality, major cardiovascular events and re-hospitalization at 6 and 12 months. (3) Results: The study included a total of 138 patients. The mean age was 86 years; 75.4% were female. Eighty-two received DOAc, thirty-six received warfarin and twenty received P2Y12 inhibitors. The controls were 283 age- and sex-matched patients who did not receive antithrombotic treatment. A total of 38% of patients receiving warfarin underwent surgery <48 h, 52% receiving DOAc, 55% receiving P2Y12 inhibitors and, finally, 82% in the control group. Perioperative bleeding and the need for transfusion were not different between the four groups. Mortality at 6 months was higher in patients receiving warfarin and P2Y12 inhibitors (30% and 25%) in comparison to DOAc and the control group (11.6% and 10% p < 0.0001). Similarly, the other endpoints were more frequent in patients receiving warfarin and P2Y12 inhibitors. The trend was maintained for 12 months. No significant differences in mortality were found between early (<48 h) and late (>48 h) surgery independent of the type of treatment. (4) Conclusions: Our study confirmed that anticoagulants delay surgery in patients with hip fractures; however, intervention > 48 h is not associated with a poorer prognosis. This finding is relevant as it underlines that, in patients at high risk of postoperative cardiovascular complications, the careful management of anticoagulation before surgery may compensate for the delay of surgery with a very low in-hospital mortality rate (<1%). One-year survival was significantly lower in patients receiving warfarin, probably related to their worse risk profile at the moment of trauma survival.
Collapse
Affiliation(s)
- Carlo Rostagno
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, 50134 Firenze, Italy;
| | - Gaia Rubbieri
- Medicina Interna e Post-Chirurgica, AOU Careggi, 50134 Firenze, Italy; (G.R.); (A.C.); (A.C.); (G.M.M.)
| | - Mattia Zeppa
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, 50134 Firenze, Italy;
| | - Alessandro Cartei
- Medicina Interna e Post-Chirurgica, AOU Careggi, 50134 Firenze, Italy; (G.R.); (A.C.); (A.C.); (G.M.M.)
| | - Alice Ceccofiglio
- Medicina Interna e Post-Chirurgica, AOU Careggi, 50134 Firenze, Italy; (G.R.); (A.C.); (A.C.); (G.M.M.)
| | - Giulio Maria Mannarino
- Medicina Interna e Post-Chirurgica, AOU Careggi, 50134 Firenze, Italy; (G.R.); (A.C.); (A.C.); (G.M.M.)
| | | | - Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. “Casa Sollievo della Sofferenza”, 71013 San Giovanni Rotondo, Italy;
| |
Collapse
|
14
|
Guarascio M, Bertù L, Donadini MP, Antonucci E, Palareti G, Ageno W. DOACs use in extreme body-weighted patients: results from the prospective START-register. Intern Emerg Med 2023; 18:1681-1687. [PMID: 37301770 DOI: 10.1007/s11739-023-03334-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used for the treatment of venous thromboembolism (VTE) and for stroke prevention in atrial fibrillation (AF). However, evidence in obese and underweight patients is limited. We assessed the safety and effectiveness of DOACs and vitamin K antagonists (VKAs) in patients ≥ 120 kg or ≤ 50 kg enrolled in an observational prospective cohort study, the START-Register. METHODS Adult patients started on anticoagulant therapy were followed up for a median of 1.5 years (IQR 0.6-2.8). Primary efficacy outcome was the occurrence of VTE recurrence, stroke and systemic embolism. Primary safety outcome was major bleeding (MB). RESULTS 10,080 AF and VTE patients were enrolled between March 2011 and June 2021, 295 patients weighted ≤ 50 kg and 82 patients ≥ 120 kg. Obese patients were significantly younger than underweight patients. Rates of thrombotic events were low and similar between DOACs and VKAs in underweight patients (1 event on DOACs therapy [0.9% 95% CI 0.11-5.39] and 2 on VKAs [1.1% 95% CI 0.01-47.68]) and in overweight patients (0 events on DOACs, 1 on VKAs [1.6%, 95% CI 0.11-5.79]. Two MB events occurred on DOACs (1.9%, 95% CI 0.38-6.00) and 3 on VKAs (1.6%, 95% CI 0.04-22.06) in the underweight group; 1 MB on DOACs (5.3% 95% CI 0.33-16.68) and 2 on VKAs (3.3%, 95% CI 0.02-130.77) in the overweight group. CONCLUSIONS DOACs seem to be effective and safe also for the treatment of patients with extreme body weights, both underweight and overweight. Further prospective studies are needed to support these findings.
Collapse
Affiliation(s)
| | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Marco Paolo Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
- Emergency Medicine and Thrombosis and Haemostasis Center, ASST Sette Laghi, Varese, Italy
| | | | | | - Walter Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
- Emergency Medicine and Thrombosis and Haemostasis Center, ASST Sette Laghi, Varese, Italy
| |
Collapse
|
15
|
Ageno W, Antonucci E, Poli D, Bucherini E, Chistolini A, Fregoni V, Lerede T, Pancani R, Pedrini S, Pieralli F, Pignatelli P, Pizzini AM, Podda GM, Potere N, Sarti L, Testa S, Visonà A, Palareti G. Venous thromboembolism secondary to hospitalization for COVID-19: patient management and long-term outcomes. Res Pract Thromb Haemost 2023; 7:100167. [PMID: 37229314 PMCID: PMC10131739 DOI: 10.1016/j.rpth.2023.100167] [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] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/30/2023] [Accepted: 04/16/2023] [Indexed: 05/27/2023] Open
Abstract
Background Venous thromboembolism (VTE) is a complication of COVID-19 in hospitalized patients. Little information is available on long-term outcomes of VTE in this population. Objectives We aimed to compare the characteristics, management strategies, and long-term clinical outcomes between patients with COVID-19-associated VTE and patients with VTE provoked by hospitalization for other acute medical illnesses. Methods This is an observational cohort study, with a prospective cohort of 278 patients with COVID-19-associated VTE enrolled between 2020 and 2021 and a comparison cohort of 300 patients without COVID-19 enrolled in the ongoing START2-Register between 2018 and 2020. Exclusion criteria included age <18 years, other indications to anticoagulant treatment, active cancer, recent (<3 months) major surgery, trauma, pregnancy, and participation in interventional studies. All patients were followed up for a minimum of 12 months after treatment discontinuation. Primary end point was the occurrence of venous and arterial thrombotic events. Results Patients with VTE secondary to COVID-19 had more frequent pulmonary embolism without deep vein thrombosis than controls (83.1% vs 46.2%, P <.001), lower prevalence of chronic inflammatory disease (1.4% and 16.3%, P <.001), and history of VTE (5.0% and 19.0%, P <.001). The median duration of anticoagulant treatment (194 and 225 days, P = 0.9) and the proportion of patients who discontinued anticoagulation (78.0% and 75.0%, P = 0.4) were similar between the 2 groups. Thrombotic event rates after discontinuation were 1.5 and 2.6 per 100 patient-years, respectively (P = 0.4). Conclusion The risk of recurrent thrombotic events in patients with COVID-19-associated VTE is low and similar to the risk observed in patients with VTE secondary to hospitalization for other medical diseases.
Collapse
Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | | | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | | | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione Sapienza Università di Roma, Roma, Italy
| | - Vittorio Fregoni
- U.O.C. Medicina Generale, Ospedale di Sondalo, ASST della Valtellina e dell'Alto Lario, Sondalo, Italy
| | - Teresa Lerede
- Divisione di Immunoematologia e Medicina Trasfusionale & Centro Emostasi e Trombosi, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Roberta Pancani
- U.O. Pneumologia, Dipartimento Cardiotoraco-Vascolare, Azienda Ospedaliero Universitaria Pisana, Ospedale di Cisanello, Pisa, Italy
| | - Simona Pedrini
- Centro Trombosi, UO laboratorio Analisi, Fondazione Poliambulanza, Brescia, Italy
| | - Filippo Pieralli
- Dipartimento Emergenza Accettazione/Subintensiva di Medicina, AOU Careggi, Firenze, Italy
| | | | | | | | - Nicola Potere
- Dipartimento di Medicina e Scienze dell'invecchiamento, Università G. D'Annunzio, Chieti, Italy
| | - Luca Sarti
- Centro per la diagnosi e la sorveglianza della malattia tromboembolica, UO Medicinainterna d'urgenza, Azienda Ospedaliero Universitaria Policlinico di Modena, Ospedale Civile, Baggiovara, Modena, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, ASST Cremona, Cremona, Italy
| | - Adriana Visonà
- UOC Angiologia, Dipartimento di Medicina Clinica, Azienda ULSS 2 Marca Trevigiana, Ospedale San Giacomo Apostolo, Castelfranco Veneto (TV), Italy
| | | |
Collapse
|
16
|
Palareti G, Legnani C, Poli D, Ageno W, Pengo V, Testa S, Tosetto A, Prandoni P. COVID-19 pandemic affects the ability of negative D-dimer to identify venous thromboembolism patients at low risk of recurrence: insights from the Apidulcis study. Haematologica 2023; 108:923-925. [PMID: 36420801 PMCID: PMC9973493 DOI: 10.3324/haematol.2022.282130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Indexed: 11/27/2022] Open
Abstract
Not available.
Collapse
Affiliation(s)
| | | | | | - Walter Ageno
- UOC Pronto Soccorso, Medicina d'Urgenza e Centro Trombosi ed Emostasi, ASST dei Sette Laghi - Varese
| | - Vittorio Pengo
- Clinica Cardiologica, Azienda Ospedaliera di Padova - Padova - Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi, UUOO Laboratorio Analisi chimico-cliniche e microbiologiche, ASST Cremona - Cremona
| | - Alberto Tosetto
- Divisione di Ematologia, Ospedale S. Bortolo AULSS 8 Berica - Vicenza
| | | | | |
Collapse
|
17
|
Palareti G, Barinov V, Urbanek T, Cini M, Li YJ, Bouslama K, Matuška J, Mansilha A, Madaric J, Sokurenko GY, Andreozzi GM. Recurrences and bleeding during extended treatment of patients with venous thromboembolism: results of the international, prospective, observational WHITE study. INT ANGIOL 2023; 42:37-44. [PMID: 36714910 DOI: 10.23736/s0392-9590.22.04970-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Little data are available on real-life long-term treatments after a venous thromboembolism (VTE), and on recurrent VTE or bleeds events during treatments. METHODS We investigated the complications occurring during follow-up (FU) in VTE patients who had received the treatment decisions given by the clinical centers, active in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, Tunisia), which participated in the international, prospective, observational WHITE study. RESULTS FU information was collected in 1004 patients, recruited by 62 clinical centers (17 centers did not participate in FU collection). Extended treatments were proposed to 811 patients: direct oral anticoagulants (DOACs) (475), sulodexide (202), antiplatelet agents (73), vitamin K antagonists (VKAs) (45), low molecular weight heparin (LMWH) (16). All specific treatments were stopped in the remaining 193 patients. Patients who during FU used treatments different than those prescribed by the local investigators (263) or for other causes (26) were excluded from analysis. 50 primary events occurred throughout 1044 years FU in 715 patients, 4.8 incidence (×100 patient-years) [3.8 for recurrences, and 0.96 for bleeding (major or clinically relevant)]. Primary event incidence differed according to treatments (LMWH=33.3, antiplatelets =7.6, VKAs = 6.1, DOACs = 4.7, sulodexide = 4.2, all treatment stopped = 2.5), and differed across the involved countries. CONCLUSIONS DOACs were the most used drugs for extended treatments. Overall, the rate of primary events during FU was low. The investigators identified patients at low risk of recurrence and high bleeding risk. Sulodexide use for secondary prevention deserves further studies.
