Antithrombotic Therapy With or Without Aspirin After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients Taking Oral Anticoagulation: A Meta-Analysis and Network Analysis of Randomized Controlled Trials

IntroductionTrials investigating aspirin omission in patients taking oral anticoagulation (OAC) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) were not powered to assess rates of major bleeding or ischemic events.MethodsWe performed an updated meta-analysis and network analysis of randomized trials comparing treatment with or without aspirin in patients taking OAC and a P2Y12-inhibitor after PCI or ACS. The primary outcome was TIMI major bleeding.ResultsFive trials enrolling 11,542 patients allocated to antithrombotic regimens omitting (n = 5795) or including aspirin (n = 5747) were included. Aspirin omission was associated with a lower risk of TIMI major bleeding (RR = 0.56, 95% CI [0.44–0.71]; P < 0.001) but a trend towards a higher risk of MI (RR = 1.21, 95% CI [0.99–1.47]; P = 0.06), which was significantly higher when only non-vitamin K antagonist OAC (NOAC)-based trials were considered (P_interaction = 0.02). The risk of stent thrombosis was comparable with both strategies (RR = 1.29, 95% CI [0.87–1.90]; P = 0.20), with a trend towards a higher risk of ST with aspirin omission when only NOAC-based trials were considered (P_interaction = 0.06). Risks of stroke and death were similar with both strategies. Network meta-analysis ranked dabigatran (low dose) without aspirin as the best strategy for bleeding reduction (P-score = 0.86) and apixaban with aspirin as the best strategy for MI reduction (P-score = 0.66).ConclusionsIn patients taking OAC after PCI or ACS, aspirin omission is associated with a lower risk of TIMI major bleeding, with a numerically increased risk of MI, which is statistically significant when only NOAC-based trials are considered. This supports individualization of the treatment regimen based on patient risk.     

NOAC-Based Sual Therapy Versus Warfarin-Based Triple Therapy After Percutaneous Coronary Intervention or Acute Coronary Syndrome in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis

BackgroundSeveral randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta-analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients.MethodsThe major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome.ResultsA total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94–1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99–2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41–0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding.ConclusionIn conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis.     

A Meta-analysis of Randomized Controlled Trials Comparing Percutaneous Coronary Intervention With Medical Therapy in Stable Angina Pectoris

There continues to remain uncertainty regarding the effect of percutaneous coronary intervention (PCI) vs medical therapy in patients with stable angina. We therefore performed a systematic review and study-level meta-analysis of randomized controlled trials of patients with stable angina comparing PCI vs medical therapy for each of the following individual outcomes: all-cause mortality, cardiovascular (CV) mortality, myocardial infarction (MI), and angina relief. We used 8 strategies to identify eligible trials including bibliographic database searches of MEDLINE, PubMed, EMBASE, and the Cochrane Controlled Trials Registry until November 2011. Two independent reviewers undertook decisions about study eligibility and data abstraction. Data were pooled using a random effects model. Ten prospective randomized controlled trials fulfilled our eligibility criteria and they included a total of 6752 patients. We did not detect differences between PCI vs medical therapy for all-cause mortality (663 events; relative risk [RR], 0.97 [confidence interval (CI), 0.84-1.12]; I² = 0%), CV mortality (214 events; RR, 0.91 [CI, 0.70-1.17]; I² = 0%), MI (472 events; RR, 1.09 [CI, 0.92-1.29]; I² = 0%), or angina relief at the end of follow-up (2016 events; RR, 1.10 [CI, 0.97-1.26]; I²=85%). PCI was not associated with reductions in all-cause or CV mortality, MI, or angina relief. Considering the cost implication and the lack of clear clinical benefit, these findings continue to support existing clinical practice guidelines that medical therapy be considered the most appropriate initial clinical management for patients with stable angina.     

