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Nagao A, Deguchi A, Nogami K. Real-world long-term safety and effectiveness of turoctocog alfa in the treatment of haemophilia A in Japan: results from a multicentre, non-interventional, post-marketing study. Hematology 2024; 29:2316540. [PMID: 38376107 DOI: 10.1080/16078454.2024.2316540] [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: 04/20/2023] [Accepted: 02/05/2024] [Indexed: 02/21/2024] Open
Abstract
OBJECTIVES To assess the safety and effectiveness of turoctocog alfa in previously treated patients (PTPs) and previously untreated patients (PUPs) with haemophilia A in a real-world setting in Japan. METHODS This multicentre, non-interventional, post-marketing study recruited patients with haemophilia A who initiated treatment with turoctocog alfa from 18 sites (08/2014-12/2018). The primary endpoint was adverse events (AEs) during the 2-year study period. RESULTS The safety and effectiveness analysis set included 39 patients. In total, 13 (33.3%) patients reported ≥1 AE; incidence rate was 60.4 events/100 patient-years of exposure (PYE). Treatment was withdrawn in two cases: pruritus in a PTP and factor VIII inhibitor development in a PUP. Inhibitor development occurred in 2.6% of all patients, with an incidence rate of 3.8 events/100 PYE. The rate of inhibitor development was 0%, 25% and 20% in PTPs, PUPs and PUPs with severe type, respectively. The haemostatic success rate was 91.4% for 383 bleeding episodes and 85.7% for 14 surgeries. The negative binomial annualised bleeding rate for the prophylaxis regimen was 6.19 episodes/year (95% CI, 3.69-10.38). The mean (SD) total consumption of turoctocog alfa (n = 34; excluding FVIII inhibitors) was 5,382.6 (7,180.1) IU/kg/year/patient; consumption was 4,133.1 (1,452.4) IU/kg/year/patient for prophylaxis. DISCUSSION The effectiveness and safety profiles were comparable to those observed in other turoctocog alfa trials; effectiveness analysis and consumption were not affected by treatment regimens. CONCLUSION Long-term use of turoctocog alfa therapy in clinical practice posed no newly identified safety issues and was effective for prophylaxis and treatment of bleeds in patients with haemophilia A in Japan.
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Affiliation(s)
- Azusa Nagao
- Department of Blood Coagulation, Ogikubo Hospital, Tokyo, Japan
| | - Ayumi Deguchi
- Medical Affairs, Novo Nordisk Pharma Ltd., Tokyo, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Abu-Assi E, Lizancos Castro A, Cespón-Fernández M, González-Bermúdez I, Raposeiras Roubin S. Relative performance evaluation of four bleeding risk scores in atrial fibrillation patients. What does the new DOAC score provide? Int J Cardiol 2024; 407:132018. [PMID: 38579940 DOI: 10.1016/j.ijcard.2024.132018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/16/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Recently, the direct oral anticoagulant (DOAC) score was developed and better predicted major bleeding in DOAC-treated patients with atrial fibrillation (AF) than HASBLED did. Little is known on the new score's performance regarding other bleeding risk in AF. METHODS We studied 14,672 patients diagnosed with AF between 2014 and 2018. During follow-up, we assessed the performance of DOAC score compared with the HASBLED, ORBIT and SWISS scores at predicting major bleeding in DOACs and non-DOACs users. Discrimination, calibration and decision curve analysis (DCA) were used to assess the risk scorer's performance. RESULTS There were 1484 (10.1%) patients on DOACs, 9730 on vitamin K antagonist (VKA), and 3458 on non-oral anticoagulants. Over a median of 3.5 years of follow-up, 79 major bleedings occurred in the DOAC patients, and 486 in the VKA patients (cumulative incidences = 7.4 and 13.9 per 100 patient-years, respectively). Amongst the DOAC patients, the DOAC score discrimination was moderate (C-statistic = 0.711), but significantly higher than HASBLED (C = 0.640; p = 0.03), ORBIT (C = 0.660; p = 0.04), and SWISS scores (C = 0.637; p = 0.002). The DCA showed higher net benefit using DOAC score compared with the remaining scores. In the VKA patients, DOAC score showed the highest discrimination (c-statistic = 0.709), followed by ORBIT (C = 0.692; p = 0.07), HASBLED and SWISS (C = 0.635 and 0.624, respectively; p < 0.01). All risk scores calibrated well, although HASBLED showed relatively poor calibration. CONCLUSIONS The new DOAC bleeding risk score is a valid and reasonable predictor of major bleeding over a median of 3.5 years of follow-up. Physicians can be reassured about the applicability of DOAC score for bleeding risk stratification in AF patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04364516.
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Affiliation(s)
- Emad Abu-Assi
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain.
| | - Andrea Lizancos Castro
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - María Cespón-Fernández
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
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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.
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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
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Kartas A, Papazoglou AS, Moysidis DV, Despotopoulos S, Baroutidou A, Kosmidis D, Koutsakis A, Liori S, Apostolopoulou S, Frogoudaki A, Tzifa A, Galatas A, Alexandridis G, Spiridonidis E, Doundoulakis I, Karagiannidis E, Karvounis H, Ziakas A, Giannakoulas G. Use of apixaban in adults with congenital heart disease and atrial arrhythmias: The PROTECT-AR study. Int J Cardiol 2024; 406:131993. [PMID: 38565389 DOI: 10.1016/j.ijcard.2024.131993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/29/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) and atrial arrhythmias (AA) face an increased risk of thromboembolic events. Limited data exist on the use of non-vitamin K oral anticoagulants for thromboprophylaxis in ACHD. We aimed to assess the effectiveness and safety of apixaban in ACHD patients with AA. METHODS PROTECT-AR (NCT03854149) was a prospective, multicenter, observational study conducted from 2019 to 2023. ACHD patients with atrial fibrillation, atrial flutter, or intra-atrial re-entrant tachycardia on routine apixaban treatment were included. The historical control group consisted of patients previously on vitamin K antagonist (VKA), who were analyzed prior to their transition to apixaban. The primary effectiveness endpoint was the composite of stroke or thromboembolism. The primary safety endpoint was major bleeding. RESULTS The study enrolled 218 ACHD patients with AA on apixaban, of which 73 were previous VKA users. The analysis covered 527 patient-years of prospective exposure to apixaban and 169 patient-years of retrospective exposure to VKA. The annualized rate of stroke or thromboembolism was 0.6% in the apixaban group and 1.8% in the VKA group (absolute difference - 1.2%; upper limit of one-sided 95% confidence interval [CI] 0.9%, lower than the predefined non-inferiority margin of +1.8%, Pnon-inferiority < 0.001). The annualized rate of major bleeding was 1.5% in the apixaban group and 2.4% in the VKA group (hazard ratio 0.64; 95% CI 0.19-2.10, P = 0.48). CONCLUSION In ACHD patients with AA, routine apixaban use exhibited a non-inferior rate of stroke or thromboembolism compared to historical VKA use, alongside a similar rate of major bleeding.
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Affiliation(s)
- Anastasios Kartas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Andreas S Papazoglou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Dimitrios V Moysidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Stefanos Despotopoulos
- Department of Pediatric and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, Athens, Greece
| | - Amalia Baroutidou
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Diamantis Kosmidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Athanasios Koutsakis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Sotiria Liori
- Second Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Sotiria Apostolopoulou
- Department of Pediatric and Adult Congenital Heart Disease, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Afrodite Tzifa
- Department of Congenital Heart Disease, Mitera Childrens' Hospital, Athens, Greece
| | - Apostolos Galatas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Georgios Alexandridis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Efstathios Spiridonidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | | | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - Antonios Ziakas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, St. Kiriakidi 1, 54636 Thessaloniki, Greece.
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Slišković AM, Palić J, Božina T, Ganoci L, Vrkić Kirhmajer M, Trkulja V, Bulum J, Šimičević L. Common P-glycoprotein ( ABCB1) polymorphisms do not seem to be associated with the risk of rivaroxaban-related bleeding events: Preliminary data. Biochem Med (Zagreb) 2024; 34:020703. [PMID: 38665866 PMCID: PMC11042566 DOI: 10.11613/bm.2024.020703] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/16/2024] [Indexed: 04/28/2024] Open
Abstract
Introduction Considering conflicting previous reports, we aimed to evaluate whether the common ABCB1 polymorphisms (rs1128503, rs2032582, rs1045642, rs4148738) affected the risk of bleeding in rivaroxaban-treated patients. Materials and methods We report preliminary data from a larger nested case-control study. Consecutive adults started on rivaroxaban for any indication requiring > 6 months of treatment were followed-up to one year. Patients who experienced major or non-major clinically relevant bleeding during the initial 6 months were considered cases, whereas subjects free of bleeding over > 6 months were controls. The polymorphisms of interest (rs1128503, rs2032582, rs1045642, rs4148738) were in a strong linkage disequilibrium, hence patients were classified regarding the "load" of variant alleles: 0-2, 3-5 or 6-8. The three subsets were balanced regarding a range of demographic, comorbidity, comedication and genetic characteristics. A logistic model was fitted to probability of bleeding. Results There were 60 cases and 220 controls. Raw proportions of cases were similar across the subsets with increasing number of ABCB1 variant alleles (0-2, N = 85; 3-6, N = 133; 6-8, N = 62): 22.4%, 21.8%, and 19.4%, respectively. Fully adjusted probabilities of bleeding were also similar across the subsets: 22.9%, 27.5% and 17.7%, respectively. No trend was observed (linear, t = -0.63, df = 273, P = 0.529; quadratic, t = -1.10, df = 273, P = 0.272). Of the 15 identified haplotypes, the completely variant (c.1236T_c.2677T(A)_c.3435T_c.2482-2236A) (40.7%) and completely wild-type (C_G_C_G) (39.5%) haplotypes prevailed, and had a closely similar prevalence of cases: 21.1% vs. 23.1%, respectively. Conclusions The evaluated common ABCB1 polymorphisms do not seem to affect the risk of early bleeding in patients started on rivaroxaban.
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Affiliation(s)
- Ana Marija Slišković
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Jozefina Palić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Tamara Božina
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Lana Ganoci
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Majda Vrkić Kirhmajer
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Vladimir Trkulja
- Department of Pharmacology, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Joško Bulum
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, Zagreb, Croatia
- Department of Internal Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Livija Šimičević
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, University of Zagreb School of Medicine, Zagreb, Croatia
- Division of Pharmacogenomics and Therapy Individualization, Department of Laboratory Diagnostics, University Hospital Centre Zagreb, Zagreb, Croatia
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Ramotowski B, Lewandowski P, Słomski T, Maciejewski P, Budaj A. Platelet reactivity and activated clotting time predict hemorrhagic site complications in patients with chronic coronary syndromes undergoing percutaneous coronary interventions. Coron Artery Dis 2024; 35:292-298. [PMID: 38241058 DOI: 10.1097/mca.0000000000001336] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND Radial access is preferred in patients with chronic coronary syndromes (CCSs) treated with ad hoc percutaneous coronary intervention (PCI). Antithrombotic and antiplatelet treatment before PCI may affect outcomes at vascular access sites. QuikClot Radial is a kaolin-based band that may shorten hemostasis time. Using point-of-care testing, we investigated the effect of antithrombotic and antiplatelet treatment on access-site complications. METHODS This prospective observational study included consecutive patients with CCS on chronic aspirin therapy referred for ad hoc PCI. The activated clotting time (ACT), global thrombosis test and VerifyNow P2Y 12 test were done sequentially after unfractionated heparin (UFH) and clopidogrel administration. Patients were monitored for radial artery patency, bleeding and local hematoma until discharge. RESULTS We enrolled 40 patients [mean age, 68.8 ± 8.8 years; men, 30 (75%)] who received UFH (median dose, 8000 IU; interquartile range, 7000-9000 IU) and clopidogrel (600 mg). All radial arteries remained patent during follow-up. Local bleeding and hematomas were noted in 11 patients (27.5%) each. Patients with bleeding had lower mean platelet activity at 2 h [122.5 ± 51 platelet reactivity units (PRU) vs. 158.7 ± 43 PRU, P = 0.04] and higher ACT (216.9 ± 40 s vs. 184.6 ± 28 s, P = 0.006) than patients without bleeding. An ACT >196 s at 2 h predicted bleeding or hematoma (AUC, 0.72; 95% CI, 0.56-0.85, P = 0.008). CONCLUSION Lower platelet activity and higher ACT after PCI were associated with higher bleeding risk at a vascular access site. Point-of-care testing of ACT after the procedure may help identify patients with CCS undergoing PCI who are at higher risk of access-site bleeding.
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Affiliation(s)
- Bogumił Ramotowski
- Department of Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
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Zhang S, Zhao M, Zhong S, Niu J, Zhou L, Zhu B, Su H, Cao W, Xing Q, Yan H, Han X, Fu Q, Li Q, Chen L, Yang F, Zhang N, Wu H, He L, Qin S. Association between CYP2C9 and VKORC1 genetic polymorphisms and efficacy and safety of warfarin in Chinese patients. Pharmacogenet Genomics 2024; 34:105-116. [PMID: 38470454 DOI: 10.1097/fpc.0000000000000526] [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: 03/13/2024]
Abstract
OBJECTIVES Genetic variation has been a major contributor to interindividual variability of warfarin dosage requirement. The specific genetic factors contributing to warfarin bleeding complications are largely unknown, particularly in Chinese patients. In this study, 896 Chinese patients were enrolled to explore the effect of CYP2C9 and VKORC1 genetic variations on both the efficacy and safety of warfarin therapy. METHODS AND RESULTS Univariate analyses unveiled significant associations between two specific single nucleotide polymorphisms rs1057910 in CYP2C9 and rs9923231 in VKORC1 and stable warfarin dosage ( P < 0.001). Further, employing multivariate logistic regression analysis adjusted for age, sex and height, the investigation revealed that patients harboring at least one variant allele in CYP2C9 exhibited a heightened risk of bleeding events compared to those with the wild-type genotype (odds ratio = 2.16, P = 0.04). Moreover, a meta-analysis conducted to consolidate findings confirmed the associations of both CYP2C9 (rs1057910) and VKORC1 (rs9923231) with stable warfarin dosage. Notably, CYP2C9 variant genotypes were significantly linked to an increased risk of hemorrhagic complications ( P < 0.00001), VKORC1 did not demonstrate a similar association. CONCLUSION The associations found between specific genetic variants and both stable warfarin dosage and bleeding risk might be the potential significance of gene detection in optimizing warfarin therapy for improving patient efficacy and safety.
