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Efficacy of nicorandil on the prevention of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention.
Zhang, X, Yang, S, Zhang, P, Fu, N
Coronary artery disease. 2020;(3):284-288
Abstract
OBJECTIVES The purpose of this study was to explore the effect of nicorandil on the incidence of contrast-induced nephropathy in patients with coronary heart disease undergoing percutaneous coronary intervention. METHODS This study randomized 300 patients undergoing percutaneous coronary intervention to receive conventional treatment in the control group (hydration only; n = 150) vs. nicorandil therapy (nicorandil 10 mg three times daily plus hydration; n = 150). The primary endpoint was the incidence of contrast-induced nephropathy, defined as rise in serum creatinine ≥44.2 μmol/L or >25% above baseline within 72 hours after exposure to contrast administered during percutaneous coronary intervention. Secondary endpoints included differences in post-percutaneous coronary intervention serum creatinine, blood urea nitrogen, creatinine clearance rate, cystatin-C, and occurrence of major adverse events. RESULTS Contrast-induced nephropathy incidence was 3.3% (5/150) in the nicorandil group vs. 10.7% (16/150) in the control group (P < 0.05). At 48 and 72 hours after contrast administration, cystatin-C levels were significantly lower and creatinine clearance rate were significantly higher with nicroandil therapy compared to conventional treatment (all P values <0.05). No statistical difference was observed in the incidence of major post-procedure side effect events in hospital and fourteen days of follow-up period between the nicorandil group and control group (3.3% vs. 4.0%, P > 0.05). CONCLUSION Compared to conventional treatment, oral nicorandil therapy was associated with less contrast-induced nephropathy and improved renal function following contrast administration during percutaneous coronary intervention.
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Dual Versus Triple Therapy for Atrial Fibrillation After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis.
Khan, SU, Osman, M, Khan, MU, Khan, MS, Zhao, D, Mamas, MA, Savji, N, Al-Abdouh, A, Hasan, RK, Michos, ED
Annals of internal medicine. 2020;(7):474-483
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Abstract
BACKGROUND The safety and effectiveness of dual therapy (direct oral anticoagulant [DOAC] plus P2Y12 inhibitor) versus triple therapy (vitamin K antagonist plus aspirin and P2Y12 inhibitor) in patients with nonvalvular atrial fibrillation (AF) after percutaneous coronary intervention (PCI) is unclear. PURPOSE To examine the effects of dual versus triple therapy on bleeding and ischemic outcomes in adults with AF after PCI. DATA SOURCES Searches of PubMed, EMBASE, and the Cochrane Library (inception to 31 December 2019) and ClinicalTrials.gov (7 January 2020) without language restrictions; journal Web sites; and reference lists. STUDY SELECTION Randomized controlled trials that compared the effects of dual versus triple therapy on bleeding, mortality, and ischemic events in adults with AF after PCI. DATA EXTRACTION Two independent investigators abstracted data, assessed the quality of evidence, and rated the certainty of evidence. DATA SYNTHESIS Four trials encompassing 7953 patients were selected. At the median follow-up of 1 year, high-certainty evidence showed that dual therapy was associated with reduced risk for major bleeding compared with triple therapy (risk difference [RD], -0.013 [95% CI, -0.025 to -0.002]). Low-certainty evidence showed inconclusive effects of dual versus triple therapy on risks for all-cause mortality (RD, 0.004 [CI, -0.010 to 0.017]), cardiovascular mortality (RD, 0.001 [CI, -0.011 to 0.013]), myocardial infarction (RD, 0.003 [CI, -0.010 to 0.017]), stent thrombosis (RD, 0.003 [CI, -0.005 to 0.010]), and stroke (RD, -0.003 [CI, -0.010 to 0.005]). The upper bounds of the CIs for these effects were compatible with possible increased risks with dual therapy. LIMITATION Heterogeneity of study designs, dosages of DOACs, and types of P2Y12 inhibitors. CONCLUSION In adults with AF after PCI, dual therapy reduces risk for bleeding compared with triple therapy, whereas its effects on risks for death and ischemic end points are still unclear. PRIMARY FUNDING SOURCE None.
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[Antithrombotic Therapy in Patients with Acute Coronary Syndrome and Atrial Fibrillation].
