Assuntos
Fibrilação Atrial , Diltiazem , Hemorragia , Metoprolol , Pirazóis , Piridonas , Rivaroxabana , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Piridonas/efeitos adversos , Piridonas/uso terapêutico , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Diltiazem/efeitos adversos , Diltiazem/uso terapêutico , Metoprolol/efeitos adversos , Metoprolol/uso terapêutico , Feminino , Masculino , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Idoso , Pessoa de Meia-IdadeRESUMO
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) is indicated after percutaneous coronary intervention (PCI) to reduce the risk of atherothrombotic events. Approximately 30% of the US population has a CYP2C19 no-function allele that reduces the effectiveness of clopidogrel, but not prasugrel or ticagrelor, after PCI. We have shown improved outcomes with the integration of CYP2C19 genotyping into clinical care to guide the selection of prasugrel or ticagrelor in CYP2C19 no-function allele carriers. However, the influence of patient-specific demographic, clinical, and other genetic factors on outcomes with genotype-guided DAPT has not been defined. In addition, the impact of genotype-guided de-escalation from prasugrel or ticagrelor to clopidogrel in patients without a CYP2C19 no-function allele has not been investigated in a diverse, real-world clinical setting. The Precision Antiplatelet Therapy after Percutaneous Coronary Intervention (Precision PCI) Registry is a multicenter US registry of patients who underwent PCI and clinical CYP2C19 testing. The registry is enrolling a diverse population, assessing atherothrombotic and bleeding events over 12 months, collecting DNA samples, and conducting platelet function testing in a subset of patients. The registry aims to define the influence of African ancestry and other patient-specific factors on clinical outcomes with CYP2C19-guided DAPT, evaluate the safety and effectiveness of CYP2C19-guided DAPT de-escalation following PCI in a real-world setting, and identify additional genetic influences of clopidogrel response after PCI, with the ultimate goal of establishing optimal strategies for individualized antiplatelet therapy that improves outcomes in a diverse, real-world population.
Assuntos
Clopidogrel , Citocromo P-450 CYP2C19 , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Cloridrato de Prasugrel , Medicina de Precisão , Sistema de Registros , Ticagrelor , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Citocromo P-450 CYP2C19/genética , Medicina de Precisão/métodos , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Ticagrelor/administração & dosagem , Ticagrelor/uso terapêutico , Cloridrato de Prasugrel/administração & dosagem , Cloridrato de Prasugrel/uso terapêutico , Cloridrato de Prasugrel/efeitos adversos , Terapia Antiplaquetária Dupla/métodos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Aspirina/uso terapêutico , Antagonistas do Receptor Purinérgico P2Y/administração & dosagem , Antagonistas do Receptor Purinérgico P2Y/efeitos adversos , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controleRESUMO
BACKGROUND: Limited real-world evidence is available comparing the safety and effectiveness of apixaban and low-molecular-weight heparins (LMWHs) for preventing recurrent venous thromboembolism (VTE) in patients with active cancer receiving anticoagulation in an extended treatment setting. This study evaluated the risk of bleeding and recurrent VTE in patients with cancer-associated VTE who were prescribed apixaban or LMWH for ≥3 months. METHODS: A US commercial claims database was used to identify adult patients with VTE and active cancer who initiated apixaban or LMWH 30 days following the first VTE diagnosis and had ≥3 months of continuous enrollment and 3 months of primary anticoagulation treatment. Patients were followed from the day after the end of primary anticoagulation treatment until the earliest of: date of disenrollment, discontinuation of index anticoagulant, switch to another anticoagulant, or end of the study period. Inverse-probability treatment weighting (IPTW) was used to balance treatment cohorts. Incidence rates (IRs) for the outcomes were calculated per 100 person-years (PY). Cox proportional hazard models were used to evaluate the adjusted risk of recurrent VTE, major bleeding (MB), and clinically relevant nonmajor bleeding (CRNMB). RESULTS: A total of 13,564 apixaban- and 2,808 LMWH-treated patients were analyzed. Post-IPTW, the treatment cohorts were balanced. Patients receiving apixaban had lower adjusted IRs for recurrent VTE (4.1 vs 9.6 per 100 PY), MB (6.3 vs 12.6), and CRNMB (26.1 vs 36.0) versus LMWH (P<.0001 for all comparisons) during the follow-up period. Patients on apixaban had a lower adjusted risk of recurrent VTE (hazard ratio [HR], 0.42; 95% CI, 0.34-0.53), MB (HR, 0.50; 95% CI, 0.41-0.61), and CRNMB (HR, 0.76; 95% CI, 0.68-0.85) versus LMWH. CONCLUSIONS: Extended anticoagulation treatment of ≥3 months with apixaban was associated with lower rates of recurrent VTE, MB, and CRNMB compared with LMWH in adults with cancer-associated VTE.