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Affiliation(s)
- Suli Zhang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Mingzhe Zhao
- Affiliated Mental Health Center & Hangzhou Seventh People's Hospital, Zhejiang University School of Medicine, Hangzhou
| | - Shilong Zhong
- Department of Pharmacy, Guangdong Provincial People's Hospital, Guangdong
| | - Jiamin Niu
- Department of Cardiology, Jinan City People's Hospital, Jinan
| | - Lijuan Zhou
- Translational Medicine Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou
| | - Bin Zhu
- Shanghai Baio Technology Co., Ltd., Shanghai
| | - Haili Su
- Department of Cardiology, Huhhot First Hospital, Huhhot
| | - Wei Cao
- Translational Medicine Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou
| | - Qinghe Xing
- Institutes of Biomedical Sciences, Fudan University
| | - Hongli Yan
- Reproductive, Medicine Center, Changhai Hospital, Navy Medical University, Shanghai
| | - Xia Han
- Department of Cardiology, Jinan City People's Hospital, Jinan
| | - Qihua Fu
- Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai
- Shanghai Key Laboratory of Clinical Molecular Diagnostics for Pediatrics, Shanghai
| | - Qiang Li
- Department of Geriatrics, Shandong Provincial Third Hospital, Shandong
| | - Luan Chen
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Fan Yang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Na Zhang
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Hao Wu
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Lin He
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
| | - Shengying Qin
- Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders (Ministry of Education), Shanghai Jiao Tong University, Shanghai
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8
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Krucoff M, Spirito A, Baber U, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Ticagrelor with or without aspirin following percutaneous coronary intervention in high-risk patients with concomitant peripheral artery disease: A subgroup analysis of the TWILIGHT randomized clinical trial. Am Heart J 2024; 272:11-22. [PMID: 38458371 DOI: 10.1016/j.ahj.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The optimal antiplatelet regimen after percutaneous coronary intervention (PCI) in patients with peripheral artery disease (PAD) is still debated. This analysis aimed to compare the effect of ticagrelor monotherapy versus ticagrelor plus aspirin in patients with PAD undergoing PCI. METHODS In the TWILIGHT trial, patients at high ischemic or bleeding risk that underwent PCI were randomized after 3 months of dual antiplatelet therapy (DAPT) to aspirin or matching placebo in addition to open-label ticagrelor for 12 additional months. In this post-hoc analysis, patient cohorts were examined according to the presence or absence of PAD. The primary endpoint was Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding. The key secondary endpoint was a composite of all-cause death, myocardial infarction (MI), or stroke. Endpoints were assessed at 12 months after randomization. RESULTS Among 7,119 patients, 489 (7%) had PAD and were older, more likely to have comorbidities, and multivessel disease. PAD patients had more bleeding or ischemic complications than no-PAD patients. Ticagrelor monotherapy compared to ticagrelor plus aspirin was associated with less BARC 2, 3, or 5 bleeding in PAD (4.6% vs 8.7%; HR 0.52; 95%CI 0.25-1.07) and no-PAD patients (4.0% vs 7.0%; HR 0.56; 95%CI 0.45-0.69; interaction P-value .830) and a similar risk of death, MI, or stroke in these 2 groups (interaction P-value .446). CONCLUSIONS Despite their higher ischemic and bleeding risk, patients with PAD undergoing PCI derived a consistent benefit from ticagrelor monotherapy after 3 months of DAPT in terms of bleeding reduction without any relevant increase in ischemic events. CLINICAL TRIAL REGISTRY INFORMATION:: https://www. CLINICALTRIALS gov/study/NCT02270242.
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Affiliation(s)
- Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, NC
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY; St. Francis Hospital, Roslyn, Roslyn, NY
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, No. 83 Wenhua Road, Shenyang 110016, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Mathew RO, Sidhu MS, Rihal CS, Lennon R, El-Hajjar M, Yager N, Lyubarova R, Abdul-Nour K, Weitz S, O'Cochlain DF, Murthy V, Levisay J, Marzo K, Graham J, Dzavik V, So D, Goodman S, Rosenberg YD, Pereira N, Farkouh ME. Safety and Efficacy of CYP2C19 Genotype-Guided Escalation of P2Y 12 Inhibitor Therapy After Percutaneous Coronary Intervention in Chronic Kidney Disease: a Post Hoc Analysis of the TAILOR-PCI Study. Cardiovasc Drugs Ther 2024; 38:447-457. [PMID: 36445624 PMCID: PMC10225474 DOI: 10.1007/s10557-022-07392-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) is a risk factor for ischemic and bleeding events with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Whether the presence of CYP2C19 loss of function (LOF) alleles modifies this risk, and whether a genotype-guided (GG) escalation of P2Y12 inhibitor therapy post PCI is safe in this population is unclear. METHODS This was a post hoc analysis of randomized patients in TAILOR PCI. Patients were divided into two groups based on estimated glomerular filtration rate (eGFR) threshold of < 60 ml/min/1.73 m2 for CKD (n = 539) and non-CKD (n = 4276). The aggregate of cardiovascular death, stroke, myocardial infarction, stent thrombosis, and severe recurrent coronary ischemia at 12-months post-PCI was assessed as the primary endpoint. Secondary endpoint was major or minor bleeding. RESULTS Mean (standard deviation) eGFR among patients with CKD was 49.5 (8.4) ml/min/1.72 m2. Among all patients, there was no significant interaction between randomized strategy and CKD status for any endpoint. Among LOF carriers, the interaction between randomized strategy and CKD status on composite ischemic outcome was not significant (p = 0.2). GG strategy was not associated with an increased risk of bleeding in either CKD group. CONCLUSIONS In this exploratory analysis, escalation of P2Y12 inhibitor therapy following a GG strategy did not reduce the primary outcome in CKD. However, P2Y12 inhibitor escalation following a GG strategy was not associated with increased bleeding risk in CKD. Larger studies in CKD are needed. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT01742117?term=TAILOR-PCI&draw=2&rank=1 . NCT01742117.
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Affiliation(s)
- Roy O Mathew
- Department of Medicine, Loma Linda VA Health Care System, 11201 Benton Street, Loma Linda, CA, 92357, USA.
| | - Mandeep S Sidhu
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA.
| | | | - Ryan Lennon
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Mohammed El-Hajjar
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Neil Yager
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | - Radmila Lyubarova
- Department of Medicine, Albany Medical College, 43 New Scotland Avenue Albany, Schenectady, NY, 12208, USA
| | | | - Steven Weitz
- Cardiology Associates of Schenectady, Schenectady, NY, USA
| | | | - Vishakantha Murthy
- Department of Endocrine and Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Justin Levisay
- Department of Medicine, North Shore University Health System, Evanston, IL, USA
| | - Kevin Marzo
- Department of Medicine, Winthrop University Hospital, Mineola, NY, USA
| | - John Graham
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Vlad Dzavik
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
| | - Derek So
- Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Shaun Goodman
- Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | | | | | - Michael E Farkouh
- Department of Medicine, University Health Network-Toronto General Hospital, Toronto, ON, Canada
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10
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Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
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Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
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11
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Martin TC, Duewell BE, Juul JJ, Rinka JRG, Rein L, Feih JT. Comparison of Outcomes in Patients Requiring Mechanical Circulatory Support Who Received Cangrelor in Addition to Anticoagulation Versus Anticoagulation Alone. J Cardiothorac Vasc Anesth 2024; 38:1328-1336. [PMID: 38521630 DOI: 10.1053/j.jvca.2024.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES To evaluate the safety of cangrelor administered concurrently with heparin or bivalirudin in patients on mechanical circulatory support. DESIGN A single-center, retrospective cohort study of adult patients consecutively admitted between January 2016 and October 2020. SETTING A tertiary medical center. PARTICIPANTS Adult patients admitted to the cardiovascular intensive care unit put on mechanical circulatory support for acute myocardial infarction (AMI) or non-AMI indications. Patients who received cangrelor underwent percutaneous coronary intervention with stenting during the index event or within the last year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of major bleeding, defined by the Extracorporeal Life Support Organization criteria, in patients with mechanical circulatory support receiving cangrelor plus anticoagulation with heparin or bivalirudin with or without aspirin versus patients who did not receive cangrelor. Sixty-eight patients were included in the study. Twenty-nine patients received cangrelor, and 39 did not. Cangrelor was not associated with an increase in major bleeding; however, the CI was wide (adjusted hazard ratio 1.93, 95% CI 0.61-6.11; p = 0.262). CONCLUSIONS Patients receiving cangrelor did not appear to be at higher risk of major bleeding compared to patients not receiving cangrelor. Larger trials should be conducted to better evaluate the safety of cangrelor in patients with mechanical circulatory support.
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Affiliation(s)
- Trent C Martin
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI.
| | | | - Janelle J Juul
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
| | - Joseph R G Rinka
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; School of Pharmacy, Concordia University Wisconsin, Mequon, WI
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Joel T Feih
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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12
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Zhang Y, Wang M, Su S. Individualized antiplatelet therapy for non-cardiogenic ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107711. [PMID: 38580158 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107711] [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: 02/06/2024] [Revised: 03/26/2024] [Accepted: 04/02/2024] [Indexed: 04/07/2024] Open
Abstract
OBJECTIVE This research aims to investigate the impact of individualized antiplatelet therapy guided by thromboelastography with platelet mapping (TEG-PM) on the clinical outcomes of patients with non-cardiogenic ischemic stroke. METHODS Among a total of 1264 patients, 684 individuals diagnosed with non-cardiogenic ischemic stroke underwent TEG-PM testing. Based on the adjustment of antiplatelet medication, these patients were divided into individual and control groups. Within the individual group, in accordance with the TEG-PM test results, a Maximum amplitude (MA) value greater than 47mm was defined as high residual platelet reactivity (HRPR), while an MA value less than 31mm was defined as low residual platelet reactivity (LRPR). Patients with arachidonic acid (AA) less than 50% and adenosine diphosphate (ADP) less than 30% were classified as aspirin-resistant or clopidogrel-resistant. Treatment strategies for antiplatelet medication were subsequently adjusted accordingly, encompassing increment, decrement, or replacement of drugs. Meanwhile, the control group maintained their original medication regimen without alterations. RESULTS The individual group included 487 patients, while the control group had 197. In the individual group, approximately 175 patients (35.9%) were treated with increased medication dosages, 89 patients (18.3%) with reduced dosages, and 223 patients (45.8%) switched medications. The results showed that the incidence rate of ischemic events in the individual group was lower than that of the control group (5.54% vs. 12.6%, P = 0.001), but no significant difference was observed in bleeding events. Cox regression analysis revealed age (hazard ratio, 1.043; 95% CI, 1.01-1.078; P = 0.011) and coronary heart disease (hazard ratio, 1.902; 95% CI, 1.147-3.153; P = 0.013) as significant risk factors for adverse events. CONCLUSION Individualized antiplatelet therapy based on TEG-PM results can reduce the risk of ischemic events in patients with non-cardiogenic ischemic stroke without increasing the risk of bleeding events or mortality. Advanced age and coronary heart disease were identified as risk factors affecting the outcomes of individualized antiplatelet therapy.
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Affiliation(s)
- Yifan Zhang
- Department of Neurological Center, Shenzhen Baoan People's Hospital, Shenzhen, China; Department of Critical Care Medicine, Shenzhen Baoan People's Hospital, Shenzhen, China
| | - Moli Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shengyuan Su
- Department of Critical Care Medicine, Shenzhen Baoan People's Hospital, Shenzhen, China.
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13
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Xue L, Ma G, Holford N, Qin Q, Ding Y, Hannam JA, Ding X, Fan H, Ji Z, Yang B, Shen H, Shen Z, Miao L. A Randomized Trial Comparing Standard of Care to Bayesian Warfarin Dose Individualization. Clin Pharmacol Ther 2024; 115:1316-1325. [PMID: 38439157 DOI: 10.1002/cpt.3207] [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: 10/11/2023] [Accepted: 01/24/2024] [Indexed: 03/06/2024]
Abstract
The quality of warfarin treatment may be improved if management is guided by the use of models based upon pharmacokinetic-pharmacodynamic theory. A prospective, two-armed, single-blind, randomized controlled trial compared management aided by a web-based dose calculator (NextDose) with standard clinical care. Participants were 240 adults receiving warfarin therapy following cardiac surgery, followed up until the first outpatient appointment at least 3 months after warfarin initiation. We compared the percentage of time spent in the international normalized ratio acceptable range (%TIR) during the first 28 days following warfarin initiation, and %TIR and count of bleeding events over the entire follow-up period. Two hundred thirty-four participants were followed up to day 28 (NextDose: 116 and standard of care: 118), and 228 participants (114 per arm) were followed up to the final study visit. Median %TIR tended to be higher for participants receiving NextDose guided warfarin management during the first 28 days (63 vs. 56%, P = 0.13) and over the entire follow-up period (74 vs. 71%, P = 0.04). The hazard of clinically relevant minor bleeding events was lower for participants in the NextDose arm (hazard ratio: 0.21, P = 0.041). In NextDose, there were 89.3% of proposed doses accepted by prescribers. NextDose guided dose management in cardiac surgery patients requiring warfarin was associated with an increase in %TIR across the full follow-up period and fewer hemorrhagic events. A theory-based, pharmacologically guided approach facilitates higher quality warfarin anticoagulation. An important practical benefit is a reduced requirement for clinical experience of warfarin management.
