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Othman HY, Zaki IAH, Isa MR, Ming LC, Zulkifly HH. A systematic review of thromboembolic complications and outcomes in hospitalised COVID-19 patients. BMC Infect Dis 2024; 24:484. [PMID: 38730292 PMCID: PMC11088167 DOI: 10.1186/s12879-024-09374-1] [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: 11/14/2023] [Accepted: 05/03/2024] [Indexed: 05/12/2024] Open
Abstract
Thromboembolic (TE) complications [myocardial infarction (MI), stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE)] are common causes of mortality in hospitalised COVID-19 patients. Therefore, this review was undertaken to explore the incidence of TE complications and mortality associated with TE complications in hospitalised COVID-19 patients from different studies. A literature search was performed using ScienceDirect and PubMed databases using the MeSH term search strategy of "COVID-19", "thromboembolic complication", "venous thromboembolism", "arterial thromboembolism", "deep vein thrombosis", "pulmonary embolism", "myocardial infarction", "stroke", and "mortality". There were 33 studies included in this review. Studies have revealed that COVID-19 patients tend to develop venous thromboembolism (PE:1.0-40.0% and DVT:0.4-84%) compared to arterial thromboembolism (stroke:0.5-15.2% and MI:0.8-8.7%). Lastly, the all-cause mortality of COVID-19 patients ranged from 4.8 to 63%, whereas the incidence of mortality associated with TE complications was between 5% and 48%. A wide range of incidences of TE complications and mortality associated with TE complications can be seen among hospitalized COVID-19 patients. Therefore, every patient should be assessed for the risk of thromboembolic complications and provided with an appropriate thromboprophylaxis management plan tailored to their individual needs.
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Affiliation(s)
- Hanies Yuhana Othman
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia
| | - Izzati Abdul Halim Zaki
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia
- Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia
| | - Mohamad Rodi Isa
- Faculty of Medicine, Universiti Teknologi MARA Selangor, Sungai Buloh Campus, Sungai Buloh, Selangor, Malaysia
| | - Long Chiau Ming
- School of Medical and Life Sciences, Sunway University, Sunway City, Selangor, Malaysia
| | - Hanis Hanum Zulkifly
- Department of Clinical Pharmacy, Fakulti Farmasi, Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Bandar Puncak Alam, Selangor, Malaysia.
- Cardiology Therapeutics Research Group, Universiti Teknologi MARA, Puncak Alam, Selangor, Malaysia.
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Enblom-Larsson A, Renlund H, Andréasson B, Holmberg H, Liljeholm M, Själander A. Thromboembolic events, major bleeding and mortality in essential thrombocythaemia and polycythaemia vera-A matched nationwide population-based study. Br J Haematol 2024; 204:1740-1751. [PMID: 38351734 DOI: 10.1111/bjh.19337] [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: 09/27/2023] [Revised: 01/22/2024] [Accepted: 02/01/2024] [Indexed: 05/15/2024]
Abstract
Thromboembolic events and bleeding are known complications in essential thrombocythaemia (ET) and polycythaemia vera (PV). Using multiple Swedish health care registers, we assessed the rate of arterial and venous events, major bleeding, all-cause stroke and all-cause mortality in ET and PV compared to matched controls. For each patient with ET (n = 3141) and PV (n = 2604), five matched controls were randomly selected. In total, 327 and 405 arterial or venous events were seen in the group of ET and PV patients respectively. Compared to corresponding controls, the rate of venous thromboembolism, major bleeding and all-cause mortality per 100 treatment years was significantly increased among both ET (0.63, 0.79 and 3.70) and PV patients (0.94, 1.20 and 4.80). The PV patients also displayed a significantly higher rate of arterial events and all-cause stroke compared to controls. When dividing the cohort into age groups, we found a significantly higher rate of arterial and venous events in all age groups of PV patients, and the rate of all-cause mortality was significantly higher in both ET and PV patients in all ages above the age of 50. This study confirms that PV and ET are diseases truly marked by thromboembolic complications and bleeding.
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Affiliation(s)
| | - Henrik Renlund
- Uppsala Clinical Research Centre Uppsala University, Uppsala, Sweden
| | | | - Henrik Holmberg
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Maria Liljeholm
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Anders Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Flumignan RL, Tinôco JDDS, Pascoal PI, Areias LL, Cossi MS, Fernandes MI, Costa IK, Souza L, Matar CF, Tendal B, Trevisani VF, Atallah ÁN, Nakano LC. Prophylactic anticoagulants for people hospitalized with COVID-19: systematic review. Br J Surg 2021; 108:e299-e300. [PMID: 34109373 PMCID: PMC8406890 DOI: 10.1093/bjs/znab197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/04/2021] [Indexed: 11/13/2022]
Affiliation(s)
- R L Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - J D de Sá Tinôco
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - P I Pascoal
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - L L Areias
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - M S Cossi
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - M I Fernandes
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - I K Costa
- Department of Nursing, Federal University of Rio Grande do Norte, Natal, Brazil
| | - L Souza
- Department of Public Health, State University of Rio Grande do Norte, Natal, Brazil
| | - C F Matar
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - B Tendal
- Living Guidelines Program, Cochrane Australia, Melbourne, Victoria, Australia
| | - V F Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Á N Atallah
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - L C Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Purroy F, Arqué G. Influence of thromboembolic events in the prognosis of COVID-19 hospitalized patients. Results from a cross sectional study. PLoS One 2021; 16:e0252351. [PMID: 34106984 PMCID: PMC8189499 DOI: 10.1371/journal.pone.0252351] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/12/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND COVID-19 may predispose to both venous and arterial thromboembolism event (TEE). Reports on the prevalence and prognosis of thrombotic complications are still emerging. OBJECTIVE To describe the rate of TEE complications and its influence in the prognosis of hospitalized patients with COVID-19 after a cross-sectional study. METHODS We evaluated the prevalence of TEE and its relationship with in-hospital death among hospitalized patients with COVID-19 who were admitted between 1st March to 20th April 2020 in a multicentric network of sixteen Hospitals in Spain. TEE was defined by the occurrence of venous thromboembolism (VTE), acute ischemic stroke (AIS), systemic arterial embolism or myocardial infarction (MI). RESULTS We studied 1737 patients with proven COVID-19 infection of whom 276 died (15.9%). TEE were presented in 64 (3.7%) patients: 49 (76.6%) patients had a VTE, 8 (12.5%) patients had MI, 6 (9.4%%) patients had AIS, and one (1.5%) patient a thrombosis of portal vein. TEE patients exhibited a diffuse profile: older, high levels of D-dimer protein and a tendency of lower levels of prothrombin. The multivariate regression models, confirmed the association between in-hospital death and age (odds ratio [OR] 1.12 [95% CI 1.10-1.14], p<0.001), diabetes (OR 1.49 [95% CI 1.04-2.13], p = 0.029), chronic obstructive pulmonary disease (OR 1.61 [95% CI 1.03-2.53], p = 0.039), ICU care (OR 9.39 [95% CI 5.69-15.51], p<0.001), and TTE (OR 2.24 [95% CI 1.17-4.29], p = 0.015). CONCLUSIONS Special attention is needed among hospitalized COVID-19 patients with TTE and other comorbidities as they have an increased risk of in-hospital death.
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Affiliation(s)
- Francisco Purroy
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
- Stroke Unit, Department of Neurology, Hospital Universitari Arnau de Vilanova, Lleida, Spain
- Medicine Department, Universitat de Lleida, Lleida, Spain
- Medicine Department, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
| | - Gloria Arqué
- Clinical Neurosciences Group, Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
- Experimental Medicine Department, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida, Lleida, Spain
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Abstract
Anticoagulation management in patients with cirrhosis presents several challenges as a result of alterations in hemostasis. Historically vitamin k antagonists and low molecular weight heparins have been the agents of choice in this patient population. Direct oral anticoagulants (DOACs) may provide an alternative to traditional anticoagulant therapy. To evaluate the rate of major bleeding among patients receiving DOACs or warfarin with cirrhosis. A retrospective, observational, cohort study of adult patients admitted between January 2012 and July 2018 with diagnosis of cirrhosis receiving anticoagulation with DOAC or warfarin therapy was performed. Patients were stratified based on the receipt of a DOAC or warfarin. The primary endpoint was incidence of major bleeding at 90 days. Secondary endpoints included stroke or embolic event at 90 days as well as rehospitalization and mortality at 1 year. One hundred sixty-seven patients were included for analysis; of which 110 received warfarin and 57 received a DOAC. The most commonly used DOAC was apixaban (52.6%) followed by rivaroxaban (45.6%) and dabigratran (1.8%). The incidence of major bleeding was similar between warfarin and DOAC groups (9.1% vs. 5.2% p = 0.381). No difference in the rate of stroke or recurrent embolic event at 90 days was identified between the two groups (0% vs. 1.58% p = 0.341; 1.8% vs. 1.8% p = 0.731). In conclusion DOACs appear to be a safe alternative to warfarin in patients with mild to moderate cirrhosis. Further studies are warranted to confirm these findings.
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Affiliation(s)
- Kyle A Davis
- Department of Pharmacy, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston Salem, NC, 27157, USA.
| | - Joel Joseph
- Department of Internal Medicine, Wake Forest Baptist Health, 1 Medical Center Boulevard, Winston Salem, NC, 27157, USA
| | - Sarah A Nisly
- Department of Pharmacy, Wake Forest Baptist Health, School of Pharmacy, Wingate University, 515 N. Main St, Wingate, NC, 28174, USA
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Abstract
BACKGROUND People with chronic heart failure (HF) are at risk of thromboembolic events, including stroke, pulmonary embolism, and peripheral arterial embolism; coronary ischaemic events also contribute to the progression of HF. The use of long-term oral anticoagulation is established in certain populations, including people with HF and atrial fibrillation (AF), but there is wide variation in the indications and use of oral anticoagulation in the broader HF population. OBJECTIVES To determine whether long-term oral anticoagulation reduces total deaths and stroke in people with heart failure in sinus rhythm. SEARCH METHODS We updated the searches in CENTRAL, MEDLINE, and Embase in March 2020. We screened reference lists of papers and abstracts from national and international cardiovascular meetings to identify unpublished studies. We contacted relevant authors to obtain further data. We did not apply any language restrictions. SELECTION CRITERIA Randomised controlled trials (RCT) comparing oral anticoagulants with placebo or no treatment in adults with HF, with treatment duration of at least one month. We made inclusion decisions in duplicate, and resolved any disagreements between review authors by discussion, or a third party. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, and assessed the risks and benefits of antithrombotic therapy by calculating odds ratio (OR), accompanied by the 95% confidence intervals (CI). MAIN RESULTS We identified three RCTs (5498 participants). One RCT compared warfarin, aspirin, and no antithrombotic therapy, the second compared warfarin with placebo in participants with idiopathic dilated cardiomyopathy, and the third compared rivaroxaban with placebo in participants with HF and coronary artery disease. We pooled data from the studies that compared warfarin with a placebo or no treatment. We are uncertain if there is an effect on all-cause death (OR 0.66, 95% CI 0.36 to 1.18; 2 studies, 324 participants; low-certainty evidence); warfarin may increase the risk of major bleeding events (OR 5.98, 95% CI 1.71 to 20.93, NNTH 17). 2 studies, 324 participants; low-certainty evidence). None of the studies reported stroke as an individual outcome. Rivaroxaban makes little to no difference to all-cause death compared with placebo (OR 0.99, 95% CI 0.87 to 1.13; 1 study, 5022 participants; high-certainty evidence). Rivaroxaban probably reduces the risk of stroke compared to placebo (OR 0.67, 95% CI 0.47 to 0.95; NNTB 101; 1 study, 5022 participants; moderate-certainty evidence), and probably increases the risk of major bleeding events (OR 1.65, 95% CI 1.17 to 2.33; NNTH 79; 1 study, 5008 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS Based on the three RCTs, there is no evidence that oral anticoagulant therapy modifies mortality in people with HF in sinus rhythm. The evidence is uncertain if warfarin has any effect on all-cause death compared to placebo or no treatment, but it may increase the risk of major bleeding events. There is no evidence of a difference in the effect of rivaroxaban on all-cause death compared to placebo. It probably reduces the risk of stroke, but probably increases the risk of major bleedings. The available evidence does not support the routine use of anticoagulation in people with HF who remain in sinus rhythm.
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Affiliation(s)
- Eduard Shantsila
- University of Birmingham, Institute of Cardiovascular Sciences, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- 1st Department of Cardiology and Angiology, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Gregory Yh Lip
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
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Schernthaner-Reiter MH, Siess C, Micko A, Zauner C, Wolfsberger S, Scheuba C, Riss P, Knosp E, Kautzky-Willer A, Luger A, Vila G. Acute and Life-threatening Complications in Cushing Syndrome: Prevalence, Predictors, and Mortality. J Clin Endocrinol Metab 2021; 106:e2035-e2046. [PMID: 33517433 DOI: 10.1210/clinem/dgab058] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Cushing syndrome (CS) results in significant morbidity and mortality. OBJECTIVE To study acute and life-threatening complications in patients with active CS. METHODS We performed a retrospective cohort study using inpatient and outpatient records of patients with CS in a tertiary center. A total of 242 patients with CS were included, including 213 with benign CS (pituitary n = 101, adrenal n = 99, ectopic n = 13), and 29 with malignant disease. We collected acute complications necessitating hospitalization, from appearance of first symptoms of hypercortisolism until 1 year after biochemical remission. Mortality data were obtained from the national registry. Baseline factors relating to and predicting acute complications were tested using uni- and multivariate analysis. RESULTS The prevalence of acute complications was 62% in patients with benign pituitary CS, 40% in patients with benign adrenal CS, and 100% in patients with ectopic CS. Complications observed in patients with benign CS included infections (25%), thromboembolic events (17%), hypokalemia (13%), hypertensive crises (9%), cardiac arrhythmias (5%), and acute coronary events (3%). Among these patients, 23% had already been hospitalized for acute complications before CS was suspected, and half of complications occurred after the first surgery. Glycated hemoglobin (HbA1c) and 24-hour urinary free cortisol positively correlated with the number of acute complications per patient. Patients with malignant disease had significantly higher rates of acute complications. Mortality during the observation period was 2.8% and 59% in benign and malignant CS, respectively. CONCLUSIONS This analysis highlights the whole spectrum of acute and life-threatening complications in CS, and their high prevalence even before disease diagnosis and after successful surgery.
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Affiliation(s)
- Marie Helene Schernthaner-Reiter
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christina Siess
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexander Micko
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christian Zauner
- Clinical Division of Gastroenterology and Hepatology, Intensive Care Unit, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna; Austria
| | - Stefan Wolfsberger
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Christian Scheuba
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Alexandra Kautzky-Willer
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Anton Luger
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
| | - Greisa Vila
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, Austria
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Grandone E, Tiscia G, Pesavento R, De Laurenzo A, Ceccato D, Sartori MT, Mirabella L, Cinnella G, Mastroianno M, Dalfino L, Colaizzo D, Vettor R, Intrieri M, Ostuni A, Margaglione M. Use of low-molecular weight heparin, transfusion and mortality in COVID-19 patients not requiring ventilation. J Thromb Thrombolysis 2021; 52:772-778. [PMID: 33844150 PMCID: PMC8040353 DOI: 10.1007/s11239-021-02429-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 01/08/2023]
Abstract
It is still debated whether prophylactic doses of low-molecular- weight heparin (LMWH) are always effective in preventing Venous Thromboembolism (VTE) and mortality in COVID-19. Furthermore, there is paucity of data for those patients not requiring ventilation. We explored mortality and the safety/efficacy profile of LMWH in a cohort of Italian patients with COVID-19 who did not undergo ventilation. From the initial cohort of 422 patients, 264 were enrolled. Most (n = 156, 87.7%) received standard LMWH prophylaxis during hospitalization, with no significant difference between medical wards and Intensive Care Unit (ICU). Major or not major but clinically relevant hemorrhages were recorded in 13 (4.9%) patients: twelve in those taking prophylactic LMWH and one in a patient taking oral anticoagulants (p: n.s.). Thirty-nine patients (14.8%) with median age 75 years. were transfused. Hemoglobin (Hb) at admission was significantly lower in transfused patients and Hb at admission inversely correlated with the number of red blood cells units transfused (p < 0.001). In-hospital mortality occurred in 76 (28.8%) patients, 46 (24.3%) of whom admitted to medical wards. Furthermore, Hb levels at admittance were significantly lower in fatalities (g/dl 12.3; IQR 2.4 vs. 13.3; IQR 2.8; Mann–Whitney U-test; p = 0.001). After the exclusion of patients treated by LMWH intermediate or therapeutic doses (n = 32), the logistic regression showed that prophylaxis significantly and independently reduced mortality (OR 0.31, 95% CI 0.13–0.85). Present data show that COVID-19 patients who do not require ventilation benefit from prophylactic doses of LMWH.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy.