Optimal Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: Insights From a Network Meta-Analysis of Randomized Trials

BackgroundWith newer generation drug eluting stents (DES), the minimal duration of dual antiplatelet therapy (DAPT) recommended by guidelines has been reduced to 6 months in patients with stable coronary artery disease. Whether shorter duration of DAPT is safe in patients presenting with acute coronary syndrome (ACS) remains controversial. Our aim of this study was to investigate the optimal DAPT duration (≤3 months vs. 6 months vs. 12 months vs. >12 months) among patients with ACS undergoing percutaneous coronary intervention (PCI).MethodsPUBMED and EMBASE were searched through January 2020 for randomized controlled trials of DAPT duration in patients with ACS. The ischemic outcomes were all-cause death, myocardial infarction, and stent thrombosis. The safety outcome was major and/or clinically relevant bleeding.ResultsOur search identified 14 eligible trials enrolling a total of 31,837 patients comparing different DAPT duration in patients with ACS. Short-term DAPT (≤3 months or 6 months) did not increase ischemic outcomes compared to long-term DAPT (12 months and >12 months). For bleeding outcomes, ≤3 months DAPT was associated with significant reduction in bleeding compared to 6 months, 12 months or >12 months DAPT (OR [95% CI]: 0.60 [0.37–0.98]; 0.68 [0.54–0.85] and 0.43 [0.34–0.54], respectively). These findings were similar when limited to 2nd generation DES.ConclusionsData from this meta-analysis of randomized trials support short-term (≤3 months and 6 months) DAPT in patients with ACS undergoing PCI. Guidelines might need to consider short-term DAPT even in patients presenting with ACS, especially in this era of newer generation DES.     

Safety and Efficacy of Ultra Short-duration Dual Antiplatelet Therapy After Percutaneous Coronary Interventions: A Meta-analysis of Randomized Controlled Trials

Dual antiplatelet therapy (DAPT) is required after percutaneous coronary intervention (PCI) to reduce stent thrombosis, but DAPT increases bleeding risks. The optimal duration of DAPT that provides the maximum protective ischemic effect along with the minimum bleeding risk is unclear. This is the first meta-analysis comparing outcomes for 1-month versus longer DAPT strategies following PCI.We searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to October 2021) for randomized controlled trials that compared 1-month duration vs > 1-month duration of DAPT following PCI. We used a random-effects model to calculate risk ratio (RR) with 95% confidence interval (CI). The co-primary outcomes for study selection were all-cause mortality, major bleeding, and stent thrombosis. Secondary outcomes included myocardial infarction (MI), cardiovascular mortality, ischemic stroke and target vessel revascularization. A total of five randomized controlled trials were included [n = 29,355; 1-month DAPT(n = 14,662) vs > 1-month DAPT (n = 14,693)]. There was no statistically significant difference between the two groups in terms of all-cause mortality (RR 0.89; 95% CI 0.78-1.03; P = 0.12) and stent thrombosis (RR 1.07; 95% CI 0.80-1.43; P = 0.65). Similarly, there were no significant differences in MI, cardiovascular mortality, ischemic stroke, and target vessel revascularization. The rate of major bleeding was significantly lower in the group treated with DAPT for 1-month (RR 0.74; 95% CI 0.56-0.99, P = 0.04).There is no difference in all-cause mortality, cardiovascular mortality, MI, stent thrombosis, ischemic stroke, and target vessel revascularization with 1-month of DAPT following PCI with contemporary drug eluting stents compared to longer DAPT duration.     

冠心病合并心房颤动患者冠状动脉介入治疗术后抗栓治疗调查及随访

目的:调查冠心病合并永久性非瓣膜病心房颤动(房颤)患者在冠状动脉介入治疗(PCI)术后的抗栓治疗情况并随访。方法:选取2000年1月～2005年9月我院因冠心病行PCI术入院并伴有永久性非瓣膜病房颤的患者62例,将资料完整的56例患者分为华法林治疗组(n=33)和非华法林治疗组(n=23),了解患者术后抗凝和抗血小板治疗状况,并对患者在PCI术后1年进行电话或门诊随访。结果:56例患者年龄(69.6±8.9)岁。PCI术后有33例(58.9%)房颤患者抗栓治疗中含华法林;23例(41.1%)术后未使用华法林。女性患者中应用华法林治疗的比例较男性低(P<0.05)。随访期间非华法林治疗组2例发生脑栓塞,与华法林治疗组比较栓塞发生率(8.7%比0)有增高趋势,但差异未达到统计学意义(P=0.08)。支架内再狭窄率和严重出血发生率非华法林治疗组与华法林治疗组比较均无统计学差异(P>0.05)。结论:由于缺乏大规模临床试验证据,对于既有抗凝又有联合抗血小板治疗指征的永久性房颤患者在PCI术后,实际临床上给予患者的抗栓治疗方法有多种,对于这部分患者的抗栓治疗需要更大规模的研究以指导临床治疗。     