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Affiliation(s)
- Ling Xue
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- Department of Pharmacology, Faculty of Medicine, University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Guangda Ma
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Nick Holford
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Qiong Qin
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yinglong Ding
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Jacqueline A Hannam
- Department of Pharmacology and Clinical Pharmacology, University of Auckland, Auckland, New Zealand
| | - Xiaoliang Ding
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hongyou Fan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Zhenchun Ji
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Biwen Yang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Han Shen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Zhenya Shen
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Cardiovascular Science, Soochow University, Suzhou, China
| | - Liyan Miao
- Department of Pharmacy, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, The First Affiliated Hospital of Soochow University, Suzhou, China
- Institute for Interdisciplinary Drug Research and Translational Sciences, Soochow University, Suzhou, China
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14
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Campbell AM, Pae E, Lee E, Jacisin T, Price A, DeAngelo J. Off-Label Reduced Dose Apixaban in Older Adults With Atrial Fibrillation and Associated Outcomes. Ann Pharmacother 2024; 58:572-580. [PMID: 37712551 DOI: 10.1177/10600280231199137] [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] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Apixaban is commonly used to prevent stroke in older adults with nonvalvular atrial fibrillation (AF). Although its package insert has specific dose reduction criteria, providers may dose reduce outside of these parameters based on clinical scenarios. OBJECTIVE The primary objective was to determine the incidence of apixaban off-label reduced dosing, while secondarily determining the safety and efficacy outcomes associated with such dosing. METHODS A retrospective analysis of patients aged 65 and older with orders for apixaban for AF was institutional review board (IRB)-approved and conducted across 3 academic medical centers. Patients receiving off-label reduced-dose apixaban (ie, "underdosed") were matched to a cohort of patients dosed according to the package insert at the standard dosing (5 mg twice daily) using stratified random sampling. Secondary outcomes included 1-year incidence of major bleeding, clinically relevant non-major bleeding (CRNMB), stroke or transient ischemic attack (TIA), and mortality. The Fisher exact tests were used to compare between-group differences. RESULTS Of the 1172 patients meeting initial inclusion criteria, 201 (17%) were dosed off-label, with 175 (15%) "underdosed." The 147 "underdosed" patients with documented follow-up were matched with 139 patients receiving standard Food and Drug Administration (FDA)-labeled dosing. There were no significant differences in incidence of stroke (2.7% vs 2.2%), major bleeding (0% vs 0.7%), and CRNMB (2.7% vs 1.4%) in the off-label reduced dosing versus standard dosing groups. All-cause mortality was higher in the off-label reduced-dose group (16 [10.9%] vs 2 [1.4%], P < 0.05). CONCLUSION AND RELEVANCE Older adults with nonvalvular AF are commonly prescribed lower-than-recommended doses of apixaban. However, no significant association was found between empiric off-label reduced dosing and stroke or bleeding outcomes.
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Affiliation(s)
- Ashley M Campbell
- R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy, Banner-University Medical Center Tucson, Tucson, AZ, USA
| | - Elizabeth Pae
- Department of Pharmacy, Banner-University Medical Center Tucson, Tucson, AZ, USA
| | | | - Timothy Jacisin
- Department of Pharmacy, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Alina Price
- Department of Pharmacy, Banner-University Medical Center Tucson, Tucson, AZ, USA
| | - Jessica DeAngelo
- R. Ken Coit College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy, Banner-University Medical Center Tucson, Tucson, AZ, USA
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15
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Triska J, Haddadin F, Madanat L, Jabri A, Daher M, Birnbaum Y, Jneid H. The Cost of Breaking Even: a Perspective on the Net Clinical Impact of Adding Aspirin to Antithrombotic Therapies in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. Cardiovasc Drugs Ther 2024; 38:605-619. [PMID: 35829979 DOI: 10.1007/s10557-022-07367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Outcomes from randomized controlled trials (RCTs) inform the latest recommendations on percutaneous coronary intervention (PCI) management of a short period of oral anticoagulation (OAC), a P2Y12 receptor inhibitor, and aspirin for 1 week or until hospital discharge in patients with atrial fibrillation (AF) undergoing PCI, and up to 4 weeks in individuals considered to be at high-risk for ischemic events, followed by discontinuation of aspirin and continuation of OAC and a P2Y12 inhibitor for up to 12 months. METHODS We examined and summarized the outcomes of bleeding and major adverse cardiac events (MACEs) from RCTs and meta-analyses, published between 2013 and 2022, comparing therapy with OAC and a P2Y12 inhibitor with and without aspirin in AF patients undergoing PCI with stenting. RESULTS Data comparing dual therapy with OAC and a P2Y12 inhibitor alone to triple therapy with OAC, a P2Y12 inhibitor, and aspirin with respect to the risks of MACEs, including stent thrombosis within the first 30 days, are underpowered and inconclusive. The addition of aspirin does not appear to be associated with a decreased risk of ischemic events, even in patients with high-risk CHA2DS2-VASc scores, but does significantly increase bleeding hazards. The increased safety of newer generation drug-eluting stents may have further minimized any theoretical anti-ischemic benefits of aspirin. The possible attenuation of the pleiotropic effects of concomitant cardiovascular medications by aspirin may also have been a contributing factor. CONCLUSION The addition of aspirin to OAC and a P2Y12 inhibitor is likely associated with a net clinical harm in patients with AF who undergo PCI with stenting, even within the first 1-4 weeks after PCI. Revisiting the guideline recommendations to administer aspirin in this timeframe may be warranted.
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Affiliation(s)
- Jeffrey Triska
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Faris Haddadin
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Luai Madanat
- Department of Medicine, William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Marilyne Daher
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yochai Birnbaum
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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16
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Tu ZH, Perez AD, Diaz TE, Loop MS, Clarke M. Safety and Efficacy of Direct Oral Anticoagulants vs Warfarin in Patients With Obesity and Venous Thromboembolism: A Retrospective Analysis. Tex Heart Inst J 2024; 51:e238260. [PMID: 38748549 PMCID: PMC11095664 DOI: 10.14503/thij-23-8260] [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] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
BACKGROUND Current venous thromboembolism guidelines recommend using direct oral anticoagulants (DOACs) over warfarin regardless of obesity status; however, evidence remains limited for the safety and efficacy of DOAC use in patients with obesity. This retrospective analysis sought to demonstrate the safety and efficacy of DOACs compared with warfarin in a diverse population of patients with obesity in light of current prescribing practices. METHODS A retrospective cohort study was conducted at a large academic health system between July 2014 and September 2019. Adults with an admission diagnosis of deep vein thrombosis (DVT) or pulmonary embolism, with weight greater than 120 kg or a body mass index greater than 40, and who were discharged on an oral anticoagulant were included. Outcomes included occurrence of a thromboembolic event (DVT, pulmonary embolism, or ischemic stroke), bleeding event requiring hospitalization, and all-cause mortality within 12 months following index admission. RESULTS Out of 787 patients included, 520 were in the DOAC group and 267 were in the warfarin group. Within 12 months of index hospitalization, thromboembolic events occurred in 4.23% of patients in the DOAC group vs 7.12% of patients in the warfarin group (hazard ratio, 0.6 [95% CI, 0.32-1.1]; P = .082). Bleeding events requiring hospitalization occurred in 8.85% of DOAC patients vs 10.1% of warfarin patients (hazard ratio, 0.93 [95% CI, 0.57-1.5]; P = .82). A DVT occurred in 1.7% and 4.9% of patients in the DOAC and warfarin groups, respectively (hazard ratio, 0.35 [95% CI, 0.15-0.84]; P = .046). CONCLUSION No significant differences could be determined between DOACs and warfarin for cumulative thromboembolic or bleeding events, pulmonary embolism, ischemic stroke, or all-cause mortality. The risk of DVT was lower with apixaban and rivaroxaban. Regardless of patient weight or body mass index, physicians prescribed DOACs more commonly than warfarin.
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Affiliation(s)
- Zoe H. Tu
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas
| | - Alejandro D. Perez
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Thomas E. Diaz
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Matthew S. Loop
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, Auburn, Alabama
| | - Megan Clarke
- Department of Pharmacy, Novant Health New Hanover Regional Medical Center, Wilmington, North Carolina
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Ray WA, Chung CP, Stein CM, Smalley W, Zimmerman E, Dupont WD, Hung AM, Daugherty JR, Dickson A, Murray KT. Serious Bleeding in Patients With Atrial Fibrillation Using Diltiazem With Apixaban or Rivaroxaban. JAMA 2024; 331:1565-1575. [PMID: 38619832 PMCID: PMC11019444 DOI: 10.1001/jama.2024.3867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 02/29/2024] [Indexed: 04/16/2024]
Abstract
Importance Diltiazem, a commonly prescribed ventricular rate-control medication for patients with atrial fibrillation, inhibits apixaban and rivaroxaban elimination, possibly causing overanticoagulation. Objective To compare serious bleeding risk for new users of apixaban or rivaroxaban with atrial fibrillation treated with diltiazem or metoprolol. Design, Setting, and Participants This retrospective cohort study included Medicare beneficiaries aged 65 years or older with atrial fibrillation who initiated apixaban or rivaroxaban use and also began treatment with diltiazem or metoprolol between January 1, 2012, and November 29, 2020. Patients were followed up to 365 days through November 30, 2020. Data were analyzed from August 2023 to February 2024. Exposures Diltiazem and metoprolol. Main Outcomes and Measures The primary outcome was a composite of bleeding-related hospitalization and death with recent evidence of bleeding. Secondary outcomes were ischemic stroke or systemic embolism, major ischemic or hemorrhagic events (ischemic stroke, systemic embolism, intracranial or fatal extracranial bleeding, or death with recent evidence of bleeding), and death without recent evidence of bleeding. Hazard ratios (HRs) and rate differences (RDs) were adjusted for covariate differences with overlap weighting. Results The study included 204 155 US Medicare beneficiaries, of whom 53 275 received diltiazem and 150 880 received metoprolol. Study patients (mean [SD] age, 76.9 [7.0] years; 52.7% female) had 90 927 person-years (PY) of follow-up (median, 120 [IQR, 59-281] days). Patients receiving diltiazem treatment had increased risk for the primary outcome (RD, 10.6 [95% CI, 7.0-14.2] per 1000 PY; HR, 1.21 [95% CI, 1.13-1.29]) and its components of bleeding-related hospitalization (RD, 8.2 [95% CI, 5.1-11.4] per 1000 PY; HR, 1.22 [95% CI, 1.13-1.31]) and death with recent evidence of bleeding (RD, 2.4 [95% CI, 0.6-4.2] per 1000 PY; HR, 1.19 [95% CI, 1.05-1.34]) compared with patients receiving metoprolol. Risk for the primary outcome with initial diltiazem doses exceeding 120 mg/d (RD, 15.1 [95% CI, 10.2-20.1] per 1000 PY; HR, 1.29 [95% CI, 1.19-1.39]) was greater than that for lower doses (RD, 6.7 [95% CI, 2.0-11.4] per 1000 PY; HR, 1.13 [95% CI, 1.04-1.24]). For doses exceeding 120 mg/d, the risk of major ischemic or hemorrhagic events was increased (HR, 1.14 [95% CI, 1.02-1.27]). Neither dose group had significant changes in the risk for ischemic stroke or systemic embolism or death without recent evidence of bleeding. When patients receiving high- and low-dose diltiazem treatment were directly compared, the HR for the primary outcome was 1.14 (95% CI, 1.02-1.26). Conclusions and Relevance In Medicare patients with atrial fibrillation receiving apixaban or rivaroxaban, diltiazem was associated with greater risk of serious bleeding than metoprolol, particularly for diltiazem doses exceeding 120 mg/d.
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Affiliation(s)
- Wayne A. Ray
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Cecilia P. Chung
- Department of Medicine, University of Miami, Miami, Florida
- Miami VA Healthcare System, Miami, Florida
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Walter Smalley
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eli Zimmerman
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - William D. Dupont
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Adriana M. Hung
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James R. Daugherty
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Alyson Dickson
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Katherine T. Murray
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
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18
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Steiner-Gager GM, Siller-Matula JM. Abbreviated dual antiplatelet therapy after acute coronary syndrome. Lancet 2024; 403:1823-1825. [PMID: 38599219 DOI: 10.1016/s0140-6736(24)00586-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Gloria M Steiner-Gager
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna 1090, Austria; Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna 1090, Austria.