- Ob/Gyn Department of The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Giovanni Tiscia
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | | | - Antonio De Laurenzo
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | - Davide Ceccato
- Department of Internal Medicine, University of Padua, Padua, Italy
| | | | - Lucia Mirabella
- Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, Foggia, Italy
| | - Mario Mastroianno
- Scientific Direction, Fondazione I.R.C.C.S. "Casa Sollievo Della Sofferenza", S. Giovanni Rotondo, Foggia, Italy
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, University of Bari, Bari, Italy
| | - Donatella Colaizzo
- Thrombosis and Haemostasis Unit, Fondazione I.R.C.C.S. "Casa Sollievo della Sofferenza", Viale Cappuccini, S. Giovanni Rotondo, 71013, Foggia, Italy
| | - Roberto Vettor
- Department of Internal Medicine, University of Padua, Padua, Italy
| | - Mariano Intrieri
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Angelo Ostuni
- Immunohematology and Transfusion Medicine Service, Azienda Ospedaliero-Universitaria Consorziale Policlinico di Bari, University of Bari "Aldo Moro", and Struttura Regionale Coordinamento Puglia, Bari, Italy
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9
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Tranexamic acid should be avoided for acute gastrointestinal bleeds. Drug Ther Bull 2021; 59:84. [PMID: 33753352 DOI: 10.1136/dtb.2021.000016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Overview of: The HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet 2020; 395:1927-36.
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10
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Yamakawa M, Kuno T, Mikami T, Takagi H, Gronseth G. Clinical Characteristics of Stroke with COVID-19: A Systematic Review and Meta-Analysis. J Stroke Cerebrovasc Dis 2020; 29:105288. [PMID: 32992199 PMCID: PMC7456266 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105288] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [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] [Received: 08/04/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) potentially increases the risk of thromboembolism and stroke. Numerous case reports and retrospective cohort studies have been published with mixed characteristics of COVID-19 patients with stroke regarding age, comorbidities, treatment, and outcome. We aimed to depict the frequency and clinical characteristics of COVID-19 patients with stroke. METHODS PubMed and EMBASE were searched on June 10, 2020, to investigate COVID-19 and stroke through retrospective cross-sectional studies, case series/reports according to PRISMA guidelines. Study-specific estimates were combined using one-group meta-analysis in a random-effects model. RESULTS 10 retrospective cohort studies and 16 case series/reports were identified including 183 patients with COVID-19 and stroke. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% ([95% confidential interval (CI)]: [0.6-1.6], I2 = 62.9%). Mean age was 66.6 ([58.4-74.9], I2 = 95.1%), 65.6% was male (61/93 patients). Mean days from symptom onset of COVID-19 to stroke was 8.0 ([4.1-11.9], p< 0.001, I2 = 93.1%). D-dimer was 3.3 μg/mL ([1.7-4.9], I2 = 86.3%), and cryptogenic stroke was most common as etiology at 50.7% ([31.0-70.4] I2 = 64.1%, 39/71patients). Case fatality rate was 44.2% ([27.9-60.5], I2 = 66.7%, 40/100 patients). CONCLUSIONS This systematic review assessed the frequency and clinical characteristics of stroke in COVID-19 patients. The frequency of detected stroke in hospitalized COVID-19 patients was 1.1% and associated with older age and stroke risk factors. Frequent cryptogenic stroke and elevated d-dimer level support increased risk of thromboembolism in COVID-19 associated with high mortality. Further study is needed to elucidate the pathophysiology and prognosis of stroke in COVID-19 to achieve most effective care for this population.
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Affiliation(s)
- Mai Yamakawa
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Toshiki Kuno
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, First Avenue, 16th street, New York 10003, NY, USA.
| | - Takahisa Mikami
- Department of Neurology, Tufts Medical Center, Boston, MA, USA
| | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Gary Gronseth
- University of Kansas Medical Center, Department of Neurology, Kansas City, KS, USA
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11
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Bala MM, Celinska-Lowenhoff M, Szot W, Padjas A, Kaczmarczyk M, Swierz MJ, Undas A. Antiplatelet and anticoagulant agents for secondary prevention of stroke and other thromboembolic events in people with antiphospholipid syndrome. Cochrane Database Syst Rev 2020; 10:CD012169. [PMID: 33045766 PMCID: PMC8094585 DOI: 10.1002/14651858.cd012169.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by arterial or venous thrombosis (or both), and/or pregnancy morbidity in association with the presence of antiphospholipid antibodies. The prevalence of APS is estimated at 40 to 50 cases per 100,000 people. The most common sites of thrombosis are cerebral arteries and deep veins of the lower limbs. People with a definite APS diagnosis have an increased lifetime risk of recurrent thrombotic events. OBJECTIVES To assess the effects of antiplatelet (AP) or anticoagulant agents, or both, for the secondary prevention of recurrent thrombosis, particularly ischemic stroke, in people with APS. SEARCH METHODS We last searched the MEDLINE, Embase, CENTRAL, Cochrane Stroke Group Trials Register, and ongoing trials registers on 22 November 2019. We checked reference lists of included studies, systematic reviews, and practice guidelines. We also contacted experts in the field. SELECTION CRITERIA We included randomized controlled trials (RCTs) that evaluated any anticoagulant or AP agent, or both, in the secondary prevention of thrombosis in people with APS, according to the criteria valid when the study took place. We did not include studies specifically addressing women with obstetrical APS. DATA COLLECTION AND ANALYSIS Pairs of review authors independently worked on each step of the review, following Cochrane methods. We summarized the evidence using the GRADE approach. MAIN RESULTS We identified eight studies including 811 participants that compared different AP or anticoagulant agents. NOAC (non-VKA oral anticoagulant: rivaroxaban 15 or 20 mg/d) versus standard-dose VKA (vitamin K antagonist: warfarin at moderate International Normalized Ratio [INR] - 2.5) or adjusted [INR 2.0-3.0] dose): In three studies there were no differences in any thromboembolic event (including death) and major bleeding (moderate-certainty evidence), but an increased risk of stroke (risk ratio [RR] 14.13, 95% confidence interval [CI] 1.87 to 106.8; moderate-certainty evidence). One of the studies reported a small benefit of rivaroxaban in terms of quality of life at 180 days measured as health state on Visual Analogue Scale (mean difference [MD] 7 mm, 95% CI 2.01 to 11.99; low-certainty evidence), but not measured as health utility on a scale from 0 to 1 (MD 0.04, 95% CI -0.02 to 0.10; low-certainty evidence). High-dose VKA (warfarin with a target INR of 3.1 to 4.0 [mean 3.3] or 3.5 [mean 3.2]) versus standard-dose VKA (warfarin with a target INR of 2.0 to 3.0 [mean 2.3] or 2.5 [mean 2.5]): In two studies there were no differences in the rates of thrombotic events and major bleeding (RR 2.22, 95% CI 0.79 to 6.23, low-certainty evidence), but an increased risk of minor bleeding in one study during a mean of 3.4 years (standard deviation [SD] 1.2) of follow-up (RR 2.55, 95% CI 1.07 to 6.07). In both trials there was evidence of a higher risk of any bleeding (hazard ratio [HR] 2.03 95% CI 1.12 to 3.68; low-certainty evidence) in the high-dose VKA group, and for this outcome (any bleeding) the incidence is not different, only the time to event is showing an effect. Standard-dose VKA plus a single AP agent (warfarin at a target INR of 2.0 to 3.0 plus aspirin 100 mg/d) versus standard-dose VKA (warfarin at a target INR of 2.0 to 3.0): One high-risk-of-bias study showed an increased risk of any thromboembolic event with combined treatment (RR 2.14, 95% CI 1.04 to 4.43; low-certainty evidence) and reported on major bleeding with five cases in the combined treatment group and one case in the standard-dose VKA treatment group, resulting in RR 7.42 (95% CI 0.91 to 60.7; low-certainty evidence) and no differences for secondary outcomes (very low- to low-certainty evidence). Single/dual AP agent and standard-dose VKA (pooled results): Two high-risk-of-bias studies compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin or unspecified VKA at a target INR of 2.0 to 3.0 or 2.0 to 2.5) with a single AP agent (aspirin 100 mg/d), but did not provide any conclusive evidence regarding the effects of those drugs in people with APS (very low-certainty evidence). One of the above-mentioned studies was a three-armed study that compared a combination of AP and VKA (aspirin 100 mg/d plus warfarin at a target INR of 2.0 to 2.5) with dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) and dual AP therapy (aspirin 100 mg/d plus cilostazol 200 mg/d) versus a single AP treatment (aspirin 100 mg/d). This study reported on stroke (very low-certainty evidence) but did not report on any thromboembolic events, major bleeding, or any secondary outcomes. We identified two ongoing studies and three studies are awaiting classification. AUTHORS' CONCLUSIONS The evidence identified indicates that NOACs compared with standard-dose VKAs may increase the risk of stroke and do not appear to alter the risk of other outcomes (moderate-certainty evidence). Using high-dose VKA versus standard-dose VKA did not alter the risk of any thromboembolic event or major bleeding but may increase the risk of any form of bleeding (low-certainty evidence). Standard-dose VKA combined with an AP agent compared with standard-dose VKA alone may increase the risk of any thromboembolic event and does not appear to alter the risk of major bleeding or other outcomes (low-certainty evidence). The evidence is very uncertain about the benefit or harm of using standard-dose VKA plus AP agents versus single or dual AP therapy, or dual versus single AP therapy, for the secondary prevention of recurrent thrombosis in people with APS (very low-certainty evidence).
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Affiliation(s)
- Malgorzata M Bala
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Celinska-Lowenhoff
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Szot
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Padjas
- 2nd Department of Internal Medicine, Department of Allergy and Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz Kaczmarczyk
- Systematic Reviews Unit - Polish Cochrane Branch, Jagiellonian University Medical College, Krakow, Poland
| | - Mateusz J Swierz
- Chair of Epidemiology and Preventive Medicine, Department of Hygiene and Dietetics, Jagiellonian University Medical College, Krakow, Poland
- Systematic Reviews Unit, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Flumignan RL, Tinôco JDDS, Pascoal PI, Areias LL, Cossi MS, Fernandes MI, Costa IK, Souza L, Matar CF, Tendal B, Trevisani VF, Atallah ÁN, Nakano LC. Prophylactic anticoagulants for people hospitalised with COVID-19. Cochrane Database Syst Rev 2020; 10:CD013739. [PMID: 33502773 PMCID: PMC8166900 DOI: 10.1002/14651858.cd013739] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a serious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The primary manifestation is respiratory insufficiency that can also be related to diffuse pulmonary microthrombosis in people with COVID-19. This disease also causes thromboembolic events, such as pulmonary embolism, deep venous thrombosis, arterial thrombosis, catheter thrombosis, and disseminated intravascular coagulopathy. Recent studies have indicated a worse prognosis for people with COVID-19 who developed thromboembolism. Anticoagulants are medications used in the prevention and treatment of venous or arterial thromboembolic events. Several drugs are used in the prophylaxis and treatment of thromboembolic events, such as heparinoids (heparins or pentasaccharides), vitamin K antagonists and direct anticoagulants. Besides their anticoagulant properties, heparinoids have an additional anti-inflammatory potential, that may affect the clinical evolution of people with COVID-19. Some practical guidelines address the use of anticoagulants for thromboprophylaxis in people with COVID-19, however, the benefit of anticoagulants for people with COVID-19 is still under debate. OBJECTIVES To assess the effects of prophylactic anticoagulants versus active comparator, placebo or no intervention, on mortality and the need for respiratory support in people hospitalised with COVID-19. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, LILACS and IBECS databases, the Cochrane COVID-19 Study Register and medRxiv preprint database from their inception to 20 June 2020. We also checked reference lists of any relevant systematic reviews identified and contacted specialists in the field for additional references to trials. SELECTION CRITERIA Randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs and cohort studies that compared prophylactic anticoagulants (heparin, vitamin K antagonists, direct anticoagulants, and pentasaccharides) versus active comparator, placebo or no intervention for the management of people hospitalised with COVID-19. We excluded studies without a comparator group. Primary outcomes were all-cause mortality and need for additional respiratory support. Secondary outcomes were mortality related to COVID-19, deep vein thrombosis (DVT), pulmonary embolism, major bleeding, adverse events, length of hospital stay and quality of life. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. We used ROBINS-I to assess risk of bias for non-randomised studies (NRS) and GRADE to assess the certainty of evidence. We reported results narratively. MAIN RESULTS We identified no RCTs or quasi-RCTs that met the inclusion criteria. We included seven retrospective NRS (5929 participants), three of which were available as preprints. Studies were conducted in China, Italy, Spain and the USA. All of the studies included people hospitalised with COVID-19, in either intensive care units, hospital wards or emergency departments. The mean age of participants (reported in 6 studies) ranged from 59 to 72 years. Only three included studies reported the follow-up period, which varied from 8 to 35 days. The studies did not report on most of our outcomes of interest: need for additional respiratory support, mortality related to COVID-19, DVT, pulmonary embolism, adverse events, and quality of life. Anticoagulants (all types) versus no treatment (6 retrospective NRS, 5685 participants) One study reported a reduction in all-cause mortality (adjusted odds ratio (OR) 0.42, 95% confidence interval (CI) 0.26 to 0.66; 2075 participants). One study reported a reduction in mortality only in a subgroup of 395 people who required mechanical ventilation (hazard ratio (HR) 0.86, 95% CI 0.82 to 0.89). Three studies reported no differences in mortality (adjusted OR 1.64, 95% CI 0.92 to 2.92; 449 participants; unadjusted OR 1.66, 95% CI 0.76 to 3.64; 154 participants and adjusted risk ratio (RR) 1.15, 95% CI 0.29 to 2.57; 192 participants). One study reported zero events in both intervention groups (42 participants). The overall risk of bias for all-cause mortality was critical and the certainty of the evidence was very low. One NRS reported bleeding events in 3% of the intervention group and 1.9% of the control group (OR 1.62, 95% CI 0.96 to 2.71; 2773 participants; low-certainty evidence). Therapeutic-dose anticoagulants versus prophylactic-dose anticoagulants (1 retrospective NRS, 244 participants) The study reported a reduction in all-cause mortality (adjusted HR 0.21, 95% CI 0.10 to 0.46) and a lower absolute rate of death in the therapeutic group (34.2% versus 53%). The overall risk of bias for all-cause mortality was serious and the certainty of the evidence was low. The study also reported bleeding events in 31.7% of the intervention group and 20.5% of the control group (OR 1.8, 95% CI 0.96 to 3.37; low-certainty evidence). Ongoing studies We found 22 ongoing studies in hospital settings (20 RCTs, 14,730 participants; 2 NRS, 997 participants) in 10 different countries (Australia (1), Brazil (1), Canada (2), China (3), France (2), Germany (1), Italy (4), Switzerland (1), UK (1) and USA (6)). Twelve ongoing studies plan to report mortality and six plan to report additional respiratory support. Thirteen studies are expected to be completed in December 2020 (6959 participants), eight in July 2021 (8512 participants), and one in December 2021 (256 participants). Four of the studies plan to include 1000 participants or more. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the risks and benefits of prophylactic anticoagulants for people hospitalised with COVID-19. Since there are 22 ongoing studies that plan to evaluate more than 15,000 participants in this setting, we will add more robust evidence to this review in future updates.