Prasugrel Versus Ticagrelor in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: a Systematic Review and Meta-analysis of Randomized Trials

Purpose

Dual antiplatelet therapy (DAPT) with aspirin and ticagrelor or prasugrel is the mainstay of treatment for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). We aimed to systematically perform a head-to-head comparison of ticagrelor vs prasugrel in terms of efficacy and safety.

Methods

We searched PubMed/Medline, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) for relevant published randomized controlled trials (RCTs). The primary outcome was adverse cardiovascular events and secondary outcome was bleeding events. A random-effects meta-analysis was used to obtain the pooled estimate of each outcome.

Results

Nine RCTs with a total number of 6990 patients (3550 treated with prasugrel and 3481 treated with ticagrelor) were included. No significant difference between prasugrel and ticagrelor was observed in terms of mortality (OR 0.86, 95% CI 0.66 to 1.13, P?=?0.28), major adverse cardiovascular events (MACEs) (OR 0.85, 95% CI 0.70 to 1.03, P?=?0.10), non-fatal myocardial infarction (OR 0.78, 95% CI 0.57 to 1.06, P?=?0.11), stroke (OR 1.02, 95% CI 0.60 to 1.72, P?=?0.95), stent thrombosis (OR 0.76, 95% CI 0.47 to 1.21, P?=?0.25), thrombolysis in myocardial infarction (TIMI) defined major (OR 0.94, 95% CI 0.19 to 4.67, P?=?0.94), minor (OR 0.35, 95% CI 0.08 to 1.62, P?=?0.18) and minimal (OR 0.48, 95% CI 0.19 to 1.18, P?=?0.11) bleeding and Bleeding Academic Research Consortium (BARC) defined bleeding (OR 1.06, 95% CI 0.82 to 1.36, P?=?0.68).

Conclusion

In patients with ACS undergoing PCI, both prasugrel and ticagrelor were associated with similar cardiovascular outcomes and adverse bleeding events.

     

急性冠状动脉综合征置入支架患者使用替罗非班和阿司匹林时泮托拉唑对消化道保护作用的评价

目的:急性冠状动脉综合征(ACS)置入支架患者使用盐酸替罗非班、阿司匹林、氯吡格雷、低分子肝素(四联)时,评价泮托拉唑对消化道的保护作用.方法:选择ACS置入支架治疗的患者266例,随机分入观察组134例,对照组132例,所有患者均服用阿司匹林、氯吡格雷、低分子肝素和盐酸替罗非班.观察组患者静脉注射泮托拉唑40 mg/d 4～5天,之后改为泮托拉唑片剂40 mg/次,2次/天,服用30天.观察两组间30天全因死亡、再次心肌梗死、再次经皮冠状动脉介入治疗(PCI)、再次住院、颅内出血和消化道出血状况.结果:观察组134例患者30天内全因死亡5例、再次心肌梗死4例、再次PCI4例和再次住院8例;对照组132例患者分别为8例、6例、5例和13例,两组相比差异均无统计学意义(P>0.05);两组均无颅内出血发生.观察组消化道大出血0和总消化道出血事件3例,对照组分别为5例和15例,两组比较观察组消化道大出血和总消化道出血事件少于对照组(P<0.05),差异均有统计学意义.结论:ACS置入支架治疗的患者,盐酸替罗非班治疗是安全有效的,未见颅内出血发生.静脉注射和口服泮托拉唑并不增加30天全因死亡、再次心肌梗死、再次PCI和再次住院发生,同时可以减少30天内消化道出血发生率特别是消化道大出血事件的发生,具有良好的消化道保护作用和安全性.     