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19
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Ge Z, Kan J, Gao X, Raza A, Zhang JJ, Mohydin BS, Gao F, Shao Y, Wang Y, Zeng H, Li F, Khan HS, Mengal N, Cong H, Wang M, Chen L, Wei Y, Chen F, Stone GW, Chen SL. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial. Lancet 2024; 403:1866-1878. [PMID: 38599220 DOI: 10.1016/s0140-6736(24)00473-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Following percutaneous coronary intervention with stent placement to treat acute coronary syndromes, international clinical guidelines generally recommend dual antiplatelet therapy with aspirin plus a P2Y12 receptor inhibitor for 12 months to prevent myocardial infarction and stent thrombosis. However, data on single antiplatelet therapy with a potent P2Y12 inhibitor earlier than 12 months after percutaneous coronary intervention for patients with an acute coronary syndrome are scarce. The aim of this trial was to assess whether the use of ticagrelor alone, compared with ticagrelor plus aspirin, could reduce the incidence of clinically relevant bleeding events without an accompanying increase in major adverse cardiovascular or cerebrovascular events (MACCE). METHODS In this randomised, placebo-controlled, double-blind clinical trial, patients aged 18 years or older with an acute coronary syndrome who completed the IVUS-ACS study and who had no major ischaemic or bleeding events after 1-month treatment with dual antiplatelet therapy were randomly assigned to receive oral ticagrelor (90 mg twice daily) plus oral aspirin (100 mg once daily) or oral ticagrelor (90 mg twice daily) plus a matching oral placebo, beginning 1 month and ending at 12 months after percutaneous coronary intervention (11 months in total). Recruitment took place at 58 centres in China, Italy, Pakistan, and the UK. Patients were required to remain event-free for 1 month on dual antiplatelet therapy following percutaneous coronary intervention with contemporary drug-eluting stents. Randomisation was done using a web-based system, stratified by acute coronary syndrome type, diabetes, IVUS-ACS randomisation, and site, using dynamic minimisation. The primary superiority endpoint was clinically relevant bleeding (Bleeding Academic Research Consortium [known as BARC] types 2, 3, or 5). The primary non-inferiority endpoint was MACCE (defined as the composite of cardiac death, myocardial infarction, ischaemic stroke, definite stent thrombosis, or clinically driven target vessel revascularisation), with an expected event rate of 6·2% in the ticagrelor plus aspirin group and an absolute non-inferiority margin of 2·5 percentage points between 1 month and 12 months after percutaneous coronary intervention. The two co-primary endpoints were tested sequentially; the primary superiority endpoint had to be met for hypothesis testing of the MACCE outcome to proceed. All principal analyses were assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT03971500, and is completed. FINDINGS Between Sept 21, 2019, and Oct 27, 2022, 3400 (97·0%) of the 3505 participants in the IVUS-ACS study were randomly assigned (1700 patients to ticagrelor plus aspirin and 1700 patients to ticagrelor plus placebo). 12-month follow-up was completed by 3399 (>99·9%) patients. Between month 1 and month 12 after percutaneous coronary intervention, clinically relevant bleeding occurred in 35 patients (2·1%) in the ticagrelor plus placebo group and in 78 patients (4·6%) in the ticagrelor plus aspirin group (hazard ratio [HR] 0·45 [95% CI 0·30 to 0·66]; p<0·0001). MACCE occurred in 61 patients (3·6%) in the ticagrelor plus placebo group and in 63 patients (3·7%) in the ticagrelor plus aspirin group (absolute difference -0·1% [95% CI -1·4% to 1·2%]; HR 0·98 [95% CI 0·69 to 1·39]; pnon-inferiority<0·0001, psuperiority=0·89). INTERPRETATION In patients with an acute coronary syndrome who had percutaneous coronary intervention with contemporary drug-eluting stents and remained event-free for 1 month on dual antiplatelet therapy, treatment with ticagrelor alone between month 1 and month 12 after the intervention resulted in a lower rate of clinically relevant bleeding and a similar rate of MACCE compared with ticagrelor plus aspirin. Along with the results from previous studies, these findings show that most patients in this population can benefit from superior clinical outcomes with aspirin discontinuation and maintenance on ticagrelor monotherapy after 1 month of dual antiplatelet therapy. FUNDING The Chinese Society of Cardiology, the National Natural Scientific Foundation of China, and the Jiangsu Provincial & Nanjing Municipal Clinical Trial Project. TRANSLATION For the Mandarin translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Zhen Ge
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jing Kan
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaofei Gao
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Afsar Raza
- Airdale General Hospital, West Yorkshire, UK
| | - Jun-Jie Zhang
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | | | - Fentang Gao
- Gansu Provincial People's Hospital, Lanzhou, China
| | | | - Yan Wang
- Xiamen Heart Center, Xiamen University, Xiamen, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Li
- Affiliated Oriental Huainan General Hospital, Anhui University of Science and Technology, Huainan, China
| | | | - Naeem Mengal
- National Institute of Cardiovascular Diseases of Pakistan, Karaqi, Pakistan
| | - Hongliang Cong
- Tianjin Chest Hospital, Tianjin University, Tianjin, China
| | - Mingliang Wang
- Puto People's Hospital, Tongji University, Shanghai, China
| | | | - Yongyue Wei
- Center for Public Health and Epidemic Preparedness & Response, Peking University, Beijing, China
| | - Feng Chen
- School of Public Health, Center of Global Health, Nanjing Medical University, Nanjing, China
| | - Gregg W Stone
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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Jankowski W, Surov SS, Hernandez NE, Rawal A, Battistel M, Freedberg D, Ovanesov MV, Sauna ZE. Engineering and evaluation of FXa bypassing agents that restore hemostasis following Apixaban associated bleeding. Nat Commun 2024; 15:3912. [PMID: 38724509 PMCID: PMC11082157 DOI: 10.1038/s41467-024-48278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Direct oral anticoagulants (DOACs) targeting activated factor Xa (FXa) are used to prevent or treat thromboembolic disorders. DOACs reversibly bind to FXa and inhibit its enzymatic activity. However, DOAC treatment carries the risk of anticoagulant-associated bleeding. Currently, only one specific agent, andexanet alfa, is approved to reverse the anticoagulant effects of FXa-targeting DOACs (FXaDOACs) and control life-threatening bleeding. However, because of its mechanism of action, andexanet alfa requires a cumbersome dosing schedule, and its use is associated with the risk of thrombosis. Here, we present the computational design, engineering, and evaluation of FXa-variants that exhibit anticoagulation reversal activity in the presence of FXaDOACs. Our designs demonstrate low DOAC binding affinity, retain FXa-enzymatic activity and reduce the DOAC-associated bleeding by restoring hemostasis in mice treated with apixaban. Importantly, the FXaDOACs reversal agents we designed, unlike andexanet alfa, do not inhibit TFPI, and consequently, may have a safer thrombogenic profile.
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Affiliation(s)
- Wojciech Jankowski
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Stepan S Surov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Nancy E Hernandez
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Atul Rawal
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Marcos Battistel
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Daron Freedberg
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Mikhail V Ovanesov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Zuben E Sauna
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA.
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21
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Cha JJ, Lee SJ, Park JH, Hong SJ, Ahn TH, Chang K, Park Y, Song YB, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Jeong YH, Kim HS, Kim MH, Shin ES, Kim BK, Lim DS. Association of Age- and Body Mass Index-Stratified High On-Treatment Platelet Reactivity With Coronary Intervention Outcomes in East Asian Patients. J Am Heart Assoc 2024; 13:e031819. [PMID: 38639339 DOI: 10.1161/jaha.123.031819] [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: 07/20/2023] [Accepted: 03/12/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Although age and body mass index (BMI) significantly affect platelet reactivity units and clinical outcomes after percutaneous coronary intervention, there are limited data on the relationship between high on-treatment platelet reactivity (HPR) and clinical outcomes on age and BMI differences. Thus, we investigated the association of HPR with clinical outcomes according to age and BMI. METHODS AND RESULTS The study analyzed 11 714 patients who underwent platelet function tests after percutaneous coronary intervention. The primary end point was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), whereas the secondary end point was major bleeding. HPR was defined as platelet reactivity units ≥252. Patients were categorized by age (<67 years of age or ≥67 years of age) and BMI (≤22.6 kg/m2 or >22.6 kg/m2). Patients <67 years of age with HPR had increases in both MACCEs (adjusted hazard ratio [HR], 1.436 [95% CI, 1.106-1.867]; P=0.007) and major bleeding (adjusted HR, 1.584 [95% CI, 1.095-2.290]; P=0.015) compared with the those with non-HPR, respectively. In patients ≥67 years of age with HPR, there were no differences in MACCEs, but there was a decrease in major bleeding (adjusted HR, 0.721 [95% CI, 0.542-0.959]; P=0.024). Meanwhile, patients with HPR with BMI >22.6 kg/m2 had increases in MACCEs (adjusted HR, 1.387 [95% CI, 1.140-1.688]; P=0.001). No differences were shown in major bleeding. CONCLUSIONS HPR was linked to an increase in MACCEs or a decrease in major bleeding in patients after percutaneous coronary intervention, depending on age and BMI. This study is the first to observe that clinical outcomes in patients with HPR after percutaneous coronary intervention may vary based on age and BMI. Because the study is observational, the results should be viewed as hypothesis generating and emphasize the need for randomized clinical trials.
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Affiliation(s)
- Jung-Joon Cha
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | | | - Jae Hyoung Park
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Soon Jun Hong
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
| | - Tae Hoon Ahn
- Cardiovascular Center Chung-Ang University Gwang-myeong Hospital, Chung-Ang University College of Medicine Gwang-myeong South Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, College of Medicine Catholic University of Korea Seoul South Korea
| | - Yongwhi Park
- Department of Internal Medicine Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital Changwon South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine Seoul South Korea
| | - Sung Gyun Ahn
- Department of Cardiology Yonsei University Wonju Severance Christian Hospital Wonju South Korea
| | - Jung-Won Suh
- Department of Cardiology, Seoul National University College of Medicine Seoul National University Bundang Hospital Seongnam South Korea
| | - Sang Yeub Lee
- Cardiovascular Center Chung-Ang University Gwang-myeong Hospital, Chung-Ang University College of Medicine Gwang-myeong South Korea
| | - Jung Rae Cho
- Cardiology Division, Department of Internal Medicine Kangnam Sacred Heart Hospital, Hallym University College of Medicine Seoul South Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine Kangwon National University School of Medicine Chuncheon South Korea
| | - Young-Hoon Jeong
- Cardiovascular Center Chung-Ang University Gwang-myeong Hospital, Chung-Ang University College of Medicine Gwang-myeong South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul South Korea
| | - Moo Hyun Kim
- Department of Cardiology Dong-A University Hospital Busan South Korea
| | - Eun-Seok Shin
- Division of Cardiology Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea
| | | | - Do-Sun Lim
- Department of Cardiology, Cardiovascular Center Korea University Anam Hospital, Korea University College of Medicine Seoul South Korea
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22
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Ljung R, Matino D, Shapiro AD. Recombinant factor IX Fc for the treatment of hemophilia B. Eur J Haematol 2024; 112:678-691. [PMID: 38369860 DOI: 10.1111/ejh.14176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/20/2024]
Abstract
Current hemophilia B treatment guidelines recommend routine prophylaxis with factor IX (FIX) replacement products, tailored to maintain plasma activity at levels that will prevent bleeds. However, plasma FIX activity may not be the primary determinant or best indicator of hemostatic efficacy due to its extravascular distribution. FIX replacement therapy has evolved to include extended half-life (EHL) products that provide effective bleed protection when administered at intervals of 7 days or longer. rFIXFc is a recombinant fusion protein with an extended circulation time. rFIXFc has a biodistribution profile consistent with distribution into extravascular space, where it may support hemostasis at sites of vessel injury independent of circulating plasma activity levels. The safety and efficacy of rFIXFc prophylaxis is well established in adults, adolescents and children including previously untreated patients with hemophilia B, with substantial evidence from clinical trials and real-world clinical practice. This review describes the pharmacokinetic characteristics of rFIXFc, summarizes available safety and efficacy data, and evaluates the use of rFIXFc in special populations. Current hemophilia B treatment challenges, including target FIX plasma levels, perioperative use, and management of patients with comorbidities, are discussed together with the potential role of EHL products in the future treatment landscape of hemophilia B.
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Affiliation(s)
- Rolf Ljung
- Department of Clinical Sciences-Pediatrics, Lund University, Lund, Sweden
| | - Davide Matino
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amy D Shapiro
- Indiana Hemophilia & Thrombosis Center, Inc, Indianapolis, Indiana, USA
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23
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Pocock SJ, Owen R, Gregson J, Mt-Isa S, Baumgartner R, Ashby D, Stone GW. Quantifying the benefit-risk trade-off for individual patients in a clinical trial: principles and antithrombotic case study. J Thromb Haemost 2024; 22:1399-1409. [PMID: 38280725 DOI: 10.1016/j.jtha.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 01/12/2024] [Accepted: 01/17/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND A treatment's overall favorable benefit-risk profile does not imply that every individual patient will benefit from the treatment. OBJECTIVES To describe a statistical methodology for quantifying the benefit-risk trade-off in individual patients. METHODS The method requires a large randomized controlled trial containing a primary efficacy outcome and a primary safety outcome, for instance, the Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events-Thrombolysis in Myocardial Infarction 50 placebo-controlled trial of vorapaxar in 17 779 patients following myocardial infarction. Multivariate regression models predict each individual patient's risk of ischemic events (benefit) and major bleeding events (harm) based on their profile. Hence, each patient's predicted benefit from vorapaxar (reduction in ischemic events) and predicted risk (increase in bleeding events) were estimated. The relative importance of ischemic and bleeding events based on links to all-cause mortality was quantified, although the limitations of such weightings are noted. RESULTS Overall results demonstrated both clear benefit and harm from vorapaxar. Substantial interindividual variation in both benefit and risk facilitated distinguishing patients with a favorable benefit-risk trade-off from those who did not. Such findings were applied to recommend vorapaxar in as many as 98.3% of patients in which a favorable mortality-weighted benefit-risk trade-off was present, in 77.2% of patients with ischemic benefit 20% greater than bleeding risk, or in as few as 45.5% of patients if an annual decrease in ischemic risk of ≥0.5% was also required. CONCLUSION While overall randomized controlled trials of treatment benefit vs risk are valuable, models determining each individual patient's estimated absolute benefit and risk provide more useful insight regarding patient-specific benefit-risk trade-offs to better enable personalized therapeutic decision-making.
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Affiliation(s)
- Stuart J Pocock
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Ruth Owen
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - John Gregson
- Medical Statistics Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | - Deborah Ashby
- Imperial College School of Public Health, London, United Kingdom
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York City, New York, USA. https://twitter.com/GreggWStone
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24
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Ghafil C, Park C, Yu J, Drake A, Sundaram S, Thiele L, Graham C, Inaba K, Matsushima K. The risk of hemorrhagic complications after anticoagulation therapy in trauma patients: A multicenter evaluation. J Trauma Acute Care Surg 2024; 96:757-762. [PMID: 37962213 PMCID: PMC11043002 DOI: 10.1097/ta.0000000000004209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND The use of anticoagulation therapy (ACT) in trauma patients during the postinjury period presents a challenge given the increased risk of hemorrhage. Guidelines regarding whether and when to initiate ACT are lacking, and as a result, practice patterns vary widely. The purpose of this study is to describe the incidence of hemorrhagic complications in patients who received ACT during their hospitalization, identify risk factors, and characterize the required interventions. METHODS In this retrospective cohort study, all trauma admissions at two Level I trauma centers between January 2015 and December 2020 were reviewed. Patients with preexisting ACT use or those who developed a new indication for ACT were included for analysis. Demographic and outcome data were collected for those who received ACT during their admission. Comparisons were then made between the complications and no complications groups. A subgroup analysis was performed for all patients started on ACT within 14 days of injury. RESULTS A total of 812 patients were identified as having an indication for ACT, and 442 patients received ACT during the postinjury period. The overall incidence of hemorrhagic complications was 12.7%. Of those who sustained hemorrhagic complications, 18 required procedural intervention. On regression analysis, male sex, severe injuries, and the need for hemorrhage control surgery on arrival were all found to be associated with hemorrhagic complications after the initiation of ACT. Waiting 7 days to 14 days from the time of injury to initiate ACT reduced the odds of complications by 46% and 71%, respectively. CONCLUSION The use of ACT in trauma during the postinjury period is not without risk. Waiting 7 days to 14 days postinjury might greatly reduce the risk of hemorrhagic complications. LEVEL OF EVIDENCE Therapeutic/Care Management Study; Level IV.