Darius, H
Deutsche medizinische Wochenschrift (1946). 2020;(14):978-986
Abstract
The number of patients with atrial fibrillation (AF) is increasing due to the aging of the population. In addition, the number of patients with AF and an indication for oral anticoagulation (OAC) for the prevention of strokes increases, who are in need for a dual antiplatelet therapy (DAPT) with acetyl salicylic acid (ASA) plus a P2Y12-Inhibitor because of an acute coronary syndrome and/or coronary stent implantation. These patients did receive a triple therapy (TT) for 3-12 months in the past. Triple therapy never has been studied for efficacy or safety, however, the rate of bleeding complications in comparison to OAC or DAPT is significantly higher.Registries and smaller trials showed that dual therapy with an OAC plus a single platelet inhibitor may be sufficient to prevent strokes and stent thromboses/myocardial infarctions. Four prospective randomized trials involving all four NOACs (Non-Vitamin K oral anticoagulants) approved for stroke prevention in AF have been undertaken. The NOACs plus one antiplatelet agent were tested versus vitamin K-antagonists plus DAPT. In the meantime, the trials involving rivaroxaban (PIONEER AF-PCI), dabigatran (RE-DUAL PCI), apixaban (AUGUSTUS), and edoxaban (ENTRUST-AF-PCI) have been published. The current status is that a NOAC plus a single antiplatelet agent, mostly clopidogrel, is superior to TT with respect to the bleeding complications, without any obvious and statistically significant disadvantage for stroke rates or cardiac ischemic events. The international guidelines already recommend to treat with a NOAC and one antiplatelet agent instead of TT in case the patients bleeding risk is prevailing. Thus, TT seems not to be indicated anymore for most patients with AF and ACS or PCI.
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Novel Oral Anticoagulants Following Percutaneous Coronary Intervention.
Abadie, BQ, Cannon, CP, Cavender, MA
Circulation. Cardiovascular interventions. 2020;(7):e008465
Abstract
Antiplatelet and anticoagulant medications are the cornerstone of therapy for patients with acute coronary syndrome and have also been shown to reduce recurrent cardiovascular events in patients with stable coronary disease. Whereas antiplatelet medications have been the preferred therapy for long-term secondary prevention, the development of novel oral anticoagulants has renewed interest in the use of anticoagulation to prevent atherosclerotic events. In patients with atrial fibrillation or other indications for anticoagulation, recent clinical trials have shown the benefit of double therapy with full-dose novel oral anticoagulants and P2Y12 inhibitors compared with regimens with vitamin K antagonists. In patients without an indication for anticoagulation, the use of low doses of the factor Xa inhibitor, rivaroxaban, has shown benefit. Clinicians have many pharmacological options when treating patients following percutaneous coronary intervention. This review discusses the evidence for the use of novel oral anticoagulants, with an emphasis on patient selection, choice of therapy, and appropriate dosing of anticoagulant and antiplatelet agents, in secondary prevention strategies for atherosclerosis following coronary revascularization for patients with and without a traditional indication for anticoagulation.
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Dose-Response Effect of a Digital Health Intervention During Cardiac Rehabilitation: Subanalysis of Randomized Controlled Trial.
Widmer, RJ, Senecal, C, Allison, TG, Lopez-Jimenez, F, Lerman, LO, Lerman, A
Journal of medical Internet research. 2020;(2):e13055
Abstract
BACKGROUND Previous data have validated the benefit of digital health interventions (DHIs) on weight loss in patients following acute coronary syndrome entering cardiac rehabilitation (CR). OBJECTIVE The primary purpose of this study was to test the hypothesis that increased DHI use, as measured by individual log-ins, is associated with improved weight loss. Secondary analyses evaluated the association between log-ins and activity within the platform and exercise, dietary, and medication adherence. METHODS We obtained DHI data including active days, total log-ins, tasks completed, educational modules reviewed, medication adherence, and nonmonetary incentive points earned in patients undergoing standard CR following acute coronary syndrome. Linear regression followed by multivariable models were used to evaluate associations between DHI log-ins and weight loss or dietary adherence. RESULTS Participants (n=61) were 79% male (48/61) with mean age of 61.0 (SD 9.7) years. We found a significant positive association of total log-ins during CR with weight loss (r2=.10, P=.03). Educational modules viewed (r2=.11, P=.009) and tasks completed (r2=.10, P=.01) were positively significantly associated with weight loss, yet total log-ins were not significantly associated with differences in dietary adherence (r2=.05, P=.12) or improvements in minutes of exercise per week (r2=.03, P=.36). CONCLUSIONS These data extend our previous findings and demonstrate increased DHI log-ins portend improved weight loss in patients undergoing CR after acute coronary syndrome. DHI adherence can potentially be monitored and used as a tool to selectively encourage patients to adhere to secondary prevention lifestyle modifications. TRIAL REGISTRATION ClinicalTrials.gov (NCT01883050); https://clinicaltrials.gov/ct2/show/NCT01883050.
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Diet quality of patients with acute coronary syndrome receiving public and private health care.
