1,765 results on '"Roxana, Mehran"'
Search Results
2. The urgent need for integrated science to fight COVID-19 pandemic and beyond
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Negar Moradian, Hans D. Ochs, Constantine Sedikies, Michael R. Hamblin, Carlos A. Camargo, J. Alfredo Martinez, Jacob D. Biamonte, Mohammad Abdollahi, Pedro J. Torres, Juan J. Nieto, Shuji Ogino, John F. Seymour, Ajith Abraham, Valentina Cauda, Sudhir Gupta, Seeram Ramakrishna, Frank W. Sellke, Armin Sorooshian, A. Wallace Hayes, Maria Martinez-Urbistondo, Manoj Gupta, Leila Azadbakht, Ahmad Esmaillzadeh, Roya Kelishadi, Alireza Esteghamati, Zahra Emam-Djomeh, Reza Majdzadeh, Partha Palit, Hamid Badali, Idupulapati Rao, Ali Akbar Saboury, L. Jagan Mohan Rao, Hamid Ahmadieh, Ali Montazeri, Gian Paolo Fadini, Daniel Pauly, Sabu Thomas, Ali A. Moosavi-Movahed, Asghar Aghamohammadi, Mehrdad Behmanesh, Vafa Rahimi-Movaghar, Saeid Ghavami, Roxana Mehran, Lucina Q. Uddin, Matthias Von Herrath, Bahram Mobasher, and Nima Rezaei
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Coronavirus ,COVID-19 ,Complex problems ,Collaboration ,Interdisciplinarity ,Public health ,Medicine - Abstract
Abstract The COVID-19 pandemic has become the leading societal concern. The pandemic has shown that the public health concern is not only a medical problem, but also affects society as a whole; so, it has also become the leading scientific concern. We discuss in this treatise the importance of bringing the world’s scientists together to find effective solutions for controlling the pandemic. By applying novel research frameworks, interdisciplinary collaboration promises to manage the pandemic’s consequences and prevent recurrences of similar pandemics.
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- 2020
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3. Evolving Devices and Material in Transcatheter Aortic Valve Replacement: What to Use and for Whom
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Mauro Chiarito, Alessandro Spirito, Johny Nicolas, Alexandra Selberg, Giulio Stefanini, Antonio Colombo, Bernhard Reimers, Annapoorna Kini, Samin K. Sharma, George D. Dangas, and Roxana Mehran
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transcatheter aortic valve replacement ,aortic stenosis ,aortic regurgitation ,self-expanding valve ,balloon-expandable valve ,transcatheter heart valve ,Medicine - Abstract
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of aortic stenosis, providing a viable alternative to surgical aortic valve replacement (SAVR) for patients deemed to be at prohibitive surgical risk, but also for selected patients at intermediate or low surgical risk. Nonetheless, there still exist uncertainties regarding the optimal management of patients undergoing TAVR. The selection of the optimal bioprosthetic valve for each patient represents one of the most challenging dilemmas for clinicians, given the large number of currently available devices. Limited follow-up data from landmark clinical trials comparing TAVR with SAVR, coupled with the typically elderly and frail population of patients undergoing TAVR, has led to inconclusive data on valve durability. Recommendations about the use of one device over another in given each patient’s clinical and procedural characteristics are largely based on expert consensus. This review aims to evaluate the available evidence on the performance of different devices in the presence of specific clinical and anatomic features, with a focus on patient, procedural, and device features that have demonstrated a relevant impact on the risk of poor hemodynamic valve performance and adverse clinical events.
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- 2022
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4. Aspirin-free antithrombotic management following coronary stenting. Myth or reality?
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Davide Capodanno, Roxana Mehran, and Dominick J. Angiolillo
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Aspirin ,Ticagrelor ,Stent ,Thrombosis ,Medicine - Abstract
ABSTRACT The use of aspirin in combination with a P2Y12 receptor inhibitor, also known as dual antiplatelet therapy, is at the cornerstone of treatment for patients undergoing coronary stenting. The use of newer generation P2Y12 inhibitors (ie, prasugrel and ticagrelor), characterized by more potent antiplatelet effects and better clinical outcomes compared to clopidogrel, are recommended in high-risk patients, such as those with an acute coronary syndrome. However, this occurs at the expense of increased bleeding that accumulates with the duration of treatment. Given the poor prognostic implication, including an increased mortality rate associated with bleeding, a number of strategies aimed at reducing the risk of this adverse event while preserving efficacy have emerged. Among these, withdrawing aspirin represents an ongoing line of clinical investigation. The pharmacological reason behind such strategy relies on the central role played by the metabolic pathway of P2Y12 receptor inhibitors on platelet activation and its contribution amplifying thrombotic processes. Thus, it has been hypothesized that in the presence of a powerful P2Y12 receptor blockade, aspirin may offer minimal contribution when it comes to reducing thrombotic complications, but rather contribute to increased bleeding complications. A number of ongoing clinical investigations are currently challenging the dogma of aspirin as a mandatory background therapy in patients undergoing coronary stenting.
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- 2019
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5. Relationship between high shear stress and OCT-verified thin-cap fibroatheroma in patients with coronary artery disease.
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Naotaka Okamoto, Yuliya Vengrenyuk, Valentin Fuster, Habib Samady, Keisuke Yasumura, Usman Baber, Nitin Barman, Javed Suleman, Joseph Sweeny, Prakash Krishnan, Roxana Mehran, Samin K Sharma, Jagat Narula, and Annapoorna S Kini
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Medicine ,Science - Abstract
High-risk coronary plaques have been considered predictive of adverse cardiac events. Both wall shear stress (WSS) in patients with hemodynamically significant lesions and optical coherence tomography (OCT) -verified thin-cap fibroatheroma (TCFA) are associated with plaque rupture, the most common underlying mechanism of acute coronary syndrome. The aim of the study was to test the hypothesis that invasive coronary angiography-based high WSS is associated with the presence of TCFA detected by OCT in obstructive lesions. From a prospective study of patients who underwent OCT examination for angiographically obstructive lesions (Yellow II), we selected patients who had two angiographic projections to create a 3-dimensional reconstruction model to allow assessment of WSS. The patients were divided into 2 groups according to the presence and absence of TCFA. Mean WSS was assessed in the whole lesion and in the proximal, middle and distal segments. Of 70 patients, TCFA was observed in 13 (19%) patients. WSS in the proximal segment (WSSproximal) (10.20 [5.01, 16.93Pa]) and the whole lesion (WSSlesion) (12.37 [6.36, 14.55Pa]) were significantly higher in lesions with TCFA compared to WSSproximal (5.84 [3.74, 8.29Pa], p = 0.02) and WSSlesion (6.95 [4.41, 11.60], p = 0.04) in lesions without TCFA. After multivariate analysis, WSSproximal was independently associated with the presence of TCFA (Odds ratio 1.105; 95%CI 1.007-1.213, p = 0.04). The optimal cutoff value of WSSproximal to predict TCFA was 6.79 Pa (AUC: 0.71; sensitivity: 0.77; specificity: 0.63 p = 0.02). Our results demonstrate that high WSS in the proximal segments of obstructive lesions is an independent predictor of OCT-verified TCFA.
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- 2020
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6. Guided and unguided de-escalation from potent P2Y(12) inhibitors among patients with acute coronary syndrome
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Samin K. Sharma, Carlo Andrea Pivato, Anne H. Tavenier, George Dangas, Kiyuk Chang, Frans Beerkens, Dominick J. Angiolillo, Marco Valgimigli, Mauro Chiarito, Samantha Sartori, Johny Nicolas, Davide Capodanno, Roxana Mehran, Usman Baber, Renicus S Hermanides, Jur ten Berg, Davide Cao, Annapoorna Kini, Arnoud W J van 't Hof, Matteo Nardin, Cardiologie, MUMC+: MA Med Staf Spec Cardiologie (9), RS: Carim - H01 Clinical atrial fibrillation, and RS: Carim - B04 Clinical thrombosis and Haemostasis
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medicine.medical_specialty ,Acute coronary syndrome ,Ticagrelor ,Prasugrel ,medicine.medical_treatment ,DOSE PRASUGREL ,Hemorrhage ,Percutaneous Coronary Intervention ,Internal medicine ,Humans ,Medicine ,Pharmacology (medical) ,P2Y(12) inhibitor ,Stroke ,ELDERLY-PATIENTS ,POLYMORPHISMS ,Aspirin ,business.industry ,Percutaneous coronary intervention ,DUAL ANTIPLATELET THERAPY ,medicine.disease ,Clopidogrel ,OPEN-LABEL ,GENE ,De-escalation ,ASPIRIN ,Conventional PCI ,Cardiology and Cardiovascular Medicine ,business ,INTERVENTION ,Platelet Aggregation Inhibitors ,medicine.drug - Abstract
Aim Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full-dose potent P2Y12 inhibitors in ACS patients who underwent PCI. Methods and results PubMed, Google Scholar, and Cochrane Central Register of Controlled Trials were searched for eligible randomized controlled trials. Aspirin monotherapy trials were excluded. Five randomized trials (n = 10 779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1242; platelet function guided to clopidogrel n = 1304; unguided to clopidogrel n = 1672; unguided to lower dose n = 1170) vs. standard DAPT (control group n = 5391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥2 bleeding (HR 0.57, 95% CI 0.42–0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis, and stroke (HR 0.77, 95% CI 0.62–0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies. Conclusion De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing (PFT), was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.
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- 2022
7. Balloon-Expandable versus Self-Expandable Valves in Transcatheter Aortic Valve Implantation: Complications and Outcomes from a Large International Patient Cohort
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Astrid C. van Nieuwkerk, Raquel B Santos, Leire Andraka, Didier Tchetche, Fabio S. de Brito, Marco Barbanti, Ran Kornowski, Azeem Latib, Augusto D’Onofrio, Flavio Ribichini, Francisco Ten, Nicolas Dumonteil, Jan Baan, Jan J. Piek, Alexandre Abizaid, Samantha Sartori, Paola D’Errigo, Giuseppe Tarantini, Mattia Lunardi, Katia Orvin, Matteo Pagnesi, Juan Manuel Nogales-Asensio, Angie Ghattas, George Dangas, Roxana Mehran, and Ronak Delewi
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aortic valve stenosis ,transcatheter aortic valve implantation ,mortality ,stroke ,balloon-expandable ,self-expandable ,Medicine - Abstract
Background: Both balloon-expandable (BE) and self-expandable (SE) valves for transcatheter aortic valve implantation (TAVI) are broadly used in clinical practice. However, adequately powered randomized controlled trials comparing these two valve designs are lacking. Methods: The CENTER-study included 12,381 patients undergoing transfemoral TAVI. Patients undergoing TAVI with a BE-valve (n = 4096) were compared to patients undergoing TAVI with an SE-valve (n = 4096) after propensity score matching. Clinical outcomes including one-year mortality and stroke rates were assessed. Results: In the matched population of n = 5410 patients, the mean age was 81 ± 3 years, 60% was female, and the STS-PROM predicted 30-day mortality was 6.2% (IQR 4.0–12.4). One-year mortality was not different between patients treated with BE- or SE-valves (BE: 16.4% vs. SE: 17.0%, Relative Risk 1.04, 95%CI 0.02–1.21, p = 0.57). One-year stroke rates were also comparable (BE: 4.9% vs. SE: 5.3%, RR 1.09, 95%CI 0.86–1.37, p = 0.48). Conclusion: This study suggests that one-year mortality and stroke rates were comparable in patients with severe aortic valve stenosis undergoing TAVI with either BE or SE-valves.
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- 2021
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8. Intracoronary Imaging, Cholesterol Efflux, and Transcriptomics after Intensive Statin Treatment in Diabetes
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Surbhi Chamaria, Kipp W. Johnson, Yuliya Vengrenyuk, Usman Baber, Khader Shameer, Aparna A. Divaraniya, Benjamin S. Glicksberg, Li Li, Samit Bhatheja, Pedro Moreno, Akiko Maehara, Roxana Mehran, Joel T. Dudley, Jagat Narula, Samin K. Sharma, and Annapoorna S. Kini
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Medicine ,Science - Abstract
Abstract Residual atherothrombotic risk remains higher in patients with versus without diabetes mellitus (DM) despite statin therapy. The underlying mechanisms are unclear. This is a retrospective post-hoc analysis of the YELLOW II trial, comparing patients with and without DM (non-DM) who received rosuvastatin 40 mg for 8–12 weeks and underwent intracoronary multimodality imaging of an obstructive nonculprit lesion, before and after therapy. In addition, blood samples were drawn to assess cholesterol efflux capacity (CEC) and changes in gene expression in peripheral blood mononuclear cells (PBMC). There was a significant reduction in low density lipoprotein-cholesterol (LDL-C), an increase in CEC and beneficial changes in plaque morphology including increase in fibrous cap thickness and decrease in the prevalence of thin cap fibro-atheroma by optical coherence tomography in DM and non-DM patients. While differential gene expression analysis did not demonstrate differences in PBMC transcriptome between the two groups on the single-gene level, weighted gene coexpression network analysis revealed two modules of coexpressed genes associated with DM, Collagen Module and Platelet Module, related to collagen catabolism and platelet function respectively. Bayesian network analysis revealed key driver genes within these modules. These transcriptomic findings might provide potential mechanisms responsible for the higher cardiovascular risk in DM patients.