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Affiliation(s)
- Cameron Ghafil
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Caroline Park
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Jeremy Yu
- Department of Preventive Medicine, University of Southern California, 1845 N Soto St. Los Angeles, CA, USA 90032
| | - Andrew Drake
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Shivani Sundaram
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Lisa Thiele
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Caleb Graham
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd. Dallas, TX, USA 75390
| | - Kenji Inaba
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, 2051 Marengo St. Los Angeles, CA, USA 90033
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25
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Afzal A, Gage BF, Suhong L, Schoen M, Sanfilippo KM. Modest performance of risk-prediction models for anticoagulant-related bleeding in patients with chronic liver disease. Thromb Res 2024; 237:138-140. [PMID: 38583311 DOI: 10.1016/j.thromres.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 04/02/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Amber Afzal
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America.
| | - Brian F Gage
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America
| | - Luo Suhong
- Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
| | - Martin Schoen
- Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
| | - Kristen M Sanfilippo
- Department of Medicine, Washington University in St Louis, St Louis, MO, United States of America; Department of Medicine, St. Louis Veterans Administration Medical Center, St Louis, MO, United States of America
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Waranugraha Y, Lin LY, Tsai CT. Head-to-head comparison between left atrial appendage occlusion and non-vitamin K oral anticoagulants in non-valvular atrial fibrillation patients: A systematic review and meta-analysis study. Trends Cardiovasc Med 2024; 34:225-233. [PMID: 36775218 DOI: 10.1016/j.tcm.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
Left atrial appendage occlusion (LAAO) was found to be non-inferior to warfarin. In non-valvular atrial fibrillation (AF), there is still a scarcity of data comparing LAAO versus non-vitamin K oral anticoagulants (NOACs). Our purpose was to compare the clinical benefits between LAAO and NOACs in non-valvular AF patients. The patient, intervention, comparison, and outcome principles were used to develop the research question in this systematic review and meta-analysis. Literature searches were conducted in online scientific databases such as ProQuest, PubMed, and ScienceDirect. All important information was extracted. The random-effect model was applied to estimate all pooled effects. The Mantel-Haenszel statistical method was used to determine the pooled risk ratio (RR) and 95% confidence interval (CI). A total of 4411 participants from 5 studies were involved. LAAO significantly decreased the cardiovascular mortality risk compared to NOACs (RR = 0.56; 95% CI = 0.42 to 0.75; p <0.01). Major bleeding risk in the LAAO group was significantly lower than in the NOACs group (RR = 0.66; RR = 0.53 to 0.82; p <0.01). A significantly lower risk of major bleeding or non-major bleeding in the patients receiving LAAO than NOACs was also observed in this meta-analysis (RR = 0.66; 95% CI = 0.54 to 0.81; p <0.01). LAAO was superior to the NOACs in reducing cardiovascular mortality, major bleeding, and major or non-major bleeding risks in non-valvular AF patients. In high-risk thromboembolism and bleeding patients, LAAO can be considered first as a long-term treatment strategy.
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Affiliation(s)
- Yoga Waranugraha
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Universitas Brawijaya Hospital, Malang, Indonesia
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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Fatima B, Mohan A, Altaie I, Abughosh S. Predictors of adherence to direct oral anticoagulants after cardiovascular or bleeding events in Medicare Advantage Plan enrollees with atrial fibrillation. J Manag Care Spec Pharm 2024; 30:408-419. [PMID: 38701026 PMCID: PMC11068655 DOI: 10.18553/jmcp.2024.30.5.408] [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: 05/05/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated. OBJECTIVE To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data. METHODS This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable. RESULTS Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50). CONCLUSIONS Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.
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Haymart B, Kong X, Ali M, Schaefer JK, Froehlich JB, Ryan N, Stallings B, Barnes GD, Kaatz S. Prevalence of Guideline-Discordant Aspirin Use and Associated Adverse Events in Patients on Warfarin for Mechanical Valve Replacement. Am J Med 2024; 137:449-453. [PMID: 38280559 DOI: 10.1016/j.amjmed.2024.01.015] [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: 12/05/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND For patients on warfarin for mechanical heart valve replacement, the 2020 American College of Cardiology and American Heart Association Guidelines recommend only adding aspirin in patients with a specific indication for antiplatelet therapy. This contrasts with prior guidelines, which recommended concomitant aspirin therapy. We sought to assess the prevalence of guideline-discordant aspirin use among patients on warfarin for mechanical heart valve replacement and to compare adverse event rates among patients with and without concomitant aspirin. METHODS Patients on warfarin for mechanical heart valve replacement were identified from the Michigan Anticoagulation Quality Improvement Initiative registry. Patients with myocardial infarction, percutaneous coronary intervention, or coronary artery bypass within the past 12 months were excluded. Patients were divided into 2 groups based on aspirin use. Patient characteristics and bleeding and thromboembolic outcomes were compared. RESULTS Four hundred forty-four patients met the inclusion criteria, with 341 (76.8%) on concomitant aspirin. The aspirin group was older (50.6 vs 46.3 years, P = .028) and had more hypertension (57.8% vs 46.6%, P = .046) but other patient characteristics were similar. The aspirin group had a higher rate of bleeding events (28.3 vs 13.3 per 100 patient-years, P < .001) and bleed-related emergency department visits (11.8 vs 2.9 per 100 patient-years, P = .001) compared with the non-aspirin group. There was no observed difference in rates of ischemic stroke (0.56 vs 0.48 per 100 patient-years, P = .89). CONCLUSIONS A significant proportion of patients on warfarin for mechanical heart valve replacement are on guideline-discordant aspirin. Aspirin deprescribing in select patients may safely reduce bleeding events.
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Affiliation(s)
- Brian Haymart
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.
| | - Xiaowen Kong
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mona Ali
- Department of Heart and Vascular Services, Corewell Health William Beaumont University Hospital, Royal Oak, Mich
| | - Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - James B Froehlich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Noelle Ryan
- Ambulatory Anticoagulation Services, Henry Ford Health, Detroit, Mich
| | | | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Health, Detroit, Mich
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Kürzinger ML, El-Haddad C, Gouin-Soboleva T, Fazekas Z, Granados D, Benito-Garcia E, Djoudi Y. Structured benefit-risk assessment for enoxaparin, in the context of its label extension, for the extended treatment of deep vein thrombosis and pulmonary embolism, and prevention of its recurrence in patients with active cancer. Pharmacoepidemiol Drug Saf 2024; 33:e5795. [PMID: 38680090 DOI: 10.1002/pds.5795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Guidelines recommend low-molecular-weight heparins (LMWHs) for patients with cancer-associated thrombosis. However, until recently, only dalteparin and tinzaparin were approved in the European Economic Area (EEA) for these patients. This study compares the benefit-risk profile of enoxaparin with dalteparin and tinzaparin for the extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrence in adult patients with active cancer. METHODS A semi-quantitative structured benefit-risk assessment was conducted for the label-extension application of enoxaparin based on the benefit-risk action team descriptive framework: define decision context; determine key benefit and risk outcomes; identify data sources; extract data; interpret results. RESULTS The key benefits were defined as reduced all-cause mortality and venous thromboembolism (VTE) recurrence (including symptomatic DVT, fatal PE or non-fatal PE); the key risks were major and non-major bleeding of clinical significance, and heparin-induced thrombocytopenia (HIT). Enoxaparin demonstrated comparable effects for the reduction of VTE recurrence and all-cause mortality versus other EEA-approved LMWHs (dalteparin, tinzaparin). There was no evidence of a significant difference between enoxaparin and the comparator groups with regard to incidence of major and non-major bleeding. The data on HIT were too limited to assess the difference between the two groups. CONCLUSIONS The assessment demonstrated a favourable benefit-risk profile for enoxaparin similar to that of other EEA-approved LMWHs for the treatment of DVT and PE and the prevention of recurrence in patients with active cancer and thus supported the label-extension approval.
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Affiliation(s)
| | - Chantal El-Haddad
- Sanofi, Global Epidemiology and Benefit-Risk, PSPV, Gentilly, France
| | | | - Zita Fazekas
- Sanofi, Global Regulatory Affairs-EU-GenMed, Vienna, Austria
| | - Denis Granados
- Sanofi, Global Epidemiology and Benefit-Risk, PSPV, Gentilly, France
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Nguyen Van D, Le Van Q, Nguyen Thi Thu N, Bui Van G, Ta Van T. The impact of trans-arterial embolization on the result of chemoradiotherapy in oral cavity cancer. Ear Nose Throat J 2024; 103:NP272-NP277. [PMID: 34821166 DOI: 10.1177/01455613211054181] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: Evaluation of the hemostatic effect of trans-arterial embolization on patients with advanced oral cavity cancer who had bleeding complications while undergoing definitive concurrent chemoradiotherapy (CCRT). Additionally, assess the effect of trans-arterial embolization on treatment response following concurrent chemoradiotherapy, as well as overall survival (OS) and progression-free survival (PFS) in the group of patients following the intervention. Method: From September 2018-June 2021, a retrospective descriptive study was conducted on 16 patients with inoperable, locally advanced oral cavity cancer who received definitive concurrent chemoradiotherapy, experienced acute bleeding complications, and received selective intravascular intervention with various embolization materials at Vietnam National Cancer Hospital. Results: After selective embolization, 16/16 patients ceased bleeding; 1 patient re-bled for the second time after 3 weeks. The average duration of chemoradiotherapy interruption due to intervention was 6.7 days. After CCRT, 15/16 (93.75%) patients achieved a response, with 9/16 (56.25%) patients achieving a complete response. The median OS was 14 months (range, 3-26 months), and the median PFS was 10 months (range, 3-20 months). There were no significant complications, particularly neurological side effects. ConclusionsTumor bleeding is a common and serious complication of CCRT treatment in patients with locally advanced oral cavity cancer. Embolization is a safe and effective method of controlling acute bleeding that has no adverse effect on the outcome of definitive concurrent chemoradiotherapy.
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Affiliation(s)
- Dang Nguyen Van
- Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
- Department of Head and neck Radiation Oncology, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Quang Le Van
- Department of Oncology, Hanoi Medical University, Hanoi, Vietnam
| | - Nhung Nguyen Thi Thu
- Department of Head and neck Radiation Oncology, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - Giang Bui Van
- Radiology Center, Vietnam National Cancer Hospital, Hanoi, Vietnam
| | - To Ta Van
- Center of Pathology and Molecular biology, Vietnam National Cancer Hospital, Hanoi, Vietnam
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Lee SH, Lee SJ, Heo JH, Ahn SG, Doh JH, Shin S, Shim J, Her AY, Kim BG, Lim SW, Kwon TG, Lee KH, Kim D, Lee YJ, Yu HT, Kim TH, Shin DH, Pak HN, Kim JS. Optimal antithrombotic strategy in patients with atrial fibrillation beyond 1 year after drug-eluting stent implantation: Design and rationale of the randomized ADAPT AF-DES trial. Am Heart J 2024; 271:48-54. [PMID: 38401647 DOI: 10.1016/j.ahj.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Both anticoagulation and antiplatelet therapies are recommended after percutaneous coronary intervention (PCI) in patients with atrial fibrillation (AF). Although contemporary guidelines recommend discontinuation of antiplatelet therapy 1 year after drug-eluting stent (DES) implantation due to excessive bleeding risk, supporting randomized trials are still lacking. METHODS The ADAPT AF-DES trial is a multicenter, prospective, open-label, randomized, non-inferiority trial, enrolling 960 patients with AF with a CHA2DS2-VASc score > 1, who underwent PCI with DES implantation at least 12 months before enrollment. Eligible patients are randomly assigned to receive either non-vitamin K antagonist oral anticoagulant (NOAC) monotherapy or NOAC plus clopidogrel combination therapy. The primary outcome is net adverse clinical event (NACE) at 1 year after randomization, defined as a composite of all-cause death, myocardial infarction, stent thrombosis, stroke, systemic embolism, and major or clinically relevant non-major bleeding, as defined by the International Society on Thrombosis and Hemostasis criteria. We hypothesize that NOAC monotherapy would be non-inferior to NOAC plus clopidogrel combination therapy for NACE in patients with AF beyond 12 months after DES implantation. CONCLUSIONS The ADAPT AF-DES trial will evaluate the efficacy and safety of NOAC monotherapy versus NOAC plus clopidogrel combination therapy in patients with AF beyond 12 months after PCI with DES implantation. The ADAPT AF-DES trial will provide robust evidence for an optimal antithrombotic strategy in patients with AF after DES implantation. CLINICAL TRIAL REGISTRATION https://www. CLINICALTRIALS gov. Unique identifier: NCT04250116.