Costa, IMNBC, Silva, DGD, Barreto Filho, JAS, Oliveira, JLM, Silva, JRS, Buarque, MDBM, Nascimento, T, Jorge, JG, Almeida, AS, Almeida-Santos, MA, et al
Nutrition (Burbank, Los Angeles County, Calif.). 2019;:131-137
Abstract
OBJECTIVE The aim of this study was to investigate the quality of the diets consumed by patients with acute coronary syndrome (ACS) who received public and private health care. METHODS This observational, prospective, longitudinal cohort study evaluated patients with ACS who attended three private and one public cardiology reference hospitals. Information about dietary parameters during the 6 mo before the acute ACS event was collected at admission and 180 d later using a semiquantitative food frequency questionnaire. Diet quality was assessed using the Alternative Healthy Eating Index (2010), and a multilinear regression model was developed to evaluate the associated variables. RESULTS The 581 volunteers included in this study comprised 325 (55.9%) and 256 (44.1%) patients treated at private and public hospitals, respectively. Although the dietary index increased significantly after ACS (P < 0001), diet quality remained unsatisfactory, particularly in terms of reductions in the consumption of cardioprotective components (vegetables, fruits, and eicosapentaenoic and docosahexaenoic fatty acids). Compared with patients receiving private health care, those attending a public hospital reported lower dietary quality (P < 0.001). The best diet quality was found to correlate with female sex (P < 0.001), receipt of dietary guidance at hospital discharge (P < 0.001), private health care (P < 0.001), a stable relationship status (P, 0.016), and older age (P < 0.001). CONCLUSION The overall post-ACS diet quality remained unsatisfactory, especially in terms of cardioprotective components and among patients receiving public health care. Sociodemographic factors and the assistance model/quality were determinants of the observed differences in dietary quality.
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A multi-stage association study of plasma cytokines identifies osteopontin as a biomarker for acute coronary syndrome risk and severity.
Yu, K, Yang, B, Jiang, H, Li, J, Yan, K, Liu, X, Zhou, L, Yang, H, Li, X, Min, X, et al
Scientific reports. 2019;(1):5121
Abstract
Cytokines play a critical role in the pathogenesis and development of cardiovascular diseases. However, data linking cytokines to risk and severity of acute coronary syndrome (ACS) are still limited. We measured plasma profile of 280 cytokines using a quantitative protein microarray in 12 ACS patients and 16 healthy controls, and identified 15 differentially expressed cytokines for ACS. Osteopontin, chemokine ligand 23, brain derived neurotrophic factor and C-reactive protein (CRP) were further validated using immunoassay in two independent case-control studies with a total of 210 ACS patients and 210 controls. We further examined their relations with incident ACS among 318 case-control pairs nested within the Dongfeng-Tongji cohort, and found plasma osteopontin and CRP concentrations were associated with incident ACS, and the multivariable-adjusted odds ratio (95% confidence interval) was 1.29 (1.06-1.57) per 1-SD increase for osteopontin and 1.30 (1.02-1.66) for CRP, respectively. Higher levels of circulating osteopontin were also correlated with higher severity of ACS, and earlier ACS onset time. Adding osteopontin alone or in combination with CRP modestly improved the predictive ability of ACS beyond the Framingham risk scores. Our findings suggested that osteopontin might be a biomarker for incident ACS, using osteopontin adds moderately to traditional cardiovascular risk factors.
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The Role of Colchicine in Acute Coronary Syndromes.
Vaidya, K, Martínez, G, Patel, S
Clinical therapeutics. 2019;(1):11-20
Abstract
PURPOSE Because inflammation is a key process implicated in the pathogenesis of atherosclerosis at all stages, including plaque formation, progression, instability, and rupture, and because colchicine has unique anti-inflammatory properties, this review article summarizes the pathophysiologic mechanisms underpinning inflammation in atherosclerosis and acute coronary syndrome (ACS), outlines anti-inflammatory therapeutic approaches that have been tested thus far, and evaluates the evidence supporting the potential role of colchicine in improving outcomes and reducing cardiovascular morbidity and mortality in patients after ACS. METHODS PubMed was searched for publications on colchicine and ACSs and atherosclerosis, and www.clinicaltrials.org was searched for completed and ongoing trials of colchicine use in ACSs. FINDINGS Despite contemporary optimal medical therapy, patients remain at a high risk of future events after an ACS because of residual inflammation at culprit and nonculprit sites. Several attempts have been made to address this with targeted anti-inflammatory therapies, but until the recent promising results of canakinumab (an anti-interleukin-1β monoclonal antibody), most have failed to find any prognostic benefit in large clinical trials with hard end points. The pathogenic role of neutrophils and monocytes in atheroinflammation is well established, and a fundamental component in this process is the activation of the NOD-like receptor protein 3 inflammasome, a cytosolic multiprotein complex that, when activated by a stress signal such as cholesterol crystals, drives caspase-1-dependent release of 2 key proinflammatory cytokines, which are predictive of future adverse cardiovascular events: interleukin-1β and interleukin-18. Colchicine is a widely available, inexpensive, and well-tolerated medication that, among several anti-inflammatory mechanisms of action, inhibits activation of the NOD-like receptor protein 3 inflammasome complex. A seminal trial has found the beneficial properties of colchicine in reducing adverse cardiovascular events in the stable coronary artery disease population. IMPLICATIONS Despite promising results in small prospective observational and randomized trials, there is a need for more evidence evaluating the role of colchicine as a secondary preventive agent after ACSs.