Collapse
Affiliation(s)
| | - Victor Barinov
- Central State Medical Academy of the Office of the President of the Russian Federation, Volynskaya Clinical Hospital N.1, Moscow, Russia
| | | | - Michela Cini
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - Young-Jun Li
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | | | | | | | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | | | | | | |
Collapse
|
18
|
Elmi G, Allegri D, Aluigi L, Antignani PL, Aspide R, Camaggi V, DI Giulio R, Domanico A, Rinaldi ER, Martignani A, Palareti G. Management and outcomes of calf deep vein thrombosis in patients with contraindication to full anticoagulation due to bleeding. Int Angiol 2023; 42:229-238. [PMID: 36700289 DOI: 10.23736/s0392-9590.23.04947-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND This prospective observational study was aimed at assessing early outcomes of inpatients with isolated distal deep vein thrombosis (IDDVT) and coexisting bleeding. METHODS Patients received enoxaparin 4000 units daily or intermediate doses, and ultrasound surveillance (US). Primary outcomes were extension to the popliteal vein (PDVT) or symptomatic pulmonary embolism (PE), bleeding complications during the treatment and the composite of PDVT and bleeding complications. Secondary outcomes were recurrent IDDVTs and death. RESULTS 90/95 patients completed the study period (30 days). PDVT occurred in 2/41 (4.9%) and in 3/45 (6.7%) subjects receiving enoxaparin 4000 units and intermediate doses respectively (OR 1.39; 95% CI: 0.22-11; P=0.72). PE occurred in only one of the 4 untreated subjects (25% vs. 0 patients taking enoxaparin 4000 units or intermediate doses; P=1.0). Recurrent IDDVTs occurred in 29 subjects (32.2%), more frequently during enoxaparin 4000 (19/29, 65.5%). Four patients died (4.4%). Bleeding complications occurred in 8 subjects (8.9%), all treated with intermediate doses (0 vs. 17.8%; P=1.0). Enoxaparin 4000 units significantly reduced the risk of the composite outcome compared with higher doses (4.9% vs. 24.4%; OR 6.31; 95% CI: 1.56-42.65; P=0.02). Major trauma significantly increased the risk of PDVT (OR 20.92; 95% CI: 2.82-427.51, P=0.01; logistic regression P=0.01). Patients with major trauma are also at increased bleeding risk (OR 5; 95% CI: 1.06-23.76, P=0.04; logistic regression P=0.03). CONCLUSIONS Enoxaparin 4000 units daily, supported by US, may be an option for selected patients.
Collapse
Affiliation(s)
- Giovanna Elmi
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy -
| | - Davide Allegri
- Department of Clinical Governance and Quality, Bologna Local Healthcare Authority, Bologna, Italy
| | | | | | - Raffaele Aspide
- Anesthesia and Intensive Care Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna (ISNB), Bologna, Italy
| | - Valeria Camaggi
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Rosella DI Giulio
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Andrea Domanico
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Elisa R Rinaldi
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | - Alberto Martignani
- Ultrasound Program, Medical Department, Maggiore Hospital, AUSL Bologna, Bologna, Italy
| | | |
Collapse
|
19
|
Prandoni P, Lensing AWA, Prins MH, Ciammaichella M, Pirillo S, Pace F, Zalunardo B, Bottino F, Ageno W, Muiesan ML, Forlin M, Depietri L, Bova C, Costantini N, Caviglioli C, Migliaccio L, Noventa F, Levi M, Davidson BL, Palareti G. Prevalence of pulmonary embolism among patients with recent onset of dyspnea on exertion. A cross-sectional study. J Thromb Haemost 2023; 21:68-75. [PMID: 36695397 DOI: 10.1016/j.jtha.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Exertional dyspnea is a frequently encountered complaint in clinical practice. However, the prevalence of pulmonary embolism (PE) among patients with dyspnea on exertion has not been reported. OBJECTIVE The objective of this study was to assess the prevalence of objectively confirmed PE among consecutive patients visiting an emergency department because of recent onset of exertional dyspnea. METHODS Patients aged ≤75 years with recent (<1 month) marked exertional dyspnea had a systematic workup for PE, irrespective of concomitant signs or symptoms of venous thromboembolism and alternative explanations for dyspnea. PE was excluded on the basis of a low pretest clinical probability and normal age-adjusted D-dimer. All other patients had computed tomography pulmonary angiography. An interim analysis after inclusion of 400 patients would stop recruitment if the 95% confidence interval (CI) of the PE prevalence had a lower limit exceeding 20%. RESULTS The study was prematurely terminated after the inclusion of 417 patients. In 134 patients (32.1%), PE was excluded based on low clinical probability and normal D-dimer. PE was found in 134 (47.3%) of the remaining 283 patients, for an overall prevalence of 32.1% (95% CI, 27.8-36.8). PE was present in 40 of 204 (19.6%) patients without other findings suspicious for PE and in 94 of 213 patients (44.1%) with such findings. PE involved a main pulmonary artery in 37% and multiple lobes in 87% of the patients. CONCLUSION The angiographic demonstration of PE is common in patients presenting with recent onset of marked exertional dyspnea, including 20% without other findings suggesting pulmonary embolism.
Collapse
Affiliation(s)
| | | | - Martin H Prins
- Department of Clinical Epidemiology, University of Maastricht, The Netherlands
| | | | - Silvana Pirillo
- Department of Radiology, S. Giovanni-Addolorata Hospital, Rome, Italy
| | | | - Beniamino Zalunardo
- Angiology Unit and Emergency Medicine Unit, San Giacomo Hospital, Castelfranco Veneto, Italy
| | | | - Walter Ageno
- Department of Internal Medicine, University of Insubria, Varese, Italy
| | - Maria L Muiesan
- Department of Internal Medicine, University of Brescia and ASST Spedali Civili, Brescia, Italy
| | - Marco Forlin
- Emergency Department, Civic Hospital, Pieve di Soligo, Italy
| | - Luca Depietri
- Cardiovascular Medicine, Civic Hospital, Reggio Emilia, Italy
| | - Carlo Bova
- Department of Internal Medicine, Civic Hospital, Cosenza, Italy
| | | | - Cosimo Caviglioli
- Emergency Department, University of Firenze Careggi, Florence, Italy
| | | | - Franco Noventa
- Department of Molecular Medicine, University of Padua, Padua, Italy
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bruce L Davidson
- Washington State University Floyd College of Medicine, Seattle, Washington State, USA
| | | | | |
Collapse
|
20
|
Ageno W, Bertù L, Bucherini E, Camporese G, Dentali F, Iotti M, Lessiani G, Parisi R, Prandoni P, Sartori M, Visonà A, Bigagli E, Palareti G. Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial. BMJ 2022; 379:e072623. [PMID: 36520715 PMCID: PMC9682494 DOI: 10.1136/bmj-2022-072623] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare two different treatment durations of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT). DESIGN Randomised, double blind, placebo controlled clinical trial. SETTING 28 outpatient clinics specialising in venous thromboembolism. PARTICIPANTS 402 adults (≥18 years) with symptomatic isolated distal DVT. INTERVENTIONS After receiving standard dose rivaroxaban for six weeks, participants were randomly assigned to receive rivaroxaban 20 mg or placebo once daily for an additional six weeks. Follow-up was for 24 months from study inclusion. MAIN OUTCOMES MEASURES The primary efficacy outcome was recurrent venous thromboembolism during follow-up after randomisation, defined as the composite of progression of isolated distal DVT, recurrent isolated distal DVT, proximal DVT, symptomatic pulmonary embolism, or fatal pulmonary embolism. The primary safety outcome was major bleeding after randomisation until two days from the last dose of rivaroxaban or placebo. An independent committee adjudicated the outcomes. RESULTS 200 adults were randomised to receive additional rivaroxaban treatment and 202 to receive placebo. Isolated distal DVT was unprovoked in 81 (40%) and 86 (43%) patients, respectively. The primary efficacy outcome occurred in 23 (11%) patients in the rivaroxaban arm and 39 (19%) in the placebo arm (relative risk 0.59, 95% confidence interval 0.36 to 0.95; P=0.03, number needed to treat 13, 95% confidence interval 7 to 126). Recurrent isolated distal DVT occurred in 16 (8%) patients in the rivaroxaban arm and 31 (15%) in the placebo arm (P=0.02). Proximal DVT or pulmonary embolism occurred in seven (3%) patients in the rivaroxaban arm and eight (4%) in the placebo arm (P=0.80). No major bleeding events occurred. CONCLUSIONS Rivaroxaban administered for six additional weeks in patients with isolated distal DVT who had an uneventful six week treatment course reduces the risk of recurrent venous thromboembolism, mainly recurrent isolated distal DVT, over a two year follow-up without increasing the risk of haemorrhage. TRIAL REGISTRATION EudraCT 2016-000958-36; ClinicalTrials.gov NCT02722447.
Collapse
Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | | | - Giuseppe Camporese
- Unit of Angiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy
| | - Matteo Iotti
- Cardiovascular Medicine Unit - AUSL-IRCCS, Reggio Emilia, Italy
| | - Gianfranco Lessiani
- Angiology Unit, Department of Internal Medicine, Villa Serena Hospital, Città Sant'Angelo, Italy
| | - Roberto Parisi
- Department of Medicine, SS Giovanni e Paolo Hospital, Venice, Italy
| | | | - Michelangelo Sartori
- Division of Angiology and Blood Coagulation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Adriana Visonà
- Angiology Unit, Azienda ULSS 2 Marca Trevigiana, Castelfranco Veneto, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | | |
Collapse
|
21
|
Fumagalli RM, Aimasso U, Valeriani E, Mumoli N, Szlaszynska M, Antonucci E, Palareti G, Mastroiacovo D, Di Nisio M, Barco S. Quality of warfarin anticoagulation in adults with short bowel syndrome on home parenteral nutrition. VASA 2022; 51:320-322. [PMID: 36059217 DOI: 10.1024/0301-1526/a001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Umberto Aimasso
- Unit of Dietetics and Clinical Nutrition, Città della Salute e della Scienza, Torino, Italy
| | - Emanuele Valeriani
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, Magenta, Italy.,Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | | | | | | | | | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Switzerland.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| |
Collapse
|
22
|
Abdulrehman J, Elbaz C, Aziz D, Parpia S, Fazelzad R, Eischer L, Rodger MA, Cannegieter SC, Ten Cate-Hoek A, Nagler M, Schulman S, Rezende SM, Olié V, Palareti G, Marcucci M, Douketis J, Poli D, Zabczyk M, de Sousa DA, Miranda B, Cushman M, Tosetto A, Le Gal G, Kearon C, Skeith L. Recurrence after stopping anticoagulants in women with combined oral contraceptive-associated venous thromboembolism: A systematic review and meta-analysis. Br J Haematol 2022; 199:130-142. [PMID: 35877546 DOI: 10.1111/bjh.18331] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 11/29/2022]
Abstract
The risk of recurrence after discontinuation of anticoagulation for a combined oral contraceptive (COC)-associated venous thromboembolism (VTE) is unclear. Therefore, we conducted a systematic review and meta-analysis to estimate the incidence of recurrent VTE among women with COC-associated VTE, unprovoked VTE and to compare the incidence of recurrent VTE between the two groups. The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase Classic +Embase and Medline ALL to July 2020 and citations from included studies were searched. Randomized controlled trials, prospective cohort studies and meta-analyses of these study types were selected. The analysis was conducted by random-effects model. Nineteen studies were identified including 1537 women [5828 person-years (PY)] with COC-associated VTE and 1974 women (7798 PY) with unprovoked VTE. Studies were at low risk of bias. The incidence rate of VTE recurrence was 1.22/100 PY [95% confidence interval (CI) 0.92-1.62, I2 = 6%] in women with COC-associated VTE, 3.89/100 PY (95% CI 2.93-5.17, I2 = 74%) in women with unprovoked VTE and the unadjusted incidence rate ratio was 0.34 (95% CI 0.26-0.46, I2 = 3%). The recurrence risk in women after COC-associated VTE is low and lower than after an unprovoked VTE.
Collapse
Affiliation(s)
| | - Carolyne Elbaz
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - David Aziz
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Rouhi Fazelzad
- Library and Information Services, University Health Network (UHN)- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arina Ten Cate-Hoek
- Thrombosis Expertise Center, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Valérie Olié
- Santé publique France, French national public health agency, Saint-Maurice, France
| | | | - Maura Marcucci
- Department of Health Research Methods, Evidence, and Impact, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, Ontario, Canada
| | - Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Michal Zabczyk
- Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Krakow, Poland
| | - Diana Aguiar de Sousa
- Hospital de Santa Maria, Lisbon School of Medicine, University of Lisbon, Lisboa, Portugal
| | - Bruno Miranda
- Physiology Institute - Lisbon School of Medicine, University of Lisbon, Lisboa, Portugal
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Alberto Tosetto
- Hemophilia and Thrombosis Center, Hematology Department, S. Bortolo Hospital, Vicenza, Italy
| | - Gregoire Le Gal
- Ottawa Health Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Leslie Skeith
- Division of Hematology and Hematological Malignancies, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
23
|
Poli D, Antonucci E, Ageno W, Prandoni P, Barillari G, Bitti G, Imbalzano E, Bucherini E, Chistolini A, Fregoni V, Galliazzo S, Gandolfo A, Grifoni E, Mastroianni F, Panarello S, Pesavento R, Pedrini S, Sala G, Pignatelli P, Preti P, Simonetti F, Sivera P, Visonà A, Villalta S, Marcucci R, Palareti G. Thromboembolic Complications in COVID-19 Patients Hospitalized in Italian Ordinary Wards: Data from the Multicenter Observational START-COVID Register. TH Open 2022; 6:e251-e256. [PMID: 36299804 PMCID: PMC9467691 DOI: 10.1055/a-1878-6806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/21/2022] [Indexed: 11/11/2022] Open
Abstract
Background
Coronavirus disease 2019 (COVID-19) infection causes acute respiratory insufficiency with severe interstitial pneumonia and extrapulmonary complications; in particular, it may predispose to thromboembolic disease. The reported incidence of thromboembolic complications varies from 5 to 30% of cases.