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Affiliation(s)
- Sang-Hyup Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung-Jun Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ho Heo
- Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea
| | - Sung Gyun Ahn
- Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Joon-Hyoung Doh
- Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Sanghoon Shin
- Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Jaemin Shim
- Korea University Medical Center, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University College of Medicine, Kangwon National University School of Medicine, Chuncheon, Republic of Korea
| | - Byung Gyu Kim
- Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Sang Wook Lim
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Republic of Korea
| | - Taek-Geun Kwon
- Konyang University Hospital, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Kyoung-Hoon Lee
- Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Daehoon Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Joon Lee
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Tae Yu
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae-Hoon Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong-Ho Shin
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hui-Nam Pak
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Sun Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Rehan ST, Ali A, Shuja SH, Eqbal F, Ahmed J, Ullah W, Asghar MS. Effects of Anticoagulation on Patients With Intra-Aortic Balloon Pump-A Meta-Analysis of 19,427 Patients. Am J Ther 2024; 31:e335-e338. [PMID: 38227903 DOI: 10.1097/mjt.0000000000001684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Affiliation(s)
- Syeda Tayyaba Rehan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Abraish Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Hasan Shuja
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Farea Eqbal
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Jawad Ahmed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Waqas Ullah
- Department of Cardiology, Thomas Jefferson University Hospitals, Philadelphia, PA
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Rajsic S, Breitkopf R, Treml B, Jadzic D, Innerhofer N, Eckhardt C, Oberleitner C, Bukumiric Z. Association of anti-factor Xa-guided anticoagulation with hemorrhage during ECMO support: A systematic review and meta-analysis. Clin Cardiol 2024; 47:e24273. [PMID: 38693831 PMCID: PMC11063723 DOI: 10.1002/clc.24273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/08/2024] [Accepted: 04/15/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) is associated with complex hemostatic changes. Systemic anticoagulation is initiated to prevent clotting in the ECMO system, but this comes with an increased risk of bleeding. Evidence on the use of anti-Xa-guided monitoring to prevent bleeding during ECMO support is limited. Therefore, we aimed to analyze the association between anti-factor Xa-guided anticoagulation and hemorrhage during ECMO. METHODS A systematic review and meta-analysis was performed (up to August 2023). PROSPERO CRD42023448888. RESULTS Twenty-six studies comprising 2293 patients were included in the analysis, with six works being part of the meta-analysis. The mean anti-Xa values did not show a significant difference between patients with and without hemorrhage (standardized mean difference -0.05; 95% confidence interval [CI]: -0.19; 0.28, p = .69). We found a positive correlation between anti-Xa levels and unfractionated heparin dose (UFH; pooled estimate of correlation coefficients 0.44; 95% CI: 0.33; 0.55, p < .001). The most frequent complications were any type of hemorrhage (pooled 36%) and thrombosis (33%). Nearly half of the critically ill patients did not survive to hospital discharge (47%). CONCLUSIONS The most appropriate tool for anticoagulation monitoring in ECMO patients is uncertain. Our analysis did not reveal a significant difference in anti-Xa levels in patients with and without hemorrhagic events. However, we found a moderate correlation between anti-Xa and the UFH dose, supporting its utilization in monitoring UFH anticoagulation. Given the limitations of time-guided monitoring methods, the role of anti-Xa is promising and further research is warranted.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Dragana Jadzic
- Anesthesia and Intensive Care Department, Pain Therapy ServiceCagliari UniversityCagliariItaly
| | - Nicole Innerhofer
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Christine Eckhardt
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Christoph Oberleitner
- Department of Anaesthesiology and Intensive Care MedicineMedical University InnsbruckInnsbruckAustria
| | - Zoran Bukumiric
- Institute of Medical Statistics and Informatics, Faculty of MedicineUniversity of BelgradeBelgradeSerbia
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Birocchi S, Rocchetti M, Minardi A, Podda GM, Squizzato A, Cattaneo M. Guided Anti-P2Y12 Therapy in Patients Undergoing PCI: Three Systematic Reviews with Meta-analyses of Randomized Controlled Trials with Homogeneous Design. Thromb Haemost 2024; 124:482-496. [PMID: 37549688 DOI: 10.1055/a-2149-4344] [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: 08/09/2023]
Abstract
BACKGROUND The value of guided therapy (GT) with anti-P2Y12 drugs in percutaneous coronary intervention (PCI) is unclear. Meta-analyses lumped together randomized controlled trials (RCTs) with heterogeneous designs, comparing either genotype-GT or platelet function test (PFT)-GT with unguided therapy. Some meta-analysis also included RCTs that did not explore GT, but included the effects of switching patients with high on-treatment platelet reactivity (HTPR) to alternative therapies (HTPR-Therapy). We performed three distinct systematic reviews/meta-analyses, each exploring only RCTs with homogeneous design. METHODS MEDLINE, Embase, and Central databases were searched for RCTs testing genotype-GT, PFT-GT, or HTPR-Therapy in PCI-treated patients, through October 1, 2022. Two reviewers extracted the data. Risk ratios (RRs) (95% confidence intervals) were calculated. Primary outcomes were major bleedings (MBs) and major adverse cardiovascular events (MACE). RESULTS In seven genotype-GT RCTs, RRs were: MB, 1.06 (0.73-1.54; p = 0.76); MACE, 0.65 (0.47-0.91; p = 0.01), but significant risk reduction was observed in RCTs performed in China (0.30, 0.16-0.54; p < 0.0001) and not elsewhere (0.75, 0.48-1.18; p = 0.21). In six PFT-GT RCTs, RRs were: MB, 0.91 (0.64-1.28, p = 0.58); MACE, 0.82 (0.56-1.19; p = 0.30): 0.62 (0.42-0.93; p = 0.02) in China, 1.08 (0.82-1.41; p = 0.53) elsewhere. In eight HTPR-Therapy RCTs, RRs were: MB, 0.71 (0.41-1.23; p = 0.22); MACE, 0.57 (0.44-0.75; p < 0.0001): 0.56 (0.43-0.74, p < 0.0001) in China, 0.58 (0.27-1.23, p = 0.16) elsewhere. CONCLUSION No GT strategy affected MB. Overall, genotype-GT but not PFT-GT reduced MACE. However, genotype-GT and PFT-GT reduced MACE in China, but not elsewhere. PFT-GT performed poorly compared to HTPR-Therapy, likely due to inaccurate identification of HTPR patients by PFT.
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Affiliation(s)
- Simone Birocchi
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Matteo Rocchetti
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Minardi
- Divisione di Cardiologia, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Gian Marco Podda
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Alessandro Squizzato
- Research Center on Thromboembolic Disorders and Antithrombotic Therapies, ASST Lariana, University of Insubria, Como, Italy
| | - Marco Cattaneo
- Divisione di Medicina Generale II, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
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Knox H, Edwin SB, Giuliano C, Paxton RA. Venous Thromboembolism Prophylaxis in Low Body Weight Critically Ill Patients. J Intensive Care Med 2024; 39:493-498. [PMID: 38111295 DOI: 10.1177/08850666231217693] [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] [Indexed: 12/20/2023]
Abstract
OBJECTIVE To compare bleeding and thromboembolic events in low body weight patients receiving reduced-dose venous thromboembolism (VTE) prophylaxis versus standard-dose VTE prophylaxis. DESIGN Multicenter, retrospective, cohort study. SETTING Five Ascension Health Hospitals. PATIENTS Adult, critically ill, low body weight (≤50 kg) patients who received either reduced-dose VTE prophylaxis (n = 140) or standard-dose VTE prophylaxis (n = 279) for at least 48 h. INTERVENTION Reduced-dose prophylaxis (enoxaparin 30 mg daily or heparin 5000 units every 12 h subcutaneously) or standard-dose prophylaxis (enoxaparin 40 mg daily, enoxaparin 30 mg every 12 h, or heparin 5000 units every 8 h subcutaneously). MEASUREMENTS AND MAIN RESULTS A total of 419 patients were included with a mean weight of 45.1 ± 4.2 kg in the standard-dose group and 44.0 ± 5.1 kg in the reduced-dose prophylaxis group (P = .02). The primary endpoint, composite bleeding, was significantly lower in patients receiving reduced-dose prophylaxis (5% vs 12.5%, P = .02). After adjusting for confounding factors, results remained consistent demonstrating reduced composite bleeding with reduced-dose prophylaxis (odds ratio: 0.36, 95% confidence interval: 0.14-0.96). Major bleeding events occurred in 3.6% of reduced-dose patients compared with 8.6% in standard-dose patients (P = .056). Clinically relevant nonmajor bleeding (5.4% vs 2.9%, P = .24) and VTE (2.2% vs 0%, P = .08) events were similar between groups. CONCLUSIONS A reduced-dose VTE prophylaxis strategy in low body weight, critically ill patients was associated with a lower risk of composite bleeding and similar rate of thromboembolism.
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Affiliation(s)
- Helena Knox
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Stephanie B Edwin
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
| | - Christopher Giuliano
- Department of Pharmacy, Ascension St. John Hospital, Detroit, MI, USA
- Department of Pharmacy, Wayne State University, Eugene Applebaum Applebaum College of Pharmacy and Health Sciences, Detroit, MI, USA
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Valenti GG, Sabo C, Hyde M, Rajpurkar M. Real-world experience of direct oral anticoagulant use in a single pediatric center. Pediatr Blood Cancer 2024; 71:e30926. [PMID: 38449356 DOI: 10.1002/pbc.30926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/16/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Pediatric venous thromboembolism has increased by 130%-200%, specifically in hospitalized children, and direct oral anticoagulants (DOACs) offer several therapeutic advantages. METHODS This study aims to evaluate the real-world epidemiological and outcome data from a retrospective review of pediatric patients treated with DOACs from January 1, 2013 to December 31, 2022. In this single-center, IRB-approved study, 65 patients were identified and analyzed using SPSS statistical software, and a descriptive statistical analysis was conducted. RESULTS Of the 65 patients, 37% were on apixaban, 61.5% were on rivaroxaban, and 1.5% were on dabigatran. Per the 2023 ISTH outcome definitions, one (2%) patient had a major bleeding episode, six (9%) had clinically relevant non-major bleeding, three (5%) patients had patient-important heavy menstrual bleeding (HMB), and one (1.5%) patient had minor bleeding. Seven (19%) of 37 postmenarchal patients had evidence of HMB. Six (9.2%) patients had recurrent venous thromboembolism while on a DOAC (one was on apixaban, and five were on rivaroxaban) and were transitioned to other forms of anticoagulation. CONCLUSION Thus, bleeding rates after DOAC therapy are comparable to previous DOAC trials, as well as other anticoagulants in pediatrics. HMB is an important outcome measure and should continue to be investigated. This study reports a higher rate of recurrent thrombosis (9.2%) compared to other trials. However, this observation may be attributed to patients who had ongoing risk factors, as well as a longer duration of study follow-up. Additional multicentered outcome studies evaluating DOAC use in children are needed to determine long-term recurrence and HMB risks.
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Affiliation(s)
- Gianna G Valenti
- Department of Pediatrics, Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Cynthia Sabo
- Department of Pediatrics, Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Michelle Hyde
- Department of Pediatrics, Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Madhvi Rajpurkar
- Department of Pediatrics, Pediatric Hematology Oncology, Children's Hospital of Michigan, Detroit, Michigan, USA
- Central Michigan University School of Medicine, Mount Pleasant, South Carolina, USA
- Wayne State University School of Medicine, Detroit, Michigan, USA
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Onuk T, Polat F, Yaylak B, Akyüz Ş, Kolak Z, Durak F. Comparison of ticagrelor and clopidogrel in anemic patients with acute coronary syndrome: efficacy and safety outcomes over one year. Eur J Clin Pharmacol 2024; 80:759-770. [PMID: 38360988 DOI: 10.1007/s00228-024-03653-1] [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: 11/11/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE This retrospective study aimed to investigate the potential impact of ticagrelor and clopidogrel treatment on cardiovascular outcomes in patients with anemia and acute coronary syndrome (ACS) and to provide insights into the optimal therapeutic approach for this vulnerable patient population. METHODS A retrospective research design was employed, involving patients diagnosed with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) between 2014 and 2021. Inclusion criteria required a hemoglobin level below 12 mg/dL and a minimum 12-month P2Y12 inhibitor treatment. Comprehensive clinical, biochemical, and echocardiographic data were collected from the hospital's electronic repository. The primary efficacy endpoint was major adverse cardiovascular events (MACE), encompassing total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke. Major hemorrhage was the primary safety endpoint. Secondary outcomes included total mortality, cardiovascular mortality, reinfarction, ischemic stroke, and hemorrhagic stroke, individually. RESULTS Patients treated with ticagrelor (n = 118) and clopidogrel (n = 538) were compared. No significant difference was observed in major adverse cardiovascular events (MACE) and major bleeding between ticagrelor and clopidogrel treatment groups (MACE: clopidogrel 10.0% vs. ticagrelor 11.0%, p = 0.75; major bleeding: clopidogrel 2.8%, ticagrelor 2.5%, p = 0.88). Patients with hemoglobin levels ≤ 8 mg/dL demonstrated significantly higher MACE and major bleeding rates in the ticagrelor group (p = 0.008 and p = 0.002, respectively). Among patients aged ≥ 75 years, ticagrelor treatment was associated with a higher risk of major bleeding (p = 0.04). CONCLUSIONS Ticagrelor and clopidogrel exhibited comparable efficacy and safety outcomes in anemic ACS patients over a one-year period. Although ticagrelor demonstrated superiority in reducing ischemic events, it is crucial to recognize the limitations of retrospective studies in informing clinical practice. This study offers valuable insights into tailoring antiplatelet therapy for anemic ACS patients and provides guidance for personalized treatment strategies, acknowledging the hypothesis-generating nature of retrospective analyses.
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Affiliation(s)
- Tolga Onuk
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye.
| | - Fuat Polat
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Barış Yaylak
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Şükrü Akyüz
- Department of Cardiology, Okan University Faculty of Health Sciences, Istanbul, Türkiye
| | - Zeynep Kolak
- Department of Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Educatıon Research Hospıtal, Selimiye Mah. T?bbiye Cad. No.25 ?sk?dar, Istanbul, Türkiye
| | - Furkan Durak
- Department of Cardiology, Prof. Dr. İlhan Varank Sancaktepe Training and Research Hospital, Istanbul, Türkiye
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Giordano P, Pollio B, Sottilotta G, Biasoli C, Daniele F, De Cristofaro R, Peyvandi F, Villa MR, Castaman G. Pattern of use and clinical outcomes with rIX-FP in pediatric/adolescent patients with haemophilia B in Italy: Results from IDEAL real-world study. Eur J Haematol 2024; 112:765-775. [PMID: 38223989 DOI: 10.1111/ejh.14168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES To evaluate pattern of use and clinical outcomes in pediatric/adolescent patients enrolled in the IDEAL study. METHODS This post-hoc analysis of IDEAL retrospective-prospective observational study focused on patients <18 years, 100% on prophylaxis during the entire observation period. RESULTS Thirteen subjects (median age 10.0 years; 61.5% ≤ 11 years) were analyzed. The infusion frequency changed from 2/week in 84.6% (N = 11) of patients with previous rFIX, to less than 1/weekly in 76.9% (N = 9) with rIX-FP and the annualized number of infusions reduced of 57% (p = .002), from a mean ± SD of 95.1 ± 22.77 to 40.4 ± 6.79, respectively. Annualized mean consumption decreased of about 56% (p = .001), from 3748.4 ± 1155.40 IU/kg with previous rFIX, to 1656.8 ± 456.63 IU/kg of rIX-FP. Mean FIX trough level changed from 3.0% ± 1.98% to 10.92% ± 3.6%. Low mean Annualized Bleeding Rate was maintained across all prophylaxis regimens (0.8 ± 1.69 vs. 0.3 ± 0.89) and zero bleeding patients moved from 69.2% (N = 9) with previous rFIX to 84.6% (N = 11) with rIX-FP (p = .63). Two adverse events, none related to rIX-FP, occurred in two patients. No inhibitors development was reported. CONCLUSIONS The results in this pediatric/adolescent subgroup support rIX-FP prophylaxis may reduce infusion frequency, while providing high FIX trough levels, stable annualized bleeding rate and a good safety profile.