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Affiliation(s)
- Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Patricia If Pascoal
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Libnah L Areias
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcelly S Cossi
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - Maria Icd Fernandes
- Department of Nursing, State University of Rio Grande do Norte, Natal, Brazil
| | - Isabelle Kf Costa
- Department of Nursing, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Larissa Souza
- Department of Public Health, State University of Rio Grande do Norte, Natal, Brazil
| | - Charbel F Matar
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Britta Tendal
- Living Guidelines Program, Cochrane Australia, Melbourne, Australia
| | - Virginia Fm Trevisani
- Medicina de Urgência and Rheumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo and Universidade de Santo Amaro, São Paulo, Brazil
| | - Álvaro N Atallah
- Cochrane Brazil, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Zhang H, Dong Y, Ao X, Fu B, Dong L. Comparison of Antithrombotic Strategies in Chinese Patients in Sinus Rhythm after Bioprosthetic Mitral Valve Replacement: Early Outcomes from a Multicenter Registry in China. Cardiovasc Drugs Ther 2020; 35:1-10. [PMID: 32940891 DOI: 10.1007/s10557-020-07069-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare antithrombotic strategies in Chinese patients undergoing bioprosthetic mitral valve implantation discharged in normal sinus rhythm. METHODS At 28 hospitals in China, 1603 patients were followed for 2991.5 person-years. Adverse event and death rates during five postoperative time intervals (≤ 30, 31-90, 91-180, 181-365, and 366-730 days) were calculated in patients administered warfarin, aspirin, warfarin + aspirin, or neither treatment. RESULTS Thromboembolic and hemorrhagic events occurred in 22 (0.74/100 patient-years, 95%CI 0.43-1.05) and 28 (0.94/100 patient-years, 95%CI 0.59-1.29) patients, respectively. In the first 3 months post-surgery, warfarin-treated patients had significantly lower rates of thromboembolic events than the aspirin or untreated groups (P = 0.01, P<0.01), and a significantly lower risk of bleeding than the aspirin + warfarin group (P = 0.02). From 91 to 180 days post-surgery, thromboembolism risk was significantly lower in warfarin-treated patients relative to the aspirin-treated and untreated patients (P = 0.04, P = 0.04), but bleeding and overall adverse event rates were similar (P = 1.00). From 181 to 365 days, thromboembolic event rates did not differ significantly between the untreated and anticoagulant-treated groups (P = 1.00). CONCLUSION Warfarin is the most effective intervention for preventing thromboembolism within 6 months post-bioprosthetic MVR surgery in Chinese patients in sinus rhythm. After 6 months, further warfarin therapy was unnecessary, and aspirin should not be routinely administered.
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Affiliation(s)
- Heng Zhang
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China
| | - Yijun Dong
- Department of Thoracic Neoplasm, West China Hospital of Sichuan University, Chengdu, China
| | - Xuelian Ao
- Department of Ultrasound West China Hospital of Sichuan University, Chengdu, China
| | - Bo Fu
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Li Dong
- Department of Cardiovascular Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, China.
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14
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Dangas GD, Tijssen JGP, Wöhrle J, Søndergaard L, Gilard M, Möllmann H, Makkar RR, Herrmann HC, Giustino G, Baldus S, De Backer O, Guimarães AHC, Gullestad L, Kini A, von Lewinski D, Mack M, Moreno R, Schäfer U, Seeger J, Tchétché D, Thomitzek K, Valgimigli M, Vranckx P, Welsh RC, Wildgoose P, Volkl AA, Zazula A, van Amsterdam RGM, Mehran R, Windecker S. A Controlled Trial of Rivaroxaban after Transcatheter Aortic-Valve Replacement. N Engl J Med 2020; 382:120-129. [PMID: 31733180 DOI: 10.1056/nejmoa1911425] [Citation(s) in RCA: 310] [Impact Index Per Article: 77.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether the direct factor Xa inhibitor rivaroxaban can prevent thromboembolic events after transcatheter aortic-valve replacement (TAVR) is unclear. METHODS We randomly assigned 1644 patients without an established indication for oral anticoagulation after successful TAVR to receive rivaroxaban at a dose of 10 mg daily (with aspirin at a dose of 75 to 100 mg daily for the first 3 months) (rivaroxaban group) or aspirin at a dose of 75 to 100 mg daily (with clopidogrel at a dose of 75 mg daily for the first 3 months) (antiplatelet group). The primary efficacy outcome was the composite of death or thromboembolic events. The primary safety outcome was major, disabling, or life-threatening bleeding. The trial was terminated prematurely by the data and safety monitoring board because of safety concerns. RESULTS After a median of 17 months, death or a first thromboembolic event (intention-to-treat analysis) had occurred in 105 patients in the rivaroxaban group and in 78 patients in the antiplatelet group (incidence rates, 9.8 and 7.2 per 100 person-years, respectively; hazard ratio with rivaroxaban, 1.35; 95% confidence interval [CI], 1.01 to 1.81; P = 0.04). Major, disabling, or life-threatening bleeding (intention-to-treat analysis) had occurred in 46 and 31 patients, respectively (4.3 and 2.8 per 100 person-years; hazard ratio, 1.50; 95% CI, 0.95 to 2.37; P = 0.08). A total of 64 deaths occurred in the rivaroxaban group and 38 in the antiplatelet group (5.8 and 3.4 per 100 person-years, respectively; hazard ratio, 1.69; 95% CI, 1.13 to 2.53). CONCLUSIONS In patients without an established indication for oral anticoagulation after successful TAVR, a treatment strategy including rivaroxaban at a dose of 10 mg daily was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than an antiplatelet-based strategy. (Funded by Bayer and Janssen Pharmaceuticals; GALILEO ClinicalTrials.gov number, NCT02556203.).
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Affiliation(s)
- George D Dangas
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Jan G P Tijssen
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Jochen Wöhrle
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Lars Søndergaard
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Martine Gilard
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Helge Möllmann
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Raj R Makkar
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Howard C Herrmann
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Gennaro Giustino
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Stephan Baldus
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Ole De Backer
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Ana H C Guimarães
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Lars Gullestad
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Annapoorna Kini
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Dirk von Lewinski
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Michael Mack
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Raúl Moreno
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Ulrich Schäfer
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Julia Seeger
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Didier Tchétché
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Karen Thomitzek
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Marco Valgimigli
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Pascal Vranckx
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Robert C Welsh
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Peter Wildgoose
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Albert A Volkl
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Ana Zazula
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Ronald G M van Amsterdam
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Roxana Mehran
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
| | - Stephan Windecker
- From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.D.D., G.G., A.K., R. Mehran); National and Kapodistrian University of Athens, Athens (G.D.D.); Amsterdam University Medical Centers-University of Amsterdam, Amsterdam (J.G.P.T.), and Cardialysis, Academic Research Organization, Rotterdam (J.G.P.T., A.H.C.G., R.G.M.A.) - both in the Netherlands; the Department of Internal Medicine II, University of Ulm, Ulm (J.W., J.S.), the Department of Internal Medicine I, St. Johannes Hospital Dortmund, Dortmund (H.M.), the Department of Internal Medicine III, Heart Center, University Hospital of Cologne, Cologne (S.B.), the Department of General and Interventional Cardiology, University Hospital Hamburg-Eppendorf, Hamburg (U.S.), and Bayer, Berlin (K.T.) - all in Germany; the Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen (L.S., O.D.B.); La Cavale Blanche University Hospital, Cardiology Department, Brest (M.G.), and Clinique Pasteur, Toulouse (D.T.) - both in France; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R.R.M.); the University of Pennsylvania, Philadelphia (H.C.H.); the Department of Cardiology, Oslo University Hospital Rikshospitalet, and the Institute of Clinical Medicine, University of Oslo - all in Oslo (L.G.); the Department of Cardiology, Medical University of Graz, Graz, Austria (D.L.); Baylor Scott and White Health, Temple, TX (M.M.); the Department of Cardiology, University Hospital of La Paz, Hospital La Paz Institute for Health Research, Madrid (R. Moreno); the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (M.V., S.W.); the Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, and Faculty of Medicine and Life Sciences, University of Hasselt - all in Hasselt, Belgium (P.V.); Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (R.C.W.); Janssen Pharmaceuticals, Titusville, NJ (P.W., A.A.V.); and Bayer, São Paulo (A.Z.)
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De Backer O, Dangas GD, Jilaihawi H, Leipsic JA, Terkelsen CJ, Makkar R, Kini AS, Veien KT, Abdel-Wahab M, Kim WK, Balan P, Van Mieghem N, Mathiassen ON, Jeger RV, Arnold M, Mehran R, Guimarães AHC, Nørgaard BL, Kofoed KF, Blanke P, Windecker S, Søndergaard L. Reduced Leaflet Motion after Transcatheter Aortic-Valve Replacement. N Engl J Med 2020; 382:130-139. [PMID: 31733182 DOI: 10.1056/nejmoa1911426] [Citation(s) in RCA: 175] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Subclinical leaflet thickening and reduced leaflet motion of bioprosthetic aortic valves have been documented by four-dimensional computed tomography (CT). Whether anticoagulation can reduce these phenomena after transcatheter aortic-valve replacement (TAVR) is not known. METHODS In a substudy of a large randomized trial, we randomly assigned patients who had undergone successful TAVR and who did not have an indication for long-term anticoagulation to a rivaroxaban-based antithrombotic strategy (rivaroxaban [10 mg] plus aspirin [75 to 100 mg] once daily) or an antiplatelet-based strategy (clopidogrel [75 mg] plus aspirin [75 to 100 mg] once daily). Patients underwent evaluation by four-dimensional CT at a mean (±SD) of 90±15 days after randomization. The primary end point was the percentage of patients with at least one prosthetic valve leaflet with grade 3 or higher motion reduction (i.e., involving >50% of the leaflet). Leaflet thickening was also assessed. RESULTS A total of 231 patients were enrolled. At least one prosthetic valve leaflet with grade 3 or higher motion reduction was found in 2 of 97 patients (2.1%) who had scans that could be evaluated in the rivaroxaban group, as compared with 11 of 101 (10.9%) in the antiplatelet group (difference, -8.8 percentage points; 95% confidence interval [CI], -16.5 to -1.9; P = 0.01). Thickening of at least one leaflet was observed in 12 of 97 patients (12.4%) in the rivaroxaban group and in 33 of 102 (32.4%) in the antiplatelet group (difference, -20.0 percentage points; 95% CI, -30.9 to -8.5). In the main trial, the risk of death or thromboembolic events and the risk of life-threatening, disabling, or major bleeding were higher with rivaroxaban (hazard ratios of 1.35 and 1.50, respectively). CONCLUSIONS In a substudy of a trial involving patients without an indication for long-term anticoagulation who had undergone successful TAVR, a rivaroxaban-based antithrombotic strategy was more effective than an antiplatelet-based strategy in preventing subclinical leaflet-motion abnormalities. However, in the main trial, the rivaroxaban-based strategy was associated with a higher risk of death or thromboembolic complications and a higher risk of bleeding than the antiplatelet-based strategy. (Funded by Bayer; GALILEO-4D ClinicalTrials.gov number, NCT02833948.).
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Affiliation(s)
- Ole De Backer
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - George D Dangas
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Hasan Jilaihawi
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Jonathon A Leipsic
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Christian J Terkelsen
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Raj Makkar
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Annapoorna S Kini
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Karsten T Veien
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Mohamed Abdel-Wahab
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Won-Keun Kim
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Prakash Balan
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Nicolas Van Mieghem
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Ole N Mathiassen
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Raban V Jeger
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Martin Arnold
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Roxana Mehran
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Ana H C Guimarães
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Bjarne L Nørgaard
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Klaus F Kofoed
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Philipp Blanke
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Stephan Windecker
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
| | - Lars Søndergaard
- From the Heart Center, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Copenhagen (O.D.B., K.F.K., L.S.); the Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai Hospital (G.D.D., A.S.K., R. Mehran), and NYU Langone Health (H.J.) - both in New York; National and Kapodistrian University of Athens, Athens (G.D.D.); the Department of Medical Imaging, St. Paul's Hospital, University of British Columbia, Vancouver, Canada (J.A.L., P. Blanke); the Department of Cardiology, Aarhus University Hospital, Aarhus (C.J.T., O.N.M., B.L.N.), and the Department of Cardiology, Odense University Hospital, Odense (K.T.V.) - both in Denmark; Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles (R. Makkar); the Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg (M.A.-W.), Heart Center Leipzig, University of Leipzig, Leipzig (M.A.-W.), Kerckhoff Heart Center, Department of Cardiology and Cardiac Surgery, Bad Nauheim (W.-K.K.), and Kardiologie und Angiologie, Universitätsklinikum Erlangen, Erlangen (M.A.) - all in Germany; the Department of Internal Medicine, University of Texas Health Science Center, Houston (P. Balan); Thoraxcentrum, Erasmus Medisch Centrum (N.V.M.), European Cardiovascular Research Institute (A.H.C.G.), and Cardialysis, Academic Research Organization (A.H.C.G.) - all in Rotterdam, the Netherlands; and the Department of Cardiology, Basel University Hospital, University of Basel, Basel (R.V.J.), and the Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern (S.W.) - both in Switzerland
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16
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Ruell J, Smith A, Perera T, Carter J. The role of a specialist bridging service. A New Zealand prospective study of 600 patients. J Thromb Haemost 2019; 17:1756-1761. [PMID: 31215756 DOI: 10.1111/jth.14542] [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: 01/08/2019] [Revised: 06/07/2019] [Accepted: 06/07/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND A proposition for the Wellington hospital thrombosis service to manage periprocedure anticoagulation bridging was made after a number of cancellations and key incidents were caused by lack of a consistent management approach. We provided individual bridging assessments, with implementation, communication, and education. The only funded anticoagulants in New Zealand at that time were dabigatran, warfarin, and enoxaparin. METHODS On initiation of the bridging service, we prospectively collected data on 600 consecutive patients referred to the periprocedure bridging service between May 2015 and February 2017. We recorded the 30-day major bleeding events, thrombotic events, and related mortality. We followed the patients up for 30 days postprocedure. As part of this process, we ensured optimal transition back to their initial anticoagulant. CONCLUSION We found low rates of major bleeding 1.9% and thrombosis 0.8% at day 30 comparable to randomized controlled trials. Of the 222 patients taking dabigatran experienced no major bleeding events. We believe using a specialist coagulation service is optimal to ensure surgery can proceed safely.
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Affiliation(s)
- Jackie Ruell
- Haematology Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Alison Smith
- Haematology Department, Wellington Regional Hospital, Wellington, New Zealand
- University of Otago, Wellington, New Zealand
| | - Travis Perera
- Haematology Department, Wellington Regional Hospital, Wellington, New Zealand
- University of Otago, Wellington, New Zealand
| | - John Carter
- Haematology Department, Wellington Regional Hospital, Wellington, New Zealand
- University of Otago, Wellington, New Zealand
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17
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Grunewald C, Esscher A, Lutvica A, Parén L, Saltvedt S. [Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. Lakartidningen 2019; 116:FPL4. [PMID: 31573669] [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] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions. MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny. A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.