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Prognostic value of elevated lipoprotein(a) in patients with acute coronary syndromes.
Gencer, B, Rigamonti, F, Nanchen, D, Vuilleumier, N, Kern, I, Aghlmandi, S, Klingenberg, R, Räber, L, Auer, R, Carballo, D, et al
European journal of clinical investigation. 2019;(7):e13117
Abstract
BACKGROUND Minimal lipoprotein(a) [Lp(a)] target values are advocated for high-risk cardiovascular patients. We investigated the prognostic value of Lp(a) in the acute setting of patients with acute coronary syndromes (ACS). MATERIALS AND METHODS Plasma levels of Lp(a) were collected at time of angiography from 1711 patients hospitalized for ACS in a multicentre Swiss prospective cohort. Associations between elevated Lp(a) ≥30 mg/dL (cut-off corresponding to the 75th percentile of the assay) or Lp(a) tertiles at baseline, and major adverse cardiovascular events (MACE) at 1 year, defined as a composite of cardiac death, myocardial infarction or stroke, were assessed using hazard ratios (HR) and 95% confidence intervals (CI) adjusting for traditional cardiovascular risk factors (age, sex, smoking, diabetes, hypertension, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C] and triglycerides. RESULTS Lp(a) levels range between 2.5 and 132 mg/dL with a median value of 6 mg/dL and a mean value of 14.2 mg/dL. A total of 276 patients (23.0%) had Lp(a) plasma levels ≥30 mg/dL. Patients with elevated Lp(a) were more likely to be of female gender and to have higher levels of total cholesterol, LDL-C, HDL-C and triglycerides. Higher Lp(a) was associated with failure to reach the LDL-C target <1.8 mmol/L at 1 year (HR 1.71, 95% CI 1.13-2.58, P = 0.01). No association was found between elevated Lp(a) and MACE at 1 year (HR 1.05, 95% CI 0.64-1.73), nor for Lp(a) tertiles (HR 0.82, 95% CI 0.52-1.28, P > 0.20) or standardized continuous variables (0.98, 95% CI 0.82-1.19 for each increase of standard deviation). CONCLUSIONS Our real-world data suggest high Lp(a) levels at time of angiography are not predictive for cardiovascular outcomes in patients otherwise medically well controlled, but might be useful to identify patients who would not be on LDL-C targets 1 year after ACS.
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Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based randomized clinical trials.
Gargiulo, G, Goette, A, Tijssen, J, Eckardt, L, Lewalter, T, Vranckx, P, Valgimigli, M
European heart journal. 2019;(46):3757-3767
Abstract
AIMS: To investigate the safety and efficacy of double vs. triple antithrombotic therapy (DAT vs. TAT) in patients with atrial fibrillation (AF) and acute coronary syndrome or who underwent percutaneous coronary intervention (PCI). METHODS AND RESULTS A systematic review and meta-analysis was performed using PubMed to search for non-vitamin K antagonist oral anticoagulant (NOAC)-based randomized clinical trials comparing DAT vs. TAT in AF patients undergoing PCI. Four trials encompassing 10 234 patients (DAT = 5496 vs. TAT = 4738) were included. The primary safety endpoint (ISTH major or clinically relevant non-major bleeding) was significantly lower with DAT compared with TAT [risk ratio (RR) 0.66, 95% confidence interval (CI) 0.56-0.78; P < 0.0001; I2 = 69%], which was consistent across all available bleeding definitions. This benefit was counterbalanced by a significant increase of stent thrombosis (RR 1.59, 95% CI 1.01-2.50; P = 0.04; I2 = 0%) and a trend towards higher risk of myocardial infarction with DAT. There were no significant differences in all-cause and cardiovascular death, stroke and major adverse cardiovascular events. The comparison of NOAC-based DAT vs. vitamin K antagonist (VKA)-TAT yielded consistent results and a significant reduction of intracranial haemorrhage (RR 0.33, 95% CI 0.17-0.65; P = 0.001; I2 = 0%). CONCLUSION Double antithrombotic therapy, particularly if consisting of a NOAC instead of VKA and a P2Y12 inhibitor, is associated with a reduction of bleeding, including major and intracranial haemorrhages. This benefit is however counterbalanced by a higher risk of cardiac-mainly stent-related-but not cerebrovascular ischaemic occurrences.