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Affiliation(s)
- Paola Giordano
- B. Trambusti General and Specialised Paediatrics Unit, Giovanni XXIII Hospital, University of Bari, Bari, Italy
| | - Berardino Pollio
- Regional Reference Centre for Inherited Bleeding and Thrombotic Disorders, Transfusion Medicine, Regina Margherita Children Hospital, Turin, Italy
| | | | - Chiara Biasoli
- Haemophilia and Transfusion Centre, Bufalini Hospital, Cesena, Italy
| | - Filomena Daniele
- Haemostasis and Thrombosis Service, Ospedale Civile dell'Annunziata, Cosenza, Italy
| | - Raimondo De Cristofaro
- Haemorrhagic and Thrombotic Disease Service, Area of Haematological and Oncological Sciences, IRCCS Fondazione Policlinico Universitario A. Gemelli, Rome, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Haemophilia and Thrombosis Centre, and Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Maria Rosaria Villa
- Haemophilia and Thrombosis Centre, Hematology Unit, Ospedale del Mare, Naples, Italy
| | - Giancarlo Castaman
- Centre for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
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Ahmed H, Reeve N, Farewell D, Hamilton F, Ponsford M, Hippisley-Cox J, Noble S. Risk of bleeding amongst warfarin and direct oral anticoagulant users prescribed immediate antibiotics for respiratory tract infection: Cohort study. Pharmacoepidemiol Drug Saf 2024; 33:e5794. [PMID: 38680080 DOI: 10.1002/pds.5794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 02/20/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Incidence of bleeding amongst warfarin and direct oral anticoagulant (DOAC) users is greater following a respiratory tract infection (RTI). It is unclear whether immediate antibiotics modify this association. We estimated the risk of bleeding amongst warfarin and DOAC users with RTI by antibiotic treatment. METHODS This retrospective cohort study used data from the Clinical Practice Research Datalink (CPRD) GOLD for adults in England prescribed warfarin or a DOAC, who sought primary care for an RTI between 1st January 2011 and 31st December 2019. Outcomes were major bleeding (hospital admission for intracranial or gastrointestinal bleeding), and non-major bleeding (hospital admission or General Practice consult for epistaxis, haemoptysis, or haematuria). Cox models derived hazard ratios (HRs) and 95% confidence intervals (CIs) for each outcome, adjusting for confounders using inverse probability of treatment weighting. RESULTS Of 14 817 warfarin and DOAC users consulting for an RTI, 8768 (59%) were prescribed immediate antibiotics and 6049 (41%) were not. Approximately 49% were female, and median age was 76 years. Antibiotics were associated with reduced risk of major bleeding (adjusted HR 0.38, 95% CI 0.25 to 0.58). This was consistent across several sensitivity analyses. Antibiotics were also associated with a reduced risk of non-major bleeding (adjusted HR 0.78, 95% CI 0.61 to 0.99). CONCLUSIONS Immediate antibiotics were associated with reduced risk of bleeding amongst warfarin and DOAC users with an RTI. Further work is needed to understand mechanisms and confirm whether a lower threshold for antibiotic use for RTI in this population may be beneficial.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Nicola Reeve
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Mark Ponsford
- Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | - Julia Hippisley-Cox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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Wang Z, Zhang A, Xu Z, Wang N, Zhang J, Meng J, Dong S, Ma J, Hu Y, Ouyang J, Chen Z, An Q, Cheng X, Wu R. Efficacy and safety of avatrombopag in Chinese children with persistent and chronic primary immune thrombocytopenia: A multicentre observational retrospective study in China. Br J Haematol 2024; 204:1958-1965. [PMID: 38362793 DOI: 10.1111/bjh.19342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/16/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Abstract
Avatrombopag (AVA) is a novel thrombopoietin receptor agonist (TPO-RA) that has been recently approved as a second-line therapy for immune thrombocytopenia (ITP) in adults; however, its safety and efficacy data in children are lacking. Here, we demonstrated the efficacy and safety of AVA as second-line therapy in children with ITP. A multicentre, retrospective, observational study was conducted in children with persistent or chronic ITP who did not respond to or relapsed from previous treatment and were treated with AVA for at least 12 weeks between August 2020 and December 2022. The outcomes were the responses (defined as achieving a platelet count ≥30 × 109/L, twofold increase in platelet count from baseline and absence of bleeding), including rapid response within 4 weeks, sustained response at weeks 12 and 24, bleeding control and adverse events (AEs). Thirty-four (18 males) patients with a mean age of 6.3 (range: 1.9-15.3) years were enrolled. The median number of previous treatment types was four (range: 1-6), and 41.2% patients switched from other TPO-RAs. Within 4 weeks, overall response (OR) was achieved in 79.4% patients and complete response (CR, defined as a platelet count ≥100 × 109/L and the absence of bleeding) in 67.7% patients with a median response time of 7 (range: 1-27) days. At 12 weeks, OR was achieved in 88.2%, CR in 76.5% and sustained response in 44% of patients. At 24 weeks, 22/34 (64.7%) patients who achieved a response and were followed up for 24 weeks were evaluated; 12/22 (54.55%) achieved a sustained response. During AVA therapy, median platelet counts increased by week 1 and were maintained throughout the treatment period. The proportion of patients with grade 1-3 bleeding decreased from 52.95% at baseline to 2.94% at 12 weeks, while concomitant ITP medications decreased from 36.47% at baseline to 8.82% at 12 weeks, with only 9 (26.47%) patients receiving rescue therapy 23 times within 12 weeks. There were 61.8% patients with 59 AEs: 29.8% with Common Terminology Criteria for Adverse Events grade 1 and the rest with grade 2. These findings show that AVA could achieve a rapid and sustained response in children with persistent or chronic ITP as a second-line treatment, with good clinical bleeding control and reduction of concomitant ITP therapy, without significant AEs.
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Affiliation(s)
- Zhifa Wang
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Aijun Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Zhongjin Xu
- Department of Hematology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Nan Wang
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jialu Zhang
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jinxi Meng
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Shuyue Dong
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jingyao Ma
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yu Hu
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Juntao Ouyang
- Hematologic Disease Laboratory, Hematology Centre, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, National Centre for Children's Health, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Zhenping Chen
- Hematologic Disease Laboratory, Hematology Centre, Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, National Centre for Children's Health, Ministry of Education, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qi An
- Department of Hematology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Xiaoling Cheng
- Department of Pharmacy, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Runhui Wu
- Beijing Key Laboratory of Pediatric Hematology-Oncology, National Key Discipline of Pediatrics (Capital Medical University), Key Laboratory of Major Diseases in Children, Hemophilia Comprehensive Care Centre, Hematology Centre, National Centre for Children's Health, Ministry of Education, Beijing Children's Hospital, Capital Medical University, Beijing, China
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Mokart D, Serre E, Bruneel F, Kouatchet A, Lemiale V, Chow-Chine L, Faucher M, Sannini A, Valade S, Bisbal M, Gonzalez F, Servan L, Darmon M, Azoulay E. Acute pulmonary embolism in cancer patients admitted to intensive care unit: Impact of anticoagulant treatment on 90-day mortality and risk factors, results of a multicentre retrospective study. Thromb Res 2024; 237:129-137. [PMID: 38583310 DOI: 10.1016/j.thromres.2024.03.027] [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: 02/16/2024] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a life-threatening situation in cancer patients. In this situation, anticoagulant therapy is complex to administer due to the risk of bleeding. Only few studies have been conducted when these patients are admitted to the intensive care unit (ICU). The aim of this study was to assess the association between anticoagulation strategies as well as other factors with 90-day mortality in patients with cancer and PE admitted to ICU. Major bleeding was also evaluated according to the type of anticoagulation. METHODS Retrospective study carried out in 4 ICUs in France over a 12-year period (2009-2021). All patients with cancer and PE were included. An overlap propensity score weighting analysis was performed in the subgroup of patients treated with either unfractionated heparins (UFH) alone or low-molecular-weight heparins (LMWH) alone on 90-day mortality and major bleeding. RESULTS A total of 218 consecutive cancer patients admitted to ICU and presenting PE were included. The 90-day mortality rate was 42 % for the global cohort. After propensity score analysis in the subgroup of patients treated with either "UFH alone" (n = 80) or "LMWH alone" (n = 71), the 90-day mortality was similar in patients treated with UFH alone (42.6 %) vs LMWH alone (39.9 %): OR = 1.124, CI 95 % [0.571-2.214], p = 0.750. There was a significant increased toward major bleeding rates in the "UFH alone" group (25.5 %) as compared to "LMWH alone" group (11.5 %), p = 0.04. CONCLUSION In 218 patients admitted to ICU and presenting PE, the 90-day mortality rate was 42 %. Treatment with UFH alone was associated with a mortality comparable to treatment with LMWH alone but it appeared to be more prone to major bleeding.
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Affiliation(s)
- Djamel Mokart
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France.
| | - Edouard Serre
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Fabrice Bruneel
- Medical Intensive Care Unit, University Hospital of Angers, Angers, France
| | - Achille Kouatchet
- Medical-Surgical Intensive Care Unit, Versailles Center, Mignot Hospital, Le Chesnay, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Laurent Chow-Chine
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Marion Faucher
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Antoine Sannini
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Sandrine Valade
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Magali Bisbal
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Frederic Gonzalez
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Luca Servan
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
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Douros A, Cui Y, Platt RW, Filion KB, Sebastiani G, Renoux C. Effectiveness and safety of direct oral anticoagulants among patients with non-valvular atrial fibrillation and liver disease: A multinational cohort study. Thromb Res 2024; 237:71-78. [PMID: 38552497 DOI: 10.1016/j.thromres.2024.03.024] [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: 11/02/2023] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND AND AIMS The effects of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) and liver disease remain poorly understood. Our multinational cohort study assessed the effectiveness and safety of DOACs in this high-risk population. METHODS We assembled two population-based cohorts in United Kingdom and in Québec of NVAF patients with liver disease initiating DOACs or vitamin K antagonists (VKAs) between 2011 and 2020. Using an as-treated exposure definition, we compared DOACs to VKAs and apixaban to rivaroxaban. After inverse probability of treatment weighting, Cox proportional hazards models estimated site-specific hazard ratios (HRs) and 95 % confidence intervals (CIs) of ischemic stroke and major bleeding. Site-specific estimates were pooled using random-effects models. Analyses were repeated among NVAF patients with cirrhosis. RESULTS There were 11,881 NVAF patients with liver disease (2683 with cirrhosis). Among those, 8815 initiated DOACs (4414 apixaban, 2497 rivaroxaban) and 3696 VKAs. The HRs (95 % CIs) for DOACs compared to VKAs were 1.01 (0.76-1.34) for ischemic stroke and 0.87 (0.77-0.99) for major bleeding. Results were consistent among patients with cirrhosis. The HRs (95 % CIs) for apixaban compared to rivaroxaban were 0.85 (0.60-1.20) for ischemic stroke and 0.80 (0.68-0.95) for major bleeding. This decreased bleeding risk was not observed among patients with cirrhosis (HR, 1.01; 95 % CI 0.72-1.43). CONCLUSIONS Among NVAF patients with liver disease, DOACs were as effective and slightly safer than VKAs, and apixaban was as effective but safer than rivaroxaban. The safety benefit with apixaban was not present among patients with cirrhosis.
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Affiliation(s)
- Antonios Douros
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Ying Cui
- Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Department of Pediatrics, McGill University, Montreal, Québec, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada
| | - Giada Sebastiani
- Department of Medicine, McGill University, Montreal, Québec, Canada; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Québec, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
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Akhtar KH, Baber U. Antiplatelet Therapy for Patients Who Have Undergone Revascularization Within the Past Year: Which Agents and for How Long? Med Clin North Am 2024; 108:539-551. [PMID: 38548462 DOI: 10.1016/j.mcna.2023.12.003] [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] [Indexed: 04/02/2024]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for at least 6 and 12 months following percutaneous coronary intervention with drug-eluting stents among patients with stable ischemic heart disease and acute coronary syndrome, respectively. Additional exposure to antiplatelet therapy reduces ischemic events but also increases bleeding risk. Conversely, shorter durations of DAPT are preferred among those at high bleeding risk. Hence, decisions surrounding duration of DAPT after revascularization should include clinical judgment, assessment of the risk of bleeding and ischemic events, and time after revascularization.
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Affiliation(s)
- Khawaja Hassan Akhtar
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Usman Baber
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.
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Kao G, Chen Y, Fan J. Efficacy and safety of antiplatelet therapy in COVID-19: Insights from a meta-analysis of randomized controlled trials. Int J Clin Pharmacol Ther 2024; 62:195-203. [PMID: 38469705 DOI: 10.5414/cp204497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND COVID-19 induces a pro-coagulant state with thrombotic events. This meta-analysis explores the efficacy and safety of antiplatelet-based therapy in COVID-19 patients through randomized controlled trials (RCTs). MATERIALS AND METHODS A systematic literature search until March 10, 2023, identified 7 RCTs involving 23,415 inpatients. Of these, 11,891 received antiplatelet-based treatment, and 11,524 received placebo/other drugs. Statistical analysis was performed using Review Manager 5.4. RESULTS The included trials involved patients with a mean age ranging from 54.3 to 62.0 years and a prevalence of hypertension ranging from 10.9 to 65.0% and coronary artery disease ranging from 3.2 to 32.7%. The pooled analysis showed no significant difference in overall mortality between groups (RR 1.0, 95% CI 0.99 - 1.01, p = 0.76). However, antiplatelet therapy significantly reduced major thrombotic events (RR 0.86, 95% CI 0.75 - 0.99, p = 0.04). Conversely, it increased major bleeding risks (RR 1.62, 95% CI 1.24 - 2.12, p = 0.0005). There was no significant difference in the incidence of invasive mechanical ventilation and respiratory death. CONCLUSION Antiplatelet therapy does not confer mortality benefit in COVID-19 patients but lowers major thrombotic events while increasing major bleeding risks. Ongoing large RCTs will provide more information on the therapeutic value of this therapy.
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Mushahid H, Shah SA, Farhan SH, Shuja MH, Balasingam K, Siddiqui AA, Hameed I, Akram K, Mushahid S, Usman MS. Differential Use of Glycoprotein IIb/IIIa Inhibitors with Bivalirudin in Patients with STEMI Undergoing PCI: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2024; 24:385-398. [PMID: 38683263 DOI: 10.1007/s40256-024-00636-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 05/01/2024]
Abstract
AIM The efficacy and safety of bivalirudin when used concurrently with glycoprotein IIb/IIIa inhibitors (GPI) is uncertain. In this systematic review and meta-analysis, we aimed to evaluate the efficacy and safety of bivalirudin versus heparin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) and to explore the impact of differential use (greater and balanced) of GPI. METHODS Online databases were queried from inception to March 2023 to identify eight randomized controlled trials (n = 22,483) for inclusion. The primary outcomes included all-cause mortality, major bleeding, major adverse cardiovascular events (MACE), and net adverse clinical events (NACE). Secondary efficacy endpoints included cardiac death, reinfarction, stent thrombosis (ST), and stroke. Data were pooled using a random-effects model to derive risk ratios (RRs) and 95% confidence intervals (CIs). RESULTS When compared to heparin, bivalirudin was associated with a significant reduction in all-cause mortality (RR 0.83; 95% CI 0.72-0.97; P = 0.02), major bleeding (RR 0.73; 95% CI 0.57-0.93; P = 0.01), cardiac death (RR 0.79; 95% CI 0.66-0.94; P = 0.01), and NACE (RR 0.80; 95% CI 0.72-0.89; P < 0.0001). However, while the bivalirudin arm showed an increased likelihood of ST in the greater GPI subgroup (RR 1.70; 95% CI 1.13-2.56; P = 0.01), it was associated with a decreased likelihood of ST in the balanced GPI subgroup (RR 0.40; 95% CI 0.24-0.65; P = 0.0003). CONCLUSION Overall, our findings suggest that bivalirudin may be a more efficacious intervention than heparin for reducing certain adverse events in patients with STEMI undergoing primary PCI.