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- 2017
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9. Edoxaban versus Vitamin K Antagonist for Atrial Fibrillation after TAVR
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Thomas Pilgrim, Diego López-Otero, José Luis Zamorano, James Jin, Roxana Mehran, Cathy Chen, Peter Nordbeck, Eric Boersma, Envisage-Tavi Af Investigators, Holger Thiele, Christian Hengstenberg, Rainer Hambrecht, Fayaz A. Shawl, George Dangas, Nicolas M. Van Mieghem, Luis Nombela-Franco, Kentaro Hayashida, Piera Capranzano, Anil Duggal, Yusuke Watanabe, Pascal Vranckx, Josep Rodés-Cabau, Raul Moreno, Usman Baber, Roland Veltkamp, Petra Laeis, Marco Valgimigli, Hyo-Soo Kim, Felix Meincke, Richard A. Anderson, Patrick Ohlmann, Irene Lang, Hans Lanz, Masanori Yamamoto, Helge Möllmann, Shigeru Saito, Martin Unverdorben, and Cardiology
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Male ,medicine.medical_specialty ,Gastrointestinal bleeding ,Vitamin K ,Pyridines ,medicine.drug_class ,Kaplan-Meier Estimate ,Transcatheter Aortic Valve Replacement ,chemistry.chemical_compound ,Postoperative Complications ,Edoxaban ,Thromboembolism ,Internal medicine ,Atrial Fibrillation ,80 and over ,Humans ,Medicine ,Myocardial infarction ,Mortality ,610 Medicine & health ,Stroke ,Aged ,Aged, 80 and over ,business.industry ,Hazard ratio ,Anticoagulants ,Phenindione ,Atrial fibrillation ,4-Hydroxycoumarins ,General Medicine ,Vitamin K antagonist ,medicine.disease ,Confidence interval ,Intention to Treat Analysis ,Thiazoles ,chemistry ,Cardiology ,Female ,Gastrointestinal Hemorrhage ,business ,Factor Xa Inhibitors - Abstract
BACKGROUND The role of direct oral anticoagulants as compared with vitamin K antagonists for atrial fibrillation after successful transcatheter aortic-valve replacement (TAVR) has not been well studied. METHODS We conducted a multicenter, prospective, randomized, open-label, adjudicator-masked trial comparing edoxaban with vitamin K antagonists in patients with prevalent or incident atrial fibrillation as the indication for oral anticoagulation after successful TAVR. The primary efficacy outcome was a composite of adverse events consisting of death from any cause, myocardial infarction, ischemic stroke, systemic thromboembolism, valve thrombosis, or major bleeding. The primary safety outcome was major bleeding. On the basis of a hierarchical testing plan, the primary efficacy and safety outcomes were tested sequentially for noninferiority, with noninferiority of edoxaban established if the upper boundary of the 95% confidence interval for the hazard ratio did not exceed 1.38. Superiority testing of edoxaban for efficacy would follow if noninferiority and superiority were established for major bleeding. RESULTS A total of 1426 patients were enrolled (713 in each group). The mean age of the patients was 82.1 years, and 47.5% of the patients were women. Almost all the patients had atrial fibrillation before TAVR. The rate of the composite primary efficacy outcome was 17.3 per 100 person-years in the edoxaban group and 16.5 per 100 person-years in the vitamin K antagonist group (hazard ratio, 1.05; 95% confidence interval [CI], 0.85 to 1.31; P���=���0.01 for noninferiority). Rates of major bleeding were 9.7 per 100 person-years and 7.0 per 100 person-years, respectively (hazard ratio, 1.40; 95% CI, 1.03 to 1.91; P���=���0.93 for noninferiority); the difference between groups was mainly due to more gastrointestinal bleeding with edoxaban. Rates of death from any cause or stroke were 10.0 per 100 person-years in the edoxaban group and 11.7 per 100 person-years in the vitamin K antagonist group (hazard ratio, 0.85; 95% CI, 0.66 to 1.11). CONCLUSIONS In patients with mainly prevalent atrial fibrillation who underwent successful TAVR, edoxaban was noninferior to vitamin K antagonists as determined by a hazard ratio margin of 38% for a composite primary outcome of adverse clinical events. The incidence of major bleeding was higher with edoxaban than with vitamin K antagonists. (Funded by Daiichi Sankyo; ENVISAGE-TAVI AF ClinicalTrials.gov number, NCT02943785.).
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- 2021
10. Bridging Antiplatelet Therapy After Percutaneous Coronary Intervention
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Subhash Banerjee, E. Magnus Ohman, Sunil V. Rao, Alexander E. Sullivan, Michael G. Nanna, W. Schuyler Jones, Dominick J. Angiolillo, Jeffrey B. Washam, Deepak L. Bhatt, Jennifer A. Rymer, Sarah Cantrell, Roxana Mehran, and Tracy Y. Wang
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medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Percutaneous coronary intervention ,Stent ,Tirofiban ,Perioperative ,chemistry.chemical_compound ,Cangrelor ,chemistry ,Coronary stent ,medicine ,Eptifibatide ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business ,Risk assessment ,medicine.drug - Abstract
Patients undergoing early surgery after coronary stent implantation are at increased risk for mortality from ischemic and hemorrhagic complications. The optimal antiplatelet strategy in patients who cannot discontinue dual antiplatelet therapy (DAPT) before surgery is unclear. Current guidelines, based on surgical and clinical characteristics, provide risk stratification for bridging therapy with intravenous antiplatelet agents, but management is guided primarily by expert opinion. This review summarizes perioperative risk factors to consider before discontinuing DAPT and reviews the data for intravenous bridging therapies. Published reports have included bridging options such as small molecule glycoprotein IIb/IIIa inhibitors (eptifibatide or tirofiban) and cangrelor, an intravenous P2Y12 inhibitor. However, optimal management of these complex patients remains unclear in the absence of randomized controlled data, without which an argument can be made both for and against the use of perioperative intravenous bridging therapy after discontinuing oral P2Y12 inhibitors. Multidisciplinary risk assessment remains a critical component of perioperative care.
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- 2021
11. Types of myocardial injury and mid-term outcomes in patients with COVID-19
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Valentin Fuster, Zhongjie Zhang, Johny Nicolas, Mauro Chiarito, Matteo Nardin, Samantha Sartori, Samin K. Sharma, Roxana Mehran, Davide Cao, Annapoorna Kini, Carlo Andrea Pivato, George Dangas, Yuliya Vengrenyuk, and Parasuram Krishnamoorthy
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Adult ,Male ,medicine.medical_specialty ,Myocardial Infarction ,Comorbidity ,Coronary Artery Disease ,Coronary artery disease ,Internal medicine ,Outcome Assessment, Health Care ,medicine ,Humans ,Myocardial infarction ,Mortality ,Renal Insufficiency, Chronic ,Aged ,Retrospective Studies ,Aged, 80 and over ,Heart Failure ,biology ,SARS-CoV-2 ,business.industry ,Health Policy ,Mortality rate ,Hazard ratio ,COVID-19 ,Middle Aged ,Prognosis ,medicine.disease ,Troponin ,Heart failure ,Acute Disease ,Chronic Disease ,Cardiology ,biology.protein ,Female ,New York City ,Cardiology and Cardiovascular Medicine ,business ,Kidney disease - Abstract
Aims To evaluate the acute and chronic patterns of myocardial injury among patients with coronavirus disease-2019 (COVID-19), and their mid-term outcomes. Methods and results Patients with laboratory-confirmed COVID-19 who had a hospital encounter within the Mount Sinai Health System (New York City) between 27 February 2020 and 15 October 2020 were evaluated for inclusion. Troponin levels assessed between 72 h before and 48 h after the COVID-19 diagnosis were used to stratify the study population by the presence of acute and chronic myocardial injury, as defined by the Fourth Universal Definition of Myocardial Infarction. Among 4695 patients, those with chronic myocardial injury (n = 319, 6.8%) had more comorbidities, including chronic kidney disease and heart failure, while acute myocardial injury (n = 1168, 24.9%) was more associated with increased levels of inflammatory markers. Both types of myocardial injury were strongly associated with impaired survival at 6 months [chronic: hazard ratio (HR) 4.17, 95% confidence interval (CI) 3.44–5.06; acute: HR 4.72, 95% CI 4.14–5.36], even after excluding events occurring in the first 30 days (chronic: HR 3.97, 95% CI 2.15–7.33; acute: HR 4.13, 95% CI 2.75–6.21). The mortality risk was not significantly different in patients with acute as compared with chronic myocardial injury (HR 1.13, 95% CI 0.94–1.36), except for a worse prognostic impact of acute myocardial injury in patients Conclusion Chronic and acute myocardial injury represent two distinctive patterns of cardiac involvement among COVID-19 patients. While both types of myocardial injury are associated with impaired survival at 6 months, mortality rates peak in the early phase of the infection but remain elevated even beyond 30 days during the convalescent phase.
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- 2021
12. Perioperative risk and antiplatelet management in patients undergoing non-cardiac surgery within 1 year of PCI
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Ridhima Goel, Matthew A. Levin, Samin K. Sharma, Zaha Waseem, Bonnie Lupo, George Dangas, Annapoorna Kini, Mauro Chiarito, Rashi Bedekar, Roxana Mehran, Davide Cao, Anastasios Roumeliotis, Samantha Sartori, Jeffrey S. Jhang, Deepak L. Bhatt, Rishi Chandiramani, Johny Nicolas, Usman Baber, Zhongjie Zhang, and Bimmer E. Claessen
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medicine.medical_specialty ,Hematology ,Blood transfusion ,business.industry ,medicine.medical_treatment ,Percutaneous coronary intervention ,Perioperative ,medicine.disease ,Surgery ,Internal medicine ,Conventional PCI ,Medicine ,In patient ,cardiovascular diseases ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business ,Mace - Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, especially in patients with recent percutaneous coronary intervention (PCI). We aimed to illustrate the types and timing of different surgeries occurring after PCI, and to evaluate the risk of thrombotic and bleeding events according to the perioperative antiplatelet management. Patients undergoing urgent or elective non-cardiac surgery within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, or stent thrombosis) at 30 days. Perioperative bleeding was defined as ≥ 2 units of blood transfusion. A total of 1092 surgeries corresponding to 747 patients were classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones, and were associated with an increased risk of both MACE and bleeding. Preoperative interruption of antiplatelet therapy (of any kind) occurred in 44.6% of all NCS and was more likely for procedures occurring later post-PCI and at intermediate risk. There was no significant association between interruption of antiplatelet therapy and adverse cardiac events. Among patients undergoing NCS within 1 year of PCI, perioperative ischemic and bleeding events primarily depend on the estimated surgical risk and urgency of the procedure, which are increased early after PCI. Preoperative antiplatelet interruption was not associated with an increased risk of cardiac events.
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- 2021
13. Increasing Participation of Women in Cardiovascular Trials
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Michelle L. O'Donoghue, Emily S. Lau, Leslie Cho, Jeanne E. Poole, Kathryn J. Lindley, Amanda R. Vest, Kara J Denby, Roxana Mehran, Amy Sarma, and Modele O. Ogunniyi
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Clinical cardiology ,medicine.medical_specialty ,Ejection fraction ,business.industry ,Institute of medicine ,medicine.disease ,Food and drug administration ,Coronary artery disease ,Underrepresented Minority ,Heart failure ,medicine ,Professional association ,Cardiology and Cardiovascular Medicine ,business ,Intensive care medicine - Abstract
Although some progress has been made in the last 3 decades to increase the number of women in clinical cardiology trials, review of recent cardiovascular literature demonstrates that women and underrepresented minority women are still underrepresented in most clinical cardiology trials. This is especially notable in trials of patients with coronary artery disease, heart failure with reduced ejection fraction, and arrhythmia studies, especially those involving devices and procedures. Despite the call from National Institutes of Health, Food and Drug Administration, Institute of Medicine, and various professional societies, the gap remains. This paper seeks to identify the barriers for low enrollment and retention from patient, clinician, research team, study design, and system perspectives, and offers recommendations to improve recruitment and retention in the current era.
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- 2021
14. Impact of Chronic Kidney Disease on Revascularization and Outcomes in Patients with ST-Elevation Myocardial Infarction
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Kalpit Devani, Habib Samady, Roxana Mehran, Hani Jneid, Edward Leinaar, Shimin Zheng, Subhash Banerjee, Deepak L. Bhatt, Hemang B. Panchal, Timir K. Paul, Mamas A. Mamas, Christopher J. White, Debabrata Mukherjee, and Shahyar M. Gharacholou
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Adult ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,urologic and male genital diseases ,Revascularization ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Renal Dialysis ,Internal medicine ,Myocardial Revascularization ,medicine ,Humans ,In patient ,Hospital Mortality ,030212 general & internal medicine ,Myocardial infarction ,Hospital Costs ,Renal Insufficiency, Chronic ,Dialysis ,Aged ,Aged, 80 and over ,business.industry ,Guideline ,Odds ratio ,Acute Kidney Injury ,Length of Stay ,Middle Aged ,Prognosis ,medicine.disease ,United States ,female genital diseases and pregnancy complications ,Cross-Sectional Studies ,Conventional PCI ,Cardiology ,ST Elevation Myocardial Infarction ,Female ,Cardiology and Cardiovascular Medicine ,business ,Kidney disease - Abstract
Chronic kidney disease (CKD) in patients with ST-elevation myocardial infarction (STEMI) is associated with worse outcomes. We assessed the impact of CKD on guideline directed coronary revascularization and outcomes among STEMI patients. The Nationwide Inpatient Sample dataset from 2012-2014 was used to identify patients with STEMI using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were categorized as non-CKD, CKD without dialysis, and CKD with dialysis (CKD-HD). Outcomes were revascularization, death and acute renal failure requiring dialysis (ARFD). A total of 534,845 were included (88.9% non-CKD; 9.6% CKD without dialysis, and 1.5% CKD-HD). PCI was performed in 77.4% non-CKD, 56.2% CKD without dialysis, and 48% CKD-HD patients (p < 0.0001). In-hospital mortality and ARFD were significantly higher in CKD patients (16.5% and 40.6%) compared with non-CKD patients (7.12% and 7.17%) (p < 0.0001). In-hospital mortality was significantly lower in patients treated revascularization compared with patients treated medically (non-CKD: adjusted odds ratio (aOR) 0.280, p < 0.0001; CKD without dialysis: aOR 0.39, p < 0.0001; CKD-HD: aOR 0.48, p < 0.0001). CKD was associated with higher length of hospital stay and cost (5.86 ± 13.97, 7.57 ± 26.06 and 3.99 ± 11.09 days; p < 0.0001; $25,696 ± $63,024, $35,666 ± $104,940 and $23,264 ± $49,712; p < 0.0001 in non-CKD, CKD without dialysis and CKD-HD patients respectively). In conclusion, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. Coronary revascularization for STEMI in CKD patients was associated with lower mortality compared to medical management. The presence of CKD in patients with STEMI is associated with higher mortality and ARFD, prolonged hospital stay and higher hospital cost.