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Affiliation(s)
- Charlotta Grunewald
- Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden
| | - Annika Esscher
- Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden
| | - Ajlana Lutvica
- Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden
| | - Lisa Parén
- Sahlgrenska universitetssjukhuset - Obstetriken Goteborg, Sweden Sahlgrenska universitetssjukhuset - Obstetriken Goteborg, Sweden
| | - Sissel Saltvedt
- Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden
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18
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Kosmidou I, Liu Y, Alu MC, Liu M, Madhavan M, Chakravarty T, Makkar R, Thourani VH, Biviano A, Kodali S, Leon MB. Antithrombotic Therapy and Cardiovascular Outcomes After Transcatheter Aortic Valve Replacement in Patients With Atrial Fibrillation. JACC Cardiovasc Interv 2019; 12:1580-1589. [PMID: 31439338 DOI: 10.1016/j.jcin.2019.06.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 05/29/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The study sought to determine the patterns of antithrombotic therapy and association with clinical outcomes in patients with atrial fibrillation (AF) and CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) score ≥2 following transcatheter aortic valve replacement (TAVR). BACKGROUND The impact of antithrombotic regimens on clinical outcomes in patients with AF and severe aortic stenosis treated with TAVR is unknown. METHODS In the randomized PARTNER II (Placement of Aortic Transcatheter Valve II) trial and associated registries, 1,621 patients with prior AF and CHA2DS2-VASc score ≥2 comprised the study cohort. Outcomes were analyzed according to antithrombotic therapy. RESULTS During the 5-year enrollment period, 933 (57.6%) patients were discharged on oral anticoagulant therapy (OAC). Uninterrupted antiplatelet therapy (APT) for at least 6 months or until an endpoint event was used in 544 of 933 (58.3%) of patients on OAC and 77.5% of patients not on OAC. At 2 years, patients on OAC had a similar rate of stroke (6.6% vs. 5.6%; p = 0.53) and the composite outcome of death or stroke (29.7% vs. 31.8%; p = 0.33), compared with no OAC. OAC with APT was associated with a reduced rate of stroke (5.4% vs. 11.1%; p = 0.03) and death or stroke (29.7% vs. 40.1%; p = 0.01), compared with no OAC or APT. Following adjustment, OAC with APT and APT alone were both associated with reduced rates of stroke compared with no OAC or APT (hazard ratio for OAC+APT: 0.43, 95% confidence interval: 0.22 to 0.85; p = 0.015; hazard ratio for APT alone: 0.32, 95% confidence interval: 0.16 to 0.65; p = 0.002), while OAC alone was not. CONCLUSIONS Among patients with prior AF undergoing TAVR, antiplatelet with or without anticoagulant therapy was associated with a reduced risk of stroke at 2 years, implicating multifactorial stroke mechanisms in this population.
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Affiliation(s)
- Ioanna Kosmidou
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York.
| | - Yangbo Liu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Maria C Alu
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Mengdan Liu
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Mahesh Madhavan
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Tarun Chakravarty
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raj Makkar
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Vinod H Thourani
- Department of Cardiac Surgery, Medstar Heart and Vascular Institute/Georgetown University, Washington, DC
| | - Angelo Biviano
- Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Susheel Kodali
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Martin B Leon
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Department of Medicine, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
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Grilz E, Mauracher L, Posch F, Königsbrügge O, Zöchbauer‐Müller S, Marosi C, Lang I, Pabinger I, Ay C. Citrullinated histone H3, a biomarker for neutrophil extracellular trap formation, predicts the risk of mortality in patients with cancer. Br J Haematol 2019; 186:311-320. [PMID: 30968400 PMCID: PMC6618331 DOI: 10.1111/bjh.15906] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/19/2019] [Indexed: 12/15/2022]
Abstract
Prior studies indicate that neutrophil extracellular traps (NETs) are associated with arterial thromboembolism (ATE) and mortality. We investigated the association between NET formation biomarkers (citrullinated histone H3 [H3Cit], cell-free DNA [cfDNA], and nucleosomes) and the risk of ATE and all-cause mortality in patients with cancer. In this prospective cohort study, H3Cit, cfDNA and nucleosome levels were determined at study inclusion, and patients with newly diagnosed cancer or progressive disease after remission were followed for 2 years for ATE and death. Nine-hundred and fifty-seven patients were included. The subdistribution hazard ratios for ATE of H3Cit, cfDNA and nucleosomes were 1·0 per 100 ng/ml increase (95% confidence interval [95% CI]: 0·7-1·4, P = 0·949), 1·0 per 100 ng/ml (0·9-1·2, P = 0·494) increase and 1·1 per 1-unit increase (1·0-1·2, P = 0·233), respectively. Three-hundred and seventy-eight (39·5%) patients died. The hazard ratio (HR) for mortality of H3Cit and cfDNA per 100 ng/ml increase was 1·1 (1·0-1·1, P < 0·001) and 1·1 (1·0-1·1, P < 0·001), respectively. The HR for mortality of nucleosome levels per 1-unit increase was 1·0 (1·0-1·1, P = 0·233). H3Cit, cfDNA and nucleosome levels were not associated with the risk of ATE in patients with cancer. Elevated H3Cit and cfDNA levels were associated with higher mortality in patients with cancer.
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Affiliation(s)
- Ella Grilz
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Lisa‐Marie Mauracher
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Florian Posch
- Division of OncologyDepartment of MedicineMedical University of GrazGrazAustria
| | - Oliver Königsbrügge
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Sabine Zöchbauer‐Müller
- Clinical Division of OncologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Christine Marosi
- Clinical Division of OncologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Irene Lang
- Clinical Division of CardiologyDepartment of Medicine IIMedical University of ViennaViennaAustria
| | - Ingrid Pabinger
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
| | - Cihan Ay
- Clinical Division of Haematology and HaemostaseologyDepartment of Medicine IMedical University of ViennaViennaAustria
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20
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Lacey J, Corbett J, Forni L, Hooper L, Hughes F, Minto G, Moss C, Price S, Whyte G, Woodcock T, Mythen M, Montgomery H. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med 2019; 51:232-251. [PMID: 31204514 PMCID: PMC7877883 DOI: 10.1080/07853890.2019.1628352] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/28/2019] [Accepted: 05/28/2019] [Indexed: 01/02/2023] Open
Abstract
Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry. Materials and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome. Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; "dehydration" and "hypovolaemia" are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes. Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours. Key messages Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis. Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice. Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.
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Affiliation(s)
- Jonathan Lacey
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Jo Corbett
- Department of Sport & Exercise Science, University of Portsmouth, Portsmouth, UK
| | - Lui Forni
- Intensive Care Unit, Royal Surrey County Hospital, Guildford, UK
| | - Lee Hooper
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fintan Hughes
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Gary Minto
- Department of Anaesthesia, University Hospitals Plymouth, Plymouth, UK
- Peninsula School of Medicine, Plymouth, UK
| | - Charlotte Moss
- Division of Surgery & Interventional Science, University College London, London, UK
| | - Susanna Price
- Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Greg Whyte
- Research Institute for Sport & Exercise Science, Liverpool John Moores University, UK
| | - Tom Woodcock
- Formerly Consultant University Hospitals Southampton NHS Trust, Southampton, UK
| | - Michael Mythen
- Institute of Sport Exercise & Health, University College London, London, UK
| | - Hugh Montgomery
- Centre for Human Health and Performance, University College London, London, UK
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21
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Lindeman JH, Hulsbos L, van den Bogaerdt AJ, Geerts M, van Gool AJ, Hamming JF, van Dijk RA, Schaapherder AF. Qualitative evaluation of coronary atherosclerosis in a large cohort of young and middle-aged Dutch tissue donors implies that coronary thrombo-embolic manifestations are stochastic. PLoS One 2018; 13:e0207943. [PMID: 30481212 PMCID: PMC6258539 DOI: 10.1371/journal.pone.0207943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 11/08/2018] [Indexed: 01/14/2023] Open
Abstract
Background and aims With the intention to gain support for the hypothesis that incident ischemic complications of atherosclerotic disease involve a stochastic aspect, we performed a histological, qualitative evaluation of the epidemiology of coronary atherosclerotic disease in a cohort of aortic valve donors. Patients and methods Donors (n = 695, median age 54, range 11–65 years) were dichotomized into a non-cardiovascular (non-CVD) and a cardiovascular disease death (CVD) group. Consecutive 5 mm proximal left coronary artery segments were Movat stained, and the atherosclerotic burden for each segment was graded (revised AHA-classification). Results Non-CVD and CVD groups showed steep increase of atherosclerosis severity beyond the age of 40, resulting in an endemic presence of advanced atherosclerosis in men over 40 and women over 50 years. In fact, only 19% of the non-CVD and 6% of the CVD donors over 40 years were classified with a normal LCA or a so called non-progressive lesion type. Fibrous calcified plaques (FCP), the consolidated remnants of earlier ruptured lesions, dominated in both non-CVD and CVD donors. Estimates of the atherosclerosis burden (i.e. average lesion grade, proportion of FCPs, and average number of FCPs per cross-section) were all higher in the CVD group (p<1.10−16, p<0.0001, and p<0.05, respectively). Conclusions Dominance of consolidated FCP lesions in males over 40 and females over 50 years, show that plaque ruptures in the left coronary artery are common. However, the majority of these ruptures remain asymptomatic. This implies that the atherosclerotic process is repetitive. A relative difference in disease burden between CVD and non-CVD donors supports the concept that complications of atherosclerotic disease involve a stochastic element.
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Affiliation(s)
- Jan H. Lindeman
- Dept. of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Luuk Hulsbos
- Dept. of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Marlieke Geerts
- Dept. of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jaap F. Hamming
- Dept. of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Rogier A. van Dijk
- Dept. of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
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22
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Abstract
BACKGROUND Although utilization of anticoagulation in patients with atrial fibrillation (AF) has increased in recent years, contemporary data regarding thromboembolism and mortality incidence rates are limited outside of clinical trials. This study aimed to investigate the impact of the direct oral anticoagulants (DOACs) on the clinical outcomes of patients with AF included in the Tasmanian Atrial Fibrillation Study. METHODS The medical records of all patients with a primary or secondary diagnosis of AF who presented to public hospitals in Tasmania, Australia, between 2011 and 2015, were retrospectively reviewed. We investigated overall thromboembolic events (TEs), ischemic stroke/transient ischemic attack (IS/TIA), and mortality incidence rates in patients admitted to the Royal Hobart Hospital, the main teaching hospital in the state. We compared outcomes in 2 time periods: prior to the availability of DOACs (pre-DOAC; 2011 to mid-2013) and following their general availability after government subsidization (post-DOAC; mid-2013 to 2015). RESULTS Of the 2390 patients with AF admitted during the overall study period, 942 patients newly prescribed an antithrombotic medication (465 and 477 from the pre-DOAC and post-DOAC time periods, respectively) were followed. We observed a significant decrease in the incidence rates of overall TE (3.2 vs 1.7 per 100 patient-years [PY]; P < .001) and IS/TIA (2.1 vs 1.3 per 100 PY; P = .022) in the post-DOAC compared to the pre-DOAC period. All-cause mortality was significantly lower in the post-DOAC period (2.9 vs 2.2 per 100 PY, P = .028). Increasing age, prior stroke, and admission in the pre-DOAC era were all risk factors for TE, IS/TIA, and mortality in this study population. The risk of IS/TIA was more than doubled (hazard ratio: 2.54; 95% confidence interval: 1.17-5.52) in current smokers compared to ex- and nonsmokers. CONCLUSION Thromboembolic event and all-cause mortality rates were lower following the widespread availability of DOACs in this population.
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Affiliation(s)
- Endalkachew Admassie
- 1 Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Leanne Chalmers
- 2 School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Luke R Bereznicki
- 1 Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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23
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Xing Y, Sun Y, Li H, Tang M, Huang W, Zhang K, Zhang D, Zhang D, Ma Q. CHA 2DS 2-VASc score as a predictor of long-term cardiac outcomes in elderly patients with or without atrial fibrillation. Clin Interv Aging 2018; 13:497-504. [PMID: 29636604 PMCID: PMC5880186 DOI: 10.2147/cia.s147916] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The CHA2DS2-VASc score is often used for stroke risk stratification in atrial fibrillation (AF) patients. However, its usefulness in patients ≥75 years of age with or without AF is unclear. OBJECTIVE We aimed to investigate whether the CHA2DS2-VASc score can predict ischemic stroke (IS), transient ischemic attack, thromboembolism (TE), and mortality in elderly patients with and without AF. MATERIALS AND METHODS During 2013-2014, 1,071 patients (36.3% with concomitant AF) at least 75 years old were enrolled, and the follow-up ended on July 15, 2017. Variables included sociodemographic characteristics, complications, drugs taken, laboratory results, and echocardiographic parameters. The primary end points were IS, transient ischemic attack, and TE, expressed as IS/TE. All-cause mortality was a secondary end point. Survival curves and mortality risks were assessed via Kaplan-Meier survival analysis and compared by log-rank tests. RESULTS The average follow-up duration was 2.57±1.37 years. Overall, 167 patients (5.6%) died and 77 (7.2%) developed IS/TE. The CHA2DS2-VASc score was associated with IS/TE in patients 75 years or older with and without AF, and patients with a CHA2DS2-VASc score ≥5 had a higher risk of stroke. However, the CHA2DS2-VASc score was not related to all-cause mortality. CONCLUSION The CHA2DS2-VASc score can predict IS/TE, but not mortality, in elderly patients (≥75 years) with or without AF.
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Affiliation(s)
- Yunli Xing
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Ying Sun
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongwei Li
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Mei Tang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Wei Huang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Kan Zhang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Dai Zhang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Deqiang Zhang
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Qing Ma
- Department of Geriatrics and Gerontology, Beijing Friendship Hospital, Capital Medical University, Beijing, People’s Republic of China
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24
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Pol T, Held C, Westerbergh J, Lindbäck J, Alexander JH, Alings M, Erol C, Goto S, Halvorsen S, Huber K, Hanna M, Lopes RD, Ruzyllo W, Granger CB, Hijazi Z. Dyslipidemia and Risk of Cardiovascular Events in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Therapy: Insights From the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) Trial. J Am Heart Assoc 2018; 7:e007444. [PMID: 29419390 PMCID: PMC5850246 DOI: 10.1161/jaha.117.007444] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/04/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Dyslipidemia is a major risk factor for cardiovascular events. The prognostic importance of lipoproteins in patients with atrial fibrillation is not well understood. We aimed to explore the association between apolipoprotein A1 (ApoA1) and B (ApoB) and cardiovascular events in patients with atrial fibrillation receiving oral anticoagulation. METHODS AND RESULTS Using data from the ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation) trial, ApoA1 and ApoB plasma levels were measured at baseline in 14 884 atrial fibrillation patients. Median length of follow-up was 1.9 years. Relationships between continuous levels of ApoA1 and ApoB and clinical outcomes were evaluated using Cox models adjusted for cardiovascular risk factors, medication including statins, and cardiovascular biomarkers. A composite ischemic outcome (ischemic stroke, systemic embolism, myocardial infarction, and cardiovascular death) was used as the primary end point. Median (25th, 75th) ApoA1 and ApoB levels were 1.10 (0.93, 1.30) and 0.70 g/L (0.55, 0.85), respectively. In adjusted analyses, higher levels of ApoA1 were independently associated with a lower risk of the composite ischemic outcome (hazard ratio, 0.81; P<0.0001). Similar results were observed for the individual components of the composite outcome. ApoB was not significantly associated with the composite ischemic outcome (P=0.8240). Neither apolipoprotein was significantly associated with major bleeding. There was no interaction between lipoproteins and randomized treatment for the primary outcome (both P values ≥0.2448). CONCLUSIONS In patients with atrial fibrillation on oral anticoagulation, higher levels of ApoA1 were independently associated with lower risk of ischemic cardiovascular outcomes. Investigating therapies targeting dyslipidemia may thus be useful to improve cardiovascular outcomes in patients with atrial fibrillation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00412984.