Aim
We conducted a multicenter, Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe the clinical characteristics of patients at admission and bleeding and thrombotic events occurring during the hospital stay.
Results
The number of hospitalized patients included in the START-COVID-19 Register was 1,135, and the number of hospitalized patients in ordinary wards included in the study was 1,091, with 653 (59.9%) being males and 71 years (interquartile range 59–82 years) being the median age. During the observation, two (0.2%) patients had acute coronary syndrome episodes and one patient (0.1%) had an ischemic stroke; no other arterial thrombotic events were recorded. Fifty-nine patients had symptomatic venous thromboembolism (VTE) (5.4%) events, 18 (30.5%) deep vein thrombosis (DVT), 39 (66.1%) pulmonary embolism (PE), and 2 (3.4%) DVT+PE. Among patients with DVT, eight (44.4%) were isolated distal DVT and two cases were jugular thrombosis. Among patients with PE, seven (17.9%) events were limited to subsegmental arteries. No fatal PE was recorded. Major bleeding events occurred in nine (1.2%) patients and clinically relevant nonmajor bleeding events in nine (1.2%) patients. All bleeding events occurred among patients receiving thromboprophylaxis, more frequently when treated with subtherapeutic or therapeutic dosages.
Conclusion
Our findings confirm that patients admitted to ordinary wards for COVID-19 infection are at high risk for thromboembolic events. VTE recorded among these patients is mainly isolated PE, suggesting a peculiar characteristic of VTE in these patients.
Collapse
Affiliation(s)
- Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | | | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | | | | | | | | | | | - Antonio Chistolini
- Dipartimento di Medicina Traslazionale e di Precisione, Sapienza Università di Roma, Roma, Italy
| | - Vittorio Fregoni
- U.O.C. Medicina Generale, ASST Valtellina e Alto Lario Ospedale di Sondalo, Italy
| | - Silvia Galliazzo
- UOC Medicina Generale, Ospedale San Valentino, Montebelluna (TV), Italy
| | - Alberto Gandolfo
- SC (UCO) Clinica Medica, ASUGI, Ospedale di Cattinara, Trieste, Italy
| | - Elisa Grifoni
- Medicina Interna 2, Ospedale San Giuseppe, Empoli (Fi), Italy
| | - Franco Mastroianni
- UOC Medicina Interna, Covid Unit, EE Ospedale F. Miulli, Acquaviva delle Fonti (Ba), Italy
| | | | | | - Simona Pedrini
- UO, laboratorio Analisi, Fondazione Poliambulanza Brescia, Italy
| | - Girolamo Sala
- UOC Medicina II, Ospedale di Circolo Busto Arsizio (Va), Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Medicina Interna Covid e Centro Trombosi Sapienza, Università di Roma, Roma, Italy
| | - Paola Preti
- Unità di Medicina Interna, Malattie Vascolari e Metaboliche Policlinico San Matteo, Pavia, Italy
| | - Federico Simonetti
- UOC Ematologia Aziendale – Ospedale Versilia –Lido di Camaiore (Lucca), Italy
| | - Piera Sivera
- SCDU Ematologia e terapie cellulari, AO Ordine Mauriziano Umberto 1° Torino, Italy
| | - Adriana Visonà
- UOC Angiologia, Ospedale San Giacomo Apostolo, Castelfranco Veneto (Treviso), Italy
| | - Sabina Villalta
- UOC Medicina Generale, Ospedale San Giacomo Apostolo, Castelfranco Veneto (Treviso), Italy
| | - Rossella Marcucci
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | | |
Collapse
|
24
|
Poli D, Antonucci E, Ageno W, Prandoni P, Palareti G, Marcucci R. Low in-hospital mortality rate in patients with COVID-19 receiving thromboprophylaxis: data from the multicentre observational START-COVID Register. Intern Emerg Med 2022; 17:1013-1021. [PMID: 34973126 PMCID: PMC8720160 DOI: 10.1007/s11739-021-02891-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/11/2021] [Indexed: 12/20/2022]
Abstract
COVID-19 infection causes respiratory pathology with severe interstitial pneumonia and extra-pulmonary complications; in particular, it may predispose to thromboembolic disease. The current guidelines recommend the use of thromboprophylaxis in patients with COVID-19, however, the optimal heparin dosage treatment is not well-established. We conducted a multicentre, Italian, retrospective, observational study on COVID-19 patients admitted to ordinary wards, to describe clinical characteristic of patients at admission, bleeding and thrombotic events occurring during hospital stay. The strategies used for thromboprophylaxis and its role on patient outcome were, also, described. 1091 patients hospitalized were included in the START-COVID-19 Register. During hospital stay, 769 (70.7%) patients were treated with antithrombotic drugs: low molecular weight heparin (the great majority enoxaparin), fondaparinux, or unfractioned heparin. These patients were more frequently affected by comorbidities, such as hypertension, atrial fibrillation, previous thromboembolism, neurological disease, and cancer with respect to patients who did not receive thromboprophylaxis. During hospital stay, 1.2% patients had a major bleeding event. All patients were treated with antithrombotic drugs; 5.4%, had venous thromboembolism [30.5% deep vein thrombosis (DVT), 66.1% pulmonary embolism (PE), and 3.4% patients had DVT + PE]. In our cohort the mortality rate was 18.3%. Heparin use was independently associated with survival in patients aged ≥ 59 years at multivariable analysis. We confirmed the high mortality rate of COVID-19 in hospitalized patients in ordinary wards. Treatment with antithrombotic drugs is significantly associated with a reduction of mortality rates especially in patients older than 59 years.
Collapse
Affiliation(s)
- Daniela Poli
- Centro Trombosi, Azienda Ospedaliero Universitaria Careggi, Viale Morgagni, 85-50134, Firenze, Italy.
| | | | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | | | | | - Rossella Marcucci
- Fondazione Arianna Anticoagulazione, Bologna, Italy
- Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
- Centro Trombosi, Azienda Ospedaliero Universitaria Careggi, Viale Morgagni, 85-50134, Firenze, Italy
| |
Collapse
|
25
|
Antonucci E, Barcella L, Russo L, Chistolini A, Serrao A, Elmi G, Sivera P, Falanga A, Palareti G. PO-58: Cancer-associated venous thromboembolism: the Onco-VTE START2 - Registry. Thromb Res 2022. [DOI: 10.1016/s0049-3848(22)00248-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
26
|
Palareti G, Bignamini AA, Urbanek T, Cini M, Li YJ, Madaric J, Bouslama K, Sokurenko GY, Andreozzi GM, Matuška J, Mansilha A, Barinov V. Influence of clinical presentation, site, and extent of venous thrombosis on decision about duration of anticoagulation: Data from the international, prospective, observational white study. Thromb Res 2022; 211:140-146. [DOI: 10.1016/j.thromres.2022.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 10/19/2022]
|
27
|
Menichelli D, Poli D, Antonucci E, Biccirè FG, Palareti G, Pignatelli P, Pastori D. Bleeding and mortality risk in patients implanted with mechanical prosthetic heart valves with and without thrombocytopenia. Insights from the nationwide PLECTRUM registry. Platelets 2022; 33:1018-1023. [PMID: 35021929 DOI: 10.1080/09537104.2022.2026909] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Previous studies showed that mechanical prosthetic heart valve (MPHV) patients may develop thrombocytopenia, but its association with clinical outcomes has not been investigated. We enrolled 1,663 patients with available platelet count from the multicenter nationwide retrospective PLECTRUM registry to investigate the association of thrombocytopenia with all-cause mortality and major bleeding (MB) in patients implanted with MPHV. Thrombocytopenia was defined by platelet count <150 × 109/L. Overall, 44.9% of patients were women and the mean age was 56.7 years. At baseline, 184 (11.1%) patients had thrombocytopenia. Patients with thrombocytopenia were more frequently men and elderly. Platelet count showed an age-dependent decline in men but not in women. We found an increased risk of death in patients with age ≥ 65 years, with a low anticoagulation quality, concomitant arterial hypertension, heart failure, a higher INR range, or with thrombocytopenia (OR 1.739, 95%CI 1.048-2.886, p = .032). At multivariable logistic regression, patients with age ≥65 years, concomitant AF and thrombocytopenia (OR 1.907, 95%CI 1.219-2.983, p = .005) had an increased risk of MBs. In MPHV patients, thrombocytopenia is associated with an increased risk of death and MB. There is a growing need for a sex- and age-specific threshold to define platelet count in adult patients.
Collapse
Affiliation(s)
- Danilo Menichelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero - Universitaria Careggi, Florence, Italy
| | | | - Flavio Giuseppe Biccirè
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy.,Department of General and Specialized Surgery "Paride Stefanini", Sapienza University of Rome, Viale del Policlinico, Rome, Italy
| | | | - Pasquale Pignatelli
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | |
Collapse
|
28
|
Palareti G, Legnani C, Antonucci E, Cosmi B, Falanga A, Poli D, Mastroiacovo D, Pengo V, Ageno W, Testa S. Do women with venous thromboembolism bleed more than men during anticoagulation? Data from the real-life, prospective START-Register. Ther Adv Drug Saf 2022; 12:20420986211062965. [PMID: 34987749 PMCID: PMC8689616 DOI: 10.1177/20420986211062965] [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: 05/09/2021] [Accepted: 11/06/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Venous thromboembolism (VTE) is a frequent and serious disease that requires immediate and long-term anticoagulant treatment, which is inevitably associated with a risk of bleeding complications. Some studies, though not all, reported a higher risk of bleeding in female patients treated with either old anticoagulants [vitamin k antagonists (VKAs)] or recent anticoagulants [direct oral anticoagulants (DOACs)]. Furthermore, analyses of clinical trials reported an abnormal vaginal bleeding in women of reproductive age treated with DOACs. This study aimed at comparing the risk of bleeding in an inception cohort of VTE women and men included in a prospective observational registry. Methods: Baseline characteristics and bleeding events occurring during anticoagulation in patients of both sexes, included in the START-Register after a first VTE, were analyzed. Results: In all, 1298 women were compared with 1290 men. Women were older and more often had renal diseases; their index events were often provoked (often by hormonal contraception and pregnancy), and more frequently presented as isolated pulmonary embolism (PE). The rate of bleeding was similar in women (2.9% patient-years) and men (2.1% patient-years), though it was higher when uterine bleeds were included (3.5% patient-years, p = 0.0141). More bleeds occurred in VKA- than DOAC-treated patients (6.4% versus 2.6%, respectively; p = 0.0013). At multivariate analysis, age ⩾ 75 years was associated with higher prevalence of bleeds. Conclusion: The occurrence of bleeding was not different between women and men during anticoagulation after VTE. Only after inclusion of vaginal/uterine bleeds, the rate of bleeding was higher in women. The incidence of bleeding was higher in women treated with VKAs. Plain Language Summary
Collapse
Affiliation(s)
- Gualtiero Palareti
- 'Arianna Anticoagulazione' Foundation, Via Paolo Fabbri, 1/3, 40138 Bologna, Italy
| | | | | | - Benilde Cosmi
- Unit of Angiology & Blood Coagulation, Department of Specialty, Diagnostics & Experimental Medicine, University Hospital, IRCCS, Bologna, Italy
| | - Anna Falanga
- Dipartimento di Medicina e Chirurgia, Università Milano Bicocca, Milan, Italy; UOC Immunoematologia e Medicina Trasfusionale ASST, Bergamo, Italy
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | | | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padua, Padua, Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| |
Collapse
|
29
|
Palareti G, Bignamini A, Cini M, Li YJ, Urbanek T, Madaric J, Bouslama K, Sokurenko GY, Andreozzi GM, Matuška J, Mansilha A, Barinov V. Unprovoked or provoked venous thromboembolism: not the prevalent criterion to decide on anticoagulation extension in clinical practice of various countries-the prospective, international, observational WHITE study. Intern Emerg Med 2022; 17:71-82. [PMID: 34313959 PMCID: PMC8313672 DOI: 10.1007/s11739-021-02765-1] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Abstract
The decision on treatment after a first venous thromboembolism (VTE) to prevent recurrences may be influenced by many factors. The prospective, observational, WHITE study aimed to analyze how this issue was tackled in every-day clinical practice in various countries, which have sensibly different socio-economic conditions and healthcare systems. Doctors active in 79 Internal or Vascular clinical centers in 7 countries (China, Czechia, Poland, Portugal, Russia, Slovakia, and Tunisia) enrolled VTE patients after the maintenance treatment phase. The present report analyzed information, collected in the central database, regarding the baseline characteristics, index events, type and duration of anticoagulant therapy and decision on post-maintenance treatment. From April 2018 to December 2020, 1240 patients were enrolled, 58% with an unprovoked index event. Direct oral anticoagulants (DOACs) were used in > 85% of all cases in China, Poland, Portugal, Russia and Czechia, in 52% in Slovakia and in no patient in Tunisia. The maintenance anticoagulation lasted in average approximately 6 months. Altogether, anticoagulation was stopped in 20%, extended in about 50%, regardless of whether the event was unprovoked or provoked and shifted to antithrombotics (mainly sulodexide or aspirin) in the remaining patients. In conclusion, some differences in VTE patient management were found between countries. The provoked/unprovoked nature of the index event, instead, was not the prevalent criterion to drive the decision on extension of anticoagulation, without large variations between countries. DOACs were the most widely used anticoagulant drugs, whereas > 25% of patients received antithrombotic drugs instead of anticoagulants as extended treatment.