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- 2021
15. Outcomes of Transcatheter Aortic Valve Implantation in Patients With Chronic and End-Stage Kidney Disease
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Angela Palazzo, Roxana Mehran, Hani Jneid, Karim El Hachem, Hafeez Ul Hassan Virk, Fu'ad Al-Azzam, Bing Yue, Michelle T. Lee, Samin K. Sharma, Mahboob Alam, Joshua Hahn, Kevin L. Greason, and Chayakrit Krittanawong
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Male ,medicine.medical_specialty ,Hypertension, Pulmonary ,Comorbidity ,Transcatheter Aortic Valve Replacement ,Pulmonary Disease, Chronic Obstructive ,Internal medicine ,Atrial Fibrillation ,medicine ,Humans ,Mitral Valve Stenosis ,Hospital Mortality ,Renal Insufficiency, Chronic ,Heart Failure ,business.industry ,Mortality rate ,Atrial fibrillation ,Aortic Valve Stenosis ,Odds ratio ,medicine.disease ,Pulmonary hypertension ,Confidence interval ,Stenosis ,Logistic Models ,Treatment Outcome ,Heart failure ,Multivariate Analysis ,Cardiology ,Kidney Failure, Chronic ,Female ,Cardiology and Cardiovascular Medicine ,business ,Kidney disease - Abstract
Patients with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are at higher risk of aortic stenosis. Data regarding transcatheter aortic valve implantation (TAVI) in these patients are limited. Herein, we aim to investigate TAVI outcomes in patients with ESKD and CKD. We analyzed clinical data of patients with ESKD and CKD who underwent TAVI from 2008 to 2018 in a large urban healthcare system. Patients' demographics were compared, and significant morbidity and mortality outcomes were noted. Multivariable analyses were used to adjust for potential baseline variables. A total of 643 patients with CKD underwent TAVI with an overall in-hospital mortality of 5.1%, whereas 84 patients with ESKD underwent TAVI with an overall mortality rate of 11.9%. The most frequently observed comorbidities in patients with CKD were heart failure, atrial fibrillation (AF), mitral stenosis (MS), pulmonary hypertension, and chronic lung disease. After multivariable analysis, MS (adjusted odds ratio (OR) 3.92; 95% confidence interval (CI) 1.09 to 11.1, p
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- 2022
16. Invasive Management of Coronary Artery Disease in Advanced Renal Disease
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Sripal Bangalore, Keyvan Karimi Galougahi, Steven J. Chadban, Ziad A. Ali, Glenn M. Chertow, and Roxana Mehran
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Population ,030232 urology & nephrology ,Renal function ,Disease ,Review ,030204 cardiovascular system & hematology ,urologic and male genital diseases ,law.invention ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,coronary artery bypass graft ,Epidemiology ,Medicine ,Intensive care medicine ,education ,education.field_of_study ,business.industry ,percutaneous coronary intervention ,Percutaneous coronary intervention ,medicine.disease ,female genital diseases and pregnancy complications ,Diseases of the genitourinary system. Urology ,Nephrology ,revascularization ,RC870-923 ,atherosclerosis ,business ,chronic kidney disease ,coronary artery disease ,Kidney disease - Abstract
Coronary artery disease (CAD) is highly prevalent in chronic kidney disease (CKD). CKD modifies the effects of traditional risk factors on atherosclerosis, with CKD-specific mechanisms, such as inflammation and altered mineral metabolism, playing a dominant pathophysiological role as kidney function declines. Traditional risk models and cardiovascular screening tests perform relatively poorly in the CKD population, and medical treatments including lipid-lowering therapies have reduced efficacy. Clinical presentation of cardiac ischemia in CKD is atypical, whereas invasive therapies are associated with higher rates of complications than in with patients with normal or near normal kidney function. The main focus of the present review is on the invasive approach to management of CAD in late-stage CKD, with an in-depth discussion of the findings of the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA)-CKD trial, and their implications for therapeutic approach and future research in this area. We also briefly discuss the existing evidence in the epidemiology, pathogenesis, diagnosis, and medical management of CAD in late-stage CKD, end-stage kidney disease (ESKD), and kidney transplant recipients. We enumerate the evidence gap left by the frequent exclusion of patients with CKD from randomized controlled trials and highlight the priority areas for future research in the CKD population.
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- 2021
17. Ending Gender Inequality in Cardiovascular Clinical Trial Leadership
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Gail D. Pearson, Faiez Zannad, Cindy L. Grines, Anuradha Lala, Monica R. Shah, Carolyn S.P. Lam, Roxana Mehran, Padma Kaul, Harriette G.C. Van Spall, James H. Revkin, Tabassome Simon, Mary Norine Walsh, Ileana L. Piña, Barbara Casadei, Annabelle Santos Volgman, Thomas F. Deering, Martha Gulati, Biykem Bozkurt, Judith S. Hochman, and Women As One Scientific Expert Panel
- Subjects
Position statement ,medicine.medical_specialty ,Steering committee ,education ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,5. Gender equality ,Randomized controlled trial ,law ,medicine ,030212 general & internal medicine ,10. No inequality ,health care economics and organizations ,Gender inequality ,Research leadership ,business.industry ,Equity (finance) ,humanities ,3. Good health ,Clinical trial ,Family medicine ,Professional association ,Cardiology and Cardiovascular Medicine ,business - Abstract
Women are under-represented as leaders of cardiovascular randomized controlled trials, representing 1 in 10 lead authors of cardiovascular trials published in high-impact journals. Although the proportion of cardiovascular specialists who are women has increased in recent years, the proportion of cardiovascular clinical trialists who are women has not. This gap, underpinned by systemic sexism, has not been adequately addressed. The benefits of diverse randomized controlled trial leadership extend to patients and professionals. In this position statement, we present strategies adopted by some organizations to end gender inequality in research leadership. We offer an actionable roadmap for early-career researchers, scientists, academic institutions, professional societies, trial sponsors, and journals to follow, with the goal of harnessing the strength of women and under-represented groups as research leaders and facilitating a just culture in the cardiovascular clinical trial enterprise.
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- 2021
18. Drug-coated stents versus bare metal stents in Academic Research Consortium-defined high bleeding risk patients
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Stuart J. Pocock, Sunil V. Rao, Hans-Peter Stoll, Davide Capodanno, Philip Urban, Samuel Copt, Martin B. Leon, Mitchell W. Krucoff, Roxana Mehran, Sara Sadozai Slama, Guillaume Marquis-Gravel, Jean-François Tanguay, and Marie-Claude Morice
- Subjects
Target lesion ,medicine.medical_specialty ,education.field_of_study ,business.industry ,Population ,Drug-Eluting Stents ,Coronary Artery Disease ,Prosthesis Design ,medicine.disease ,Drug-Coated Stents ,Clinical Practice ,Percutaneous Coronary Intervention ,Treatment Outcome ,Risk Factors ,Clinical Research ,Internal medicine ,Humans ,Medicine ,Bare metal ,Stents ,Myocardial infarction ,Stent thrombosis ,Cardiology and Cardiovascular Medicine ,business ,education - Abstract
BACKGROUND: More effective and progressively safer generations of drug-elut-ing stents (DES) have replaced bare metal stents (BMS) in rou-tine clinical practice. However, patients considered to be at high bleeding risk (HBR) have traditionally been underrepresented in pivotal DES trials. AIMS: The aim of this study was to model the safety and effectiveness of drug-coated stents (DCS) versus BMS in HBR patients according to the Academic Research Consortium (ARC) criteria. METHODS: Participants from the LEADERS FREE (LF) and LEADERS FREE II (LFII) studies were pooled into one data set. Participants were treated with 30 days of DAPT. The primary safety (composite of cardiac death, myocardial infarction, or stent thrombosis) and effectiveness (target lesion revascularisation) endpoints were compared between DCS and BMS in the subgroup of patients satisfying the ARC-HBR definition using propensity-score modelling. RESULTS: From the 3,635 participants included in the combined LF and LFII data set, 2,898 (79.7%) satisfied the ARC-HBR criteria (DCS: 1,923; BMS: 975). The primary safety endpoint occurred in 184 (9.8%) and in 132 (13.8%) participants in the DCS and BMS groups, respectively (adjusted HR 0.72, 95% CI: 0.57-0.91; p=0.006). The risk of the primary effectiveness endpoint was also significantly lower with DCS (6.2%) versus BMS (8.8%) (adjusted HR 0.70, 95% CI: 0.52-0.94; p=0.016). The safety and effectiveness of DCS versus BMS were consistent according to ARC-HBR status (p for interaction=0.206 and 0.260, respectively). CONCLUSIONS: DCS are safer and more effective than BMS in an ARC-defined HBR population.
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- 2021
19. Meta-Analysis of Anticoagulation Therapy for the Prevention of Cardiovascular Events in Patients With Peripheral Arterial Disease
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Aakash Garg, Rami O. Tadros, Usman Baber, Haroon Kamran, Reza Masoomi, Daniel Han, Arthur Tarricone, Prakash Krishnan, Rheoneil A. Lascano, Amit Hooda, Roxana Mehran, Serdar Farhan, Kurt Huber, and Rohit Malhotra
- Subjects
medicine.medical_specialty ,Myocardial Infarction ,MEDLINE ,Hemorrhage ,Disease ,030204 cardiovascular system & hematology ,Cochrane Library ,Amputation, Surgical ,law.invention ,Peripheral Arterial Disease ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Humans ,030212 general & internal medicine ,Randomized Controlled Trials as Topic ,business.industry ,Absolute risk reduction ,Anticoagulants ,Confidence interval ,Stroke ,Cardiovascular Diseases ,Meta-analysis ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,Vascular Surgical Procedures ,Platelet Aggregation Inhibitors ,Mace - Abstract
Peripheral artery disease (PAD) remains a major cause of morbidity and future cardiovascular events despite advancement in the surgical interventions and optimal medical therapy. The aim of our study is to evaluate the efficacy and safety of anticoagulation (AC) therapy for reducing cardiovascular and limb events in patients with PAD. PUBMED, Medline, and Cochrane Library were searched through 2020 for randomized clinical trials comparing major adverse cardiovascular events (MACE) and risk of major bleeding (MB), between AC and standard of care (SOC) therapy, among patients with PAD. Meta-analysis was performed using weighted pooled absolute risk difference (RD) with 95% confidence interval (CI) and fixed effects model for overall and sub-groups of full dose (FD) and low dose (LD) AC therapies. Amongst 17,684 patients from 7 different studies, the addition of AC to SOC therapy was associated with MACE reduction (RD -0.022, 95% CI -0.033 to -0.012, p0.001) and increased MB (RD 0.02, 95% CI 0.014 to 0.025, p0.001). For FD, MACE reduction was (RD -0.021, 95% CI -0.042 to 0.001, p = 0.061) and MB (RD 0.036, 95% CI 0.025 to 0.047, p0.001). For LD, MACE reduction was (RD -0.023, 95% CI -0.035 to -0.011, p0.001) and MB (RD 0.011, 95% CI 0.005 to 0.017, p0.001). In conclusion, addition of AC to the current SOC therapy can mitigate future MACE events in patients with PAD albeit at risk of increased bleeding. LD AC is associated with an efficacy/safety net benefit compared to FD AC therapy.
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- 2021
20. Sexual Harassment, Victim Blaming, and the Potential Impact on Women in Cardiology
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Garima Sharma, Christina Mansour, Gina Lundberg, Kamala P Tamirisa, Laxmi S. Mehta, Annabelle Santos Volgman, Purvi Parwani, and Roxana Mehran
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Potential impact ,business.industry ,Voices in Cardiology ,Victim blaming ,ACCWIC ,Criminology ,WIC ,VB ,Viewpoint ,Harassment ,Medicine ,STEMM ,Cardiology and Cardiovascular Medicine ,business - Published
- 2021
21. Impact of Percutaneous Coronary Intervention on Outcomes in Patients With Heart Failure
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Bimmer E. Claessen, Javed Butler, Hal Skopicki, Mark C. Petrie, Adrian F. Hernandez, Deepak L. Bhatt, Gregg C. Fonarow, Stefan D. Anker, Puja B. Parikh, Roxana Mehran, and Varun Bhasin
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Acute coronary syndrome ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,law.invention ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,cardiovascular diseases ,030212 general & internal medicine ,Ejection fraction ,business.industry ,Percutaneous coronary intervention ,medicine.disease ,surgical procedures, operative ,medicine.anatomical_structure ,Heart failure ,Conventional PCI ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Coronary artery disease (CAD) is highly prevalent in patients with heart failure (HF) and accounts for nearly two-thirds of cases. The use of percutaneous coronary intervention (PCI) in HF patients with CAD has markedly increased and has been suggested to be associated with improved outcomes in numerous observational studies. Randomized data comparing the impact of PCI with that of coronary artery bypass graft (CABG) or contemporary guideline-directed medical therapy alone on clinical outcomes and myocardial recovery in patients with HF are lacking. The purpose of this review is to describe the available evidence regarding the impact of PCI in acute HF (in the presence and absence of an acute coronary syndrome), chronic HF with reduced ejection fraction, and HF with preserved ejection fraction. Adequately-powered randomized clinical trials examining the outcomes with PCI in these distinct HF populations are warranted.