Assuntos
Heparina de Baixo Peso Molecular , Neoplasias , Pirazóis , Piridonas , Tromboembolia Venosa , Humanos , Piridonas/uso terapêutico , Piridonas/efeitos adversos , Piridonas/administração & dosagem , Pirazóis/uso terapêutico , Pirazóis/efeitos adversos , Pirazóis/administração & dosagem , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Neoplasias/complicações , Neoplasias/tratamento farmacológico , Feminino , Heparina de Baixo Peso Molecular/uso terapêutico , Heparina de Baixo Peso Molecular/efeitos adversos , Heparina de Baixo Peso Molecular/administração & dosagem , Masculino , Pessoa de Meia-Idade , Idoso , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Anticoagulantes/administração & dosagem , Hemorragia/induzido quimicamente , Hemorragia/etiologia , Resultado do Tratamento , Adulto , Inibidores do Fator Xa/uso terapêutico , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/administração & dosagemRESUMO
BACKGROUND: Antithrombotic treatment (ATT) post-left atrial appendage occlusion (LAAO) remains controversial. Furthermore, most of the patients undergoing LAAO are at a very high bleeding risk. AIMS: This study aimed to compare a simplified versus conventional ATT after LAAO in very high bleeding risk patients. METHODS: This is a multicentre, retrospective study including very high bleeding risk patients, according to the Bleeding Academic Research Consortium (BARC) definition, who underwent LAAO. These included patients at >4% risk of BARC 3 to 5 bleeding or >1% risk of intracranial bleeding after the procedure. Two groups were established based on the discharge ATT. The simplified group included single antiplatelet treatment or no treatment, and the conventional group comprised dual antiplatelet treatment or anticoagulation (combined or not with antiplatelet therapy). RESULTS: A total of 1,135 patients were included. The mean CHA2DS2-VASc and HAS-BLED scores were 4.5±1.5 and 3.7±1.0, respectively. There were no differences in the composite endpoint (death, stroke, transient ischaemic attack, device-related thrombus or major bleeding) between the 2 groups (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.59-1.11; p=0.188). Although the rate of major bleeding during the first year was numerically lower in the simplified group, it did not reach statistical significance (HR 0.67, 95% CI: 0.41-1.10; p=0.104). Nonetheless, patients with previous major bleeding presented a significantly lower rate of major bleeding when using the simplified treatment (HR 0.61, 95% CI: 0.36-0.99; p=0.049). CONCLUSIONS: In patients with very high bleeding risk, a simplified ATT after LAAO seems to be as effective as conventional protocols. Furthermore, patients with a history of major bleeding experienced a lower risk of major bleeding with the simplified ATT.
Assuntos
Apêndice Atrial , Fibrilação Atrial , Fibrinolíticos , Hemorragia , Inibidores da Agregação Plaquetária , Humanos , Apêndice Atrial/cirurgia , Masculino , Feminino , Idoso , Estudos Retrospectivos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/efeitos adversos , Idoso de 80 Anos ou mais , Fibrinolíticos/uso terapêutico , Fibrinolíticos/efeitos adversos , Hemorragia/induzido quimicamente , Resultado do Tratamento , Fatores de Risco , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Medição de Risco , Terapia Antiplaquetária Dupla/métodos , Pessoa de Meia-Idade , Oclusão do Apêndice Atrial EsquerdoRESUMO
BACKGROUND: Acute coronary syndrome (ACS) is frequently accompanied by newly diagnosed atrial fibrillation (AF). AIMS: We aimed to compare the risk of major adverse cardiovascular events (MACE) in ACS patients presenting with known, newly diagnosed, or no AF. METHODS: In our multicentre, prospective registry study, we included patients with confirmed ACS. Patients are classified as having known, newly diagnosed or no AF. Newly diagnosed AF is subdivided according to the duration of the episode, time of onset, post-coronary artery bypass graft (CABG) or spontaneous occurrence, and treatment with oral anticoagulants (OAC). The primary endpoint is MACE at 1 year. Key secondary endpoints include ischaemic stroke and bleeding complications. RESULTS: Amongst 4,433 patients with confirmed ACS, 3,598 (81.2%) had no AF, 438 (9.9%) had newly diagnosed AF, and 397 (9.0%) had known AF. The rates of OAC treatment at discharge were 53.4% in patients with newly diagnosed AF and 89.2% in patients with known AF. After adjusting for baseline imbalances, only new AF was independently associated with increased rates of MACE, whereas known AF was not (hazard ratio [HR] 1.52, 95% confidence interval [CI]: 1.19-1.90 and HR 0.93, 95% CI: 0.70-1.23). For ACS patients with newly diagnosed AF, episodes lasting >24 hours were associated with a higher risk of MACE compared to episodes <24 hours (HR 1.99, 95% CI: 1.36-2.93). Episodes of new AF occurring post-CABG had more favourable outcomes compared to spontaneously occurring new AF (HR for MACE 0.52, 95% CI: 0.31-0.86). OAC treatment rates were higher in the new AF subcategories with higher rates of MACE and ischaemic stroke. CONCLUSIONS: Newly diagnosed AF in ACS patients was associated with higher rates of MACE and ischaemic stroke compared to ACS patients without or with known AF. Among the ACS patients with new AF, an episode lasting >24 hours was associated with worse outcomes than shorter episodes, while post-CABG occurrence of AF showed relatively better outcomes compared to spontaneously occurring AF. Only 53% of new AF patients were discharged on OAC therapy versus 89% with known AF.