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Affiliation(s)
- Tymon Pol
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Claes Held
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - Johan Westerbergh
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Marco Alings
- Working Group on Cardiovascular Research the Netherlands, Utrecht, The Netherlands
| | - Cetin Erol
- Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Shinya Goto
- Department of Medicine, School of Medicine, Tokai University, Isehara, Japan
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
- University of Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenshopital, Vienna, Austria
- Medical School, Sigmund Freud University, Vienna, Austria
| | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke Health, Durham, NC
| | | | | | - Ziad Hijazi
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
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25
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Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and it leads to significant morbidity and mortality, predominantly from ischemic stroke. Vitamin K antagonists, mainly warfarin, have been used for decades to prevent ischemic stroke in AF, but their use is limited due to interactions with food and other drugs, as well as the requirement for regular monitoring of the international normalized ratio. Rivaroxaban, a direct factor Xa inhibitor and the most commonly used non-vitamin K oral anticoagulant, avoids many of these challenges and is being prescribed with increasing frequency for stroke prevention in non-valvular AF. Randomized controlled trial (RCT) data from the ROCKET-AF(Rivaroxaban once daily oral direct Factor Xa inhibition compared with vitamin K antagonism for prevention of stroke and embolism trial in atrial fibrillation) trial have shown rivaroxaban to be non-inferior to warfarin in preventing ischemic stroke and systemic embolism and to have comparable overall bleeding rates. Applicability of the RCT data to real-world practice can sometimes be limited by complex clinical scenarios or multiple comorbidities not adequately represented in the trials. Available real-world evidence in non-valvular AF patients with comorbidities - including renal impairment, acute coronary syndrome, diabetes mellitus, malignancy, or old age - supports the use of rivaroxaban as safe and effective in preventing ischemic stroke in these subgroups, though with some important considerations required to reduce bleeding risk. Patient perspectives on rivaroxaban use are also considered. Real-world evidence indicates superior rates of drug adherence with rivaroxaban when compared with vitamin K antagonists and with alternative non-vitamin K oral anticoagulants - perhaps, in part, due to its once-daily dosing regimen. Furthermore, self-reported quality of life scores are highest among patients compliant with rivaroxaban therapy. The generally high levels of patient satisfaction with rivaroxaban therapy contribute to overall favorable clinical outcomes.
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Affiliation(s)
- Kavitha Vimalesvaran
- Department of Cardiology, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Seth J Dockrill
- Department of Cardiology, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Diana A Gorog
- Department of Cardiology, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
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Bai Y, Guo SD, Deng H, Shantsila A, Fauchier L, Ma CS, Lip GYH. Effectiveness and safety of oral anticoagulants in older patients with atrial fibrillation: a systematic review and meta-regression analysis. Age Ageing 2018; 47:9-17. [PMID: 28985259 DOI: 10.1093/ageing/afx103] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [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: 03/11/2017] [Accepted: 06/12/2017] [Indexed: 11/14/2022] Open
Abstract
Background and objective the study analysed the effectiveness and safety of warfarin use compared with warfarin non-use and non-vitamin K antagonist oral anticoagulants (NOACs) in atrial fibrillation (AF) patients aged ≥65 years. Methods after searching PubMed and the Cochrane Library, 26 studies were included, with 10 comparing warfarin with warfarin non-use and 16 comparing warfarin with NOACs, in older AF patients (≥65 years). Results warfarin use was superior to no antithrombotic therapy [relative risk (RR) 0.59, 95% confidence interval (CI) 0.51-0.76, I2 = 12.3%, n = 8] and aspirin (RR 0.44, 95% CI 0.24-0.64, I2 = 0.0%, n = 5) for stroke/thromboembolism (TE) prevention. Warfarin use was associated with a non-significant increase in risk of major bleeding compared with no antithrombotic therapy (RR 1.26, 95% CI 0.99-1.52, I2 = 0.0%, n = 7) and aspirin (RR 1.20, 95% CI 0.91-1.50, I2 = 0.0%, n = 5). NOACs were superior to warfarin for stroke/TE prevention [hazard ratio (HR) 0.81, 95% CI 0.73-0.89, I2 = 56.6%, n = 9], and also were associated with reduced risk of major bleeding compared to warfarin (HR 0.87, 0.77-0.97, I2 = 86.1%, n = 9). Conclusions warfarin use was superior to warfarin non-use, aspirin and no antithrombotic therapy in reducing the risk of stroke/TE in older AF patients, but with a possible increase in major bleeding. NOACs were superior to warfarin for stroke/TE prevention, with reduced risk of major bleeding.
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Affiliation(s)
- Ying Bai
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B18 7QH, UK
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Shi-Dong Guo
- Emergency Department of China-Japan Friendship Hospital, No. 2 Yinghua Dongjie, Hepingli, Chaoyang District, Beijing100029, China
| | - Hai Deng
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou, China
| | - Alena Shantsila
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B18 7QH, UK
| | - Laurent Fauchier
- Service de Cardiologie, Pole Coeur Thorax Vasculaire, Centre Hospitalier, Universitaire Trousseau et Faculté de Médecine, Université Franis Rabelais, Tours, France
| | - Chang-Sheng Ma
- Cardiovascular Center, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, Beijing Shi, China
| | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B18 7QH, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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27
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Momi S, Pitchford SC, Alberti PF, Minuz P, Del Soldato P, Gresele P. Nitroaspirin plus clopidogrel versus aspirin plus clopidogrel against platelet thromboembolism and intimal thickening in mice. Thromb Haemost 2017; 93:535-43. [PMID: 15735806 DOI: 10.1160/th04-07-0464] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryClopidogrel plus aspirin is the treatment of choice for patients undergoing percutaneous, coronary interventions with stenting, but it does not prevent restenosis. NCX-4016, a nitric oxide-releasing aspirin (nitroaspirin), exerts a wider range of antiplatelet actions compared to aspirin, superior antithrombotic activity and reduces restenosis after arterial injury in animals. The aim of the present study was to compare the combination of nitroaspirin plus clopidogrel with aspirin plus clopidogrel in a model of platelet pulmonary thromboembolism, bleeding and intimal thickening in mice. Drugs were administered orally for 5 days; the antithrombotic effects were evaluated against collagen plus epinephrine-induced pulmonary thromboembolism, the haemorrhagic effects by tail transection bleeding time and the effects on neointima proliferation by histomorphology of photochemically injured femoral arteries. Lung platelet emboli were reduced significantly and more effectively by nitroaspirin plus clopidogrel (-56%, p< 0.05 vs control) than by aspirin plus clopidogrel (-26%, p< 0.05 vs control). Ex vivo platelet aggregation was inhibited maximally by nitroaspirin plus clopidogrel. Aspirin plus clopidogrel strikingly prolonged the bleeding time while nitroaspirin plus clopidogrel induced a lesser prolongation. Nitroaspirin plus clopidogrel significantly reduced intimal thickening of the femoral artery while aspirin plus clopidogrel was ineffective. Nitroaspirin plus clopidogrel is more effective and less prohaemorrhagic than aspirin plus clopidogrel in mice; provided these data are confirmed in other animal models, nitroaspirin plus clopidogrel may represent a new regimen to be tested in patients undergoing coronary revascularization procedures.
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Affiliation(s)
- Stefania Momi
- Department of Internal Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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28
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Kikura M, Takada T, Sato S. Age- and sex-specific incidence, risk, and latency period of a perioperative acute thromboembolism syndrome (PATS). Thromb Haemost 2017; 91:725-32. [PMID: 15045134 DOI: 10.1160/th03-10-0613] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryWe investigated age- and sex-specific incidence, risk factors, and latency period of a perioperative acute thromboembolism syndrome (PATS) in a large cohort study. We prospectively analyzed data on 21903 consecutive surgery patients to determine the incidence of myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, and cardiovascular death within 30 postoperative days. Among 255 (1.2 percent) patients with thromboembolism, 105 (0.48 percent) suffered myocardial infarction (mean latency: 5 days), 30 (0.14 percent) suffered pulmonary embolism (6 days), 23 (0.11 percent) suffered deep venous thrombosis (10 days), 97 (0.44 percent) suffered stroke (11 days), and 13 (0.06 percent) died (12 days). The critical period was postoperative week 1 for myocardial infarction and pulmonary embolism, and postoperative week 1 and 2 for deep venous thrombosis, stroke, and death. Risk of all events increased with age (P<0.0001), particularly for over 70 years (odds ratio: 12.5; 95 percent confidence interval, 7.8 to 19.9). Males had an increased risk (P<0.0001) of myocardial infarction (odds ratio; 1.5; 95 percent confidence interval, 1.0 to 2.3). Females had an increased risk (P<0.0001) of pulmonary embolism (odds ratio: 2.7; 95 percent confidence interval, 1.3 to 5.9) and deep venous thrombosis (odds ratio: 9.8; 95 percent confidence interval, 3.3 to 29.3). Risk of thromboembolic event was higher (P<0.0001) in patients with a history of arterial thrombotic events or cancer. Trend analysis indicates that thromboembolic events will increase 3-fold over the next decade. Our findings enable identification of higher risk patients for prophylactic anti-thromboembolic treatment and awareness of the critical postoperative period.
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Affiliation(s)
- Mutsuhito Kikura
- Department of Anesthesiology and Pain Clinic, Seirei-Mikatabara General Hospital, Mikatabara-cho 3453, Hamamatsu, Japan.
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Peyvandi F, Scully M, Kremer Hovinga JA, Knöbl P, Cataland S, De Beuf K, Callewaert F, De Winter H, Zeldin RK. Caplacizumab reduces the frequency of major thromboembolic events, exacerbations and death in patients with acquired thrombotic thrombocytopenic purpura. J Thromb Haemost 2017; 15:1448-1452. [PMID: 28445600 DOI: 10.1111/jth.13716] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [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: 01/24/2017] [Indexed: 11/25/2022]
Abstract
Essentials Acquired thrombotic thrombocytopenic purpura (aTTP) is linked with significant morbidity/mortality. Caplacizumab's effect on major thromboembolic (TE) events, exacerbations and death was studied. Fewer caplacizumab-treated patients had a major TE event, an exacerbation, or died versus placebo. Caplacizumab has the potential to reduce the acute morbidity and mortality associated with aTTP. SUMMARY Background Acquired thrombotic thrombocytopenic purpura (aTTP) is a life-threatening autoimmune thrombotic microangiopathy. In spite of treatment with plasma exchange and immunosuppression, patients remain at risk for thrombotic complications, exacerbations, and death. In the phase II TITAN study, treatment with caplacizumab, an anti-von Willebrand factor Nanobody® was shown to reduce the time to confirmed platelet count normalization and exacerbations during treatment. Objective The clinical benefit of caplacizumab was further investigated in a post hoc analysis of the incidence of major thromboembolic events and exacerbations during the study drug treatment period and thrombotic thrombocytopenic purpura-related death during the study. Methods The Standardized Medical Dictionary for Regulatory Activities (MedDRA) Query (SMQ) for 'embolic and thrombotic events' was run to investigate the occurrence of major thromboembolic events and exacerbations in the safety population of the TITAN study, which consisted of 72 patients, of whom 35 received caplacizumab and 37 received placebo. Results Four events (one pulmonary embolism and three aTTP exacerbations) were reported in four patients in the caplacizumab group, and 20 such events were reported in 14 patients in the placebo group (two acute myocardial infarctions, one ischemic stroke, one hemorrhagic stroke, one pulmonary embolism, one deep vein thrombosis, one venous thrombosis, and 13 aTTP exacerbations). Two of the placebo-treated patients died from aTTP during the study. Conclusion In total, 11.4% of caplacizumab-treated patients and 43.2% of placebo-treated patients experienced one or more major thromboembolic events, experienced an exacerbation, or died. This analysis shows the potential for caplacizumab to reduce the risk of major thromboembolic morbidities and mortality associated with aTTP.
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Affiliation(s)
- F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - M Scully
- Department of Haematology, University College London Hospital, London, UK
| | - J A Kremer Hovinga
- University Clinic of Hematology & Central Hematology Laboratory, Inselspital, Bern University Hospital and Department of Clinical Research, University of Bern, Bern, Switzerland
| | - P Knöbl
- Department of Medicine 1, Division of Hematology and Hemostasis, Medical University of Vienna, Vienna, Austria
| | - S Cataland
- Department of Internal Medicine, Ohio State University, Columbus, OH, USA
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30
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Abstract
BACKGROUND The number of patients treated with novel oral anticoagulants (NOACs) is increasing. Despite growing clinical relevance, guidelines on the perioperative management of neurosurgical patients treated with NOACs are still lacking. The aim of this study was to analyze the occurrence of postoperative bleeding events and factors that might influence bleeding rates in these patients. METHODS Out of 1353 consecutive patients undergoing cranial neurosurgical procedures, 30 (2.2%) received NOACs preoperatively. The rates of perioperative and postoperative intracranial bleeding events, rate of postoperative thromboembolic events, hematologic findings, morbidity, and mortality were reviewed. A subanalysis of factors influencing the bleeding risk of these patients and the bleeding rate depending on the preoperative discontinuation time of NOACS, with cutoff of 24 and 48 hours, was performed as well. RESULTS The rate of perioperative bleeding was 13.3% (n = 4 of 30). Postoperative bleeding led to death in 2 patients. The median discontinuation time was significantly shorter in the patients experiencing a bleeding event compared to those without a bleeding event (1.5 days [range 0-3 days] vs. 11 days [range, 0-120 days]). The rate of perioperative thromboembolic events was 3.3% (n = 1), and overall mortality was 13.3% (n = 4). CONCLUSIONS The postoperative bleeding rate in patients undergoing cranial surgery treated with NOACs was 13.3%. A shorter preoperative discontinuation time seems to have a significant effect on bleeding rate. Further studies evaluating the management and postsurgical outcomes of these patients are warranted.
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Affiliation(s)
- Davide Marco Croci
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland.
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
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31
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Proietti M, Boriani G, Laroche C, Diemberger I, Popescu MI, Rasmussen LH, Sinagra G, Dan GA, Maggioni AP, Tavazzi L, Lane DA, Lip GYH. Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry. Europace 2017; 19:535-543. [PMID: 28431068 DOI: 10.1093/europace/euw150] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 02/25/2016] [Accepted: 04/10/2016] [Indexed: 11/13/2022] Open
Abstract
AIMS Physical activity is protective against cardiovascular (CV) events, both in general population and in high-risk CV cohorts. However, the relationship between physical activity with major adverse outcomes in atrial fibrillation (AF) is not well-established. Our aim was to analyse this relationship in a 'real-world' AF population. Second, we investigated the influence of physical activity on arrhythmia progression. METHODS AND RESULTS We studied all patients enrolled in the EURObservational Research Programme on AF (EORP-AF) Pilot Survey. Physical activity was defined as 'none', 'occasional', 'regular', and 'intense', based on patient self-reporting. Data on physical activity were available for 2442 patients: 38.9% reported none, 34.7% occasional, 21.7% regular, and 4.7% intense physical activity. Prevalence of the principal CV risk factors progressively decreased from none to intense physical activity. Lower rates of CV death, all-cause death, and composite outcomes were found in AF patients who reported regular and intense physical activity (P < 0.0001). Increasing physical activity was inversely associated with CV death/any thromboembolic event (TE)/bleeding in the whole cohort, irrespective of gender, paroxysmal AF, elderly age, or high stroke risk. Any level of physical activity intensity was significantly associated with lower risk of CV death/any TE/bleeding at 1-year follow-up. Physical activity was not significantly associated with arrhythmia progression. CONCLUSION Atrial fibrillation patients taking regular exercise were associated with a lower risk of all-cause death, even when we considered various subgroups, including gender, elderly age, symptomatic status, and stroke risk class. Efforts to increase physical activity among AF patients may improve outcomes in these patients.