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- 2021
22. Current state-of-the-art antiplatelet and anticoagulation therapy in diabetic patients with coronary artery disease
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Victor Razuk, Roxana Mehran, Johny Nicolas, and Gennaro Giustino
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medicine.medical_specialty ,business.industry ,medicine.drug_class ,Anticoagulant ,Complex disease ,Anticoagulants ,Coronary Artery Disease ,medicine.disease ,law.invention ,Coronary artery disease ,Fibrinolytic Agents ,Randomized controlled trial ,law ,Diabetes mellitus ,Antithrombotic ,Diabetes Mellitus ,medicine ,Humans ,Molecular Medicine ,In patient ,Cardiology and Cardiovascular Medicine ,business ,Intensive care medicine ,Platelet Aggregation Inhibitors ,Organ system - Abstract
Diabetes mellitus is a complex disease that leads to long-term damage to various organ systems. Among the numerous cardiovascular disease-related complications, thrombotic events frequently occur in patients with diabetes. Although guidelines exist for treating and preventing most diabetes-related co-morbidities, the evidence on antithrombotic therapy in primary and secondary prevention is limited due to the scarcity of randomized trials dedicated to patients with diabetes mellitus. Most of the available data are derived from studies that only included a small proportion of patients with diabetes. The present review provides an overview of the status of knowledge on antiplatelet and anticoagulation therapy in patients with diabetes, focusing on the risk-benefit balance of these therapies and future treatment strategies.Lay abstract Patients with diabetes are at increased risk for heart diseases. In fact, heart attacks often occur silently in diabetic patients. Other complications, such as acute decrease in brain or limb perfusion, are also common especially in high-risk diabetic patients. Over the last decade, several drugs for the treatment of diabetes and its associated complications have emerged. Among these therapies, antithrombotic drugs play a pivotal role in preventing these accidents. However, the evidence on antithrombotic drugs use in prevention is limited due to the scarcity of studies dedicated to patients with diabetes. In this review, we provide an aerial view of the latest evidence on the optimal use of antithrombotic drugs in patients with diabetes and heart disease.
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- 2021
23. Incidence, predictors, and outcomes associated with acute kidney injury in patients undergoing transcatheter aortic valve replacement: from the BRAVO-3 randomized trial
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Bimmer E. Claessen, Thierry Lefèvre, Efthymios N. Deliargyris, Roxana Mehran, Nicolas Dumonteil, Didier Tchetche, Antonio Colombo, George Dangas, Birgit Vogel, Jaya Chandrasekhar, Jurriën M. ten Berg, Anita W. Asgar, Prodromos Anthopoulos, Peter Wijngaard, Christian Hengstenberg, Stephan Windecker, Melissa Aquino, Samantha Sartori, John G. Webb, and David Hildick-Smith
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medicine.medical_specialty ,medicine.medical_treatment ,Population ,030204 cardiovascular system & hematology ,urologic and male genital diseases ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Valve replacement ,Internal medicine ,medicine ,Clinical endpoint ,Bivalirudin ,030212 general & internal medicine ,education ,education.field_of_study ,business.industry ,Acute kidney injury ,EuroSCORE ,General Medicine ,medicine.disease ,female genital diseases and pregnancy complications ,Cardiology ,Cardiology and Cardiovascular Medicine ,business ,Kidney disease ,medicine.drug - Abstract
Acute kidney injury (AKI) is not uncommon in patients undergoing transcatheter aortic valve replacement (TAVR). We examined the incidence, predictors, and outcomes of AKI from the BRAVO 3 randomized trial. The BRAVO-3 trial included 802 patients undergoing transfemoral TAVR randomized to bivalirudin vs. unfractionated heparin (UFH). The primary endpoint of the trial was Bleeding Academic Research Consortium (BARC) type ≥ 3b bleeding at 48 h. Total follow-up was to 30 days. AKI was adjudicated using the modified RIFLE (Valve Academic Research Consortium, VARC 1) criteria through 30-day follow-up, and in a sensitivity analysis AKI was assessed at 7 days (modified VARC-2 criteria). We examined the incidence, predictors, and 30-day outcomes associated with diagnosis of AKI. We also examined the effect of procedural anticoagulant (bivalirudin or unfractionated heparin, UFH) on AKI within 48 h after TAVR. The trial population had a mean age of 82.3 ± 6.5 years including 48.8% women with mean EuroScore I 17.05 ± 10.3%. AKI occurred in 17.0% during 30-day follow-up and was associated with greater adjusted risk of 30-day death (13.0% vs. 3.5%, OR 5.84, 95% CI 2.62–12.99) and a trend for more BARC ≥ 3b bleeding (15.1% vs. 8.6%, OR 1.80, 95% CI 0.99–3.25). Predictors of 30-day AKI were baseline hemoglobin, body weight, and pre-existing coronary disease. AKI occurred in 10.7% at 7 days and was associated with significantly greater risk of 30-day death (OR 6.99, 95% CI 2.85–17.15). Independent predictors of AKI within 7 days included pre-existing coronary or cerebrovascular disease, chronic kidney disease (CKD), and transfusion which increased risk, whereas post-dilation was protective. The incidence of 48-h AKI was higher with bivalirudin compared to UFH in the intention to treat cohort (10.9% vs. 6.5%, p = 0.03), but not in the per-protocol assessment (10.7% vs. 7.1%, p = 0.08). In the BRAVO 3 trial, AKI occurred in 17% at 30 days and in 10.7% at 7 days. AKI was associated with a significantly greater adjusted risk for 30-day death. Multivariate predictors of AKI at 30 days included baseline hemoglobin, body weight, and prior coronary artery disease, and predictors at 7 days included pre-existing vascular disease, CKD, transfusion, and valve post-dilation. Bivalirudin was associated with greater AKI within 48 h in the intention to treat but not in the per-protocol analysis.
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- 2021
24. Apixaban or Vitamin K Antagonists and Aspirin or Placebo According to Kidney Function in Patients With Atrial Fibrillation After Acute Coronary Syndrome or Percutaneous Coronary Intervention
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Renato D. Lopes, M. Cecilia Bahit, Stephan Windecker, Peter Sinnaeve, Daniel Wojdyla, Ziad Hijazi, Sigrun Halvorsen, Harald Darius, Alexander Parkhomenko, Otávio Berwanger, Robert F. Storey, Zhuokai Li, Roxana Mehran, John H. Alexander, Ronald Aronson, Suzanne de Waha-Thiele, and Christopher B. Granger
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Male ,medicine.medical_specialty ,Acute coronary syndrome ,Vitamin K ,Pyridones ,medicine.drug_class ,Kidney ,Placebo ,Gastroenterology ,Percutaneous Coronary Intervention ,Physiology (medical) ,Internal medicine ,Atrial Fibrillation ,medicine ,Humans ,Acute Coronary Syndrome ,610 Medicine & health ,Aged ,Aged, 80 and over ,Aspirin ,business.industry ,Anti-Inflammatory Agents, Non-Steroidal ,Atrial fibrillation ,Middle Aged ,Vitamin K antagonist ,medicine.disease ,Clinical trial ,Pyrazoles ,Female ,Apixaban ,Cardiology and Cardiovascular Medicine ,business ,Fibrinolytic agent ,Factor Xa Inhibitors ,medicine.drug - Abstract
Background: In the AUGUSTUS trial (An Open-Label, 2×2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban Versus Vitamin K Antagonist and Aspirin Versus Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), apixaban resulted in less bleeding and fewer hospitalizations than vitamin K antagonists, and aspirin caused more bleeding than placebo in patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention treated with a P2Y 12 inhibitor. We evaluated the risk-benefit balance of antithrombotic therapy according to kidney function. Methods: In 4456 patients, the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formula was used to calculate baseline estimated glomerular filtration rate (eGFR). The effect of apixaban versus vitamin K antagonists and aspirin versus placebo was assessed across kidney function categories by using Cox models. The primary outcome was International Society on Thrombosis and Haemostasis major or clinically relevant nonmajor bleeding. Secondary outcomes included death or hospitalization and ischemic events (death, stroke, myocardial infarction, stent thrombosis [definite or probable], or urgent revascularization). Creatinine clearance Results: Overall, 30%, 52%, and 19% had an eGFR of >80, >50 to 80, and 30 to 50 mL·min –1 ·1.73 m –2 , respectively. At the 6-month follow-up, a total of 543 primary outcomes of bleeding, 1125 death or hospitalizations, and 282 ischemic events occurred. Compared with vitamin K antagonists, patients assigned apixaban had lower rates for all 3 outcomes across most eGFR categories without significant interaction. The absolute risk reduction with apixaban was most pronounced in those with an eGFR of 30 to 50 mL·min –1 ·1.73 m –2 for bleeding events with rates of 13.1% versus 21.3% (hazard ratio, 0.59; 95% CI, 0.41–0.84). Patients assigned aspirin had a higher risk of bleeding in all eGFR categories with an even greater increase among those with eGFR >80 mL·min –1 ·1.73 m –2 : 16.6% versus 5.6% (hazard ratio, 3.22; 95% CI, 2.19–4.74; P for interaction=0.007). The risk of death or hospitalization and ischemic events were comparable to aspirin and placebo across eGFR categories with hazard ratios ranging from 0.97 (95% CI, 0.76–1.23) to 1.28 (95% CI, 1.02–1.59) and from 0.75 (95% CI, 0.48–1.17) to 1.34 (95% CI, 0.81–2.22), respectively. Conclusions: The safety and efficacy of apixaban was consistent irrespective of kidney function, compared with warfarin, and in accordance with the overall trial results. The risk of bleeding with aspirin was consistently higher across all kidney function categories. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02415400.
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- 2021
25. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention
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David P. Faxon, David J. Moliterno, Jacqueline Saw, David R. Holmes, Jean Francois Tanguay, Shaun G. Goodman, Deepak L. Bhatt, Renato D. Lopes, C. Michael Gibson, Roxana Mehran, Christopher P. Cannon, Dominick J. Angiolillo, Christopher B. Granger, John W. Eikelboom, and Matthew J. Price
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Administration, Oral ,History, 21st Century ,Percutaneous Coronary Intervention ,Fibrinolytic Agents ,Physiology (medical) ,Atrial Fibrillation ,Antithrombotic ,medicine ,Humans ,cardiovascular diseases ,Aspirin ,business.industry ,Anticoagulants ,Percutaneous coronary intervention ,Atrial fibrillation ,medicine.disease ,Clopidogrel ,Surgery ,Clinical trial ,Conventional PCI ,Platelet aggregation inhibitor ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non–vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12inhibitor, preferably clopidogrel, in combination with a non–vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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- 2021
26. Ticagrelor Monotherapy Versus Dual-Antiplatelet Therapy After PCI
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Marco Valgimigli, Roxana Mehran, Anna Franzone, Bruno R. da Costa, Usman Baber, Raffaele Piccolo, Eùgene P. McFadden, Pascal Vranckx, Dominick J. Angiolillo, Sergio Leonardi, Davide Cao, George D. Dangas, Shamir R. Mehta, Patrick W. Serruys, C. Michael Gibson, Gabriel P. Steg, Samin K. Sharma, Christian Hamm, Richard Shlofmitz, Christoph Liebetrau, Carlo Briguori, Luc Janssens, Kurt Huber, Maurizio Ferrario, Vijay Kunadian, David J. Cohen, Aleksander Zurakowski, Keith G. Oldroyd, Han Yaling, Dariuz Dudek, Samantha Sartori, Brian Kirkham, Javier Escaned, Dik Heg, Stephan Windecker, Stuart Pocock, Peter Jüni, Patrick Serruys, Shamir Mehta, Michael C. Gibson, Adnan Kastrati, Mitchel Krucoff, Magnus E. Ohman, Paul Gurbel, Timothy D. Henry, David Moliterno, Dierik Heg, Eugene McFadden, Steven O. Marx, Bruce Darrow, Nicola Corvaja, Douglas DeStefano, Newsha Ghodsi, Jose Meller, Theresa Franklin-Bond, Jin Young Cha, Zaha Waseem, Giora Weisz, Ran Kornowski, Keith Oldroyd, Upendra Kaul, Bernhard Witzenbichler, Vladimir Dzavik, Robert Gil, Gennaro Sardella, Edouard Benit, Roberto Diletti, Marcello Dominici, Ton Slagboom, Paweł Buszman, Leonardo Bolognese, Carlo Tumscitz, Krzysztof Bryniarski, Adel Aminian, Mathias Vrolix, Ivo Petrov, Scot Garg, Christoph Naber, Janusz Prokopczuk, and Philippe Gabriel Steg
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medicine.medical_specialty ,Aspirin ,animal structures ,business.industry ,medicine.medical_treatment ,Hazard ratio ,Percutaneous coronary intervention ,030204 cardiovascular system & hematology ,Lower risk ,medicine.disease ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,Conventional PCI ,medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,business ,Ticagrelor ,Stroke ,medicine.drug - Abstract
Objectives The aim of this study was to compare ticagrelor monotherapy with dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) with drug-eluting stents. Background The role of abbreviated DAPT followed by an oral P2Y12 inhibitor after PCI remains uncertain. Methods Two randomized trials, including 14,628 patients undergoing PCI, comparing ticagrelor monotherapy with standard DAPT on centrally adjudicated endpoints were identified, and individual patient data were analyzed using 1-step fixed-effect models. The protocol was registered in PROSPERO ( CRD42019143120 ). The primary outcomes were the composite of Bleeding Academic Research Consortium type 3 or 5 bleeding tested for superiority and, if met, the composite of all-cause death, myocardial infarction, or stroke at 1 year, tested for noninferiority against a margin of 1.25 on a hazard ratio (HR) scale. Results Bleeding Academic Research Consortium type 3 or 5 bleeding occurred in fewer patients with ticagrelor than DAPT (0.9% vs. 1.7%, respectively; HR: 0.56; 95% confidence interval [CI]: 0.41 to 0.75; p Conclusions Ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without a concomitant increase in ischemic events.