Assuntos
Síndrome Coronariana Aguda , Anticoagulantes , Fibrilação Atrial , Sistema de Registros , Humanos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Síndrome Coronariana Aguda/terapia , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/diagnóstico , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Estudos Prospectivos , Anticoagulantes/uso terapêutico , Ponte de Artéria Coronária/efeitos adversos , Resultado do Tratamento , Fatores de Risco , Idoso de 80 Anos ou mais , Hemorragia/induzido quimicamente , AVC Isquêmico/epidemiologia , AVC Isquêmico/etiologiaRESUMO
OBJECTIVES: To evaluate whether the effectiveness and safety of low (81 mg daily) versus high-dose (325 mg daily) aspirin is consistent across races among patients with established atherosclerotic cardiovascular disease (ASCVD). DESIGN: A secondary analysis of the randomised controlled trial ADAPTABLE was performed. SETTING: The study was conducted in 40 centres and one health plan participating in the National Patient-Centred Clinical Research Network (PCORnet) in the USA. PARTICIPANTS: Among 15 076 participants with established ASCVD, 14 096 had self-reported race available and were included in the analysis. Participants were divided according to self-reported race as Black (n=1311, 9.3%), White (n=11 990, 85.1%) or other race (n=795, 5.6%). INTERVENTIONS: Participants were randomised to open-label daily aspirin doses of 81 mg versus 325 mg in a 1:1 ratio for a median of 26.2 months. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary effectiveness endpoint was a composite of death from any cause, hospitalisation for myocardial infarction or hospitalisation for stroke. The primary safety endpoint was hospitalisation for bleeding requiring blood product transfusion. RESULTS: Estimated cumulative incidence of the primary effectiveness endpoint at median follow-up with the 81 mg and the 325 mg daily doses were 6.70% and 7.12% in White participants (adjusted HR: 1.00 [95% CI: 0.88 to 1.15]); 12.27% and 10.69% in Black participants (adjusted HR: 1.40 [95% CI: 1.02 to 1.93]); and 6.88% and 7.69% in other participants (adjusted HR: 0.86 [95% CI: 0.54 to 1.39]) (p-interaction=0.12), respectively. There was no significant interaction between self-reported race and assigned aspirin dose regarding the secondary effectiveness and the primary safety endpoints. CONCLUSION: Race is not an effect modifier on the impact of aspirin dosing on effectiveness and safety in patients with established ASCVD. In clinical practice, treatment decisions regarding aspirin dose in secondary prevention of ASCVD should not be influenced by race. TRIAL REGISTRATION NUMBER: NCT02697916.
Assuntos
Aspirina , Aterosclerose , Inibidores da Agregação Plaquetária , Prevenção Secundária , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Aterosclerose/prevenção & controle , Doenças Cardiovasculares/prevenção & controle , Relação Dose-Resposta a Droga , Hemorragia/induzido quimicamente , Hospitalização/estatística & dados numéricos , Infarto do Miocárdio/prevenção & controle , Infarto do Miocárdio/etnologia , Infarto do Miocárdio/epidemiologia , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/uso terapêutico , Prevenção Secundária/métodos , Acidente Vascular Cerebral/prevenção & controle , Resultado do Tratamento , Estados Unidos/epidemiologia , Brancos , Negro ou Afro-AmericanoRESUMO
BACKGROUND: Atrial fibrillation (AF) is prevalent among patients with end-stage kidney disease (ESKD) undergoing dialysis, and both conditions are associated with a heightened risk of cardiovascular diseases. Anticoagulation is essential for preventing thromboembolic complications in these patients. This study aimed to evaluate the effects of factor Xa inhibitors compared to vitamin K antagonists (VKAs) for AF patients on dialysis. METHODS: A comprehensive search of PubMed and Embase databases was conducted to identify relevant studies published up to June 2024. Eligible studies compared factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) with VKAs in AF patients on dialysis, with primary outcomes of stroke or systemic embolism(SSE) and major bleeding. RESULTS: A total of 7 studies (3 randomized controlled trials and 4 observational cohorts) were included. For the RCTs, the use of factor Xa inhibitors was associated with a reduced risk of SSE compared to VKAs (odds ratio [OR] = 0.37, 95% confidence interval [CI]:0.15-0.93). There was no significant difference in the risk of major bleeding events between the two groups (OR = 0.65, 95%CI:0.32-1.33). Observational cohort studies yielded similar results with a decreased risk of SSE (hazard ratio [HR] = 0.74, 95%CI:0.57-0.96) and no significant difference in major bleeding (HR = 0.87, 95%CI:0.62-1.22). No differences in treatment effect between apixaban and rivaroxaban were observed for efficacy (p-interaction = 0.44) and safety (p-interaction = 0.21) outcomes. CONCLUSION: Factor Xa inhibitors, particularly apixaban and rivaroxaban, were associated with a lower risk of SEE without an increase in major bleeding, which might be convenient alternatives to VKAs in managing AF in patients with ESKD on dialysis.