Collapse
Affiliation(s)
- Gualtiero Palareti
- Arianna Anticoagulazione Foundation, Via Paolo Fabbri 1/3, 401138, Bologna, Italy.
| | - Angelo Bignamini
- School of Specialization in Hospital Pharmacy, University of Milan, Milan, Italy
| | - Michela Cini
- Arianna Anticoagulazione Foundation, Via Paolo Fabbri 1/3, 401138, Bologna, Italy
| | - Young-Jun Li
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | | | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | | | | | | | | | | | - Victor Barinov
- Central State Medical Academy of the Office of the President of the Russian Federation, Clinical hospital N. 1 "Volynskaya", Moscow, Russia
| |
Collapse
|
30
|
Cesaro A, Gragnano F, Calabrò P, Moscarella E, Santelli F, Fimiani F, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Pelliccia F, Bossone E, Pengo V, Gresele P, Marcucci R. Prevalence and clinical implications of eligibility criteria for prolonged dual antithrombotic therapy in patients with PEGASUS and COMPASS phenotypes: Insights from the START-ANTIPLATELET registry. Int J Cardiol 2021; 345:7-13. [PMID: 34695525 DOI: 10.1016/j.ijcard.2021.10.138] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [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: 07/23/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022]
Abstract
AIM To analyze the prevalence and clinical implications of the eligibility criteria for prolonged dual antithrombotic therapy with ticagrelor 60 mg twice daily and/or rivaroxaban 2.5 mg twice daily in a contemporary real-world ACS registry. METHODS Patients from the START-ANTIPLATELET registry (NCT02219984) were stratified according to the eligibility criteria of the PEGASUS and COMPASS studies to investigate the proportion of patients eligible for prolonged dual antithrombotic therapy at discharge and after 1-year of DAPT. Net adverse clinical events (NACE), defined as all-cause death, myocardial infarction, stroke, and major bleeding, at 1 year were also evaluated and compared among groups. RESULTS 1844 were considered for the analysis at baseline. Out of 849 event-free patients continually receiving dual antiplatelet therapy for at least 1 year, 577 (68%) and 583 (68.7%) met at least one eligibility criterion for ticagrelor and rivaroxaban, respectively. In the PEGASUS-like patients, age was the most common criterion (71% of cases). The presence ≥2 cardiovascular risk factors was the most common eligibility criterion in the COMPASS-like patients (80.8%). At 1-year follow-up, 211 (11.4%) and 119 (6.5%) patients experienced NACE and MACE, respectively. The incidence of NACEs was higher in the PEGASUS-only group (15.4% vs. 8.4%; p = 0.008) and numerically higher in the COMPASS-only group (10.9% vs. 8.4%; p = 0.299). CONCLUSIONS In a contemporary real-world ACS cohort, approximately two-thirds of patients that complete 1-year DAPT met the eligibility criteria for ticagrelor 60 mg twice daily or rivaroxaban 2.5 mg twice daily, showing a higher risk of NACEs.
Collapse
Affiliation(s)
- Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy.
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Francesco Santelli
- Department of Political Science, "Federico II" University, Naples, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Diseases, A.O.R.N. Dei Colli "V. Monaldi", Naples, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, School of Medicine, "Federico II" University, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University Sapienza of Rome, Rome, Italy
| | | | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic diseases, University of Florence, Florence, Italy
| | | |
Collapse
|
31
|
Cesaro A, Gragnano F, Calabrò P, Moscarella E, Santelli F, Fimiani F, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Pelliccia F, Bossone E, Pengo V, Gresele P, Marcucci R. 760 Prevalence of eligibility criteria for prolonged dual antithrombotic therapy in patients with PEGASUS and COMPASS phenotypes: insights from the start-antiplatelet registry. Eur Heart J Suppl 2021. [DOI: 10.1093/eurheartj/suab140.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
After 1 year of dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS), clinicians face the dilemma of choosing between prolonged DAPT with aspirin and ticagrelor 60 mg twice daily (PEGASUS strategy) or aspirin and rivaroxaban 2.5 mg twice daily (COMPASS strategy). In recent years, there has been a widespread discussion about the optimal duration of DAPT and the best combination of drugs. To analyse the prevalence and clinical implications of the eligibility criteria for prolonged dual antithrombotic therapy with ticagrelor 60 mg twice daily and/or rivaroxaban 2.5 mg twice daily in a contemporary real-world ACS registry.
Methods and results
Patients from the START-ANTIPLATELET registry (NCT02219984) were stratified according to the eligibility criteria of the PEGASUS and COMPASS studies to investigate the proportion of patients eligible for prolonged dual antithrombotic therapy at discharge and after 1-year of DAPT. Net adverse clinical events (NACE), defined as all-cause death, myocardial infarction, stroke, and major bleeding, at 1 year were also evaluated and compared among groups. 1844 were considered for the analysis at baseline. Out of 849 event-free patients continually receiving dual antiplatelet therapy for at least 1 year, 577 (68%) and 583 (68.7%) met at least one eligibility criterion for ticagrelor and rivaroxaban, respectively. In the PEGASUS-like patients, age was the most common criterion (71% of cases). The presence ≥2 cardiovascular risk factors was the most common eligibility criterion in the COMPASS-like patients (80.8%). At 1-year follow-up, 211 (11.4%) and 119 (6.5%) patients experienced NACE and MACE, respectively. The incidence of NACEs was higher in the PEGASUS-only group (15.4% vs. 8.4%; P = 0.008) and numerically higher in the COMPASS-only group (10.9% vs. 8.4%; P = 0.299).
Conclusions
In a contemporary real-world ACS cohort, approximately two-thirds of patients that complete 1-year DAPT met the eligibility criteria for ticagrelor 60 mg twice daily or rivaroxaban 2.5 mg twice daily, showing a higher risk of NACEs.
Collapse
Affiliation(s)
- Arturo Cesaro
- Naples—Division of Cardiology, Department of Translational Medical Sciences, AORN S. Anna E S. Sebastiano, University of Campania ‘L. Vanvitelli’, Caserta, Italy
| | - Felice Gragnano
- Naples—Division of Cardiology, Department of Translational Medical Sciences, AORN S. Anna E S. Sebastiano, University of Campania ‘L. Vanvitelli’, Caserta, Italy
| | - Paolo Calabrò
- Naples—Division of Cardiology, Department of Translational Medical Sciences, AORN S. Anna E S. Sebastiano, University of Campania ‘L. Vanvitelli’, Caserta, Italy
| | - Elisabetta Moscarella
- Naples—Division of Cardiology, Department of Translational Medical Sciences, AORN S. Anna E S. Sebastiano, University of Campania ‘L. Vanvitelli’, Caserta, Italy
| | - Francesco Santelli
- Department of Political Science, ‘Federico II’ University, Naples, Italy
| | - Fabio Fimiani
- Unit of Inherited and Rare Cardiovascular Disease, AORN dei Colli ‘V. Monaldi’, Naples, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, School of Medicine, ‘Federico II’ University, Naples, Italy
| | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University Sapienza of Rome, Rome, Italy
| | | | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic Diseases, University of Florence, Florence, Italy
| |
Collapse
|
32
|
Palareti G, Bignamini AA, Cini M, Li YJ, Urbanek T, Madaric J, Bouslama K, Sokurenko GY, Andreozzi GM, Matuška J, Mansilha A, Barinov V. Anticoagulation Duration After First Venous Thromboembolism: Real-Life Data From the International, Observational WHITE Study. Clin Appl Thromb Hemost 2021; 27:10760296211049402. [PMID: 34841907 PMCID: PMC8674483 DOI: 10.1177/10760296211049402] [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] [Indexed: 11/30/2022] Open
Abstract
Background International guidelines recommend at least three months anticoagulation in
all patients after acute venous thromboembolism (VTE) and suggest those with
unprovoked events be considered for indefinite anticoagulation if the risk
of recurrence is high and the risk of bleeding during treatment non-high.
Other authors have recently argued against using a dichotomy
unprovoked/provoked events to decide on anticoagulation duration and suggest
instead using overall risk factors present in each patient as the basis for
deciding. Aim This sub-analysis of the WHITE study aimed at assessing the reasons for the
treatment decisions taken by doctors in different countries. Results 1240 patients were recruited in 7 countries (China, Czechia, Poland,
Portugal, Russia, Slovakia, and Tunisia). Anticoagulation was extended in
51.7% and 49.3% of patients with unprovoked or provoked events (n.s.);
stopped in 15.4% versus 28.9% (P < .0001), and changed
to antithrombotic drugs (sulodexide or aspirin) in 32.9% versus 21.8%
(P < .0001). In the 430 subjects with isolated
distal deep vein thrombosis (IDDVT) anticoagulation was stopped in 34.4%,
continued in 37.0% (mainly those with post-thrombotic syndrome [PTS]) and
switched to antithrombotics in the balance. High risk of recurrence was the
most prevalent reason (>83% of cases) given to continue anticoagulation,
regardless of nature and site of the index events, followed by risk of
bleeding and presence of PTS signs. Conclusion On average, attending physicians estimated the risk of recurrence in real
life conditions, and the consequent therapeutic decision, using all the
information available, not limiting to the location or nature of the index
event.
Collapse
Affiliation(s)
| | - Angelo A Bignamini
- School of Specialization in Hospital Pharmacy, 9304University of Milan, Milan, Italy
| | - Michela Cini
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - Young-Jun Li
- Peking Union Medical College, 12501Chinese Academy of Medical Sciences, Beijing, China
| | | | - Juraj Madaric
- Clinic of Angiology, Comenius University and National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Kamel Bouslama
- Faculty of Medicine of Tunis, 59074University of Tunis El Manar, Tunis, Tunisia
| | | | | | | | | | | |
Collapse
|
33
|
Khan F, Rahman A, Tritschler T, Carrier M, Kearon C, Weitz JI, Schulman S, Couturaud F, Becattini C, Agnelli G, Brighton T, Lensing AW, Pinede L, Parpia S, Geersing GJ, Takada T, Bradbury C, Andreozzi GM, Palareti G, Prandoni P, Buller HR, Mallick R, Hutton B, Thavorn K, Le Gal G, Rodger M, Fergusson DA. Long-term risk of major bleeding after discontinuing anticoagulation for unprovoked venous thromboembolism: a systematic review and meta-analysis. Thromb Haemost 2021; 122:1186-1197. [PMID: 34753191 DOI: 10.1055/a-1690-8728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The long-term risk of major bleeding after discontinuing anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. OBJECTIVES To determine the incidence of major bleeding up to 5 years after discontinuing anticoagulation for a first unprovoked VTE. METHODS We searched MEDLINE, EMBASE, and Cochrane CENTRAL (from inception to January 2021) to identify relevant randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding after discontinuing anticoagulation in patients with a first unprovoked VTE who had completed ≥3 months of initial treatment. Unpublished data on major bleeding events and person-years were obtained from authors of included studies to calculate study-level incidence rates. Random-effects meta-analysis was used to pool results across studies. RESULTS Of 1123 records identified by the search, 20 studies (17 RCTs) and 8740 patients were included in the analysis. During 13 011 person-years of follow-up after discontinuing anticoagulation, the pooled incidence of major bleeding (n=41) and fatal bleeding (n=7) per 100 person-years was 0.35 (95% confidence interval [CI], 0.20-0.54) and 0.09 (95% CI, 0.05-0.15). The 5-year cumulative incidence of major bleeding was of 1.0% (95% CI, 0.4%-2.4%). The case-fatality rate of major bleeding after discontinuing anticoagulation was 19.9% (95% CI, 10.6%-31.1%). CONCLUSIONS Patients with a first unprovoked VTE have a non-trivial risk of major bleeding once anticoagulants are discontinued. Estimates from this study can help clinicians counsel patients about the incremental risk of major bleeding with extended anticoagulation to guide decision making about treatment duration for unprovoked VTE.