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Affiliation(s)
- Marco Proietti
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Dudley Road, B18 7QH Birmingham, UK
| | - Giuseppe Boriani
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
- Cardiology Department, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Cécile Laroche
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
| | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, University of Bologna, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Lars H Rasmussen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gianfranco Sinagra
- Cardiovascular Department, University Hospital Cattinara, AOU Ospedali Riuniti, Trieste, Italy
| | - Gheorghe-Andrei Dan
- University of Medicine, 'Carol Davila', Colentina University Hospital, Bucharest, Romania
| | - Aldo P Maggioni
- EURObservational Research Programme Department, European Society of Cardiology, Sophia Antipolis, France
- ANMCO Research Center, Firenze, Italy
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
| | - Deirdre A Lane
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Dudley Road, B18 7QH Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Dudley Road, B18 7QH Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Parsons C, Patel SI, Cha S, Shen WK, Desai S, Chamberlain AM, Luis SA, Aguilar MI, Demaerschalk BM, Mookadam F, Shamoun F. CHA 2DS 2-VASc Score: A Predictor of Thromboembolic Events and Mortality in Patients With an Implantable Monitoring Device Without Atrial Fibrillation. Mayo Clin Proc 2017; 92:360-369. [PMID: 28259228 PMCID: PMC5641434 DOI: 10.1016/j.mayocp.2016.10.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 09/16/2016] [Accepted: 10/04/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine if the CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category) predicts thromboembolism and death in patients without atrial fibrillation in a population with implantable cardiac monitoring devices. PATIENTS AND METHODS A retrospective review utilizing the Rochester Epidemiology Project research infrastructure was conducted to evaluate the CHA2DS2-VASc tool as a predictor of mortality and ischemic stroke, transient ischemic attack, or systemic embolism in patients without atrial fibrillation. An implantable device was required in the inclusion criteria to discern the absence of atrial fibrillation. The study period was January 1, 2004, through March 7, 2016. RESULTS The study population (N=1606) had a mean (SD) age of 69.8 (12.6) years and median follow-up of 4.8 years (range, 0-12 years; quartile 1, 2.6 years and quartile 3, 8.1 years). The number of thromboembolic and mortality events stratified by CHA2DS2-VASc score groupings of 0 to 2 (399 patients), 3 to 5 (756 patients), and 6 to 9 (451 patients) were 12 (3.0%), 109 (14.4%), and 123 (27.3%) and 22 (5.5%), 205 (27.1%), and 214 (47.4%), respectively. The CHA2DS2-VASc score predicted thromboembolism and death. The hazard ratios (HRs) for thromboembolic events for CHA2DS2-VASc scores 3 to 5 and 6 to 9 were 4.84 (95% CI, 2.66-8.80) and 10.53 (95% CI, 5.77-19.21) (reference group, scores 0-2). The HRs for death for the corresponding score categories were 4.45 (95% CI, 2.86-6.91) and 8.18 (95% CI, 5.23-12.78). The CHA2DS2-VASc score also predicted development of atrial fibrillation, for which the HRs for scores 3 to 5 and 6 to 9 were 1.51 (95% CI, 1.13-2.00) and 2.17 (95% CI, 1.60-2.95). CONCLUSION The CHA2DS2-VASc tool predicts thromboembolic events and overall mortality in patients without atrial fibrillation who have implantable devices.
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Affiliation(s)
| | | | - Stephen Cha
- Department of Health Sciences Research, Mayo Clinic, Scottsdale, AZ
| | - Win-Kuang Shen
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Santosh Desai
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | | | | | | | | | - Farouk Mookadam
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Fadi Shamoun
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ.
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Abstract
BACKGROUND: Warfarin dosing with a target international normalized ratio (INR) range of 1.5–2.5 has not been reported as adequate for venous thromboembolism (VTE) prophylaxis after total knee (TKR) and total hip replacement (THR) surgery. OBJECTIVE: To evaluate the rate of symptomatic VTE after TKR and THR surgery using a low-dose (INR 1.5–2.5) warfarin protocol started the evening before surgery compared with a literature cohort treated with enoxaparin. METHODS: TKR/THR patients treated with a 21-day low-dose warfarin protocol were followed via a consecutive observational design. Main outcome measures were symptomatic VTE and pulmonary embolism (PE), with major bleeds and death as secondary outcomes. Low-dose warfarin was compared with a literature cohort of patients treated with enoxaparin who received enoxaparin for a similar length of time and was evaluated for the same outcomes. Cohort event rates were derived as a weighted average using the DerSimonian model. RESULTS: VTE, PE, bleeds, and deaths in the low-dose warfarin group were 8 (1.04%), 4 (0.52%), 8 (1.04%), and 4 (0.52%), respectively. The cohort weighted average values were 35 (1.33%), 19 (0.72%), 65 (2.46%), and 18 (0.67%), respectively. Odds ratios for low-dose warfarin for VTE, PE, and VTE plus PE were 0.778 (95% CI 0.36 to 1.68), 0.717 (0.24 to 2.11), and 0.754 (0.41 to 1.42), respectively, all nonsignificant. Odds ratios for bleeds and death were 0.420 (0.20 to 0.87; p = 0.02) and 0.756 (0.26 to 2.24; NS), respectively. CONCLUSIONS: For this evaluation, low-dose warfarin was comparable to the enoxaparin cohort for development of VTE, PE, and VTE+PE. Incidences of bleeds in the enoxaparin cohort were significantly higher than in patients receiving low-dose warfarin.
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Anniccherico-Sanchez FJ, Alonso-Martinez JL, Urbieta-Echezarreta MA, Villar-Garcia I, Rojo-Alvaro J. Factors Associated with Pulmonary Embolism Recurrence and the Benefits of Long-term Anticoagulant Therapy. Cardiovasc Hematol Disord Drug Targets 2017; 17:205-211. [PMID: 28925904 DOI: 10.2174/1871529x17666170918143459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 04/03/2017] [Revised: 08/18/2017] [Accepted: 08/26/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Venous thromboemboli tend to recur. However, the causative factors underlying pulmonary embolism recurrence are not well defined. AIMS To explore the factors associated with pulmonary embolism recurrence. PATIENTS AND METHODS Patients diagnosed with pulmonary emboli between 2004 and 2013 at our institution were enrolled. Duration of anticoagulant therapy, new episodes of venous thromboembolism, and deaths were recorded. RESULTS Pulmonary embolism was diagnosed in 528 patients (median age: 76 years, interquartile range [IQR]: 16; male: 45%). The median follow-up time was 34 months (IQR: 52). In total, 477 patients completed ≥3 months of anticoagulation therapy. Permanent anticoagulation was indicated in 217 (45%) patients, and therapy was discontinued in 260 (55%) patients. Overall, 79 patients experienced a recurrence (5.6 per patient-year). Recurrence was significantly associated with anticoagulation discontinuation (4% vs. 27% of patients who maintained or discontinued therapy, respectively; P<0.001; 95% confidence interval -0.95, -0.86). The median duration between anticoagulation withdrawal and recurrence was 6.5 months (IQR: 23.25). Factors associated with recurrence were unprovoked pulmonary embolism (odds ratio [OR]: 0.45), a greater degree of pulmonary arterial obstruction (OR: 2.5), a delay in initiation of anticoagulation (OR: 3), and higher plasma D-dimer levels during treatment (OR: 2.3). Survival rates were improved for patients who maintained anticoagulation therapy relative to those who discontinued. CONCLUSION Pulmonary embolism has a high recurrence rate. Permanent anticoagulant therapy should be considered for patients with idiopathic pulmonary embolism, a high thrombotic burden, and persistently elevated D-dimer levels during treatment, and for patients where therapy was initially delayed.
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Affiliation(s)
| | | | | | - Ione Villar-Garcia
- Department of Internal Medicine A, Hospital Complex of Navarra, Pamplona, Spain
| | - Jorge Rojo-Alvaro
- Department of Internal Medicine A, Hospital Complex of Navarra, Pamplona, Spain
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Abstract
Resuming anticoagulation therapy after a potentially life-threatening bleeding complication evokes high anxiety levels among clinicians and patients trying to decide whether resuming oral anticoagulation to prevent devastating and potentially fatal thromboembolic events or discontinuing anticoagulation in hopes of reducing the risk of recurrent bleeding is best. The available evidence favors resumption of anticoagulation therapy for gastrointestinal tract bleeding and intracranial hemorrhage survivors, and it is reasonable to begin postbleeding decision making with resuming anticoagulation therapy as the default plan. After considering factors related to the index bleeding event, the underlying thromboembolic risk, and comorbid conditions, a decision to accept or modify the default plan can be made in collaboration with other care team members, the patient, and their caregivers. Although additional information is needed regarding the optimal timing of anticoagulation resumption, available evidence indicates that waiting ∼14 days may best balance the risk of recurrent bleeding, thromboembolism, and mortality after gastrointestinal tract bleeding. When to resume anticoagulation after intracranial hemorrhage is less clear, but most studies indicate that resumption within the first month of discharge is associated with better outcomes.
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Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT
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Bertozzo G, Zoppellaro G, Granziera S, Marigo L, Rossi K, Petruzzellis F, Perissinotto E, Manzato E, Nante G, Pengo V. Reasons for and consequences of vitamin K antagonist discontinuation in very elderly patients with non-valvular atrial fibrillation. J Thromb Haemost 2016; 14:2124-2131. [PMID: 27471198 DOI: 10.1111/jth.13427] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 12/16/2015] [Accepted: 07/07/2016] [Indexed: 11/29/2022]
Abstract
Essentials Anticoagulation in the elderly is still a challenge and suspension of warfarin is common. This is an observational study reporting reasons and consequences of warfarin suspension. Vascular disease, age, time in therapeutic range, and bleedings are associated with suspension. After suspension for bleeding or frailty, patients remain at high-risk of death or complications. SUMMARY Background Anticoagulation in elderly patients with non-valvular atrial fibrillation (NVAF) is still a challenge, and discontinuation of warfarin is common. The aim of this study was to analyze the aspects related to warfarin discontinuation in a real-world population. Methods This was an observational cohort study on very elderly NVAF patients naive to warfarin therapy (VENPAF). The included subjects were aged at least 80 years, and started using warfarin after a diagnosis of NVAF. Warfarin discontinuation was assessed, and the reason reported for discontinuation, the person who decided to stop treatment, subsequent antithrombotic therapy and mortality, ischemic and bleeding events were collected. Results Over a period of 5 years, warfarin was discontinued in 148 of 798 patients. Despite similar CHA2 DS2 -VASc scores, the frequencies of thromboembolic and major bleeding events were significantly higher (P = 0.01 and P = 0.001, respectively) and the time in therapeutic range (TTR) was significantly lower (P < 0.001) in patients who discontinued warfarin. Independent risk factors for warfarin discontinuation were vascular disease (hazard ratio [HR] 2.5, P < 0.001), age ≥ 85 years (HR 1.4, P = 0.04), TTR < 60% (HR 1.8, P = 0.001), and bleeding events (HR 2.3, P < 0.001). The main reasons for warfarin discontinuation were physician-perceived frailty or low life-expectancy (45.9%), bleeding complications (19.6%), and sinus rhythm restoration (16.9%). Event and death rates were very high, especially in frail patients and in those with bleeding complications. Conclusions Warfarin discontinuation is frequent in very elderly patients, and is associated with increased risks of death and adverse events. Identification of elderly patients who are at high risk of bleeding and the poor quality of anticoagulation during warfarin are still unsolved clinical problems.
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Affiliation(s)
- G Bertozzo
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - G Zoppellaro
- Department of Cardiac, Thoracic and Vascular Sciences, Cardiology Clinic, University of Padua, Padua, Italy
| | - S Granziera
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
- Department of Physical and Rehabilitation Medicine, Ospedale Classificato "Villa Salus", Mestre Venice, Padua, Italy
| | - L Marigo
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - K Rossi
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - F Petruzzellis
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - E Perissinotto
- Department of Cardiac, Thoracic and Vascular Sciences, Biostatistics, Epidemiology and Public Health Unit, University of Padua, Padua, Italy
| | - E Manzato
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - G Nante
- Department of Medicine (DIMED), Geriatric Clinic, University of Padua, Padua, Italy
| | - V Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, Cardiology Clinic, University of Padua, Padua, Italy
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Lin CY, Chang SL, Chung FP, Chen YY, Lin YJ, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang YT, Lin CH, Allamsetty S, Walia R, Te ALD, Yamada S, Chiang SJ, Tsao HM, Chen SA. Long-Term Outcome of Non-Sustained Ventricular Tachycardia in Structurally Normal Hearts. PLoS One 2016; 11:e0160181. [PMID: 27548469 PMCID: PMC4993359 DOI: 10.1371/journal.pone.0160181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 07/14/2016] [Indexed: 01/09/2023] Open
Abstract
Background The impact of non-sustained ventricular tachycardia (NSVT) on the risk of thromboembolic event and clinical outcomes in patients without structural heart disease remains undetermined. This study aimed to evaluate the association between NSVT and clinical outcomes. Methods The study population of 5903 patients was culled from the “Registry of 24-hour ECG monitoring at Taipei Veterans General Hospital” (REMOTE database) between January 1, 2002 and December 31, 2004. Of that total, we enrolled 3767 patients without sustained ventricular tachycardia, structural heart disease, and permanent pacemaker. For purposes of this study, NSVT was defined as 3 or more consecutive beats arising below the atrioventricular node with an RR interval of <600 ms (>100 beats/min) and lasting < 30 seconds. Result There were 776 deaths, 2042 hospitalizations for any reason, 638 cardiovascular (CV)-related hospitalizations, 350 ischemic strokes, 409 transient ischemic accident (TIA), 368 new-onset heart failure (HF), and 260 new-onset atrial fibrillation (AF) with a mean follow-up duration of 10 ± 1 years. In multivariate analysis, the presence of NSVT was independently associated with death (hazard ratio [HR]: 1.362, 95% confidence interval [CI]: 1.071–1.731), CV hospitalization (HR: 1.527, 95% CI: 1.171–1.992), ischemic stroke (HR: 1.436, 95% CI: 1.014–2.032), TIA (HR 1.483, 95% CI: 1.069–2.057), and new-onset HF (HR: 1.716, 95% CI: 1.243–2.368). There was no significant association between the presence of NSVT and all-cause hospitalization or new-onset AF. Conclusion In patients without structural heart disease, presence of NSVT on 24-hour monitoring was independently associated with death, CV hospitalization, ischemic stroke, TIA, and new onset heart failure.