Assuntos
Fibrilação Atrial , Inibidores do Fator Xa , Falência Renal Crônica , Diálise Renal , Vitamina K , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Inibidores do Fator Xa/uso terapêutico , Vitamina K/antagonistas & inibidores , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Hemorragia/induzido quimicamente , Anticoagulantes/uso terapêuticoRESUMO
BACKGROUND: Patients with atrial fibrillation and severe chronic kidney disease have higher risks of bleeding, thromboembolism, and mortality. However, optimal anticoagulant choice in these high-risk patients remains unclear. METHODS AND RESULTS: Using deidentified electronic health records from the Optum Labs Data Warehouse, adults with atrial fibrillation and severe chronic kidney disease (estimated glomerular filtration rate <30 mL/min per 1.73 m2) initiating warfarin, apixaban, or rivaroxaban between 2011 and 2021 were included. Using inverse probability of treatment weighting, adjusted risks of major bleeding, stroke/systemic embolism, and death were compared among agents. A total of 6794 patients were included (mean age, 78.5 years; mean estimated glomerular filtration rate, 24.7 mL/min per 1.73 m2; 51% women). Apixaban versus warfarin was associated with a lower risk of major bleeding (incidence rate, 1.5 versus 2.9 per 100 person-years; subdistribution hazard ratio [sub-HR], 0.53 [95% CI, 0.39-0.70]), and similar risks for stroke/systemic embolism (incidence rate, 1.9 versus 2.4 per 100 person-years; sub-HR, 0.80 [95% CI, 0.59-1.09]) and death (incidence rate, 4.6 versus 4.5 per 100 person-years; HR, 1.03 [95% CI, 0.82-1.29]). Rivaroxaban versus warfarin was associated with a higher risk of major bleeding (incidence rate, 4.9 versus 2.9 per 100 person-years; sub-HR, 1.65 [95% CI, 1.10-2.48]), with no difference in risks for stroke/systemic embolism and death. Apixaban versus rivaroxaban was associated with a lower risk of major bleeding (sub-HR, 0.53 [95% CI, 0.36-0.78]). CONCLUSIONS: These real-world findings are consistent with potential safety advantages of apixaban over warfarin and rivaroxaban for patients with atrial fibrillation and severe chronic kidney disease. Further randomized trials comparing individual oral anticoagulants are warranted.
Assuntos
Anticoagulantes , Fibrilação Atrial , Embolia , Hemorragia , Pirazóis , Piridonas , Insuficiência Renal Crônica , Rivaroxabana , Acidente Vascular Cerebral , Varfarina , Humanos , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrilação Atrial/mortalidade , Feminino , Masculino , Idoso , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/mortalidade , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/mortalidade , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Varfarina/efeitos adversos , Varfarina/uso terapêutico , Rivaroxabana/efeitos adversos , Rivaroxabana/uso terapêutico , Rivaroxabana/administração & dosagem , Embolia/prevenção & controle , Embolia/epidemiologia , Embolia/etiologia , Pirazóis/efeitos adversos , Pirazóis/uso terapêutico , Piridonas/efeitos adversos , Piridonas/uso terapêutico , Piridonas/administração & dosagem , Administração Oral , Medição de Risco , Idoso de 80 Anos ou mais , Fatores de Risco , Estudos Retrospectivos , Índice de Gravidade de Doença , Incidência , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/uso terapêutico , Inibidores do Fator Xa/administração & dosagemRESUMO
BACKGROUND: Percutaneous left atrial appendage closure (LAAC) has been suggested as an alternative to long-term oral anticoagulation for nonvalvular atrial fibrillation, but comparative data remain scarce. We aimed to assess ischemic and bleeding outcomes of LAAC compared with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for the prevention of cardioembolic events in patients with atrial fibrillation. METHODS AND RESULTS: Embase and MEDLINE were searched for randomized trials comparing LAAC, VKAs, and DOACs. The primary efficacy end point was any stroke or systemic embolism. Treatment effects were calculated from a network meta-analysis and ranked according to the surface under the cumulative ranking curve. Seven trials and 73 199 patients were included. The risk of the primary end point was not statistically different between LAAC versus VKAs (odds ratio [OR], 0.92 [95% CI, 0.62-1.50]) and LAAC versus DOACs (OR, 1.11 [95% CI, 0.71-1.73]). LAAC and DOACs resulted in similar risk of major or minor (OR, 0.93 [95% CI, 0.61-1.42]) and major bleeding (OR, 0.92 [95% CI, 0.58-1.46]); however, after exclusion of procedural bleeding, bleeding risk was significantly lower in those undergoing LAAC. Both LAAC and DOACs reduced the risk of all-cause death compared with VKAs (LAAC versus VKAs: OR, 0.70 [95% CI, 0.53-0.91]; DOACs versus VKAs: OR, 0.90 [95% CI, 0.85-0.95], respectively). DOACs ranked as the best treatment for stroke or systemic embolism prevention (66.9%) and LAAC for reducing major bleeding (63.9%) and death (96.4%). CONCLUSIONS: As a nonpharmacological alternative to oral anticoagulation for atrial fibrillation, LAAC showed similar efficacy and safety compared with VKAs or DOACs. Prospective confirmation from larger studies is warranted.