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- 2021
27. Hemoglobin A1c and Cardiovascular Outcomes Following Percutaneous Coronary Intervention
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Samin K. Sharma, Nitin Barman, Usman Baber, Prakash Krishnan, Roxana Mehran, Vaishvi B. Jahveri, Valentin Fuster, Annapoorna Kini, George Dangas, Reza Masoomi, Lorenzo Azzalini, Gurpreet S. Johal, Pooja Vijay, and Joseph Sweeny
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medicine.medical_specialty ,endocrine system diseases ,business.industry ,medicine.medical_treatment ,Absolute risk reduction ,nutritional and metabolic diseases ,Percutaneous coronary intervention ,030204 cardiovascular system & hematology ,medicine.disease ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,chemistry ,Internal medicine ,Cohort ,Conventional PCI ,medicine ,030212 general & internal medicine ,Myocardial infarction ,Glycated hemoglobin ,Cardiology and Cardiovascular Medicine ,business ,Mace ,Glycemic - Abstract
Objectives The aim of this study was to evaluate post–percutaneous coronary intervention (PCI) outcomes in relation to pre-procedural glycated hemoglobin (HbA1c) levels from a large, contemporary cohort. Background There are limited data evaluating associations between HbA1c, a marker of glycemic control, and ischemic risk following PCI. Methods All patients with known HbA1c levels undergoing PCI at a single institution between 2009 and 2017 were included. Patients were divided into 5 groups on the basis of HbA1c level: ≤5.5%, 5.6% to 6.0%, 6.1% to 7.0%, 7.1% to 8.0%, and >8.0%. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death or myocardial infarction (MI), at 1-year follow-up. Results A total of 13,543 patients were included (HbA1c ≤5.5%, n = 1,214; HbA1c 5.6% to 6.0%, n = 2,202; HbA1c 6.1% to 7.0%, n = 4,130; HbA1c 7.1% to 8.0%, n = 2,609; HbA1c >8.0%, n = 3,388). Patients with both low (HbA1c ≤5.5%) and high (HbA1c >8.0%) levels displayed an increased risk for MACE compared with those with values between 6.1% and 7.0%. Excess risk was driven primarily by higher rates of all-cause death among those with low HbA1c levels, while higher values were strongly associated with greater MI risk. Patterns of risk were unchanged among patients with serial HbA1c levels and persisted after multivariate adjustment. Conclusions Among patients undergoing PCI, pre-procedural HbA1c levels display a U-shaped association with 1-year MACE risk, a pattern that reflects greater risk for death in the presence of low HbA1c (≤5.5%) and higher risk for MI with higher values (>8.0%).
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- 2021
28. 2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease
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Tyler J Gluckman, Dharam J. Kumbhani, Adam Cuker, Christopher P. Cannon, Craig J. Beavers, Vinod H. Thourani, Sarah A. Spinler, Benjamin E Peterson, Steven R. Messé, Kenneth Rosenfield, Nimesh Patel, Roxana Mehran, Deepak L. Bhatt, and Joseph E. Marine
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medicine.medical_specialty ,Consensus ,medicine.drug_class ,medicine.medical_treatment ,Cardiology ,030204 cardiovascular system & hematology ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Atrial Fibrillation ,medicine ,Humans ,In patient ,030212 general & internal medicine ,Oversight Committee ,Intensive care medicine ,Societies, Medical ,Atherosclerotic cardiovascular disease ,business.industry ,Anticoagulant ,Expert consensus ,Percutaneous coronary intervention ,Atrial fibrillation ,Venous Thromboembolism ,medicine.disease ,United States ,Cardiovascular Diseases ,Cardiology and Cardiovascular Medicine ,business ,Venous thromboembolism ,Platelet Aggregation Inhibitors - Abstract
This article has been temporarily removed as it was inadvertently posted ahead of an agreed-upon embargo. The article will be reinstated upon embargo expiry. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal .
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- 2021
29. One-Year COMBO Stent Outcomes in Acute Coronary Syndrome: from the COMBO Collaboration
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Borislav Atzev, Petr Hájek, Martin Hudec, Pier Woudstra, Melissa Aquino, Zdeněk Coufal, Tiong Kiam Ong, Mascot, Roxana Mehran, Michael S. Lee, Martin Mates, Doreen Zeebregts, Karel T. Koch, Deborah N. Kalkman, Robbert J. de Winter, Peter den Heijer, Antonio Colombo, Hazem M. Warda, Jan G.P. Tijssen, Rishi Chandiramani, Vera C de Winter, Jaya Chandrasekhar, Borislav Borisov, Jarosław Wójcik, Marcel A.M. Beijk, Andrés Iñiguez, Remedee registry investigators, George Dangas, Samantha Sartori, Puk de Wilde, Usman Baber, Cardiology, ACS - Heart failure & arrhythmias, Amsterdam Cardiovascular Sciences, ACS - Pulmonary hypertension & thrombosis, and ACS - Atherosclerosis & ischemic syndromes
- Subjects
0301 basic medicine ,medicine.medical_specialty ,Acute coronary syndrome ,medicine.medical_treatment ,Endothelial progenitor cell capture ,030204 cardiovascular system & hematology ,Dual therapy stent ,Percutaneous coronary intervention ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,ST segment ,Pharmacology (medical) ,cardiovascular diseases ,Myocardial infarction ,Pharmacology ,Unstable angina ,business.industry ,Stent ,Anti-CD34 ,General Medicine ,medicine.disease ,030104 developmental biology ,Conventional PCI ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
Purpose: The COMBO biodegradable polymer sirolimus-eluting stent includes endothelial progenitor cell capture (EPC) technology for rapid endothelialization, which may offer advantage in acute coronary syndromes (ACS). We sought to analyze the performance of the COMBO stent by ACS status and ACS subtype. Methods: The COMBO collaboration (n = 3614) is a patient-level pooled dataset from the MASCOT and REMEDEE registries. We evaluated outcomes by ACS status, and ACS subtype in patients with ST segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) versus unstable angina (UA). The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Secondary outcomes included stent thrombosis (ST). Results: We compared 1965 (54%) ACS and 1649 (46.0%) non-ACS patients. ACS presentations included 40% (n = 789) STEMI, 31% (n = 600) NSTEMI, and 29% (n = 576) UA patients. Risk of 1-year TLF was greater in ACS patients (4.5% vs. 3.3%, HR 1.51 95% CI 1.01–2.25, p = 0.045) without significant differences in definite/probable ST (1.1% vs 0.5%, HR 2.40, 95% CI 0.91–6.31, p = 0.08). One-year TLF was similar in STEMI, NSTEMI, and UA (4.8% vs 4.8% vs. 3.7%, p = 0.60), but definite/probable ST was higher in STEMI patients (1.9% vs 0.5% vs 0.7%, p = 0.03). Adjusted outcomes were not different in MI versus UA patients. Conclusions: Despite the novel EPC capture technology, COMBO stent PCI was associated with somewhat greater risk of 1-year TLF in ACS than in non-ACS patients, without significant differences in stent thrombosis. No differences were observed in 1-year TLF among ACS subtypes.
- Published
- 2021
30. Radial versus femoral access for coronary interventions: An updated systematic review and meta‐analysis of randomized trials
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Bimmer E. Claessen, George Dangas, Mauro Chiarito, Ridhima Goel, Davide Cao, Roxana Mehran, Johny Nicolas, Anton Camaj, Giulio G. Stefanini, David A. Power, Rishi Chandiramani, Anastasios Roumeliotis, and Samantha Sartori
- Subjects
medicine.medical_specialty ,Percutaneous ,medicine.medical_treatment ,Psychological intervention ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Randomized controlled trial ,Risk Factors ,law ,Internal medicine ,Catheterization, Peripheral ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,030212 general & internal medicine ,Myocardial infarction ,Stroke ,Randomized Controlled Trials as Topic ,business.industry ,Percutaneous coronary intervention ,General Medicine ,medicine.disease ,Femoral Artery ,Treatment Outcome ,Meta-analysis ,Radial Artery ,Conventional PCI ,Cardiology ,Cardiology and Cardiovascular Medicine ,business - Abstract
OBJECTIVE It is still debated if benefits associated with radial versus femoral access for coronary angiography and percutaneous coronary interventions (PCI) are due to the access site selection itself, operator expertise or other underlying mechanisms. METHODS We searched PubMed, Embase, and meeting abstracts for randomized trials comparing radial versus femoral access site for coronary angiography and PCI. Primary safety endpoint was major bleeding. Coprimary efficacy endpoints were stroke and myocardial infarction (MI). This study is registered with PROSPERO. RESULTS We identified 31 trials (30,096 patients, PCI performed in 21,225 patients). Radial compared to femoral access was associated with a significant risk reduction in major bleeding (OR 0.53, 95%CI 0.42-0.66, I2 = 3.3%). Findings were consistent regardless of clinical characteristics or whether coronary angiography was performed with or without PCI. The benefit of radial access was significantly increased in studies published before 2010 and in patients with chronic coronary syndrome. Risk for stroke (OR 1.11, 95%CI 0.76-1.64, I2 = 0%) and MI (OR 0.90, 95%CI 0.79-1.04, I2 = 0%) were comparable between the groups. Risk for mortality and vascular complications were significantly lower with radial than femoral access. CONCLUSION In patients undergoing coronary angiography and PCI, radial access is associated with a significant risk reduction in bleeding, vascular complications, and mortality compared to femoral access. The risk of stroke or MI were comparable in patients with radial or femoral access.
- Published
- 2021
31. Relationship between insulin resistance, coronary plaque, and clinical outcomes in patients with acute coronary syndromes: an analysis from the PROSPECT study
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Gary S. Mintz, Patrick W. Serruys, Björn Redfors, Roxana Mehran, Gennaro Giustino, Serdar Farhan, Gregg W. Stone, Bernard De Bruyne, Birgit Vogel, Akiko Maehara, Ori Ben-Yehuda, and Thomas McAndrew
- Subjects
Male ,medicine.medical_specialty ,Acute coronary syndrome ,lcsh:Diseases of the circulatory (Cardiovascular) system ,Time Factors ,Endocrinology, Diabetes and Metabolism ,Coronary Artery Disease ,Patient Readmission ,Risk Assessment ,Percutaneous Coronary Intervention ,Insulin resistance ,Risk Factors ,Internal medicine ,Diabetes mellitus ,Intravascular ultrasound ,Diabetes Mellitus ,Prevalence ,medicine ,Clinical endpoint ,Humans ,Insulin ,Culprit and non-culprit lesion events ,Myocardial infarction ,Ultrasonography, Interventional ,Original Investigation ,Aged ,medicine.diagnostic_test ,business.industry ,Hazard ratio ,Middle Aged ,medicine.disease ,Plaque, Atherosclerotic ,United States ,Europe ,Treatment Outcome ,Glucose ,lcsh:RC666-701 ,Disease Progression ,Female ,Cardiology and Cardiovascular Medicine ,business ,Mace - Abstract
Background We investigated the association of insulin resistance (IR) with coronary plaque morphology and the risk of cardiovascular events in patients enrolled in the Providing Regional Observations to Study Predictors of Events in Coronary Tree (PROSPECT) study. Methods Patients with acute coronary syndromes (ACS) were divided based on DM status. Non-DM patients were further stratified according to homeostasis-model-assessment IR (HOMA-IR) index as insulin sensitive (IS; HOMA-IR ≤ 2), likely-IR (LIR; 2 Results Among non-diabetic patients, 109 patients (21.5%) were categorized as LIR, and 65 patients (12.8%) as DIR. Patients with DIR or DM had significantly higher rates of echolucent plaque compared with LIR and IS. In addition, DIR and DM were independently associated with increased risk of MACE compared with IS (adjusted hazard ratio [aHR] 2.29, 95% confidence interval [CI] 1.22–4.29, p = 0.01 and aHR 2.12, 95% CI 1.19–3.75, p = 0.009, respectively). Conclusions IR is common among patients with ACS. DM and advanced but not early stages of IR are independently associated with increased risk of adverse cardiovascular events. Trial Registration ClinicalTrials.gov Identifier: NCT00180466.