Collapse
Affiliation(s)
- Faizan Khan
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Tobias Tritschler
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Canada.,The Thrombosis and Atherosclerosis Research Institute, Hamilton, Canada
| | | | - Francis Couturaud
- Department of internal medicine and chest diseases, Brest University Hospital Centre, Brest, France
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine,Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Timothy Brighton
- Prince of Wales Hospital and Community Health Services, Randwick, Australia
| | | | - Laurent Pinede
- Infirmerie Protestante de Lyon, Caluire et Cuire, France
| | | | | | | | - Charlotte Bradbury
- University of Bristol, Bristol, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | - H R Buller
- Amsterdam UMC Locatie AMC, Amsterdam, Netherlands
| | | | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Kednapa Thavorn
- ICES @uOttawa, University of Ottawa Faculty of Medicine, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
| | - Marc Rodger
- Medicine, McGill University, Montreal, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
34
|
Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Shi M, Thavorn K, Hutton B, Le Gal G, Rodger M, Fergusson D. Long-term risk of recurrent venous thromboembolism among patients receiving extended oral anticoagulant therapy for first unprovoked venous thromboembolism: A systematic review and meta-analysis. J Thromb Haemost 2021; 19:2801-2813. [PMID: 34379859 DOI: 10.1111/jth.15491] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The long-term risk for recurrent venous thromboembolism (VTE) during extended anticoagulation for a first unprovoked VTE is uncertain. OBJECTIVES To determine the incidence of recurrent VTE during extended anticoagulation of up to 5 years in patients with a first unprovoked VTE. METHODS MEDLINE, EMBASE, and the Cochrane CENTRAL were searched to identify randomized trials and prospective cohort studies reporting recurrent VTE among patients with a first unprovoked VTE who were to receive anticoagulation for a minimum of six additional months after completing ≥3 months of initial treatment. Unpublished data on number of recurrent VTE and person-years, obtained from authors of included studies, were used to calculate study-level incidence rate, and random-effects meta-analysis was used to pool results. RESULTS Twenty-six studies and 15 603 patients were included in the analysis. During 11 631 person-years of follow-up, the incidence of recurrent VTE and fatal pulmonary embolism per 100 person-years was 1.41 (95% CI, 1.03-1.84) and 0.09 (0.04-0.16), with 5-year cumulative incidences of 7.1% (3.0%-13.2%) and 1.2% (0.4%-4.6%), respectively. The incidence of recurrent VTE was 1.08 (95% CI, 0.77-1.44) with direct oral anticoagulants and 1.55 (1.01-2.20) with vitamin K antagonists. The case-fatality rate of recurrent VTE was 4.9% (95% CI, 2.2%-8.7%). CONCLUSIONS In patients with a first unprovoked VTE, the long-term risk of recurrent VTE during extended anticoagulation is low but not negligible. Thus, clinicians and patients should be aware of this risk and take appropriate and timely action in case of suspicion of recurrent VTE. Estimates from this study can be used to advise patients on what to expect while receiving extended anticoagulation, and estimate the net clinical benefit of extended treatment to guide long-term management of unprovoked VTE.
Collapse
Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Miriam Kimpton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Philip S Wells
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Harry R Büller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, OK, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Francis Couturaud
- Department of Internal Medicine and Chest Diseases, Brest University Hospital, Brest, France
| | | | | | | | - Paul A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sabine Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Lisbeth Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Benilde Cosmi
- Department of Specialty, Diagnostic and Experimental Medicine, Division of Angiology and Blood Coagulation, S. Orsola Malpighi University Hospital, Bologna, Italy
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Letizia Marconi
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Antonio Palla
- Department of Surgical, Medical and Molecular Pathology, and Critical Care, University of Pisa, Pisa, Italy
| | - Sergio Siragusa
- Department Pro.Mi.Se., University of Palermo, Palermo, Italy
| | | | - Sameer Parpia
- Departments of Oncology, and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | | | | | - Minggao Shi
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ, USA
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregoire Le Gal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Marc Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Dean Fergusson
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| |
Collapse
|
35
|
Magon A, Arrigoni C, Graffigna G, Barello S, Moia M, Palareti G, Caruso R. The effect of health literacy on vaccine hesitancy among Italian anticoagulated population during COVID-19 pandemic: the moderating role of health engagement. Hum Vaccin Immunother 2021; 17:5007-5012. [PMID: 34643478 DOI: 10.1080/21645515.2021.1984123] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Assessing vaccine hesitancy and its determinants is pivotal to optimize vaccine acceptance in anticoagulated patients, given that this population has been described to have a higher risk of severe COVID-19-related complications. This study assessed the moderator role of patients' health engagement on the relationship between health literacy and vaccine hesitancy. A web-based survey was performed in Italy during the first wave (June-August 2020) and the second wave (October 2020-March 2021) of the COVID-19 pandemic, enrolling 288 patients. The rates of vaccine hesitancy reported during the first pandemic wave were 38.4% and 30.8% during the second wave (when a vaccine was available) (p = .164). A moderation analysis was performed to assess the role of health engagement in influencing the relationship from health literacy to vaccine hesitancy. Patients' health engagement enhanced the effects of health literacy on decreasing vaccine hesitancy (p < .001), suggesting that co-construction strategies for communicative action are pivotal.
Collapse
Affiliation(s)
- Arianna Magon
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Cristina Arrigoni
- Department of Public Health, Experimental and Forensic Medicine, Section of Hygiene, University of Pavia, Pavia, Italy
| | - Guendalina Graffigna
- Department of Psychology, EngageMinds Hub - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Serena Barello
- Department of Psychology, EngageMinds Hub - Consumer, Food & Health Engagement Research Center, Università Cattolica del Sacro Cuore, Milan, Italy
| | | | | | - Rosario Caruso
- Health Professions Research and Development Unit, IRCCS Policlinico San Donato, Milano, Italy
| |
Collapse
|
36
|
Khan F, Tritschler T, Kimpton M, Wells PS, Kearon C, Weitz JI, Büller HR, Raskob GE, Ageno W, Couturaud F, Prandoni P, Palareti G, Legnani C, Kyrle PA, Eichinger S, Eischer L, Becattini C, Agnelli G, Vedovati MC, Geersing GJ, Takada T, Cosmi B, Aujesky D, Marconi L, Palla A, Siragusa S, Bradbury CA, Parpia S, Mallick R, Lensing AWA, Gebel M, Grosso MA, Thavorn K, Hutton B, Le Gal G, Fergusson DA, Rodger MA. Long-Term Risk for Major Bleeding During Extended Oral Anticoagulant Therapy for First Unprovoked Venous Thromboembolism : A Systematic Review and Meta-analysis. Ann Intern Med 2021; 174:1420-1429. [PMID: 34516270 DOI: 10.7326/m21-1094] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The long-term risk for major bleeding in patients receiving extended (beyond the initial 3 to 6 months) anticoagulant therapy for a first unprovoked venous thromboembolism (VTE) is uncertain. PURPOSE To determine the incidence of major bleeding during extended anticoagulation of up to 5 years among patients with a first unprovoked VTE, overall, and in clinically important subgroups. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to 23 July 2021. STUDY SELECTION Randomized controlled trials (RCTs) and prospective cohort studies reporting major bleeding among patients with a first unprovoked VTE who were to receive oral anticoagulation for a minimum of 6 additional months after completing at least 3 months of initial anticoagulant treatment. DATA EXTRACTION Two reviewers independently abstracted data and assessed study quality. Unpublished data required for analyses were obtained from authors of included studies. DATA SYNTHESIS Among the 14 RCTs and 13 cohort studies included in the analysis, 9982 patients received a vitamin K antagonist (VKA) and 7220 received a direct oral anticoagulant (DOAC). The incidence of major bleeding per 100 person-years was 1.74 events (95% CI, 1.34 to 2.20 events) with VKAs and 1.12 events (CI, 0.72 to 1.62 events) with DOACs. The 5-year cumulative incidence of major bleeding with VKAs was 6.3% (CI, 3.6% to 10.0%). Among patients receiving either a VKA or a DOAC, the incidence of major bleeding was statistically significantly higher among those who were older than 65 years or had creatinine clearance less than 50 mL/min, a history of bleeding, concomitant use of antiplatelet therapy, or a hemoglobin level less than 100 g/L. The case-fatality rate of major bleeding was 8.3% (CI, 5.1% to 12.2%) with VKAs and 9.7% (CI, 3.2% to 19.2%) with DOACs. LIMITATION Data were insufficient to estimate incidence of major bleeding beyond 1 year of extended anticoagulation with DOACs. CONCLUSION In patients with a first unprovoked VTE, the long-term risks and consequences of anticoagulant-related major bleeding are considerable. This information will help inform patient prognosis and guide decision making about treatment duration for unprovoked VTE. PRIMARY FUNDING SOURCE Canadian Institutes of Health Research. (PROSPERO: CRD42019128597).
Collapse
Affiliation(s)
- Faizan Khan
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Tobias Tritschler
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | - Miriam Kimpton
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Philip S Wells
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Clive Kearon
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (C.K., J.I.W.)
| | - Harry R Büller
- Amsterdam University Medical Center, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands (H.R.B.)
| | - Gary E Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma (G.E.R.)
| | | | | | - Paolo Prandoni
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Gualtiero Palareti
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Cristina Legnani
- Arianna Foundation on Anticoagulation, Bologna, Italy (P.P., G.P., C.L.)
| | - Paul A Kyrle
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Sabine Eichinger
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | - Lisbeth Eischer
- Medical University of Vienna, Vienna, Austria (P.A.K., S.E., L.E.)
| | | | | | | | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Toshihiko Takada
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (G.G., T.T.)
| | - Benilde Cosmi
- Sant'Orsola-Malpighi University Hospital, Bologna, Italy (B.C.)
| | - Drahomir Aujesky
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (T.T., D.A.)
| | | | | | | | | | - Sameer Parpia
- McMaster University, Hamilton, Ontario, Canada (S.P.)
| | - Ranjeeta Mallick
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (R.M.)
| | | | | | | | - Kednapa Thavorn
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Brian Hutton
- University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (F.K., K.T., B.H.)
| | - Gregoire Le Gal
- Ottawa Hospital Research Institute, University of Ottawa, and The Ottawa Hospital, Ottawa, Ontario, Canada (M.K., P.S.W., G.L.)
| | - Dean A Fergusson
- University of Ottawa, Ottawa Hospital Research Institute, and The Ottawa Hospital, Ottawa, Ontario, Canada (D.A.F.)
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, Ontario, and McGill University, Montreal, Quebec, Canada (M.A.R.)
| | | |
Collapse
|
37
|
Prandoni P, Lensing AW, Prins MH, Villalta S, Pesavento R, Tormene D, Noventa F, Palareti G. Elastic compression stockings for prevention of the post-thrombotic syndrome in patients with and without residual vein thrombosis and/or popliteal valve reflux. Haematologica 2021; 107:303-306. [PMID: 34498448 PMCID: PMC8719094 DOI: 10.3324/haematol.2021.279680] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Indexed: 11/09/2022] Open
Abstract
Not available.
Collapse
Affiliation(s)
| | | | - Martin H Prins
- Department of Clinical Epidemiology and Technology Assessment, University of Maastricht, Maastricht
| | - Sabina Villalta
- Division of Internal Medicine, Civic Hospital of Castelfranco Veneto
| | | | | | | | | |
Collapse
|
38
|
Cavallari I, Maddaloni E, Gragnano F, Patti G, Antonucci E, Calabrò P, Cirillo P, Gresele P, Palareti G, Pengo V, Pignatelli P, Marcucci R. Ischemic and bleeding risk by type 2 diabetes clusters in patients with acute coronary syndrome. Intern Emerg Med 2021; 16:1583-1591. [PMID: 33616877 DOI: 10.1007/s11739-021-02640-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/11/2021] [Indexed: 12/12/2022]
Abstract
The risk of ischemic events carried by different clusters of type 2 diabetes mellitus (DM) in the setting of secondary prevention is not definite and the association between DM and bleeding complications is controversial. We explored these issues in the START-ANTIPLATELET, a multicenter Italian registry including acute coronary syndrome (ACS) patients. Study outcome was 1-year incidence of the net composite endpoint including major adverse cardiovascular events (MACE) or any bleeding and its individual components across different DM strata (no DM, DM with or without insulin). Out of 951 patients, 20.0% had diabetes not on insulin and 2.5% had diabetes on insulin. The rate of the net composite endpoint was highest in patients receiving insulin (39.4 per 100 person-years vs 11.7 in diabetic patients not on insulin vs 14.0 in those without DM; p = 0.007). In DM, the higher risk of MACE was regardless of insulin use (p = 0.36). Conversely, the increase in bleeding complications was limited to patients on insulin (Hazard Ratio 2.31, 95% CI 0.93-5.71 vs no DM; p = 0.0105 across DM strata). On top of aspirin, the rates of the net composite endpoint were similar with ticagrelor/prasugrel or clopidogrel irrespective of DM status (p for interaction 0.63). In conclusion, in ACS patients, type 2 DM enhances the risk of MACE regardless of the DM cluster, whereas the propensity to bleeding related to DM seems confined to insulin-treated patients.