Assuntos
Anticoagulantes , Apêndice Atrial , Fibrilação Atrial , Metanálise em Rede , Humanos , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Apêndice Atrial/cirurgia , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Administração Oral , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Hemorragia/induzido quimicamente , Resultado do Tratamento , Cateterismo Cardíaco/métodos , Cateterismo Cardíaco/efeitos adversos , Fatores de Risco , Oclusão do Apêndice Atrial EsquerdoRESUMO
SOURCE CITATION: Park DY, Hu JR, Jamil Y, et al. Shorter dual antiplatelet therapy for older adults after percutaneous coronary intervention: a systematic review and network meta-analysis. JAMA Netw Open. 2024;7:e244000. 38546647.
Assuntos
Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Humanos , Idoso , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/administração & dosagem , Terapia Antiplaquetária Dupla , Hemorragia/induzido quimicamente , Esquema de MedicaçãoRESUMO
SOURCE CITATION: Ge Z, Kan J, Gao X, et al; ULTIMATE-DAPT investigators. Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes (ULTIMATE-DAPT): a randomised, placebo-controlled, double-blind clinical trial. Lancet. 2024;403:1866-1878. 38599220.
Assuntos
Síndrome Coronariana Aguda , Aspirina , Terapia Antiplaquetária Dupla , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária , Ticagrelor , Ticagrelor/uso terapêutico , Ticagrelor/administração & dosagem , Humanos , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/terapia , Método Duplo-Cego , Aspirina/uso terapêutico , Aspirina/administração & dosagem , Inibidores da Agregação Plaquetária/uso terapêutico , Inibidores da Agregação Plaquetária/administração & dosagem , Hemorragia/induzido quimicamenteRESUMO
AIM: To evaluate the prognostic value of GDF-15 in relation the development of bleeding and events in stable CAD patients, receiving combined antithrombotic therapy. MATERIALS AND METHODS: The data was obtained from the prospective registry REGATA, 343 CAD patients (249 males), median age 68 [IQR 62; 75] years) were enrolled. Patients with sinus rhythm and concomitant PAD received acetylsalicylic acid in combination with rivaroxaban 2.5 mg bid (31.8%) or clopidogrel (24.8%). Other 43.4% with concomitant atrial fibrillation (AF) received direct oral anticoagulants in combination with antiplatelet therapy after elective percutaneous coronary interventions. Median follow-up was 12 months [IQR 9.0; 18.0]. The safety end point was major and clinically relevant bleedings (type 2-5) according to the BARC classification. Plasma samples for GDF-15 identification were taken at the inclusion and analyzed using ELISA assay. RESULTS: Frequency of BARC 2-5 bleedings was 16% (BARC 2 - 46; BARC 3 - 9; BARC 4-5 - 0), median GDF-15 level was 1185.0 pg/ml [850.0; 1680.0]. In patients with AF and concomitant MFA, the level of GDF-15 was significantly higher than in the subgroups of patients with only AF or MFA (p=0.0022). According to the quintile analysis, GDF-15 values in the top three quintiles of distribution (cut-off value >943 pg/ml) were associated with higher frequency of bleeding events: 23.2% versus 5.1%; p=0.0001. The multivariable logistic regression model demonstrated that bleeding events were independently associated with GDF-15 level>943 pg/ml (OR 2.65, 95% CI 1.11-6.30; p=0.0275), AF (OR 2.61, 95% CI 1.41-4.83; p=0.0023) and chronic kidney disease (OR 1.92, 95% CI 1.03-3.60; p=0.0401). Clinical factors determining the risk of bleeding events also determined a GDF-15 elevation. CONCLUSION: Assessment of GDF-15 level may improve bleeding risk stratification in CAD patients with concomitant AF and/or PAD receiving combined antithrombotic therapy.