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Affiliation(s)
- Hasan Mushahid
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda Ayesha Shah
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syed Husain Farhan
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Kyle Balasingam
- Edinburgh School of Medicine, University of Edinburgh, Edinburgh, UK
| | - Asad Ali Siddiqui
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Kamran Akram
- Orlando Health Heart and Vascular Institute, Orlando, FL, USA
| | - Shayan Mushahid
- Department of Medicine, The Dudley Group NHS Foundation Trust, Dudley, UK.
| | - Muhammad Shariq Usman
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Texas, Dallas, USA
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Arias-Mendoza A, Gopar-Nieto R, Juarez-Tolen J, Ordóñez-Olvera JC, Gonzalez-Pacheco H, Briseño-De la Cruz JL, Sierra-Lara Martinez D, Mendoza-García S, Altamirano-Castillo A, Montañez-Orozco A, Arzate-Ramirez A, Baeza-Herrera LA, Ortega-Hernandez JA, Miranda-Cerda G, Cruz-Martinez JE, Baranda-Tovar FM, Zabal-Cerdeira C, Araiza-Garaygordobil D. Long-Term Outcomes of Pharmacoinvasive Strategy Versus Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction: A Study from Mexico City. Am J Cardiol 2024; 218:7-15. [PMID: 38402926 DOI: 10.1016/j.amjcard.2024.02.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 01/08/2024] [Accepted: 02/04/2024] [Indexed: 02/27/2024]
Abstract
Although primary percutaneous coronary intervention (pPCI) is the treatment of choice in ST-elevation myocardial infarction (STEMI), challenges may arise in accessing this intervention for certain geodemographic groups. Pharmacoinvasive strategy (PIs) has demonstrated comparable outcomes when delays in pPCI are anticipated, but real-world data on long-term outcomes are limited. The aim of the present study was to compare long-term outcomes among real-world patients with STEMI who underwent either PIs or pPCI. This was a prospective registry including patients with STEMI who received reperfusion during the first 12 hours from symptom onset. The primary objective was cardiovascular mortality at 12 months according to the reperfusion strategy (pPCI vs PIs) and major cardiovascular events (cardiogenic shock, recurrent myocardial infarction, and congestive heart failure), and Bleeding Academic Research Consortium type 3 to 5 bleeding events were also evaluated. A total of 799 patients with STEMI were included; 49.1% underwent pPCI and 50.9% received PIs. Patients in the PIs group presented with more heart failure on admission (Killip-Kimbal >I 48.1 vs 39.7, p = 0.02) and had a lower proportion of pre-existing heart failure (0.2% vs 1.8%, p = 0.02) and atrial fibrillation (0.25% vs 1.2%, p = 0.02). No statistically significant difference was observed in cardiovascular mortality at the 12-month follow-up (hazard ratio for PIs 0.74, 95% confidence interval 0.42 to 1.30, log-rank p = 0.30) according to the reperfusion strategy used. The composite of major cardiovascular events (hazard ratio for PIs 0.98, 95% confidence interval 0.75 to 1.29, p = 0.92) and Bleeding Academic Research Consortium type 3 to 5 bleeding rates were also comparable. A low socioeconomic status, Killip-Kimball >2, age >60 years, and admission creatinine >2.0 mg/100 ml were predictors of the composite end point after multivariate analysis. In conclusion, this prospective real-world registry provides additional support that long-term major cardiovascular outcomes and bleeding are not different between patients who underwent PIs versus primary PCI.
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Affiliation(s)
- Alexandra Arias-Mendoza
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Rodrigo Gopar-Nieto
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Jessica Juarez-Tolen
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Juan Carlos Ordóñez-Olvera
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Héctor Gonzalez-Pacheco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Jose Luis Briseño-De la Cruz
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Daniel Sierra-Lara Martinez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Salvador Mendoza-García
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Alfredo Altamirano-Castillo
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Alvaro Montañez-Orozco
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Arturo Arzate-Ramirez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Luis A Baeza-Herrera
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Jorge A Ortega-Hernandez
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Greta Miranda-Cerda
- Emergency department, Hospital General Dr. Manuel Gea González, Ciudad de México, México City
| | | | | | - Carlos Zabal-Cerdeira
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City
| | - Diego Araiza-Garaygordobil
- Cardiovascular Critical Care Unit, Instituto Nacional de Cardiología "Ignacio Chávez", Ciudad de México, México City.
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Chan YH, Chen SW, Chan CY, Chao TF. Comparative safety and effectiveness of non-vitamin K oral anticoagulants versus warfarin in patients with non-valvular atrial fibrillation: A network meta-analysis. J Formos Med Assoc 2024; 123:578-586. [PMID: 37996330 DOI: 10.1016/j.jfma.2023.10.014] [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: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The introduction of non-vitamin K antagonist oral anticoagulants (NOACs), with a non-inferior or superior clinical efficacy profile compared to vitamin K antagonists (VKAs), has significantly improved the safety profile and treatment adherence of patients with non-valvular atrial fibrillation (AF). However, few studies have compared the effectiveness and safety of NOACs. Therefore, we conducted this systematic review and network meta-analysis to compare the safety and clinical effectiveness of NOACs and VKAs in patients with non-valvular AF. METHODS An online bibliographic search was conducted to retrieve real-world evidence studies published between January 2019 and June 2022. RESULTS Dabigatran was associated with lower risks of major bleeding, ischemic stroke, and intracranial hemorrhage than warfarin. Among the NOACs, only dabigatran had a lower risk of all-cause mortality than warfarin. Dabigatran was also associated with lower risks of major bleeding and intracranial hemorrhage than rivaroxaban. CONCLUSION Our meta-analysis confirms that dabigatran's real-world safety and clinical effectiveness align with the results of pivotal clinical trials.
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Affiliation(s)
- Yi-Hsin Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan; Microscopy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City, Taiwan
| | - Chih-Yu Chan
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taoyuan 33305, Taiwan; College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Chatani R, Yamashita Y, Morimoto T, Kaneda K, Mushiake K, Kadota K, Nishimoto Y, Ikeda N, Kobayashi Y, Ikeda S, Kim K, Inoko M, Takase T, Tsuji S, Oi M, Kimura T. Transition of management strategies and long-term outcomes in cancer-associated venous thromboembolism from the warfarin era to the direct oral anticoagulant era. Eur J Intern Med 2024; 123:72-80. [PMID: 38278660 DOI: 10.1016/j.ejim.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/31/2023] [Accepted: 01/16/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND There have been still limited data on the transition of management strategies and clinical outcomes after introduction of direct oral anticoagulant (DOAC) for cancer-associated venous thromboembolism (VTE) in the real-world clinical practice. METHODS Using the 2 series of multicenter COMMAND VTE registries in Japan enrolling consecutive patients with acute symptomatic VTE, we compared 695 patients with cancer-associated VTE in the Registry-1 of the warfarin era and 1507 patients in the Registry-2 of the DOAC era. RESULTS Regarding oral anticoagulation therapy, 576 patients (82.9 %) in the Registry-1 received warfarin, whereas 1119 patients (79.6 %) in the Registry-2 received DOACs. The cumulative 3-year incidence of discontinuation of anticoagulation was not significantly different between the 2 registries (56.7 % vs. 62.7 %, P = 0.11). The cumulative 5-year incidence of recurrent VTE was significantly lower in the Registry-2 than in the Registry-1 (17.7 % vs. 10.1 %, P < 0.001). The cumulative 5-year incidence of major bleeding was significantly lower in the Registry-2 than in the Registry-1 (26.6 % vs. 20.4 %, P = 0.045). The proportion of gastrointestinal bleeding numerically increased from the Registry-1 to the Registry-2 (46.7 % and 49.5 %), whereas that of intracranial bleeding numerically decreased from the Registry-1 to the Registry-2 (17.1 % and 14.1 %). CONCLUSIONS In the current historical comparison of cancer-associated VTE between the 2 large real-world registries, there was a striking change in the treatment strategies with decreased risks of recurrent VTE and major bleeding in the DOAC era compared with those in the warfarin era, while there seemed to be unmet needs of DOAC-related gastrointestinal bleeding. CLINICAL TRIAL REGISTRATION URL: http://www.umin.ac.jp/ctr/index.htm UNIQUE IDENTIFIER: UMIN000044816.
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Affiliation(s)
- Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Yugo Yamashita
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Takeshi Morimoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kazuhisa Kaneda
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazunori Mushiake
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shuhei Tsuji
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Takeshi Kimura
- Division of Cardiology, Kohka Public Hospital, Koka, Japan
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Valgimigli M, Gragnano F, Branca M, Franzone A, da Costa BR, Baber U, Kimura T, Jang Y, Hahn JY, Zhao Q, Windecker S, Gibson CM, Watanabe H, Kim BK, Song YB, Zhu Y, Vranckx P, Mehta S, Ando K, Hong SJ, Gwon HC, Serruys PW, Dangas GD, McFadden EP, Angiolillo DJ, Heg D, Calabrò P, Jüni P, Mehran R. Ticagrelor or Clopidogrel Monotherapy vs Dual Antiplatelet Therapy After Percutaneous Coronary Intervention: A Systematic Review and Patient-Level Meta-Analysis. JAMA Cardiol 2024; 9:437-448. [PMID: 38506796 PMCID: PMC10955340 DOI: 10.1001/jamacardio.2024.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 01/13/2024] [Indexed: 03/21/2024]
Abstract
Importance Among patients undergoing percutaneous coronary intervention (PCI), it remains unclear whether the treatment efficacy of P2Y12 inhibitor monotherapy after a short course of dual antiplatelet therapy (DAPT) depends on the type of P2Y12 inhibitor. Objective To assess the risks and benefits of ticagrelor monotherapy or clopidogrel monotherapy compared with standard DAPT after PCI. Data Sources MEDLINE, Embase, TCTMD, and the European Society of Cardiology website were searched from inception to September 10, 2023, without language restriction. Study Selection Included studies were randomized clinical trials comparing P2Y12 inhibitor monotherapy with DAPT on adjudicated end points in patients without indication to oral anticoagulation undergoing PCI. Data Extraction and Synthesis Patient-level data provided by each trial were synthesized into a pooled dataset and analyzed using a 1-step mixed-effects model. The study is reported following the Preferred Reporting Items for Systematic Review and Meta-Analyses of Individual Participant Data. Main Outcomes and Measures The primary objective was to determine noninferiority of ticagrelor or clopidogrel monotherapy vs DAPT on the composite of death, myocardial infarction (MI), or stroke in the per-protocol analysis with a 1.15 margin for the hazard ratio (HR). Key secondary end points were major bleeding and net adverse clinical events (NACE), including the primary end point and major bleeding. Results Analyses included 6 randomized trials including 25 960 patients undergoing PCI, of whom 24 394 patients (12 403 patients receiving DAPT; 8292 patients receiving ticagrelor monotherapy; 3654 patients receiving clopidogrel monotherapy; 45 patients receiving prasugrel monotherapy) were retained in the per-protocol analysis. Trials of ticagrelor monotherapy were conducted in Asia, Europe, and North America; trials of clopidogrel monotherapy were all conducted in Asia. Ticagrelor was noninferior to DAPT for the primary end point (HR, 0.89; 95% CI, 0.74-1.06; P for noninferiority = .004), but clopidogrel was not noninferior (HR, 1.37; 95% CI, 1.01-1.87; P for noninferiority > .99), with this finding driven by noncardiovascular death. The risk of major bleeding was lower with both ticagrelor (HR, 0.47; 95% CI, 0.36-0.62; P < .001) and clopidogrel monotherapy (HR, 0.49; 95% CI, 0.30-0.81; P = .006; P for interaction = 0.88). NACE were lower with ticagrelor (HR, 0.74; 95% CI, 0.64-0.86, P < .001) but not with clopidogrel monotherapy (HR, 1.00; 95% CI, 0.78-1.28; P = .99; P for interaction = .04). Conclusions and Relevance This systematic review and meta-analysis found that ticagrelor monotherapy was noninferior to DAPT for all-cause death, MI, or stroke and superior for major bleeding and NACE. Clopidogrel monotherapy was similarly associated with reduced bleeding but was not noninferior to DAPT for all-cause death, MI, or stroke, largely because of risk observed in 1 trial that exclusively included East Asian patients and a hazard that was driven by an excess of noncardiovascular death.
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Affiliation(s)
- Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Mattia Branca
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Bruno R. da Costa
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City
| | - Takeshi Kimura
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University College of Medicine, Seongnam, Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Qiang Zhao
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Charles M. Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Hirotoshi Watanabe
- Kyoto University Graduate School of Medicine, Department of Cardiovascular Medicine, Kyoto, Japan
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yunpeng Zhu
- Department of Cardiovascular Surgery, Ruijin Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Belgium
| | - Shamir Mehta
- Department of Medicine, McMaster University, Hamilton, Canada
- Hamilton Health Sciences, Hamilton, Canada
| | - Kenji Ando
- Kokura Memorial Hospital, Department of Cardiology, Kitakyushu, Japan
| | - Sung Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | - Eùgene P. McFadden
- Cardialysis Core Laboratories and Clinical Trial Management, Rotterdam, the Netherlands
- Department of Cardiology, Cork University Hospital, Cork, Ireland
| | | | - Dik Heg
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Caserta, Italy
| | - Peter Jüni
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, New York
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Al Hennawi H, Khedr A, Khan MK, Ashraf MT, Sohail A, Mathbout L, Eissa A, Mathbout M, Klugherz B. Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials. Cardiovasc Revasc Med 2024; 62:73-81. [PMID: 38176962 DOI: 10.1016/j.carrev.2023.12.011] [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] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. METHODS We comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. RESULTS In this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e-42; 95 % CI, 5.68e-97, 1.37e-07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e-11; 95 % CI, 4.97e-25, 0.386). CONCLUSION Our meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.
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Affiliation(s)
| | | | | | | | - Affan Sohail
- Dow University of Health Science, Karachi, Pakistan
| | - Lein Mathbout
- Alfaisal University College of Medicine, Riyadh, Saudi Arabia
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