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- 2021
32. First and recurrent events in the ISCHEMIA trial: two sides of the same coin
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Davide Cao, Carl J. Pepine, and Roxana Mehran
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medicine.medical_specialty ,Ischemia ,business.industry ,MEDLINE ,Humans ,Medicine ,Cardiology and Cardiovascular Medicine ,business ,medicine.disease ,Surgery - Published
- 2021
33. NT‐proBNP levels and cardiopulmonary function in children with sickle cell disease
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Joanna Fishbein, Lance Feld, Elizabeth K. Fiorino, Stacey Jackson, Elizabeth C Mitchell, Roxana Mehran, Abena Appiah-Kubi, Banu Aygun, and Maria Teresa Santiago
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Male ,Pulmonary and Respiratory Medicine ,Spirometry ,medicine.medical_specialty ,Adolescent ,medicine.drug_class ,Population ,Diastole ,Anemia, Sickle Cell ,Hemolysis ,Internal medicine ,Natriuretic Peptide, Brain ,medicine ,Natriuretic peptide ,Humans ,cardiovascular diseases ,Child ,education ,Retrospective Studies ,education.field_of_study ,medicine.diagnostic_test ,business.industry ,Incidence (epidemiology) ,medicine.disease ,Pulmonary hypertension ,Peptide Fragments ,Obstructive lung disease ,Respiratory Function Tests ,Echocardiography ,Pediatrics, Perinatology and Child Health ,Cohort ,Cardiology ,Female ,business ,Biomarkers ,hormones, hormone substitutes, and hormone antagonists - Abstract
Patients with sickle cell disease (SCD) are living longer and subsequently more apt to develop cardiopulmonary dysfunction. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels have been used in adults with SCD to assess for pulmonary hypertension and mortality. While the incidence of PH is low in pediatrics, it is reasonable to presume that NT-proBNP levels can be used to assess risk for the development of cardiopulmonary morbidity. We hypothesized that NT-proBNP levels would be increased in patients with SCD compared to age-adjusted healthy children; additionally, these levels would be associated with labs indicative of hemolysis and would demonstrate evidence of obstructive lung disease and cardiac dysfunction. We retrospectively evaluated patients with SCD, 8-18 years old, at a large, tertiary care children's hospital. NT-proBNP levels were assessed in correlation with hemolytic lab work, spirometry, and echocardiographic data. The age group 8-14 years old, 75% of our cohort's population, had a median NT-proBNP of 70 pg/ml, greater than their age-adjusted counterparts (52 pg/ml). NT-proBNP levels were associated with an increased degree of hemolysis when compared with hemoglobin (Hb) (r = -0.43, p < .0001), reticulocyte count (r = .25, p = .01) and lactate dehydrogenase levels (r = .47, p < .0001). An inverse trend was found between NT-proBNP and spirometric data. Finally, a positive correlation was found between NT-proBNP and diastolic left ventricular size (r = .28, p = .047]. The correlations found suggest that NT-proBNP may be used prospectively to identify patients with SCD at increased risk for the development of cardiopulmonary dysfunction.
- Published
- 2020
34. Impact of High-Density Lipoprotein Levels on Cardiovascular Outcomes of Patients Undergoing Percutaneous Coronary Intervention With Drug-Eluting Stents
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Adam Reisman, Samin K. Sharma, Bimmer E. Claessen, Ridhima Goel, Nitin Barman, Mauro Chiarito, Rebecca Torguson, Johny Nicolas, Rishi Chandiramani, Roxana Mehran, Madhav Sharma, Davide Cao, Dhrubajyoti Bandyopadhyay, Usman Baber, Anastasios Roumeliotis, Samantha Sartori, George Dangas, Annapoorna Kini, and Joseph Sweeny
- Subjects
Male ,Drug ,medicine.medical_specialty ,medicine.medical_treatment ,media_common.quotation_subject ,New York ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,03 medical and health sciences ,chemistry.chemical_compound ,Percutaneous Coronary Intervention ,0302 clinical medicine ,High-density lipoprotein ,Risk Factors ,Internal medicine ,medicine ,Humans ,In patient ,Registries ,cardiovascular diseases ,030212 general & internal medicine ,Aged ,Retrospective Studies ,media_common ,business.industry ,Incidence ,Percutaneous coronary intervention ,Drug-Eluting Stents ,Middle Aged ,Prognosis ,Survival Rate ,surgical procedures, operative ,chemistry ,Conventional PCI ,Cardiology ,Female ,lipids (amino acids, peptides, and proteins) ,Lipoproteins, HDL ,Cardiology and Cardiovascular Medicine ,business ,Cardiovascular outcomes ,Biomarkers ,Follow-Up Studies ,Lipoprotein - Abstract
Low levels of high-density lipoprotein (HDL) have been associated with adverse cardiovascular events in epidemiologic studies. Evidence regarding its role in patients who underwent percutaneous coronary intervention (PCI) is scarce. We evaluated consecutive patients who underwent PCI with drug-eluting stents from 2012 to 2017, excluding those with unavailable baseline HDL, age18 years, presentation with ST-segment elevation myocardial infarction (MI) or shock, and coexisting neoplastic disease. The final population was stratified according to baseline HDL levels into reduced and nonreduced HDL cohorts, with cut-off value 40 mg/dl in males and 50 mg/dl in females. The primary end point was 1-year major adverse cardiovascular events (MACE), defined as the composite of death, MI, or target vessel revascularization (TVR). Among 10,843 patients included, 6,511 (60%) had reduced HDL, and 4,332 (40%) nonreduced HDL. The rate of 1-year MACE was similar between the 2 groups (7.5% vs 6.6%; p = 0.14). Although mortality and MI rates were comparable, reduced HDL was associated with significantly higher TVR 5.2% vs 4.0%; p = 0.02, a finding that attenuated after multivariable adjustment (adjusted hazard ratio 1.18, p = 0.14). Sex subgroup analysis included 7,718 (71.2%) males and 3,125 (28.8%) females. Among men, there was a trend toward higher MACE in those with reduced HDL (7.4% vs 6.0%; p = 0.08) mostly driven by TVR (5.4% vs 3.7%; p = 0.005). No association between HDL and 1-year outcomes was evident in females. Assessment for interaction between sex and reduced HDL did not reach statistical significance. In conclusion, reduced baseline HDL was not associated with increased risk of MACE in a contemporary PCI population.
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- 2020
35. Prognostic Impact of High-Sensitivity C-Reactive Protein in Patients Undergoing Percutaneous Coronary Intervention According to BMI
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Samin K. Sharma, George Dangas, Zhongjie Zhang, Niklas Beyhoff, Anastasios Roumeliotis, Vishal Kapur, Samantha Sartori, Prakash Krishnan, Moritz Blum, Davide Cao, Ridhima Goel, Joseph Sweeny, Rishi Chandiramani, Jason C. Kovacic, Nitin Barman, Roxana Mehran, Usman Baber, and Annapoorna Kini
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Population ,030204 cardiovascular system & hematology ,Overweight ,Body Mass Index ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Risk Factors ,Internal medicine ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Myocardial infarction ,education ,education.field_of_study ,biology ,business.industry ,C-reactive protein ,nutritional and metabolic diseases ,Percutaneous coronary intervention ,Prognosis ,medicine.disease ,C-Reactive Protein ,Treatment Outcome ,Conventional PCI ,biology.protein ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,Body mass index ,Mace - Abstract
The aim of this study was to determine the prevalence and prognostic implications of elevated high-sensitivity C-reactive protein (hsCRP) in patients undergoing percutaneous coronary intervention (PCI) according to body mass index (BMI).Whereas elevated hsCRP predicts adverse clinical outcome after PCI in the general population, the impact of BMI on its prognostic utility remains unclear.Data from 14,140 patients who underwent PCI between January 2009 and June 2017 at a large tertiary care center were analyzed. Patients were divided into 4 BMI categories: normal (BMI 18.5 to 25 kg/mElevated hsCRP was present in 18.9%, 23.6%, 33.3%, and 47.7% of the normal, overweight, obese, and severely obese groups, respectively. MACE rates were consistently higher in patients with elevated hsCRP across all BMI categories (normal, 13.4% vs. 8.3%; overweight, 11.2% vs. 7.2%; obese, 10.6% vs. 7.5%; severely obese, 11.9% vs. 6.5%; p 0.01 for all). After multivariate adjustment, hsCRP elevation remained significantly associated with MACE independent of BMI (hazard ratios: normal, 1.43 [95% confidence interval: 1.04 to 1.95]; overweight, 1.56 [95% confidence interval: 1.21 to 1.88]; obese, 1.40 [95% confidence interval: 1.06 to 1.84]; severely obese, 1.92 [95% confidence interval: 1.35 to 2.75]; p 0.05 for all).Among patients undergoing PCI, the prevalence of hsCRP elevation progressively increased with higher BMI. Measurement of hsCRP facilitates prognostic risk assessment for adverse outcome after PCI across a broad range of BMI.
- Published
- 2020
36. Excimer laser coronary atherectomy for uncrossable coronary lesions. A multicenter registry
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Francisco Hidalgo, Miguel Romero, Manuel Pan, Annapoorna Kini, Alfonso Jurado-Román, Samin K. Sharma, Raul Moreno, Lorenzo Azzalini, George Dangas, Javier Suárez de Lezo, Bruno García del Blanco, Rafael González, Neus Bellera, Nitin Barman, Gurpreet S. Johal, Roxana Mehran, and Soledad Ojeda
- Subjects
Atherectomy, Coronary ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Coronary Angiography ,Revascularization ,Ventricular tachycardia ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Clinical endpoint ,Humans ,Radiology, Nuclear Medicine and imaging ,Registries ,030212 general & internal medicine ,Myocardial infarction ,Fibrillation ,business.industry ,Percutaneous coronary intervention ,General Medicine ,medicine.disease ,Dissection ,Treatment Outcome ,Heart failure ,Cardiology ,Lasers, Excimer ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objectives To assess the efficacy and safety of excimer laser coronary atherectomy (ELCA), as well as, the long-term outcomes and the factors associated with ELCA failure in uncrossable lesions. Background Uncrossable lesions constitute a challenge for percutaneous coronary intervention. Methods This multicenter registry included 126 patients with 126 uncrossable lesions. Study endpoints were ELCA success, technical success and a composite of cardiac death, myocardial infarction (MI), and target-lesion revascularization (TLR) on follow-up. Predictors of ELCA failure were analyzed. Results Moderate or severe calcification was present in 79 (62.7%) of the lesions and 58 (46%) were a chronic total occlusion. ELCA success was obtained in 103 (81.8%) patients. Rotational atherectomy was attempted as bailout in 21 out of 23 ELCA failure (91.3%), being successful in 14 (66.7%) of them. Finally, technical and procedural success were achieved in 114 (90.5%) and 110 (87.3%) of the patients. Severe calcification was independently associated with ELCA failure (OR: 3.73, 95% CI: 1.35-10.32; p = .011). Two (1.6%) patients died (one after a stroke and another patient because of heart failure), 4 (3.2%) developed a non-Q MI without clinical consequences and 1 (0.8%) patient had a Q-MI. Other complications were ventricular tachycardia/fibrillation (n = 2; 1.6%) and flow-limiting dissection (n = 1, 0.8%). At follow-up (median 424 days), 3 (2.4%) patients died (1 (0.8%) from cardiovascular cause) and 15 (11.9%) required TLR. Conclusions In our multicenter experience, ELCA use demonstrated to be safe and reasonably effective with a rate of events on follow-up relatively low. Severe calcification was associated with ELCA failure.