Assuntos
Fator 15 de Diferenciação de Crescimento , Hemorragia , Sistema de Registros , Humanos , Masculino , Feminino , Idoso , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Hemorragia/etiologia , Pessoa de Meia-Idade , Fator 15 de Diferenciação de Crescimento/sangue , Estudos Prospectivos , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/sangue , Quimioterapia Combinada , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrinolíticos/administração & dosagem , Fibrinolíticos/efeitos adversos , Aspirina/administração & dosagem , Aspirina/efeitos adversos , Clopidogrel/administração & dosagem , Clopidogrel/efeitos adversos , Prognóstico , Federação Russa/epidemiologia , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/efeitos adversos , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/efeitos adversosRESUMO
ABSTRACT: The dual pathway inhibition (DPI) with low-dose rivaroxaban and aspirin in patients with stable atherosclerotic vascular disease reduces the occurrence of cardiovascular events, with no significant increase of intracranial or other critical organ bleedings. Our observational study aimed to describe the clinical performance, adherence, and persistence of DPI therapy among a real-world setting of patients with an established diagnosis of coronary artery (CAD) and/or peripheral artery disease (PAD). We prospectively included all consecutive patients with an established diagnosis of CAD and/or PAD treated with aspirin (ASA) 100 mg once daily and rivaroxaban 2.5 mg twice daily. Clinical evaluation was performed at baseline, before starting treatment, at 1 month, and every 6 months after the study drug administration. A total of 202 consecutive patients (mean age 66 ± 10 years; male 80%) eligible to DPI therapy were included. During a mean follow-up of 664 ± 177 days, the incidence rate of major bleedings and of major adverse cardiovascular events was 0.8 and 1.1 per 100 patients/year, respectively. The adherence to pharmacological treatment was 99%. Additionally, 13.4% of patients suspended the DPI therapy during the follow-up. Minor bleedings resulted the most common cause of both temporary and permanent DPI therapy discontinuation. This observational study supports the safety of DPI with low-dose rivaroxaban and aspirin among patients with CAD and PAD in a real-world setting, showing high persistence and maximum adherence to medical treatment.
Assuntos
Aspirina , Doença da Artéria Coronariana , Inibidores do Fator Xa , Hemorragia , Adesão à Medicação , Doença Arterial Periférica , Inibidores da Agregação Plaquetária , Rivaroxabana , Humanos , Rivaroxabana/efeitos adversos , Rivaroxabana/administração & dosagem , Aspirina/efeitos adversos , Aspirina/administração & dosagem , Aspirina/uso terapêutico , Masculino , Idoso , Feminino , Inibidores do Fator Xa/efeitos adversos , Inibidores do Fator Xa/administração & dosagem , Doença Arterial Periférica/tratamento farmacológico , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Doença Arterial Periférica/epidemiologia , Estudos Prospectivos , Pessoa de Meia-Idade , Hemorragia/induzido quimicamente , Resultado do Tratamento , Inibidores da Agregação Plaquetária/efeitos adversos , Inibidores da Agregação Plaquetária/administração & dosagem , Inibidores da Agregação Plaquetária/uso terapêutico , Fatores de Tempo , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/diagnóstico , Fatores de RiscoRESUMO
BACKGROUND: Direct oral anticoagulants (DOACs) have been widely applied in adults for thrombosis prophylaxis. However, the effect of DOACs in pediatric patients with congenital or acquired heart diseases who need anticoagulation therapy remains unclear. METHODS: We systematically searched the databases of PubMed, Embase, and the Cochrane Library, as well as the ClinicalTrials.gov registry and the World Health Organization's International Clinical Trials Registry Platform until June 2024 to identify relevant randomized clinical trials (RCTs). If the number of included studies was less than 5, we performed a narrative review to assess the effect of DOACs in pediatric patients. RESULTS: Four studies were included. In the UNIVERSE study, thrombotic events occurred in 2% of the rivaroxaban group and 9% of the aspirin group, with bleeding events in 36% and 41%, respectively. The ENNOBLE-ATE study showed no thromboembolic events in the edoxaban group and 1.7% in the SOC group (rate difference: -0.07%, 95% CI: -0.22 to 0.07%). Major bleeding rates were similar (rate difference: -0.03%, 95% CI: -0.18 to 0.12%). The SAXOPHONE trial showed no thromboembolic events in either group and similar major bleeding rates (-0.8%, 95% CI: -8.1 to 3.3%). In the DIVERSITY trial, 81% of dabigatran patients achieved the primary outcome versus 59.3% in the SOC group (Odds ratio: 0.342, 95% CI: 0.081-1.229). No major bleeding occurred in either group. CONCLUSION: Existing studies suggest that the use of DOACs hold promise as an effective and safe alternative for preventing and treating thromboembolism in pediatric patients with heart conditions.