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Affiliation(s)
- Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chung-Hsing Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Suresh Allamsetty
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Rohit Walia
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Abigail Louise D. Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shinya Yamada
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuo-Ju Chiang
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsuan-Ming Tsao
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
- Division of Cardiology, National Yang-Ming University Hospital, Yi-Lan, Taiwan
- * E-mail:
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Gallo de Moraes A, Vakil A, Moua T. Patent foramen ovale in idiopathic pulmonary arterial hypertension: Long-term risk and morbidity. Respir Med 2016; 118:53-57. [PMID: 27578471 DOI: 10.1016/j.rmed.2016.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Little is known about the presence of patent foramen ovale in idiopathic pulmonary arterial hypertension. While there is suspected worsening of hypoxemia confounding assessment and management of pulmonary hypertension, as well as possible increased morbidity from paradoxical emboli, there may be theoretical relief of worsening right-sided pressures by the same mechanism of right-to-left shunting. METHODS Retrospective review of consecutive patients diagnosed with idiopathic pulmonary arterial hypertension (WHO Group 1) via right heart catheterization, from 1998 to 2010. All patients also underwent a four chamber transthoracic echocardiogram with agitated saline contrast for the evaluation of patent foramen ovale. Primary clinical data was collected and compared between patients with and without patent foramen ovale along with univariable and multivariable predictors of long term survival. RESULTS One hundred and fifty five patients were included in the study, 42 with patent foramen ovale (27%). Patients with patent foramen ovale were younger at pulmonary arterial hypertension diagnosis and trended towards higher right ventricular systolic pressures on echocardiography and mean pulmonary arterial pressures by right heart catheterization. Predictors of mortality included age, diffusing capacity for carbon monoxide, and severe hypoxemia. Only diffusing capacity and age were predictive of mortality after adjustment for a priori covariables. CONCLUSION Patent foramen ovale is seen in a quarter of patients with idiopathic pulmonary arterial hypertension and associated with increased prevalence of severe hypoxemia but had no effect on long term survival.
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Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Abhay Vakil
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Teng Moua
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
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Heneghan CJ, Garcia-Alamino JM, Spencer EA, Ward AM, Perera R, Bankhead C, Alonso-Coello P, Fitzmaurice D, Mahtani KR, Onakpoya IJ. Self-monitoring and self-management of oral anticoagulation. Cochrane Database Syst Rev 2016; 7:CD003839. [PMID: 27378324 PMCID: PMC8078378 DOI: 10.1002/14651858.cd003839.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The introduction of point-of-care devices for the management of patients on oral anticoagulation allows self-testing by the patient at home. Patients who self-test can either adjust their medication according to a pre-determined dose-INR (international normalized ratio) schedule (self-management), or they can call a clinic to be told the appropriate dose adjustment (self-monitoring). Increasing evidence suggests self-testing of oral anticoagulant therapy is equal to or better than standard monitoring. This is an updated version of the original review published in 2010. OBJECTIVES To evaluate the effects on thrombotic events, major haemorrhages, and all-cause mortality of self-monitoring or self-management of oral anticoagulant therapy compared to standard monitoring. SEARCH METHODS For this review update, we re-ran the searches of the Cochrane Central Register of Controlled Trials (CENTRAL), 2015, Issue 6, the Cochrane Library, MEDLINE (Ovid, 1946 to June week 4 2015), Embase (Ovid, 1980 to 2015 week 27) on 1 July 2015. We checked bibliographies and contacted manufacturers and authors of relevant studies. We did not apply any language restrictions . SELECTION CRITERIA Outcomes analysed were thromboembolic events, mortality, major haemorrhage, minor haemorrhage, tests in therapeutic range, frequency of testing, and feasibility of self-monitoring and self-management. DATA COLLECTION AND ANALYSIS Review authors independently extracted data and we used a fixed-effect model with the Mantzel-Haenzel method to calculate the pooled risk ratio (RR) and Peto's method to verify the results for uncommon outcomes. We examined heterogeneity amongst studies with the Chi(2) and I(2) statistics and used GRADE methodology to assess the quality of evidence. MAIN RESULTS We identified 28 randomised trials including 8950 participants (newly incorporated in this update: 10 trials including 4227 participants). The overall quality of the evidence was generally low to moderate. Pooled estimates showed a reduction in thromboembolic events (RR 0.58, 95% CI 0.45 to 0.75; participants = 7594; studies = 18; moderate quality of evidence). Both, trials of self-management or self-monitoring showed reductions in thromboembolic events (RR 0.47, 95% CI 0.31 to 0.70; participants = 3497; studies = 11) and (RR 0.69, 95% CI 0.49 to 0.97; participants = 4097; studies = 7), respectively; the quality of evidence for both interventions was moderate. No reduction in all-cause mortality was found (RR 0.85, 95% CI 0.71 to 1.01; participants = 6358; studies = 11; moderate quality of evidence). While self-management caused a reduction in all-cause mortality (RR 0.55, 95% CI 0.36 to 0.84; participants = 3058; studies = 8); self-monitoring did not (RR 0.94, 95% CI 0.78 to 1.15; participants = 3300; studies = 3); the quality of evidence for both interventions was moderate. In 20 trials (8018 participants) self-monitoring or self-management did not reduce major haemorrhage (RR 0.95, 95% CI, 0.80 to 1.12; moderate quality of evidence). There was no significant difference found for minor haemorrhage (RR 0.97, 95% CI 0.67 to 1.41; participants = 5365; studies = 13). The quality of evidence was graded as low because of serious risk of bias and substantial heterogeneity (I(2) = 82%). AUTHORS' CONCLUSIONS Participants who self-monitor or self-manage can improve the quality of their oral anticoagulation therapy. Thromboembolic events were reduced, for both those self-monitoring or self-managing oral anticoagulation therapy. A reduction in all-cause mortality was observed in trials of self-management but not in self-monitoring, with no effects on major haemorrhage.
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Affiliation(s)
- Carl J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Oxford, Oxfordshire, UK, OX2 6GG
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Abstract
The aim of this study was to provide guidelines for optimal anticoagulation in Chinese patients after mechanical heart valve replacement. A Carbomedics valve was implanted in 178 patients between July 2000 and July 2003. During follow-up, 22 bleeding events and 1 thromboembolic complication occurred. The linearized rates of bleeding and thromboembolism were 5.83% and 0.26% per patient-year, respectively. The linearized mortality rate was 0.79% per patient-year. The final mean international normalized ratio (INR) was 1.68 ± 0.38, however there was a significant variation between the early and late periods of follow-up. For Chinese patients with mechanical heart valves, bleeding was the major complication rather than thromboembolism. Low-dose anticoagulation (international normalized ratio 1.4–2.0) could markedly decrease bleeding and effectively prevent thromboembolism. As the INR was most unstable in the first postoperative month, re-examination of patients in this period is critical.
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Affiliation(s)
- Xin-Min Zhou
- Department of Cardiovascular Surgery, The Second Xiang-Ya Hospital of Central South University, Changsha, Hunan 410011, China.
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Tuckuviene R, Ranta S, Albertsen BK, Andersson NG, Bendtsen MD, Frisk T, Gunnes MW, Helgestad J, Heyman MM, Jonsson OG, Mäkipernaa A, Pruunsild K, Tedgård U, Trakymiene SS, Ruud E. Prospective study of thromboembolism in 1038 children with acute lymphoblastic leukemia: a Nordic Society of Pediatric Hematology and Oncology (NOPHO) study. J Thromb Haemost 2016; 14:485-94. [PMID: 26707629 DOI: 10.1111/jth.13236] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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: 04/14/2015] [Indexed: 01/19/2023]
Abstract
UNLABELLED ESSENTIALS: Children with acute lymphoblastic leukemia (ALL) are at risk of thromboembolism (TE). This is a prospective evaluation of the incidence, risk factors and outcomes of TE in 1038 children with ALL. TE occurred in 6.1% of children, with the highest incidence (20.5%) among those aged 15-17 years. A TE-associated case fatality of 6.4% indicates that TE is a severe complication of ALL treatment. SUMMARY BACKGROUND Thromboembolism (TE) is a major toxicity in children with acute lymphoblastic leukemia (ALL) and may have a negative impact on ALL treatment. OBJECTIVES To examine the cumulative incidence, outcomes and risk factors associated with TE in children with leukemia. PATIENTS/METHODS We prospectively evaluated TE in 1038 Nordic children and adolescents (≥ 1 and < 18 years) diagnosed with ALL during 2008-2013 and treated according to the NOPHO (Nordic Society of Pediatric Hematology and Oncology)-ALL 2008 protocol. The cohort was followed until December 2014. Cox proportional regression was used to compute hazard ratios (HRs). RESULTS TE events (n = 63) occurred most frequently in conjunction with asparaginase (ASP) administration (52/63). The cumulative incidence of TE was 6.1% (95% confidence interval [CI], 4.8-7.7). Being aged 15-17 years was associated with an increased risk of TE (adjusted HR of 4.0; 95% CI, 2.1-7.7). We found a TE-associated 30-day case fatality of 6.4% (95% CI, 1.8-15.5) and TE-related truncation of ASP therapy in 36.2% (21/58). Major hemorrhage occurred in 3.5% (2/58) of anticoagulated patients. Minor hemorrhage was reported in two out of 58 patients. No major bleeds occurred in children who received low-molecular-weight heparin. CONCLUSIONS Methods to identify children and adolescents who will benefit from thromboprophylaxis during ALL treatment are called for. The truncation of ASP should be avoided. The long-term survival outcomes for ALL patients with TE require close monitoring in the future.
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Affiliation(s)
- R Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - S Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - B K Albertsen
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - N G Andersson
- Departments of Pediatrics and Coagulation Disorders, University of Lund, University Hospital, Malmö, Sweden
| | - M D Bendtsen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - T Frisk
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - M W Gunnes
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - J Helgestad
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - M M Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - O G Jonsson
- Children's Hospital, Landspitali University Hospital, Reykjavík, Iceland
| | - A Mäkipernaa
- Children's Hospital and Department of Hematology, Cancer Center, Helsinki University Central Hospital, Helsinki, Finland
| | - K Pruunsild
- Department of Oncohematology, Tallinn Children's Hospital, Tallinn, Estonia
| | - U Tedgård
- Departments of Pediatrics and Coagulation Disorders, University of Lund, University Hospital, Malmö, Sweden
| | - S S Trakymiene
- Center for Pediatric Oncology and Hematology, Children's Hospital, Affiliate of Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - E Ruud
- Department of Pediatric Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Xu JP, Shi YK, Dong L, Wei Y, Fu B, Liu RF. [Low Intensity Anticoagulation Therapy for Chinese Population with Heart Valve Replacement--3 000 Cases Follow-up]. Sichuan Da Xue Xue Bao Yi Xue Ban 2016; 47:90-92. [PMID: 27062790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate the effect of low-intensity anticoagulation therapy for Chinese population with heart valve replacement. METHODS From January 2011 to March 2012, 3 000 patients with heart valve replacement in Fuwai Hospital and West China Hospital were followed-up for 1 year, the method and intensity of postoperative anticoagulation, as well as the complications were studied and analyzed. RESULTS The rate of follow-up was 88.57%, and the cumulative follow-up was 1 726.1 patient-years (Pty). The mean oral warfarin dosage was (2.68 ± 6.45) mg/d, and the mean INR values of the patients treated in Fuwai Hospital and West China Hospital were 2.01 ± 1.10 and 186 ± 0.69 respectively (total 54 379 samples). The total rates of anticoagulation complication and mortality were 5.79% Pty and 0.12% Pty respectively, among which the morbidity and mortality of hemorrhage were 3.59% Pty and 0.12% Pty respectively, while the morbidity and mortality of thromboembolism were 2.03% Pty and 0.00% Pty respectively. There are no significant differences of actual anticoagulation intensity (P = 0.28)and the complication rates between the two hospitals . CONCLUSION The optimal intensity scope (INR) of 1.5-2.5 (mean 1.8-2.0) is safe and efficient for Chinese patients with prosthetic heart valves, and no significant regional difference in the intensity of anticoagulation therapy required.
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Shi C, Yan W, Wang G, Wang F, Li Q, Lin N. Pharmacogenetics-Based versus Conventional Dosing of Warfarin: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2015; 10:e0144511. [PMID: 26672604 PMCID: PMC4682655 DOI: 10.1371/journal.pone.0144511] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 11/19/2015] [Indexed: 12/14/2022] Open
Abstract
Background Recently, using the patient’s genotype to guide warfarin dosing has gained interest; however, whether pharmacogenetics-based dosing (PD) improves clinical outcomes compared to conventional dosing (CD) remains unclear. Thus, we performed a meta-analysis to evaluate these two strategies. Methods The PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese VIP and Chinese Wan-fang databases were searched. The Cochrane Collaboration’s tool was used to assess the risk of bias in randomized controlled trials (RCTs). The primary outcome was time within the therapeutic range (TTR); the secondary end points were the time to maintenance dose and time to first therapeutic international normalized ratio (INR), an INR greater than 4, adverse events, major bleeding, thromboembolism and death from any cause. Results A total of 11 trials involving 2,678 patients were included in our meta-analysis. The results showed that PD did not improve the TTR compared to CD, although PD significantly shortened the time to maintenance dose (MD = -8.80; 95% CI: -11.99 to -5.60; P<0.00001) and the time to first therapeutic INR (MD = -2.80; 95% CI: -3.45 to -2.15; P<0.00001). Additionally, PD significantly reduced the risk of adverse events (RR = 0.86; 95% CI: 0.75 to 0.99; P = 0.03) and major bleeding (RR = 0.36; 95% CI: 0.15 to 0.89, P = 0.03), although it did not reduce the percentage of INR greater than 4, the risk of thromboembolic events and death from any cause. Subgroup analysis showed that PD resulted in a better improvement in the endpoints of TTR and over-anticoagulation at a fixed initial dosage rather than a non-fixed initial dosage. Conclusions The use of genotype testing in the management of warfarin anticoagulation was associated with significant improvements in INR-related and clinical outcomes. Thus, genotype-based regimens can be considered a reliable and accurate method to determine warfarin dosing and may be preferred over fixed-dose regimens. Trial Registration PROSPERO Database registration: CRD42015024127.
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Affiliation(s)
- Changcheng Shi
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
- Department of Clinical Pharmacology, Hangzhou Translational Medicine Research Center, Hangzhou, Zhejiang Province, China
| | - Wei Yan
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
| | - Gang Wang
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
| | - Fei Wang
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
- Department of Clinical Pharmacology, Hangzhou Translational Medicine Research Center, Hangzhou, Zhejiang Province, China
| | - Qingyu Li
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
| | - Nengming Lin
- Department of Clinical Pharmacy, Hangzhou First People’s Hospital, Hangzhou, Zhejiang Province, China
- Department of Clinical Pharmacology, Hangzhou Translational Medicine Research Center, Hangzhou, Zhejiang Province, China
- Affiliated Hangzhou Hospital, Nanjing Medical University, Hangzhou, Zhejiang Province, China
- The first Affiliated Hangzhou Hospital, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- * E-mail:
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Chai-Adisaksopha C, Hillis C, Isayama T, Lim W, Iorio A, Crowther M. Mortality outcomes in patients receiving direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials. J Thromb Haemost 2015; 13:2012-20. [PMID: 26356595 DOI: 10.1111/jth.13139] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/30/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used as an alternative for warfarin. However, the impact of DOACs on mortality outcomes compared with warfarin remains unclear. OBJECTIVE To estimate the mortality outcomes in patients treated with DOACs vs. warfarin (or another vitamin K antagonist). METHODS MEDLINE, EMBASE and CENTRAL databases (inception to September 2014), conference abstracts and www.clinicaltrials.gov, were searched, without language restriction. Studies were selected if there were phase III, randomized trials comparing DOACs with warfarin in patients with non-valvular atrial fibrillation or venous thromboembolism. RESULTS Thirteen randomized controlled trials involving 102 707 adult patients were included in the analysis. The case-fatality rate of major bleeding was 7.57% (95% CI, 6.53-8.68; I(2) = 0%) in patients taking DOACs and 11.04% (95% CI, 9.16-13.07; I(2) = 33.3%) in patients taking warfarin. The rate of fatal bleeding in adult patients receiving DOACs was 0.16 per 100 patient-years (95% CI, 0.12-0.20; I(2) = 36.5%). When compared with warfarin, DOACs were associated with significant reductions in fatal bleeding (RR, 0.53; 95% CI, 0.43-0.64; I(2) = 0%), cardiovascular mortality (RR, 0.88; 95% CI, 0.82-0.94; I(2) = 0%) and all-cause mortality (RR, 0.91; 95% CI, 0.87-0.96; I(2) = 0%). CONCLUSIONS The use of DOACs compared with warfarin is associated with a lower rate of fatal bleeding, case-fatality rate of major bleeding, cardiovascular mortality and all-cause mortality.