Collapse
Affiliation(s)
- Ilaria Cavallari
- Department of Medicine, Unit of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Ernesto Maddaloni
- Experimental Medicine Department, Sapienza University of Rome, Rome, Italy
| | - Felice Gragnano
- Division of Cardiology, Department of Translational Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Giuseppe Patti
- Chair of Cardiology, Department of Translational Medicine, University of Eastern Piedmont, Maggiore Della Carità Hospital, Via Solaroli, 17, 28100, Novara, Italy.
| | | | - Paolo Calabrò
- Division of Cardiology, Department of Translational Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Plinio Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Vittorio Pengo
- Department of Cardo-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic Diseases, University of Florence, Florence, Italy
| |
Collapse
|
39
|
Antonucci E, Migliaccio L, Abbattista M, Caronna A, De Marchi S, Di Giorgio A, Di Giulio R, Lerede T, Garzia MG, Martinelli I, Mastroiacovo D, Marzolo M, Montevecchi E, Pastori D, Pignatelli P, Poli D, Ria L, Santoliquido A, Testa S, Palareti G. Treatment Decision-Making of Secondary Prevention After Venous Thromboembolism: Data From the Real-Life START2-POST-VTE Register. Clin Appl Thromb Hemost 2021; 26:1076029620945792. [PMID: 33063530 PMCID: PMC7573715 DOI: 10.1177/1076029620945792] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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] [Indexed: 01/15/2023] Open
Abstract
Patients with venous thromboembolism (VTE) should receive a decision on the duration of anticoagulant treatment (AT) that is often not easy to make. Sixteen Italian clinical centers included patients with recent VTE in the START2-POST-VTE register and reported the decisions taken on duration of AT in each patient and the reasons for them. At the moment of this report, 472 (66.9%) of the 705 patients included in the registry were told to stop AT in 59.3% and to extend it in 40.7% of patients. Anticoagulant treatment lasted ≥3 months in >90% of patients and was extended in patients with proximal deep vein thrombosis because considered at high risk of recurrence or had thrombophilic abnormalities. d-dimer testing, assessment of residual thrombus, and patient preference were also indicated among the criteria influencing the decision. In conclusion, Italian doctors stuck to the minimum 3 months AT after VTE, while the secondary or unprovoked nature of the event was not seen as the prevalent factor influencing AT duration which instead was the result of a complex and multifactorial evaluation of each patient.
Collapse
Affiliation(s)
| | | | - Maria Abbattista
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | | | - Sergio De Marchi
- UOC di Angiologia, Azienda Ospedaliero Universitaria Integrata Verona, Italy
| | - Angela Di Giorgio
- UOS Angiologia Columbus, Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | | | - Teresa Lerede
- USC SIMT, Centro Emostasi e Trombosi, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Maria Grazia Garzia
- UOC Ematologia-Trapianto cellule staminali, Azienda Ospedaliera S.Camillo-Forlanini, Roma, Italy
| | - Ida Martinelli
- Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, A. Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
| | - Daniela Mastroiacovo
- UOSD Angiologia e Diagnostica Vascolare, Ospedale SS Filippo e Nicola, Avezzano (L'Aquila), Italy
| | | | - Elisa Montevecchi
- UOC Angiologia dell'Ospedale San Giovanni Apostolo, Castelfranco Veneto, Treviso, Italy
| | - Daniele Pastori
- Centro Trombosi, Clinica Medica Policlinico Umberto I, Università la Sapienza Roma, Italy
| | - Pasquale Pignatelli
- Centro Trombosi, Clinica Medica Policlinico Umberto I, Università la Sapienza Roma, Italy
| | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze
| | - Luigi Ria
- UO Medicina Interna, Presidio Ospedaliero di Gallipoli (Lecce), Italy
| | - Angelo Santoliquido
- UOS Angiologia Columbus, Policlinico Universitario Agostino Gemelli, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Sophie Testa
- UO Laboratorio Analisi, Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| | | | | |
Collapse
|
40
|
Pastori D, Poli D, Antonucci E, Menichelli D, Violi F, Palareti G, Pignatelli P. Sex-based difference in anticoagulated patients with mechanical prosthetic heart valves and long-term mortality risk. Int J Clin Pract 2021; 75:e14064. [PMID: 33533555 DOI: 10.1111/ijcp.14064] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 01/17/2021] [Accepted: 01/29/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs) reduce thromboembolism in patients with mechanical prosthetic heart valves (MPHV). It is unclear whether a sex-based difference in MPHV patients regarding valve site, anticoagulation quality, and mortality risk does exist. METHODS We analysed 2111 MPHV patients from the nationwide PLECTRUM study promoted by the Italian Federation of Anticoagulation Clinics (FCSA). We analysed the site of MPHV, anticoagulation quality, as assessed by the time in therapeutic range (TiTR), and mortality risk in women and men. RESULTS The mean age of the patients was 56.8 ± 12.3 years. Women were older with a lower prevalence of ischemic heart disease and smoking habit and a higher prevalence of atrial fibrillation at baseline. Aortic MPHV was more frequent in men (74.7% vs 43.3%, P < .001), whereas mitral (41.1% vs 17.6%, P < .001) and mitro-aortic (15.6% vs 7.7%, P < .001) MPVH in women. The association between female sex and mitral/mitro-aortic site remained at multivariable logistic regression analysis (Odds Ratio 3.623, 95% Confidence Interval [CI] 2.947-4.455, P < .001). Regarding anticoagulation quality, women showed lower mean TiTR (63.0 ± 19.4 vs 57.5 ± 19.2, P < .001), and a higher proportion of TiTR < 60% (54.9% vs 43.3%, P < .001). During a mean follow-up of 123 months (21 665 pt-years), 152 deaths occurred (0.7%/year); 83 in the aortic (0.63%/year) and 69 in the mitral/mitro-aortic (0.81%/year) group. At multivariable Cox proportional hazard regression analysis, female sex was not associated with mortality (HR 0.953, 95%CI 0.678 1.340, P = .783). CONCLUSIONS Female sex is independently associated with mitral/mitro-aortic MPHV. Despite a lower TiTR in women, mortality risk did not differ between the two groups.
Collapse
Affiliation(s)
- Daniele Pastori
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Daniela Poli
- Thrombosis Centre, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | | | - Danilo Menichelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Violi
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Pasquale Pignatelli
- I Clinica Medica, Atherothrombosis Centre, Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
41
|
Gragnano F, Moscarella E, Calabrò P, Cesaro A, Pafundi PC, Ielasi A, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Pelliccia F, Gaudio C, Sasso FC, Pengo V, Gresele P, Marcucci R. Clopidogrel versus ticagrelor in high-bleeding risk patients presenting with acute coronary syndromes: insights from the multicenter START-ANTIPLATELET registry. Intern Emerg Med 2021; 16:379-387. [PMID: 32557093 DOI: 10.1007/s11739-020-02404-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 06/06/2020] [Indexed: 11/25/2022]
Abstract
Optimal dual antiplatelet therapy (DAPT) strategy in high-bleeding risk (HBR) patients presenting with acute coronary syndrome remains debated. We sought to investigate the use of clopidogrel versus ticagrelor in HBR patients with acute coronary syndrome and their impact on ischemic and bleeding events at 1 year. In the START-ANTIPLATELET registry (NCT02219984), consecutive patients with ≥ 1 HBR criteria were stratified by DAPT type in clopidogrel versus ticagrelor groups. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. Of 1209 patients with 1-year follow-up, 553 were defined at HBR, of whom 383 were considered eligible for the study as on DAPT with clopidogrel (174 or 45.4%) or ticagrelor (209 or 54.6%). Clopidogrel was more often administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group. At 1 year, after multivariate adjustment, no difference in NACEs was observed between patients on clopidogrel versus ticagrelor (19% vs. 11%, adjusted hazard ratio 1.27 [95% CI 0.71-2.27], p = 0.429). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs. In a real-world registry of patients with acute coronary syndrome, 45% were at HBR and frequently treated with clopidogrel. After adjustment for potential confounders, the duration of DAPT, but not DAPT type (stratified by clopidogrel vs. ticagrelor), was associated with the risk of ischemic and bleeding events at 1 year.
Collapse
Affiliation(s)
- Felice Gragnano
- Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100, Caserta, Italy
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Elisabetta Moscarella
- Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100, Caserta, Italy
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Paolo Calabrò
- Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100, Caserta, Italy.
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy.
| | - Arturo Cesaro
- Division of Clinical Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano", 81100, Caserta, Italy
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131, Naples, Italy
| | - Pia Clara Pafundi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Alfonso Ielasi
- Clinical and Interventional Cardiology Unit, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Giuseppe Patti
- Department of Translational Medicine, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Ilaria Cavallari
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | | | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, School of Medicine, "Federico II" University, Naples, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, I Clinica Medica, Atherothrombosis Centre, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University Sapienza of Rome, Rome, Italy
| | - Carlo Gaudio
- Department of Cardiovascular Sciences, University Sapienza of Rome, Rome, Italy
| | - Ferdinando Carlo Sasso
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Paolo Gresele
- Division of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Perugia, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic Diseases, University of Florence, Florence, Italy
| |
Collapse
|
42
|
Palareti G, Legnani C, Antonucci E, Zorzi S, Bignamini AA, Lodigiani C, Tosetto A, Bertù L, Pengo V, Testa S, Ageno W, Prisco D, Prandoni P, Poli D. Design and rationale of a randomized, placebo-controlled trial on the efficacy and safety of sulodexide for extended treatment in elderly patients after a first venous thromboembolism. Intern Emerg Med 2021; 16:359-368. [PMID: 32451933 PMCID: PMC7952285 DOI: 10.1007/s11739-020-02381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 05/16/2020] [Indexed: 11/16/2022]
Abstract
How to prevent recurrences after a first venous thromboembolic (VTE) event in elderly patients is still an open issue, especially because of the high bleeding risk of anticoagulation in these patients. The placebo-controlled "Jason" study aims at assessing the efficacy and safety for secondary VTE prevention in elderly patients of oral Sulodexide (Vessel®) administration, a mixture of glycosaminoglycans (Alfasigma, Bologna, Italy) which proved effective against recurrences in a general population (SURVET study) without major bleeding (MB) complications. 1450 patients, aged ≥ 75 years, after at least 3 months of anticoagulation treatment for a first VTE episode, are double-blind randomized to receive for 12 months either sulodexide 500 lipasemic units (LSUs) twice daily, or sulodexide 250 LSU twice daily + indistinguishable placebo, or indistinguishable placebo. Primary outcomes for efficacy are the composite of death for VTE and recurrent VTE, and occurrence of MB for safety. Secondary outcomes include stroke, cardiovascular death and other thromboembolic events, and MB + clinically relevant non-MB. The first patient is scheduled to be randomized in May 2020. The study protocol has been approved by AIFA (Agenzia Italiana del Farmaco) and the Ethics Committee of the coordinating center. Written informed consent will be obtained from all patients prior to study participation. Jason study is an investigator-initiated trial, promoted by "Arianna Anticoagulazione" Foundation, Bologna, Italy, and supported by Alfasigma, Bologna, Italy. Study findings will be disseminated to participant centers, at research conferences and in peer-reviewed journals. Trial registration numbers NCT04257487; EudraCT (2019-000570-33).