- Published
- 2020
37. Trial characteristics associated with under‐enrolment of females in randomized controlled trials of heart failure with reduced ejection fraction: a systematic review
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Yousif Eliya, Kristen Sullivan, Sera Whitelaw, Harriette G.C. Van Spall, Mohammad Alruwayeh, Roxana Mehran, Clyde W. Yancy, Lehana Thabane, and Mamas A. Mamas
- Subjects
Adult ,Male ,medicine.medical_specialty ,Asia ,MEDLINE ,030204 cardiovascular system & hematology ,Logistic regression ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Humans ,Randomized Controlled Trials as Topic ,Heart Failure ,Ejection fraction ,business.industry ,Odds ratio ,Middle Aged ,medicine.disease ,Confidence interval ,3. Good health ,Europe ,Heart failure ,North America ,Ambulatory ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
AIMS To evaluate temporal trends in the enrolment of females in randomized controlled trials (RCTs) of heart failure with reduced ejection fraction (HFrEF) published in high-impact journals, and assess RCT characteristics associated with under-enrolment. METHODS AND RESULTS We searched MEDLINE, EMBASE and CINAHL for studies published from January 2000 to May 2019 in journals with impact factor ≥10. We included RCTs that recruited adults with HFrEF. We used a 20% threshold below the sex distribution of HFrEF to define under-enrolment. We used multivariable logistic regression to assess trial characteristics independently associated with under-enrolment. We included 317 RCTs. Among the 183 097 participants, mean (standard deviation) age was 63.0 (7.0) years and 25.5% were female. Females were under-enrolled in 71.6% [95% confidence interval (CI) 66.6-76.6%] of the RCTs; enrolment did not increase significantly between 2000-2019. Sex-related eligibility criteria [odds ratio (OR) 2.05, 95% CI 1.01-4.16; P = 0.046]; recruitment in ambulatory settings (OR 2.56, 95% CI 1.37-4.81; P = 0.003); trial coordination in North America (OR 4.44, 95% CI 1.09-18.07; P = 0.037), Europe (OR 6.79, 95% CI 1.63-27.39; P = 0.018) and Asia (OR 9.33, 95% CI 1.40-12.40; P = 0.033); drug (OR 1.76, 95% CI 1.96-7.36; P
- Published
- 2020
38. Comparative influence of bleeding and ischemic risk factors on diabetic patients undergoing percutaneous coronary intervention with everolimus‐eluting stents
- Author
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Anastasios Roumeliotis, Sripal Bangalore, Ashok Seth, Marco Valgimigli, Ridhima Goel, Deepak L. Bhatt, Rishi Chandiramani, Moritz Blum, Junbo Ge, Franz-Josef Neumann, Lijuan Wang, Giulio G. Stefanini, James B. Hermiller, Roxana Mehran, Dominick J. Angiolillo, Davide Cao, Ken Kozuma, Kai Koo, Rajendra M Makkar, Mitchell W. Krucoff, Shigeru Saito, University of Zurich, and Mehran, Roxana
- Subjects
Acute coronary syndrome ,medicine.medical_specialty ,medicine.medical_treatment ,Population ,Hemorrhage ,610 Medicine & health ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,11171 Cardiocentro Ticino ,2705 Cardiology and Cardiovascular Medicine ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Diabetes Mellitus ,Humans ,2741 Radiology, Nuclear Medicine and Imaging ,Medicine ,Radiology, Nuclear Medicine and imaging ,Everolimus ,030212 general & internal medicine ,Myocardial infarction ,education ,Stroke ,Aged ,education.field_of_study ,business.industry ,Percutaneous coronary intervention ,Stent ,Drug-Eluting Stents ,General Medicine ,medicine.disease ,Treatment Outcome ,Conventional PCI ,Cardiology ,Stents ,Cardiology and Cardiovascular Medicine ,business ,Platelet Aggregation Inhibitors ,Mace - Abstract
Objective To investigate the impact of ischemic and bleeding risk factors on long-term clinical outcomes of patients with diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI) with everolimus-eluting stents. Background Second-generation drug-eluting stents have substantially improved outcomes after PCI in the general population; however, DM patients continue to experience high rates of ischemic and bleeding complications. Methods DM patients from the pooled XIENCE V registry were divided into high or low bleeding and ischemic risk groups (HBR, LBR, HIR, and LIR) based on established bleeding (age ≥ 75 years; chronic kidney disease; anemia; prior stroke; oral anticoagulation; thrombocytopenia; prior major bleeding) and ischemic (acute coronary syndrome; prior myocardial infarction [MI]; ≥3 stents implanted; ≥3 vessels treated; ≥3 lesions treated; stent length > 60 mm; bifurcation treated with ≥2 stents; chronic total occlusion) risk factors. The primary outcomes were major adverse cardiac events (MACE; cardiac death, MI, or stent thrombosis) and major bleeding at 4-year follow-up. Results A total of 3,704 DM patients were divided into four groups (21.5% LBR/LIR; 39.0% LBR/HIR; 15.6% HBR/LIR; 23.9% HBR/HIR). Compared with LBR/LIR patients, those at HBR/HIR and HBR/LIR had a significantly higher risk of MACE (HR (95% CI) 2.7 (1.9-3.9) and 2.2 (1.5-3.2), respectively) and major bleeding (2.7 (1.6-4.8) and 2.6 (1.4-4.7), respectively), while LBR/HIR patients did not. Conclusions Among DM patients undergoing PCI, presence of bleeding risk factors was associated with a higher risk of both ischemic and bleeding events, whereas commonly used features of ischemic risk did not impact long-term clinical outcomes.
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- 2020
39. Bleeding avoidance strategies in percutaneous coronary intervention
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Stephan Windecker, Davide Capodanno, Deepak L. Bhatt, Marco Valgimigli, Philip Urban, Dominick J. Angiolillo, Stefan James, Roxana Mehran, Sunil V. Rao, C. Michael Gibson, Takeshi Kimura, and Philippe Gabriel Steg
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Vascular access ,Hemorrhage ,Revascularization ,Antithrombotic treatment ,Percutaneous Coronary Intervention ,medicine ,Humans ,In patient ,Cardiac and Cardiovascular Systems ,cardiovascular diseases ,Intensive care medicine ,610 Medicine & health ,Kardiologi ,business.industry ,Anticoagulants ,Percutaneous coronary intervention ,Treatment Outcome ,surgical procedures, operative ,Drug development ,Conventional PCI ,Stents ,Cardiology and Cardiovascular Medicine ,business ,Platelet Aggregation Inhibitors ,Thrombotic complication - Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
- Published
- 2022
40. Efficacy and safety of alirocumab and evolocumab:a systematic review and meta-analysis of randomized controlled trials
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Bimmer E. Claessen, Gilles Montalescot, Ciro Indolfi, Robert S. Rosenson, Stuart J. Pocock, Samantha Sartori, Salvatore De Rosa, Birgit Vogel, Paul Guedeney, Roxana Mehran, George Dangas, Deborah N. Kalkman, Gennaro Giustino, Anton Camaj, Usman Baber, and Sabato Sorrentino
- Subjects
medicine.medical_specialty ,business.industry ,PCSK9 ,030204 cardiovascular system & hematology ,Lower risk ,medicine.disease ,Evolocumab ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Internal medicine ,Relative risk ,Medicine ,030212 general & internal medicine ,Myocardial infarction ,Cardiology and Cardiovascular Medicine ,business ,Cholesterol-lowering therapies ,Stroke ,Alirocumab - Abstract
Aims The effect of low-density lipoprotein cholesterol-lowering therapy with alirocumab or evolocumab on individual clinical efficacy and safety endpoints remains unclear. We aimed to evaluate the efficacy and safety of alirocumab and evolocumab in patients with dyslipidaemia or atherosclerotic cardiovascular disease. Methods and results We performed a review of randomized controlled trials (RCTs) comparing treatment with alirocumab or evolocumab vs. placebo or other lipid-lowering therapies up to March 2018. Primary efficacy endpoints were all-cause death, cardiovascular death, myocardial infarction (MI), and stroke. We estimated risk ratios (RR) and 95% confidence intervals (CI) using random effect models. We included 39 RCTs comprising 66 478 patients of whom 35 896 were treated with proprotein convertase subtilisin–kexin type 9 (PCSK9) inhibitors (14 639 with alirocumab and 21 257 with evolocumab) and 30 582 with controls. Mean weighted follow-up time across trials was 2.3 years with an exposure time of 150 617 patient-years. Overall, the effects of PCSK9 inhibition on all-cause death and cardiovascular death were not statistically significant (P = 0.15 and P = 0.34, respectively). Proprotein convertase subtilisin–kexin type 9 inhibitors were associated with lower risk of MI (1.49 vs. 1.93 per 100 patient-year; RR 0.80, 95% CI 0.74–0.86; I 2 = 0%; P Conclusion Proprotein convertase subtilisin–kexin type 9 inhibition with alirocumab or evolocumab was associated with lower risk of MI, stroke, and coronary revascularization, with favourable safety profile.
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- 2022
41. White blood cell count and clinical outcomes after left main coronary artery revascularization: Insights from the EXCEL trial
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Samin K. Sharma, Bimmer E. Claessen, Patrick W. Serruys, Shmuel Chen, Roxana Mehran, Joseph F. Sabik, Paul Guedeney, Annapoorna Kini, Ovidiu Dressler, Arie Pieter Kappetein, Ditian Li, Ori Ben-Yehuda, Nicolas Noiseux, Sabato Sorrentino, Gregg W. Stone, Samer Mansour, and Cardiothoracic Surgery
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Revascularization ,Coronary artery bypass surgery ,Leukocyte Count ,Percutaneous Coronary Intervention ,Risk Factors ,Internal medicine ,Outcome Assessment, Health Care ,medicine ,Clinical endpoint ,Myocardial Revascularization ,Humans ,Myocardial infarction ,cardiovascular diseases ,Stroke ,Aged ,business.industry ,Percutaneous coronary intervention ,General Medicine ,Middle Aged ,medicine.disease ,Coronary Vessels ,medicine.anatomical_structure ,Treatment Outcome ,surgical procedures, operative ,Conventional PCI ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Background: Prior studies have reported an association between elevated white blood cell count (WBCc) and worse clinical outcomes after coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). We assessed the prognostic impact of WBCc in patients undergoing revascularization for left main coronary artery disease (LMCAD). Methods: In Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL), 1905 patients with LMCAD and low or intermediate SYNTAX scores were randomized to PCI with everolimus-eluting stents versus CABG. The 1895 patients with baseline WBCc available were grouped in tertiles of WBCc (mean 5.6 ± 0.8, 7.5 ± 0.5, and 10.1 ± 1.6 × 109/L). Results: Five-year rates of the primary endpoint (death, myocardial infarction or stroke) were similar across increasing WBCc tertiles (21.2, 18.9, and 21.6%; P = 0.46). Individual components of the primary endpoint, Bleeding Academic Research Consortium (BARC) 3-5 bleeding, stent thrombosis or graft occlusion and ischemia-driven revascularization were all similar across WBCc tertiles. By multivariable analysis, WBCc as a continuous variable was not an independent predictor of adverse events (hazard radio per 1 × 109/L: 1.02; 95% CI, 0.97-1.08; P = 0.43). Results were consistent in the PCI and CABG arms individually. Conclusion: There was no association between baseline WBCc and 30-day or 5-year clinical outcomes after PCI or CABG. The absence of a clear incremental increase in events with increasing WBCc in the current analysis indicates that WBCc should not routinely be used as a prognostic marker or to guide revascularization decisions in patients with LMCAD.
- Published
- 2022
42. Nonculprit Lesion Severity and Outcome of Revascularization in Patients With STEMI and Multivessel Coronary Disease
- Author
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Irene M. Lang, Robert F. Storey, Tej Sheth, Natalia Pinilla-Echeverri, Matthias Bossard, John A. Cairns, Laurent J. Feldman, Nicholas Valettas, Roxana Mehran, Akshay Bagai, John Ducas, Jia Wang, David E. Newby, Jon-David Schwalm, Matthew Sibbald, James L. Velianou, Josep Rodés-Cabau, Stéphane Rinfret, Sripal Bangalore, Steven B. Laster, David A. Wood, Joseph D. Mills, Kevin R. Bainey, Raul Moreno, Shamir R. Mehta, and Eric A. Cohen
- Subjects
Male ,medicine.medical_specialty ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Revascularization ,Severity of Illness Index ,Coronary artery disease ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Internal medicine ,Myocardial Revascularization ,medicine ,Humans ,030212 general & internal medicine ,Myocardial infarction ,Aged ,business.industry ,Hazard ratio ,Percutaneous coronary intervention ,Middle Aged ,medicine.disease ,Confidence interval ,Stenosis ,Treatment Outcome ,Conventional PCI ,Cardiology ,ST Elevation Myocardial Infarction ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease.The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization.Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus 60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined.The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis 60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis 60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04).Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with 60%, as determined by quantitative coronary angiography.
- Published
- 2020
43. Feasibility and Utility of a Cardiovascular Risk Screening Tool in Women Undergoing Routine Gynecology Evaluation
- Author
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Roxana Mehran, Kimberly A. Skelding, Bina Ahmed, Jaya Chandrasekhar, Robert A. Wild, Sudhir Mungee, Jerri A Johnson, Ki Park, Kimberly R Barber, Jennifer Yu, Lynn Thomas, Deborah N. Kalkman, David Dobies, Cardiology, ACS - Heart failure & arrhythmias, and ACS - Atherosclerosis & ischemic syndromes
- Subjects
cardiovascular risk ,Adult ,Gestational hypertension ,Health Knowledge, Attitudes, Practice ,medicine.medical_specialty ,Ambulatory Care Facilities ,Preeclampsia ,preeclampsia ,Angina ,Obstetrics and gynaecology ,Pregnancy ,Risk Factors ,Diabetes mellitus ,medicine ,Humans ,Mass Screening ,obstetrics and gynecology ,Gynecology ,business.industry ,General Medicine ,Middle Aged ,medicine.disease ,Obesity ,United States ,Obstetrics ,Gestational diabetes ,Blood pressure ,Cardiovascular Diseases ,Heart Disease Risk Factors ,Feasibility Studies ,Women's Health ,Female ,women ,business - Abstract
Background: The goals of this multicenter survey were to examine the prevalence and patient awareness of cardiovascular risk factors, and the association between history of adverse pregnancy outcomes (APO-including gestational hypertension, gestational diabetes, and preeclampsia) and prevalence of cardiovascular risks among women presenting to outpatient obstetrics/gynecology (OB/GYN) clinics. Materials and Methods: We surveyed 2,946 female patients attending 16 outpatient OB/GYN clinics across the United States between January 2010 and January 2012. Main outcome measures were self-reported cardiovascular risk factors and symptoms such as angina and dyspnea. Results: Mean age of the patients was 51 ± 13.6 years. Cardiovascular risks and symptoms were highly prevalent (86.0% and 40.1%, respectively). Many patients did not know if they had common risk factors such as hypertension, hypercholesterolemia, or diabetes (18.4%, 32.0%, and 17.9%, respectively). Women with a history of APO were slightly more likely to be aware of common risk factors, including abnormal blood pressure (17% vs. 18.6%), high cholesterol (31.7% vs. 32%), and obesity/elevated body mass index (43.9% vs. 49.7%). Compared with patients with no history of APO, patients with APO (n = 380, 12.9%) were more likely to have risk factors (89.5% vs. 83.9%, p = 0.002) and symptoms (45.5% vs. 39.3%, p = 0.02). Conclusions: Awareness of cardiovascular risk factors and symptoms among all women surveyed in this study was poor, although awareness for some risk factors was relatively higher among patients with APO. This study demonstrates the feasibility of cardiovascular assessment in OB/GYN clinics using a simple questionnaire and its potential role for early recognition and timely intervention.