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Affiliation(s)
- C Chai-Adisaksopha
- Department of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology, Biostatistics, McMaster University, Hamilton, ON, Canada
| | - C Hillis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - T Isayama
- Department of Clinical Epidemiology, Biostatistics, McMaster University, Hamilton, ON, Canada
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, ON, Canada
| | - W Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - A Iorio
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology, Biostatistics, McMaster University, Hamilton, ON, Canada
| | - M Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology, Biostatistics, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Melgaard L, Gorst-Rasmussen A, Lane DA, Rasmussen LH, Larsen TB, Lip GYH. Assessment of the CHA2DS2-VASc Score in Predicting Ischemic Stroke, Thromboembolism, and Death in Patients With Heart Failure With and Without Atrial Fibrillation. JAMA 2015; 314:1030-8. [PMID: 26318604 DOI: 10.1001/jama.2015.10725] [Citation(s) in RCA: 235] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years [doubled], diabetes, stroke/transient ischemic attack/thromboembolism [doubled], vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-75 years, sex category [female]) is used clinically for stroke risk stratification in atrial fibrillation (AF). Its usefulness in a population of patients with heart failure (HF) is unclear. OBJECTIVE To investigate whether CHA2DS2-VASc predicts ischemic stroke, thromboembolism, and death in a cohort of patients with HF with and without AF. DESIGN, SETTING, AND POPULATION Nationwide prospective cohort study using Danish registries, including 42 987 patients (21.9% with concomitant AF) not receiving anticoagulation who were diagnosed as having incident HF during 2000-2012. End of follow-up was December 31, 2012. EXPOSURES Levels of the CHA2DS2-VASc score (based on 10 possible points, with higher scores indicating higher risk), stratified by concomitant AF at baseline. Analyses took into account the competing risk of death. MAIN OUTCOMES AND MEASURES Ischemic stroke, thromboembolism, and death within 1 year after HF diagnosis. RESULTS In patients without AF, the risks of ischemic stroke, thromboembolism, and death were 3.1% (n = 977), 9.9% (n = 3187), and 21.8% (n = 6956), respectively; risks were greater with increasing CHA2DS2-VASc scores as follows, for scores of 1 through 6, respectively: (1) ischemic stroke with concomitant AF: 4.5%, 3.7%, 3.2%, 4.3%, 5.6%, and 8.4%; without concomitant AF: 1.5%, 1.5%, 2.0%, 3.0%, 3.7%, and 7% and (2) all-cause death with concomitant AF: 19.8%, 19.5%, 26.1%, 35.1%, 37.7%, and 45.5%; without concomitant AF: 7.6%, 8.3%, 17.8%, 25.6%, 27.9%, and 35.0%. At high CHA2DS2-VASc scores (≥4), the absolute risk of thromboembolism was high regardless of presence of AF (for a score of 4, 9.7% vs 8.2% for patients without and with concomitant AF, respectively; overall P<.001 for interaction). C statistics and negative predictive values indicate that the CHA2DS2-VASc score performed modestly in this HF population with and without AF (for ischemic stroke, 1-year C statistics, 0.67 [95% CI, 0.65-0.68] and 0.64 [95% CI, 0.61-0.67], respectively; 1-year negative predictive values, 92% [95% CI, 91%-93%] and 91% [95% CI, 88%-95%], respectively). CONCLUSIONS AND RELEVANCE Among patients with incident HF with or without AF, the CHA2DS2-VASc score was associated with risk of ischemic stroke, thromboembolism, and death. The absolute risk of thromboembolic complications was higher among patients without AF compared with patients with concomitant AF at high CHA2DS2-VASc scores. However, predictive accuracy was modest, and the clinical utility of the CHA2DS2-VASc score in patients with HF remains to be determined.
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Affiliation(s)
- Line Melgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Anders Gorst-Rasmussen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark2Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Deidre A Lane
- University of Birmingham Centre for Cardiovascular Sciences City Hospital, Birmingham, England
| | - Lars Hvilsted Rasmussen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark3University of Birmingham Centre for Cardiovascular Sciences City Hospital, Birmingham, England
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Im SII, Chun KJ, Park SJ, Park KM, Kim JS, On YK. Long-term Prognosis of Paroxysmal Atrial Fibrillation and Predictors for Progression to Persistnt or Chronic Atrial Fibrillation in the Korean Population. J Korean Med Sci 2015; 30:895-902. [PMID: 26130952 PMCID: PMC4479943 DOI: 10.3346/jkms.2015.30.7.895] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 02/17/2015] [Indexed: 11/20/2022] Open
Abstract
Little is known about the long-term prognosis of or predictors for the different clinical types of atrial fibrillation (AF) in Korean populations. The aim of this study was to validate a risk stratification to assess the probability of AF progression from paroxysmal AF (PAF) to persistent AF (PeAF) or permanent AF. A total of 434 patients with PAF were consecutively enrolled (mean age; 71.7 ± 10.7 yr, 60.6% male). PeAF was defined as episodes that are sustained > 7 days and not self-terminating, while permanent AF was defined as an ongoing long-term episode. Atrial arrhythmia during follow-up was defined as atrial premature complex, atrial tachycardia, and atrial flutter. During a mean follow-up of 72.7 ± 58.3 months, 168 patients (38.7%) with PAF progressed to PeAF or permanent AF. The mean annual AF progression was 10.7% per year. In univariate analysis, age at diagnosis, body mass index, atrial arrhythmia during follow-up, left ventricular ejection fraction, concentric left ventricular hypertrophy, left atrial diameter (LAD), and severe mitral regurgitation (MR) were significantly associated with AF progression. In multivariate analysis, age at diagnosis (P = 0.009), atrial arrhythmia during follow-up (P = 0.015), LAD (P = 0.002) and MR grade (P = 0.026) were independent risk factors for AF progression. Patients with younger age at diagnosis, atrial arrhythmia during follow-up, larger left atrial chamber size, and severe MR grade are more likely to progress to PeAF or permanent AF, suggesting more intensive medical therapy with close clinical follow-up would be required in those patients.
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Affiliation(s)
- Sung II Im
- Division of Cardiology, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Kwang Jin Chun
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyoung-Min Park
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Soo Kim
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Keun On
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Wang HJ, Si QJ, Shan ZL, Guo YT, Lin K, Zhao XN, Wang YT. Effects of body mass index on risks for ischemic stroke, thromboembolism, and mortality in Chinese atrial fibrillation patients: a single-center experience. PLoS One 2015; 10:e0123516. [PMID: 25848965 PMCID: PMC4388788 DOI: 10.1371/journal.pone.0123516] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/19/2015] [Indexed: 01/24/2023] Open
Abstract
Background Obesity is considered to be related to recurrence of atrial fibrillation (AF), left atrial thrombus formation, and atrial remodeling. However, whether obesity is an independent risk factor for stroke and other thromboembolic events is still controversial. Objective This study aimed to investigate the effects of body mass index (BMI) on the risks of stroke, thromboembolism, and mortality in AF patients. Methods Patients who were diagnosed with nonvalvular AF were included in this observational, retrospective study. The study population was stratified by BMI at baseline. The Cox proportional hazard model was adopted to calculate adjusted hazard ratios of risk factors for adverse clinical events (stroke, thromboembolism, and mortality). Results A total of 1286 AF patients (males, 78.30%; mean age, 74.50 years; 94.48% paroxysmal AF) were followed up for a median of 2.1 years (IQR: 1.5–2.9 years). Overall, 159 patients died. A total of 84 strokes and 35 thromboembolic events occurred. Multivariate analysis showed that overweight (25.0≤BMI<30.0 kg/m2) and age ≥75 years were independent risk factors for ischemic stroke (both P<0.01). Obesity (BMI ≥30.0 kg/m2), age ≥75 years, persistent/permanent AF, and prior thromboembolism were independent risk factors for thromboembolism (all P<0.05). Underweight (BMI <18.5 kg/m2), age ≥75 years, prior ischemic stroke/transient ischemic attack, renal dysfunction, and heart failure were independent risk factors for all-cause deaths (all P<0.05). Conclusions Overweight or obesity may be a risk factor of ischemic stroke and thromboembolism in AF patients. Excessive low weight is significantly associated with increased all-cause mortality.
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Affiliation(s)
- Hai-Jun Wang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Quan-Jin Si
- Healthcare Department 2, Hainan Branch of Chinese PLA General Hospital, Sanya, China
- * E-mail: (YTW); (QJS)
| | - Zhao-Liang Shan
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yu-Tao Guo
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Kun Lin
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Xiao-Ning Zhao
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Yu-Tang Wang
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
- * E-mail: (YTW); (QJS)
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Nilsson H, Grove EL, Larsen TB, Nielsen PB, Skjøth F, Maegaard M, Christensen TD. Sex differences in treatment quality of self-managed oral anticoagulant therapy: 6,900 patient-years of follow-up. PLoS One 2014; 9:e113627. [PMID: 25415603 PMCID: PMC4240606 DOI: 10.1371/journal.pone.0113627] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 10/27/2014] [Indexed: 11/18/2022] Open
Abstract
Background Patient-self-management (PSM) of oral anticoagulant therapy with vitamin K antagonists has demonstrated efficacy in randomized, controlled trials. However, the effectiveness and efficacy of PSM in clinical practice and whether outcomes are different for females and males has been sparsely investigated.The objective is to evaluate the sex-dependent effectiveness of PSM of oral anticoagulant therapy in everyday clinical practice. Methods All patients performing PSM affiliated to Aarhus University Hospital and Aalborg University Hospital, Denmark in the period 1996–2012 were included in a case-series study. The effectiveness was estimated using the following parameters: stroke, systemic embolism, major bleeding, intracranial bleeding, gastrointestinal bleeding, death and time spent in the therapeutic international normalized ratio (INR) target range. Prospectively registered patient data were obtained from two databases in the two hospitals. Cross-linkage between the databases and national registries provided detailed information on the incidence of death, bleeding and thromboembolism on an individual level. Results A total of 2068 patients were included, representing 6,900 patient-years in total. Males achieved a significantly better therapeutic INR control than females; females spent 71.1% of the time within therapeutic INR target range, whereas males spent 76.4% (p<0.0001). Importantly, death, bleeding and thromboembolism were not significantly different between females and males. Conclusions Among patients treated with self-managed oral anticoagulant therapy, males achieve a higher effectiveness than females in terms of time spent in therapeutic INR range, but the incidence of major complications is low and similar in both sexes.
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Affiliation(s)
- Hanna Nilsson
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Torben Bjerregaard Larsen
- Department of Cardiology, Centre for Cardiovascular Research, Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, The Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - Marianne Maegaard
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
- * E-mail:
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Labaf A, Grzymala-Lubanski B, Stagmo M, Lövdahl S, Wieloch M, Själander A, Svensson PJ. Thromboembolism, major bleeding and mortality in patients with mechanical heart valves- a population-based cohort study. Thromb Res 2014; 134:354-9. [PMID: 24985036 DOI: 10.1016/j.thromres.2014.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [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: 03/24/2014] [Revised: 05/07/2014] [Accepted: 06/05/2014] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Low incidences of thromboembolism (TE) and bleeding in patients with mechanical heart valves (MHV) have previously been reported. This study assesses the incidence of and clinical risk factors predicting TE, major bleeding and mortality in a clinical setting. METHODS AND RESULTS All 546 patients undergoing anticoagulation treatment due to MHV replacement at hospitals in Malmö and Sundsvall in Sweden were monitored during 2008-2011 and the incidence of TE, major bleeding and mortality was prospectively followed. There were 398, 122 and 26 patients in the aortic group (AVR), mitral (MVR) group and the combined aortic/mitral valve group respectively. The incidence of TE was 1.8 and 2.2 per 100 patient-years in the AVR group MVR group respectively. The corresponding incidences of bleeding were 4.4 and 4.6, respectively. Independent predictor of thromboembolism was vascular disease (Odds ratio {OR}: 4.2; 95% CI: 1.0-17.4). Predictor of bleeding was previous bleeding (OR: 2.7; 95% CI: 1.4-5.3). Independent predictors of mortality was age (Hazard ratio {HR}: 1.03; 95% CI: 1.00-1.05), hypertension (HR: 2.4; 95% CI: 1.3-4.5), diabetes (HR: 2.4; 95% CI: 1.3-4.3) and alcohol overconsumption (HR: 5.2; 95% CI: 1.7-15.9). Standardized mortality/morbidity ratio for mortality and AMI was 0.99 (95% CI: 0.8-1.2) and 0.87 (95% CI: 0.5-1.2) respectively. CONCLUSION The incidence of TE and major bleeding in this unselected clinical population exceeds that of previously reported retrospective and randomized trials. Despite this, mortality is equal to that of the general population.
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Affiliation(s)
- Ashkan Labaf
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden.
| | - Bartosz Grzymala-Lubanski
- Department of Internal Medicine, General Hospital in Sundsvall, Sundsvall, Sweden; Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Martin Stagmo
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Cardiology, Skåne University Hospital, Malmö, Sweden
| | - Susanna Lövdahl
- Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Mattias Wieloch
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Emergency Medicine, Skåne University Hospital, Malmö, Sweden
| | - Anders Själander
- Department of Internal Medicine, General Hospital in Sundsvall, Sundsvall, Sweden; Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | - Peter J Svensson
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Department of Coagulation disorders, Skåne University Hospital, Malmö, Sweden
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Buller HR, Halperin J, Hankey GJ, Pillion G, Prins MH, Raskob GE. Comparison of idrabiotaparinux with vitamin K antagonists for prevention of thromboembolism in patients with atrial fibrillation: the Borealis-Atrial Fibrillation Study. J Thromb Haemost 2014; 12:824-30. [PMID: 24597472 DOI: 10.1111/jth.12546] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [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: 09/26/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idrabiotaparinux, a long-acting inhibitor of factor Xa, was shown to be effective in the treatment of patients with venous thromboembolism. OBJECTIVE To assess non-inferiority for the efficacy of idrabiotaparinux versus warfarin in patients with atrial fibrillation (AF) at risk of stroke and systemic embolism. Bleeding was also assessed. METHODS This randomized, double-blind trial enrolled patients with electrocardiogram-documented AF. Idrabiotaparinux was administered weekly via subcutaneous injection, and warfarin was administered daily with dose adjustment to maintain the international normalized ratio between 2.0 and 3.0. Each idrabiotaparinux injection was 3 mg for the first 7 weeks, followed by 2 mg thereafter, except in patients with a creatinine clearance of 30-50 mL min(-1) or aged ≥ 75 years. The patients received 1.5 mg after the first 7 weeks. The efficacy outcome was the composite of all fatal or non-fatal strokes and systemic embolism. The safety outcome was clinically relevant bleeding (major and clinically relevant non-major bleeding). RESULTS The study was terminated prematurely by the sponsor for strategic/commercial, not scientific, reasons, with 39% of the planned number of patients included and an average duration of treatment of 240 days. Of the 1886 idrabiotaparinux recipients, 20 developed stroke or systemic embolism (1.5% per year), whereas this occurred in 22 of the 1887 warfarin patients (1.6% per year, hazard ratio 0.98, 95% confidence interval 0.49-1.66). The annual incidence of bleeding was 6.1% in the idrabiotaparinux and 10.0% in the warfarin group (hazard ratio 0.61, 95% confidence interval 0.46-0.81). CONCLUSION If anything, despite its early termination, the idrabiotaparinux regimen studied suggested a comparable efficacy to dose-adjusted warfarin, with a lower bleeding risk.
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Affiliation(s)
- H R Buller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
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