Collapse
Affiliation(s)
- Gualtiero Palareti
- Arianna Anticoagulazione" Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy.
| | - Cristina Legnani
- Arianna Anticoagulazione" Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Emilia Antonucci
- Arianna Anticoagulazione" Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Serena Zorzi
- Arianna Anticoagulazione" Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Angelo A Bignamini
- Department of Pharmaceutical Sciences, School of Specialization in Hospital Pharmacy, University of Milan, Milan, Italy
| | - Corrado Lodigiani
- Thrombosis and Hemorrhagic Diseases Unit, Humanitas Research Hospital and Humanitas University, Rozzano (Milan), Italy
| | - Alberto Tosetto
- Divisione Di Ematologia, Centro Malattie Emorragiche E Trombotiche, AULSS8 Berica, Vicenza, Italy
| | - Lorenza Bertù
- Centro Di Ricerca Sulle Malattie Tromboemboliche E Le Terapie Antitrombotiche, Università Degli Studi dell'Insubria, Varese, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Sophie Testa
- Department of Laboratory Medicine, Haemostasis and Thrombosis Center, AO Istituti Ospitalieri, Cremona, Italy
| | - Walter Ageno
- Dipartimento Di Medicina E Chirurgia, Università Degli Studi Dell'Insubria, Varese, Italy
| | - Domenico Prisco
- DMSC Università Di Firenze, SOD Medicina Interna Interdisciplinare, AOU Careggi, Florence, Italy
| | - Paolo Prandoni
- Arianna Anticoagulazione" Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Daniela Poli
- Centro Trombosi, Azienda Ospedaliera Careggi, Florence, Italy
| |
Collapse
|
43
|
Palareti G, Antonucci E, Legnani C, Mastroiacovo D, Poli D, Prandoni P, Tosetto A, Pengo V, Testa S, Ageno W. Bleeding and thrombotic complications during treatment with direct oral anticoagulants or vitamin K antagonists in venous thromboembolic patients included in the prospective, observational START2-register. BMJ Open 2020; 10:e040449. [PMID: 33247017 PMCID: PMC7703414 DOI: 10.1136/bmjopen-2020-040449] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The proportion and characteristics of Italian patients affected by venous thromboembolism (VTE) treated with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), and complications occurring during follow-up. DESIGN A prospective cohort of 2728 VTE patients included in the Survey on anticoagulaTed pAtients RegisTer (START2-Register) from January 2014 to June 2018 was investigated. Characteristics of patients, type of treatment and complications occurring during 2962 years of follow-up were analysed. SETTING About 60 Italian anticoagulation and thrombosis centres participated in the observational START2-Register PARTICIPANTS: 2728 adult patients with VTE of a lower limb and/or pulmonary embolism (PE), with a follow-up after the initial phase treatment. INTERVENTIONS Patients could receive DOACs or VKAs; both prescribed by the National and Regional Health Systems for patients with VTE. OUTCOMES MEASURES Efficacy: rate of VTE recurrence (all thrombotic complications were also recorded). SAFETY the rate of major and clinically relevant non-major bleeding events. RESULTS Almost 80% of patients were treated with DOACs. The prevalence of symptomatic PE and impaired renal function was higher in patients receiving VKAs. Duration of anticoagulation was >180 days in approximately 70% of patients. Bleeding events were similar in both treatment groups. The overall eventuality of recurrence was significantly higher in DOAC cohorts versus VKA cohorts (HR 2.15 (1.14-4.06), p=0.018); the difference was almost completely due to recurrences occurring during extended treatment (2.73% DOAC vs 0.49% VKA, p<0.0001). All-cause mortality was higher in VKA-treated (5.9%) than in DOAC-treated patients (2.6%, p<0.001). CONCLUSION Italian centres treat most patients with VTE with DOACs and prefer VKA for those with more serious clinical conditions. Recurrences were significantly more frequent in DOAC-treated patients due to increased incidence after 180 days of treatment, probably due to reduced adherence to treatment. These results underline the importance of structured surveillance of DOAC-treated patients with VTE to strengthen treatment adherence during extended therapy.
Collapse
Affiliation(s)
| | | | | | | | - Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | - Alberto Tosetto
- Divisione di Ematologia, Ospedale San Bortolo, Vicenza, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Università di Padova, Padova, Italy
| | - Sophie Testa
- Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
| |
Collapse
|
44
|
Gresele P, Guglielmini G, Del Pinto M, Calabrò P, Pignatelli P, Patti G, Pengo V, Antonucci E, Cirillo P, Fierro T, Palareti G, Marcucci R. Peripheral arterial disease has a strong impact on cardiovascular outcome in patients with acute coronary syndromes: from the START Antiplatelet registry. Int J Cardiol 2020; 327:176-182. [PMID: 33152418 DOI: 10.1016/j.ijcard.2020.10.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/24/2020] [Accepted: 10/28/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Peripheral arterial disease (PAD) was reported to increase the risk of new cardiovascular events in patients with acute coronary syndromes (ACS). However, most of the evidence comes from randomized clinical trials. We aimed to assess the impact of PAD on cardiovascular outcome and treatment decisions in ACS patients in a current real-life setting. METHODS START-ANTIPLATELET is a multicenter registry enrolling ACS patient. Baseline clinical characteristics and treatment at discharge were recorded and follow-up was repeated at 6-months and 1-year. PAD was defined as intermittent claudication and/or previous revascularization. RESULTS Among 1442 patients enrolled, 103 (7.1%) had PAD. PAD patients were older (71.8 ± 10.6vs66.2 ± 12.6 yrs., p < 0.0001), more frequently hypertensive (90.3vs68.6%, p< 0.0001), hypercholesterolemic (66vs52%, p= 0.037), diabetic (51.5vs24%, p= 0.0001), obese (28.2vs19.3%, p= 0.029) and with previous TIA (7.8vs2.8%, p= 0.005) or stroke (11.7vs3.1%, p< 0.0001). Clinical presentation and acute treatment were similar in non-PAD and PAD patients, but the latter were discharged significantly less frequently on dual antiplatelet therapy (DAPT) (68.9vs85%, p= 0.005). After a median follow-up time of 11.1 months, major cardio/cerebrovascular event-free survival [MACCE, including cardiovascular death, MI, TIA and stroke, target-vessel revascularization (TVR) and major arterial ischemic events] was significantly shorter (9.0vs11.2 months, p= 0.02; HR 3.2, 2.4-8.4) in PAD patients and net adverse cardiovascular events (NACE = MACCE plus major hemorrhages) were significantly more frequent (19.1%vs10.5%, p = 0.049). CONCLUSIONS PAD identifies a subgroup of ACS patients at significantly increased cardiovascular risk, but these patients tend to be undertreated. Patients admitted for ACS should be screened for PAD and optimal medical therapy at discharge should be implemented.
Collapse
Affiliation(s)
- P Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy.
| | - G Guglielmini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - M Del Pinto
- Division of Cardiology, Perugia Hospital, Italy
| | - P Calabrò
- Department of Translational Medical Sciences University of Campania "Luigi Vanvitelli", Naples, Italy
| | - P Pignatelli
- Department of Clinical, Internistic, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Italy
| | - G Patti
- Department of Traslational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy
| | - V Pengo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Italy
| | - E Antonucci
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - P Cirillo
- Division of Cardiology, Department of Advanced Biomedical Sciences, "Federico II" University, Naples, Italy
| | - T Fierro
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Italy
| | - G Palareti
- Arianna Anticoagulazione Foundation, Bologna, Italy
| | - R Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | | |
Collapse
|
45
|
Cavallari I, Sagazio E, Antonucci E, Calabro' P, Gragnano F, Cirillo P, Gresele P, Palareti G, Pengo V, Pignatelli P, Marcucci R, Patti G. Ischemic and bleeding risk stratification in diabetic patients after acute coronary syndrome based on insulin requirement. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Diabetes is a known risk factor for a first or recurrent cardiovascular event, however, its association with an increased risk of bleeding is controversial. To date, no study has explored the prognostic weight of insulin therapy in the setting of ACS.
Purpose
To investigate the differential role of insulin versus no insulin therapy on ischemic and bleeding risks in patients with diabetes and ACS.
Methods
START-ANTIPLATELET is a prospective, real-world multicenter registry including consecutive patients admitted for ACS. For the purpose of this analysis, patients were stratified according to diabetes status and insulin therapy. We compared 1-year rates of major adverse cardiovascular events, a composite of cardiovascular death, myocardial infarction and stroke, and of any bleeding, according to diabetes status (no diabetes, diabetes not on insulin therapy, diabetes on insulin therapy). In addition, we evaluated the net clinical benefit of dual antiplatelet therapy with the newer P2Y12 inhibitors (ticagrelor or prasugrel) vs dual antiplatelet therapy with clopidogrel according to diabetes status.
Results
In an overall population of 907 patients, 198 had diabetes, 10.6% of whom were on insulin. From non-diabetic patients to diabetic patients not on insulin and diabetic patients on insulin there was a stepwise decrease of MACE-free survival (log-rank p 0.039) with incidence of events at 1 year being 3.8%, 6.8% (adjusted p vs no diabetes 0.49) and 12.5% (adjusted p vs no diabetes 0.047), respectively (Figure, panel A). The rates of any bleeding were higher in patients on insulin (20.8% vs 8.8% in those without diabetes and 5.8% in diabetic patients not receiving insulin; log-rank p 0.028; Figure, panel B). Multivariable analysis demonstrated an almost 5-fold increase of any bleeding in diabetic patients with vs without insulin (OR 4.98, 95% CI 1.46–16.92; p=0.010). In the overall population, the incidence of the net composite endpoint including MACE or major bleeding with the use of ticagrelor/prasugrel on top of aspirin was significantly lower compared to use of clopidogrel (4.7% vs 8.4%; OR 0.54, 95% CI 0.30–0.94, p=0.031). This net clinical benefit in patients receiving a newer P2Y12 inhibitor was regardless of the diabetes status (p for interaction 0.48).
Conclusions
In this cohort of ACS patients, the presence of diabetes stratified by insulin therapy was associated with a graded increase in the 1-year rates of MACE. Conversely, insulin therapy significantly contributed to the overall increase of bleeding risk in diabetes.
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- I Cavallari
- Campus Bio-Medico University of Rome, Cardiovascular Sciences, Rome, Italy
| | - E Sagazio
- University of Eastern Piedmont, Novara, Italy
| | - E Antonucci
- Azienda Ospedaliero, Universitaria di Bologna, Policlinico S.Orsola-Malpigh, Bologna, Italy
| | - P Calabro'
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - F Gragnano
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P Cirillo
- Parthenope University of Naples, Naples, Italy
| | - P Gresele
- University of Perugia, Perugia, Italy
| | - G Palareti
- Azienda Ospedaliero, Universitaria di Bologna, Policlinico S.Orsola-Malpigh, Bologna, Italy
| | - V Pengo
- University of Padua, Padova, Italy
| | | | | | - G Patti
- University of Eastern Piedmont, Novara, Italy
| |
Collapse
|
46
|
Pastori D, Antonucci E, Milanese A, Violi F, Pignatelli P, Palareti G, Farcomeni A. Clinical phenotypes of atrial fibrillation and risk of mortality: a cluster analysis. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.2893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Patients with atrial fibrillation (AF) experience a high mortality rate despite optimal antithrombotic treatment. Characteristics of AF patients at higher mortality risk have been barely described so far and no risk score has been specifically developed at this aim. Furthermore, a clinical approach based on risk scores present some limits such as to not consider some important risk factors for mortality, and many available scores have poor predictive value. Cluster analysis may play a role in overcoming limitations of risk scores, especially in the case of overlapping risk factors.
Purpose
To identify of clinical phenotypes by using an unbiased statistical approach, such as the cluster analysis.
Methods
Cluster analysis was used to identify clinical phenotypes of AF patients associated with all-cause mortality in 5,171 AF patients from the START registry. Clinical variables used for the analysis were age, sex, diabetes, previous cerebrovascular events, previous cardiovascular events, heart failure, peripheral artery disease, use of non-vitamin K oral anticoagulants, cancer, pulmonary disease, smoking habit, previous major bleeding. The risk of all-cause mortality in each cluster was analyzed.
Results
We identified 4 clusters (Figure 1). Cluster 1 was composed by youngest patients, with obesity and paroxysmal AF; Cluster 2 by patients with low cardiovascular risk factors and high proportion of cancer; Cluster 3 by men with diabetes and coronary and peripheral artery disease, a high proportion of thrombocytopenia, and a high use of aspirin, proton pump inhibitors, and statins; Cluster 4 included the oldest patients, mainly women, with previous cerebrovascular disease, persistent/ permanent AF, heart failure, kidney disease and anemia. In this cluster there was the highest use of digoxin and NOACs.
During 9856,84 patient/years of observation, 386 deaths (3.92%/year) occurred. Mortality rates significantly increased across clusters: 0.42%/year (cluster 1, reference group), 2.12%/year (cluster 2, adjusted hazard ratio [aHR] 3.306, 95% confidence interval [CI] 1.204–9.077, p=0.020), 4.41%/year (cluster 3, aHR 6.702, 95% CI 2.433–18.461, p<0.001) and 8.71%/year (cluster 4, aHR 8.927, 95% CI 3.238–24.605, p<0.001).