Assuntos
Anticoagulantes , Cardiopatias , Ensaios Clínicos Controlados Aleatórios como Assunto , Humanos , Criança , Anticoagulantes/uso terapêutico , Anticoagulantes/administração & dosagem , Administração Oral , Hemorragia/induzido quimicamenteRESUMO
BACKGROUND: The frequency of performance of interventional techniques in chronic pain patients receiving anticoagulant and antiplatelet therapy continues to increase. Understanding the importance of continuing chronic anticoagulant therapy, the need for interventional techniques, and determining the duration and discontinuation or temporary suspension of anticoagulation is crucial to avoiding devastating complications, primarily when neuraxial procedures are performed. Anticoagulants and antiplatelets target the clotting system, increasing the bleeding risk. However, discontinuation of anticoagulant or antiplatelet drugs exposes patients to thrombosis risk, which can lead to significant morbidity and mortality, especially in those with coronary artery or cerebrovascular disease. These guidelines summarize the current peer reviewed literature and develop consensus-based guidelines based on the best evidence synthesis for patients receiving anticoagulant and antiplatelet therapy during interventional procedures. STUDY DESIGN: Review of the literature and development of guidelines based on best evidence synthesis. OBJECTIVES: To provide a current and concise appraisal of the literature regarding the assessment of bleeding and thrombosis risk during interventional techniques for patients taking anticoagulant and/or antiplatelet medications. METHODS: Development of consensus guidelines based on best evidence synthesis included review of the literature on bleeding risks during interventional pain procedures, practice patterns, and perioperative management of anticoagulant and antiplatelet therapy. A multidisciplinary panel of experts developed methodology, risk stratification based on best evidence synthesis, and management of anticoagulant and antiplatelet therapy. It also included risk of cessation of anticoagulant and antiplatelet therapy based on a multitude of factors. Multiple data sources on bleeding risk, practice patterns, risk of thrombosis, and perioperative management of anticoagulant and antiplatelet therapy were identified. The relevant literature was identified through searches of multiple databases from 1966 through 2023. In the development of consensus statements and guidelines, we used a modified Delphi technique, which has been described to minimize bias related to group interactions. Panelists without a primary conflict of interest voted on approving specific guideline statements. Each panelist could suggest edits to the guideline statement wording and could suggest additional qualifying remarks or comments as to the implementation of the guideline in clinical practice to achieve consensus and for inclusion in the final guidelines, each guideline statement required at least 80% agreement among eligible panel members without primary conflict of interest. RESULTS: A total of 34 authors participated in the development of these guidelines. Of these, 29 participated in the voting process. A total of 20 recommendations were developed. Overall, 100% acceptance was obtained for 16 of 20 items. Total items were reduced to 18 with second and third round voting. The final results were 100% acceptance for 16 items (89%). There was disagreement for 2 statements (statements 6 and 7) and recommendations by 3 authors. These remaining 2 items had an acceptance of 94% and 89%. The disagreement and dissent were by Byron J. Schneider, MD, with recommendation that all transforaminals be classified into low risk, whereas Sanjeeva Gupta, MD, desired all transforaminals to be in intermediate risk. The second disagreement was related to Vivekanand A. Manocha, MD, recommending that cervical and thoracic transforaminal to be high risk procedures.Thus, with appropriate literature review, consensus-based statements were developed for the perioperative management of patients receiving anticoagulants and antiplatelets These included the following: estimation of the thromboembolic risk, estimation of bleeding risk, and determination of the timing of restarting of anticoagulant or antiplatelet therapy.Risk stratification was provided classifying the interventional techniques into three categories of low risk, moderate or intermediate risk, and high risk. Further, on multiple occasions in low risk and moderate or intermediate risk categories, recommendations were provided against cessation of anticoagulant or antiplatelet therapy. LIMITATIONS: The continued paucity of literature with discordant recommendations. CONCLUSION: Based on the review of available literature, published clinical guidelines, and recommendations, a multidisciplinary panel of experts presented guidelines in managing interventional techniques in patients on anticoagulant or antiplatelet therapy in the perioperative period. These guidelines provide a comprehensive assessment of classification of risk, appropriate recommendations, and recommendations based on the best available evidence.