- Published
- 2020
44. Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management
- Author
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Jeffrey S. Berger, Roxana Mehran, Mary T. Hawn, Davide Cao, Davide Capodanno, Rishi Chandiramani, Dominick J. Angiolillo, and Matthew A. Levin
- Subjects
0301 basic medicine ,medicine.medical_specialty ,Interventional cardiology ,business.industry ,medicine.medical_treatment ,Guideline ,Perioperative ,030204 cardiovascular system & hematology ,medicine.disease ,Thrombosis ,Preoperative care ,Coronary artery disease ,03 medical and health sciences ,030104 developmental biology ,0302 clinical medicine ,Coronary stent ,medicine ,Cardiology and Cardiovascular Medicine ,Risk assessment ,Intensive care medicine ,business - Abstract
Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5–25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents. Patients with coronary artery disease (CAD) are at high risk of perioperative cardiovascular complications related to non-cardiac surgery. In this Review, Mehran and colleagues summarize trial data and guideline recommendations on preoperative risk stratification and periprocedural management of patients with CAD undergoing non-cardiac surgery.
- Published
- 2020
45. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants
- Author
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Fatima Rodriguez, Barbara S. Wiggins, Ravindra Sarode, William J. Hucker, Adam Cuker, John U. Doherty, Kenneth W. Mahaffey, Roberta Florido, Gordon F. Tomaselli, John W. Eikelboom, Tyler J Gluckman, Roxana Mehran, Deborah M. Siegal, Steven R. Messé, Alexander C. Perino, and Paul P. Dobesh
- Subjects
medicine.medical_specialty ,Rivaroxaban ,business.industry ,General surgery ,Warfarin ,030204 cardiovascular system & hematology ,Dabigatran ,03 medical and health sciences ,chemistry.chemical_compound ,0302 clinical medicine ,chemistry ,Edoxaban ,Betrixaban ,medicine ,Apixaban ,In patient ,030212 general & internal medicine ,Oversight Committee ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Ty J. Gluckman, MD, FACC, Chair Niti R. Aggarwal, MD, FACC Nicole M. Bhave, MD, FACC Gregory J. Dehmer, MD, MACC Olivia N. Gilbert, MD, MSc, FACC Chayakrit Krittanawong, MD Dharam J. Kumbhani, MD, SM, FACC Javier A. Sala-Mercado, MD, PhD Andrea L. Price, CPHQ, RCIS, AACC David E.
- Published
- 2020
46. Clinical features and prognosis of patients with spontaneous coronary artery dissection
- Author
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Kipp W. Johnson, Usman Baber, Roxana Mehran, Chayakrit Krittanawong, Anirudh Kumar, Deepak L. Bhatt, Angela Palazzo, and Zhen Wang
- Subjects
Adult ,Male ,medicine.medical_specialty ,Acute coronary syndrome ,Coronary Vessel Anomalies ,Disease ,Fibromuscular dysplasia ,030204 cardiovascular system & hematology ,Coronary Angiography ,03 medical and health sciences ,0302 clinical medicine ,Carotid artery disease ,Internal medicine ,Humans ,Medicine ,Vascular Diseases ,030212 general & internal medicine ,Artery dissection ,Aged ,COPD ,business.industry ,Dissection ,Middle Aged ,Prognosis ,medicine.disease ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Scad ,Kidney disease - Abstract
There have been inconsistent reports regarding the clinical features and characteristics of patients diagnosed with spontaneous coronary artery dissection (SCAD). In addition, predictors of mortality in SCAD patients are unknown. We evaluated the prevalence, clinical characteristics, medical management, and predictors of in-hospital mortality of SCAD-related hospitalizations using data from a single health care system from January 1, 2008, to December 31, 2018. Among 30,425 patients who presented with an acute coronary syndrome, 375 (1.2%) patients were diagnosed with SCAD. Of these, the mean age was 52.2 ± 12.8 years, 64.3% were women, and 44% were white. SCAD was significantly associated with emotional stress, fibromuscular dysplasia (FMD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), and carotid artery disease compared with non-SCAD acute coronary syndrome (all p-values 0.05). Multivariable analysis showed that atrial fibrillation (OR 2.56; 95% CI 1.01-6.23; p = 0.04), steroid use (OR 7.11; 95% CI 1.31-31.2; p = 0.01), ventricular arrhythmias (OR 4.53; 95% CI 1.58-12.3; p = 0.003), and cardiac arrest (OR 16.82; 95% CI 5.14-56.5; p 0.001) were independent predictors of in-hospital mortality in SCAD patients. In conclusion, SCAD is an uncommon diagnosis that should be considered across all ages and both sexes and in patients with FMD, carotid artery disease, or PAD. Cardiac arrest, ventricular arrhythmia, steroid use, and atrial fibrillation were independently associated with in-hospital mortality in patients with SCAD.
- Published
- 2020
47. Improving the Design of Future PCI Trials for Stable Coronary Artery Disease
- Author
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Roxana Mehran, Guillaume Marquis-Gravel, Shaun G. Goodman, Yves Rosenberg, Darrel P. Francis, Bimmer E. Claessen, Peter Jüni, Faiez Zannad, Cynthia Chauhan, Donald E. Cutlip, Susan Quella, David J. Moliterno, and Robert J. Mentz
- Subjects
medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Psychological intervention ,Percutaneous coronary intervention ,State of the art review ,030204 cardiovascular system & hematology ,medicine.disease ,Placebo ,Revascularization ,law.invention ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Randomized controlled trial ,law ,Conventional PCI ,medicine ,030212 general & internal medicine ,Cardiology and Cardiovascular Medicine ,Intensive care medicine ,business - Abstract
The role of percutaneous coronary interventions in addition to medical therapy for patients with stable coronary artery disease continues to be debated in routine clinical practice, despite more than 2 decades of randomized controlled trials. The residual uncertainty arises from particular challenges facing revascularization trials. Which endpoint do doctors care about, and which do patients care about? Which participants should be enrolled? What background medical therapy should we use? When is placebo control relevant? In this paper, we discuss how these questions can be approached and examine the merits and disadvantages of possible options. Engaging multiple stakeholders, including patients, researchers, regulators, and funders, to ensure the design elements are methodologically valid and clinically meaningful should be an aspirational goal in the development of future trials.
- Published
- 2020
48. Sleep Duration and Cardiovascular Health in a Representative Community Population (from NHANES, 2005 to 2016)
- Author
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Anirudh Kumar, W.H. Wilson Tang, Hani Jneid, Zhen Wang, Usman Baber, Chayakrit Krittanawong, Roxana Mehran, and Deepak L. Bhatt
- Subjects
Male ,medicine.medical_specialty ,National Health and Nutrition Examination Survey ,Cross-sectional study ,Health Status ,Population ,030204 cardiovascular system & hematology ,Body Mass Index ,Coronary artery disease ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Diabetes mellitus ,Prevalence ,medicine ,Humans ,education ,Stroke ,Retrospective Studies ,education.field_of_study ,business.industry ,Middle Aged ,Nutrition Surveys ,medicine.disease ,United States ,Cross-Sectional Studies ,Blood pressure ,Cardiovascular Diseases ,Cardiology ,Female ,Sleep ,Cardiology and Cardiovascular Medicine ,business ,Body mass index ,030217 neurology & neurosurgery - Abstract
The 2016 American Heart Association Scientific Statement on sleep duration and cardiovascular risk suggested that optimal sleep duration is critical for cardiovascular health, with both long and short sleep duration associated with adverse health outcomes. We examined the relation between sleep duration and cardiovascular health among the general population in the United States from 2005 to 2016. We sought to investigate associations between sleep duration and the prevalence of coronary artery disease, heart failure (HF), stroke, hypertension, diabetes mellitus (DM), and hyperlipidemia. Using the National Health and Nutrition Examination Survey, we identified all patients with HF, coronary artery disease, hypertension, hyperlipidemia, DM, and stroke from 2005 to 2016. Multivariable logistic regression analyses were performed to adjust for age, sex, body mass index (BMI), marital status, educational level, physical activity, sedentary activity, depression, blood pressure, lipid profiles, and hemoglobin. In total, 32,152 National Health and Nutrition Examination Survey participants responded to the sleep survey. Both short sleepers (7 hours, n = 12,027) and long sleepers (9 hours, n = 1,058) were older and more likely to have a higher BMI than optimal sleepers (7 to 9 hours, n = 19,067; all p values0.05). After adjusting for confounding variables and in comparison to those with optimal sleep duration, short sleep duration was associated with a higher prevalence of previous stroke (odds ratio [OR] 1.45; 95% confidence intervals [CI] 1.23 to 1.70), HF (OR 1.65; 95% CI 1.40 to 1.95), DM (OR 1.35; 95% CI 1.23 to 1.49), and hyperlipidemia (OR 1.12; 95% CI 1.04 to 1.22), whereas long sleep duration was associated with a higher prevalence of previous stroke (OR 1.81; 95% CI 1.37 to 2.34) and HF (OR 1.47; 95% CI 1.08 to 1.97). In conclusion, both long and short sleep durations were associated with poor cardiovascular health in this cross-sectional study.
- Published
- 2020
49. Comparison of One-Year Outcomes in Patients >75 Versus ≤75 Years With Coronary Artery Disease Treated With COMBO Stents (From The MASCOT Registry)
- Author
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Petr Hájek, Roxana Mehran, Bryan P. Yan, Samantha Sartori, Zdeněk Coufal, Robert Gerber, Paula Tejedor, Borislav Atzev, Usman Baber, Deborah N. Kalkman, Martin Mates, Andrés Iñiguez, Tiong Kiam Ong, Muhammad Munawar, Robbert J. de Winter, George Dangas, Hazem M. Warda, Petr Kala, Martin Hudec, Houng Bang Liew, Antonio Colombo, Melissa Aquino, Michael S. Lee, Peter den Heijer, Jaya Chandrasekhar, Borislav Borisov, Jarosław Wójcik, Ahmed Khashaba, Alexandr Schee, Mascot investigators, Cardiology, ACS - Heart failure & arrhythmias, and ACS - Atherosclerosis & ischemic syndromes
- Subjects
Male ,Target lesion ,medicine.medical_specialty ,Polymers ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Global Health ,Prosthesis Design ,Coronary artery disease ,03 medical and health sciences ,Percutaneous Coronary Intervention ,Postoperative Complications ,0302 clinical medicine ,Internal medicine ,Absorbable Implants ,Clinical endpoint ,Humans ,Medicine ,Prospective Studies ,Registries ,030212 general & internal medicine ,Myocardial infarction ,Aged ,Aged, 80 and over ,business.industry ,Proportional hazards model ,Incidence ,Hazard ratio ,Stent ,Drug-Eluting Stents ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Cohort study - Abstract
Older patients who undergo coronary interventions are at greater risk of ischemic events and less likely to tolerate prolonged dual antiplatelet therapy (DAPT) due to bleeding risk. The COMBO biodegradable polymer sirolimus-eluting stent promotes rapid endothelialization through endothelial progenitor cell capture technology which may be advantageous in elderly patients. We compared 1-year clinical outcomes and DAPT cessation events in patients >75 versus ≤75 years from the MASCOT registry. MASCOT was a prospective, multicenter cohort study of all-comers undergoing attempted COMBO stenting. The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, myocardial infarction (MI) not clearly attributed to a nontarget vessel or clinically driven target lesion revascularization. Bleeding was adjudicated using the Bleeding Academic Research Consortium criteria. Adjusted outcomes were analyzed using Cox regression methods. The study included 18% (n = 479) patients >75 years and 72% (n = 2,135) patients ≤75 years. One-year TLF occurred in 4.6% patients >75 years versus 3.1% patients ≤75years of age, p = 0.10; adj hazard ratio 1.36, 95% confidence intervals 0.77 to 2.38, p = 0.29. There were no significant differences in cardiac death (1.7% vs 1.3%, p = 0.55), MI (2.1% vs 1.2%, p = 0.14), target lesion revascularization (1.7% vs 1.4%, p = 0.60) and definite stent thrombosis (0.8% vs 0.4%, p = 0.19). Major Bleeding Academic Research Consortium 3,5 bleeding (3.1% vs 1.5%, p = 0.01) and DAPT cessation rates (32.4% vs 23.0%, p 75 years treated with COMBO stents had similar TLF but significantly greater incidence of bleeding than younger patients and DAPT cessation in one-third of patients over 1 year.
- Published
- 2020
50. Implications of Kidney Disease in the Cardiac Patient
- Author
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Roxana Mehran, Bimmer E. Claessen, and Johny Nicolas
- Subjects
Male ,medicine.medical_specialty ,Population ,Contrast Media ,Tetrazoles ,030204 cardiovascular system & hematology ,Coronary artery disease ,Angiotensin Receptor Antagonists ,03 medical and health sciences ,Percutaneous Coronary Intervention ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Prevalence ,medicine ,Humans ,030212 general & internal medicine ,Renal Insufficiency, Chronic ,education ,Sodium-Glucose Transporter 2 Inhibitors ,Aged ,education.field_of_study ,Kidney ,business.industry ,Aminobutyrates ,Biphenyl Compounds ,Prognosis ,medicine.disease ,Pathophysiology ,Drug Combinations ,medicine.anatomical_structure ,Cardiovascular Diseases ,Heart failure ,Cardiology ,Valsartan ,Female ,Presentation (obstetrics) ,Cardiology and Cardiovascular Medicine ,Disease manifestation ,business ,Factor Xa Inhibitors ,Kidney disease - Abstract
Cardiovascular and renal diseases share common pathophysiological grounds, risk factors, and therapies. The 2 entities are closely interlinked and often coexist. The prevalence of kidney disease among cardiac patients is increasing. Patients have an atypical clinical presentation and variable disease manifestation versus the general population. Renal impairment limits therapeutic options and worsens prognosis. Meticulous treatment and close monitoring are required to ensure safety and avoid deterioration of kidney and heart functions. This review highlights recent advances in the diagnosis and treatment of cardiac pathologies, including coronary artery disease, arrhythmia, and heart failure, in patients with decreased renal function.
- Published
- 2020
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