Conclusions
We identified different clinical phenotypes of AF patients by cluster analysis which were specifically associated with mortality. This approach may help identify patients at higher risk of mortality.
Figure 1
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- D Pastori
- Sapienza University of Rome, Department of Internal Medicine and Medical Specialties, Rome, Italy
| | | | - A Milanese
- Sapienza University of Rome, Department of Public Health and Infectious Diseases, Rome, Italy
| | - F Violi
- Sapienza University of Rome, Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Rome, Italy
| | - P Pignatelli
- Sapienza University of Rome, Department of Clinical Internal, Anesthesiologic, and Cardiovascular Sciences, Rome, Italy
| | | | - A Farcomeni
- University of Rome Tor Vergata, Department of Economics & Finance, Rome, Italy
| |
Collapse
|
47
|
Moscarella E, Calabro P, Gragnano F, Cesaro A, Pafundi P, Patti G, Cavallari I, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Sasso F, Pengo V, Gresele P, Marcucci R. Effect of body mass index on ischemic and bleeding events in patients presenting with acute coronary syndromes: insights from the START-ANTIPLATELET registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding events as possible explanations to the obesity paradox in ACS patients.
Methods
For the purpose of this sub-study, patients enrolled in the START-ANTIPLATELET registry were stratified according to Body Mass Index (BMI) into three groups: normal, BMI <25kg/m2; overweight, BMI: 25–29.9kg/m2; obese, BMI ≥30kg/m2. The primary endpoint was net adverse clinical endpoints (NACE), defined as a composite of all-cause death, myocardial infarction (MI), stroke, and major bleeding.
Results
Patients were classified as follows: 410 (33.9%) normal, 538 (44.5%) overweight, 261 (21.6%) obese. Compared to the normal weight group, obese and overweight patients had a higher prevalence of cardiovascular risk factors, but were younger, with a better left ventricular ejection fraction (LVEF) and lower PRECISE-DAPT score. At one-year follow-up NACE was more frequently observed in normal than in overweight and obese patients (15.1%,8.6%,and9.6%, respectively; p=0.004), driven by a significantly higher rate of all-cause death (6.3%,2.6%, and 3.8%, respectively; p=0.008), while no significant differences were noted in terms of MI, stroke, and major bleeding. When correcting for confounding variables, BMI loses its power in independently predicting outcomes, failing to confirm the obesity paradox in a real-world ACS population.
Conclusions
Our study conflicts the obesity paradox in real-world ACS population, and suggest that the reduced mortality rate may be explained by a lower bleeding risk in obese patients allowing a more aggressive medical treatment, and by a better LVEF translating into a higher survival rate.
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- E Moscarella
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P Calabro
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - F Gragnano
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - A Cesaro
- S. Anna-S. Sebastiano Hospital, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - P.C Pafundi
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - G Patti
- University of L'Aquila, L'Aquila, Italy
| | | | | | | | | | | | - F.C Sasso
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - V Pengo
- General University Hospital of Alicante, Alicante, Spain
| | - P Gresele
- University of Perugia, Perugia, Italy
| | | |
Collapse
|
48
|
Gragnano F, Moscarella E, Calabro' P, Cesaro A, Pafundi P, Patti G, Antonucci E, Cirillo P, Pignatelli P, Palareti G, Pelliccia F, Sasso F, Pengo V, Gresele P, Marcucci R. Ticagrelor versus Clopidogrel in high bleeding risk patients presenting with Acute Coronary Syndromes: insights from the multicenter START-ANTIPLATELET registry. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Optimal dual antiplatelet therapy in high bleeding risk (HBR) patients with acute coronary syndromes (ACS) remains debated. Although current guidelines recommend the use of potent P2Y12 inhibitors in these patients (according to the labeled indications), clopidogrel is frequently used in clinical practice based on a perceived advantage in terms of safety in the HBR population.
Purpose
We sought to investigate the use of clopidogrel versus ticagrelor in consecutive HBR ACS patients and their impact on ischemic and bleeding events at 1 year.
Methods
ACS patients enrolled in the START-ANTIPLATELET registry with at least 1 HBR criterion were included in the present analysis and stratified according to DAPT type (clopidogrel versus ticagrelor). The primary endpoint was net adverse clinical endpoint (NACE), defined as a composite of all-cause death, myocardial infarction, stroke, and major bleeding. The secondary endpoints were major adverse cardiac and cerebral events (MACE), defined as a composite of all-cause death, myocardial infarction and stroke, each individual component of NACE and MACE, and target vessel revascularization.
Results
Among a total of 1,209 patients with 1-year follow-up in the registry, 383 patients were considered at HBR, of whom 174 (45.4%) were on clopidogrel and 209 (54.6%) on ticagrelor. Clopidogrel was more likely to be administered in patients at increased ischemic and bleeding risk, while ticagrelor in those undergoing percutaneous coronary intervention. Mean DAPT duration was longer in the ticagrelor group than in the clopidogrel group (10.40±4.29 versus 9.35±5.4; p-value=0.03). At 1-year follow-up, the risk of NACE and MACE events was significantly higher in the clopidogrel than in the ticagrelor group (NACE: HR 1.82; 95% CI 1.07–3.09; p-value=0.02; MACE: HR 1.83; 95% CI 1.04–3.24; p-value=0.03) (Figure). After multivariate adjustment for clinical and procedural characteristics, no difference in NACEs nor MACEs was observed between patients on clopidogrel versus ticagrelor (NACE: adjusted HR 1.27; 95% CI 0.71–2.27; p-value=0.42; MACE: adjusted HR 1.19; 95% CI 0.63–2.24; p-value=0.59) (Figure). Age, number of HBR criteria, and mean DAPT duration were independent predictors of NACEs.
Conclusions
In a real-world ACS registry, approximately 50% of patients are at HBR and frequently treated with clopidogrel. In HBR ACS patients, no difference was observed in ischemic and bleeding events between clopidogrel and ticagrelor after adjustment for potential confounders.
Kaplan-Meier curves at 1-year follow-up.
Funding Acknowledgement
Type of funding source: None
Collapse
Affiliation(s)
- F Gragnano
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - E Moscarella
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - P Calabro'
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - A Cesaro
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - P.C Pafundi
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - G Patti
- University of Eastern Piedmont, Novara, Italy
| | | | - P Cirillo
- Federico II University of Naples, Naples, Italy
| | | | | | | | - F.C Sasso
- university of Campania Luigi Vanvitelli, Naples, Italy
| | - V Pengo
- University of Padova, Padua, Italy
| | - P Gresele
- University of Perugia, Perugia, Italy
| | | |
Collapse
|
49
|
Poli D, Antonucci E, Vignini E, Martinese L, Testa S, Simioni P, Pengo V, Pignatelli P, Falanga A, Masciocco L, Barcellona D, Ciampa A, Chiarugi P, Paparo C, Ageno W, Palareti G. Anticoagulation resumption after intracranial hemorrhage in patients treated with VKA and DOACs. Eur J Intern Med 2020; 80:73-77. [PMID: 32522446 DOI: 10.1016/j.ejim.2020.05.020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is associated with severe prognosis and recurrent risk. This impacts on the decision to resume anticoagulation in atrial fibrillation (AF) or venous thromboembolism (VTE) patients. Purpose of our study is to evaluate the incidence rate of recurrent ICH in patients with AF or VTE resuming anticoagulation after a first ICH episode. METHODS We report data of two cohorts of AF or VTE after a first ICH. The Vitamin K antagonist (VKA) cohort (166 patients) derives from CHIRONE Study, the direct oral anticoagulant (DOAC) cohort (178 patients) derives from START2-Register RESULTS: The clinical characteristics of the two cohort are similar with the exception of more prevalence of history of previous stroke/TIA in DOAC patients with respect to VKA (p = 0.02) and serum creatinine levels>1.5 mg/dL in VKA patients with respect to DOAC(p = 0.0001). The index ICH was spontaneous in 66.4% and in 33.7% among DOAC and VKAs cohort respectively (p = 0.0001). During follow-up, 14 recurrent ICH were recorded; 9 (rate 2.5 × 100 patient-years) in VKA and 5 (rate 1.3 × 100 patient-years) in DOAC (Relative Risk 1.9; 95% CI 0.6-7.4; p = 0.2). The univariate logistic regression analysis showed that patients with recurrent ICH were more frequently males, hypertensive, with a history of previous Stroke/TIA and older than patients without recurrence. VKA patients showed a higher risk of recurrence with respect to DOAC patients (OR 1.9;95% CI 0.7-6.7). CONCLUSIONS A trend toward fewer ICH recurrences was detected among DOACs patients in comparison to the previously reported rate of patients on warfarin.
Collapse
Affiliation(s)
- Daniela Poli
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy.
| | | | - Elisa Vignini
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Lucia Martinese
- SOD Malattie Aterotrombotiche, Azienda Ospedaliero Universitaria-Careggi, Firenze, Italy
| | - Sophie Testa
- UO Laboratorio Analisi, Centro Emostasi e Trombosi A O Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Paolo Simioni
- UOSD Malattie Trombotiche ed Emorragiche, UOC Medicina Generale, AOU Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Università degli Studi di Padova, Padova, Italy
| | - Pasquale Pignatelli
- Centro Trombosi, Clinica Medica Policlinico Umberto I°, Università la Sapienza Roma, Italy
| | - Anna Falanga
- University Milan Bicocca, Dept. Medicine and Surgery, Monza and UOC SIMT, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Lucilla Masciocco
- UOC Medicina Interna, Centro Controllo Coagulazione, Presidio Ospedaliero Lastaria, Lucera (Foggia), Italy
| | - Doris Barcellona
- Struttura Dipartimentale di Emostasi e Trombosi, AOU di Cagliari, Dipartimento di Scienze Mediche e Sanita' Pubblica, Universita' di Cagliari, Cagliari, Italy
| | | | - Paolo Chiarugi
- U.O. Analisi Chimico-Cliniche, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Carmelo Paparo
- Patologia Clinica, Ospedale Maggiore Chieri (Torino), Italy
| | - Walter Ageno
- Dipartimento di Emergenza e Accettazione, Centro Trombosi ed Emostasi, Ospedale di Circolo, Università dell'Insubria, Varese, Italy
| | | |
Collapse
|
50
|
Testa S, Prandoni P, Paoletti O, Morandini R, Tala M, Dellanoce C, Giorgi-Pierfranceschi M, Betti M, Danzi GB, Pan A, Palareti G. Direct oral anticoagulant plasma levels' striking increase in severe COVID-19 respiratory syndrome patients treated with antiviral agents: The Cremona experience. J Thromb Haemost 2020; 18:1320-1323. [PMID: 32329231 PMCID: PMC7264501 DOI: 10.1111/jth.14871] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/18/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND Antiviral drugs are administered in patients with severe COVID-19 respiratory syndrome, including those treated with direct oral anticoagulants (DOACs). Concomitant administration of antiviral agents has the potential to increase their plasma concentration. A series of patients managed in the Cremona Thrombosis Center were admitted at Cremona Hospital for SARS-CoV-2 and started antiviral drugs without stopping DOAC therapy. DOAC plasma levels were measured in hospital and results compared with those recorded before hospitalization. METHODS All consecutive patients on DOACs were candidates for administration of antiviral agents (lopinavir, ritonavir, or darunavir). Plasma samples for DOAC measurement were collected 2to 4 days after starting antiviral treatment, at 12 hours from the last dose intake in patients on dabigatran and apixaban, and at 24 hours in those on rivaroxaban and edoxaban. For each patient, C-trough DOAC level, expressed as ng/mL, was compared with the one measured before hospitalization. RESULTS Of the 1039 patients hospitalized between February 22 and March 15, 2020 with COVID-19 pneumonia and candidates for antiviral therapy, 32 were on treatment with a DOAC. DOAC was stopped in 20 and continued in the remaining 12. On average, C-trough levels were 6.14 times higher during hospitalization than in the pre-hospitalization period. CONCLUSION DOAC patients treated with antiviral drugs show an alarming increase in DOAC plasma levels. In order to prevent bleeding complications, we believe that physicians should consider withholding DOACs from patients with SARS-CoV-2 and replacing them with alternative parenteral antithrombotic strategies for as long as antiviral agents are deemed necessary and until discharge.
Collapse
Affiliation(s)
- Sophie Testa
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | | | - Oriana Paoletti
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | | | - Maurizio Tala
- Haemostasis and Thrombosis Center, Cremona Hospital, Cremona, Italy
| | | | | | - Monia Betti
- Division of Pneumology, Cremona Hospital, Cremona, Italy
| | | | - Angelo Pan
- Division of Infectious Disease, Cremona Hospital, Cremona, Italy
| | | |
Collapse
|