Assuntos
Anticoagulantes , Assistência Perioperatória , Inibidores da Agregação Plaquetária , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Anticoagulantes/uso terapêutico , Anticoagulantes/efeitos adversos , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Manejo da Dor/métodos , Manejo da Dor/normas , Dor Crônica/tratamento farmacológico , Hemorragia/induzido quimicamente , Sociedades Médicas/normasAssuntos
Anticoagulantes , Apêndice Atrial , Fibrilação Atrial , Cateterismo Cardíaco , Contraindicações de Medicamentos , Falha de Tratamento , Humanos , Apêndice Atrial/fisiopatologia , Apêndice Atrial/diagnóstico por imagem , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Anticoagulantes/efeitos adversos , Anticoagulantes/administração & dosagem , Fatores de Risco , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Medição de Risco , Hemorragia/induzido quimicamente , Tomada de Decisão Clínica , Feminino , Idoso , Masculino , Seleção de PacientesAssuntos
Anticoagulantes , Apêndice Atrial , Fibrilação Atrial , Contraindicações de Medicamentos , Humanos , Apêndice Atrial/fisiopatologia , Apêndice Atrial/diagnóstico por imagem , Anticoagulantes/efeitos adversos , Anticoagulantes/administração & dosagem , Fibrilação Atrial/tratamento farmacológico , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fatores de Risco , Falha de Tratamento , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/etiologia , Medição de Risco , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Tomada de Decisão Clínica , Seleção de Pacientes , Hemorragia/induzido quimicamenteAssuntos
Anticoagulantes , Hemorragia , Trombose , Humanos , Hemorragia/induzido quimicamente , Fatores de Risco , Medição de Risco , Trombose/etiologia , Trombose/epidemiologia , Trombose/diagnóstico , Trombose/prevenção & controle , Trombose/sangue , Anticoagulantes/efeitos adversos , Anticoagulantes/uso terapêuticoRESUMO
There is insufficient data on systemic embolic events (SSEs) in patients with ischemic left ventricular aneurysm (LVA) concerning the impact of anticoagulation therapy. In this retrospective cohort study with 1043 patients with ischemic LVA, SSEs occurred in 7.2% over 2.4 years. After adjusting for relevant factors, the use of anticoagulants was independently associated with a lower incidence of SSE (3.1% vs. 9.0%, P < 0.001; subdistribution hazard ratios (SHR) 0.21, 95% confidence intervals (CI) 0.10-0.44, P < 0.001), with no significant difference in net adverse clinical events (NACEs) (10.6% vs. 13.3%, P = 0.225). Specifically, anticoagulation in patients with apical segment akinesis significantly reduced SSEs (3.9% vs. 13.6%, P = 0.002) and NACE rates (7.8% vs. 19.4%, P = 0.002). Major bleeding rates did not significantly differ between groups (5.6% vs. 3.5%, P = 0.111). These findings highlight the SSE risk in ischemic LVA and suggest potential benefits of anticoagulation, particularly in those with apical segment akinesis. These findings need to be validated in independent datasets.
Assuntos
Anticoagulantes , Aneurisma Cardíaco , Humanos , Estudos Retrospectivos , Anticoagulantes/uso terapêutico , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Prognóstico , Aneurisma Cardíaco/tratamento farmacológico , Aneurisma Cardíaco/epidemiologia , Ventrículos do Coração/patologia , Ventrículos do Coração/efeitos dos fármacos , Ventrículos do Coração/fisiopatologia , Isquemia Miocárdica/tratamento farmacológico , Isquemia Miocárdica/epidemiologia , Fatores de Risco , Hemorragia/induzido quimicamente , Hemorragia/epidemiologia , Embolia/epidemiologia , Embolia/tratamento farmacológicoRESUMO
OBJECTIVE: To evaluate the discriminative ability and calibration of the RIETE, Kuijer, and HAS-BLED models for predicting 3-month bleeding risk in patients anticoagulated for venous thromboembolism (VTE). METHODS: External validation study of a prediction model based on a retrospective cohort of patients with VTE seen at the Hospital Universitario San Ignacio, Bogotá (Colombia) between July 2021 and June 2023. The calibration of the scales was evaluated using the Hosmer-Lemeshow test and the ratio of observed to expected events (ROE) within each risk category. Discriminatory ability was assessed using the area under the curve (AUC) of a ROC curve. RESULTS: We analyzed 470 patients (median age 65 years, female sex 59.3%) with a diagnosis of deep vein thrombosis in most cases (57.4%), 5.7% bleeding events were observed. Regarding calibration, adequate calibration cannot be ruled out given the limited number of events. The discriminatory ability was limited with an area under the curve (AUC) of 0.48 (CI 0.37-0.59) for Kuijer Score, 0.58 (CI 0.47-0.70) for HAS-BLED and 0.64 (CI 0.51-0.76) for RIETE. CONCLUSION: The Kuijer, HAS-BLED, and RIETE models in patients with VTE generally do not adequately estimate the risk of bleeding at three months, with a low ability to discriminate high-risk patients. Cautious interpretation is recommended until further evidence is available.