Antithrombotic Therapy After Coronary Stenting in Patients With Nonvalvular Atrial Fibrillation

Background

The safety and efficacy of triple therapy (TT; warfarin with dual antiplatelet therapy [DAPT]) in post–percutaneous coronary intervention (PCI) patients with atrial fibrillation (AF) are unclear. We aimed to determine whether TT is associated with a decreased stroke rate and an acceptable bleeding rate in this population.

Methods

This was a single-centre, retrospective study. Primary composite outcome was death, ischemic stroke, or transient ischemic attack. Secondary outcomes included components of primary outcome, bleeding, and blood transfusion rates.

Results

Of 602 post-PCI patients with AF between 2000 and 2009, 382 received TT, 220 DAPT. Mean follow-up post PCI was 5.9 ± 5.0 months. The TT group had a higher CHADS₂ score (2.6 vs 2.1, P < 0.001), older age (72.9 vs 70.5 years, P = 0.039), more heart failure (72.3% vs 36.9%, P = 0.010), and more strokes (14.4% vs 6.4%, P = 0.010). Neither primary outcome, major bleeding, nor blood transfusion rates differed between treatment groups, but more gastrointestinal bleeding occurred with TT use (2.6% vs 0.5%, P = 0.045). Net clinical benefit was −5.2 (CHADS₂ ≤ 2), 0.9 (CHADS₂ > 2), and −3.2 (overall) per 100 patient-years.

Conclusions

Although we found no association with TT usage and a reduction in cerebrovascular ischemic or major bleeding events in post-PCI patients with AF regardless of CHADS₂ score vs DAPT, the study was likely underpowered to demonstrate a clinically relevant reduction. TT was associated with a 5-fold increase in gastrointestinal bleeding vs DAPT. Net clinical benefit calculations suggest benefits of TT in patients with CHADS₂ > 2. Stratification with CHADS₂ might be useful to determine the optimal antithrombotic therapy post PCI.     

Antithrombotic Therapy for Patients with Nonvalvular Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Review

Recent advances have expanded our ability to conduct a comprehensive genetic evaluation for dilated cardiomyopathy (DCM). By evaluating recent literature, this review aims to bring the reader up-to-date on the genetic evaluation of DCM. Updated guidelines have been published. Mutations in BAG3, including a large deletion, were identified in 2 % of DCM. Truncating mutations in TTN were reported in 25 % of DCM. Two new genes have been reported with autosomal recessive DCM. These studies illustrate the role of improved technologies while raising the possibility of a complex genetic model for DCM. The inclusion of TTN has led to an increased genetic testing detection rate of 40 %. While our ability to identify disease-causing variants has increased, so has the identification of variants of unknown significance. A genetic evaluation for DCM must therefore address this complexity.     

Meta-analysis Comparing Percutaneous Coronary Intervention With Coronary Artery Bypass Grafting for Non-ST Elevation Acute Coronary Syndrome in Patients With Multivessel or Left Main Disease

Outcomes of patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) with multivessel coronary disease (MVD) and/or unprotected left main coronary artery disease (CAD) revascularized with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is not well defined. MEDLINE/PubMed and EMBASE/Ovid were queried for studies that investigated PCI vs CABG in this disease subset. The primary outcome was major cardiac adverse events (MACE) at 30 days and long-term follow-up (3-5 years). The final analysis included 9 studies with a total of 9299 patients. No significant difference was observed between PCI and CABG in 30 days MACE (risk ratio [RR] 0.96; 95% confidence interval [CI] 0.38-2.39, all-cause mortality, myocardial infarction, and stroke. A meta-regression analysis revealed patients with a history of PCI had higher risk of MACE with PCI as compared with CABG. At long-term follow-up, PCI compared with CABG was associated with higher risk of MACE (RR 1.52; 95% CI 1.28-1.81), myocardial infarction, and repeat revascularization, while no difference was observed in the risk of stroke and all-cause mortality. In patients with NSTE-ACS and MVD or unprotected left main CAD, no differences were observed in the clinical outcomes between PCI and CABG at 30 days follow-up. With long-term follow-up, PCI was associated with a higher risk of MACE.