Residual risk reduction opportunities in patients with chronic coronary syndrome. Role of dual pathway inhibition

AbstractThere have been numerous and intriguing advancements in antithrombotic therapy for myocardial infarction since it was described in the earliest issues of Thrombosis and Haemostasis. In this article, we revisit historical breakthroughs and describe the four most challenging contemporary themes relating to antithrombotic therapy in myocardial infarction. In all four, the challenge is to find the best balance of reducing specific levels of ischaemic risks without increasing bleeding risk. The first is the question of the optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). This includes discussion of monotherapy after a period of DAPT. The second relates to the role of genotype and phenotype-guided individualisation of antiplatelet therapy. There is emerging evidence for a role of pheno/genotyping in identifying individuals at high risk for recurrent ischaemic events or in guiding the timing of cardiac surgery for patients on DAPT. The third addresses the increasing evidence for dual pathway inhibition, for example, with rivaroxaban in addition to aspirin in patients where high ischaemic and low bleeding risk is demonstrated. Finally the fourth highlights the challenge of the most appropriate combination of antiplatelet and anticoagulation therapy for patients with known atrial fibrillation after PCI. In most individuals, oral P2Y12 inhibitor therapy combined with a direct acting oral anticoagulant appears to be the best strategy based on the available evidence. Overall, the progress in antithrombotic therapy achieved over the last seven decades is remarkable, however, there are important issues to address and progress still to be made.

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Unexplained arterial thrombosis: approach to diagnosis and treatment

Hematology ◽

10.1182/hematology.2021000235 ◽

2021 ◽

Vol 2021 (1) ◽

pp. 76-84

Author(s):

Jori E. May ◽

Stephan Moll

Keyword(s):

Bleeding Risk ◽

Management Plan ◽

Left Ventricular ◽

The Past ◽

Common Causes ◽

Dual Pathway ◽

Diagnostic Framework ◽

Pathway Inhibition ◽

Structured Approach

Abstract Arterial thrombotic events in younger patients without a readily apparent etiology present significant diagnostic and management challenges. We present a structured approach to diagnosis with consideration of common causes, including atherosclerosis and embolism, as well as uncommon causes, including medications and substances, vascular and anatomic abnormalities, systemic disorders, and thrombophilias. We highlight areas of management that have evolved within the past 5 years, including the use of dual-pathway inhibition in atherosclerotic disease, antithrombotic therapy selection in embolic stroke of undetermined source and left ventricular thrombus, the role of closure of patent foramen ovale for secondary stroke prevention, and the thrombotic potential of coronavirus disease 2019 infection and vaccination. We conclude with a representative case to illustrate the application of the diagnostic framework and discuss the importance of consideration of bleeding risk and patient preference in determining the appropriate management plan.

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Dual Pathway Inhibition for Vascular Protection in Patients with Atherosclerotic Disease: Rationale and Review of the Evidence

Thrombosis and Haemostasis ◽

10.1055/s-0040-1713376 ◽

2020 ◽

Vol 120 (08) ◽

pp. 1147-1158 ◽

Cited By ~ 4

Author(s):

Jeffrey Ian Weitz ◽

Dominick J. Angiolillo ◽

Tobias Geisler ◽

Stefan Heitmeier

Keyword(s):

Secondary Prevention ◽

Antiplatelet Therapy ◽

Standard Of Care ◽

Atherosclerotic Disease ◽

Vascular Protection ◽

Coronary Syndrome ◽

Plaque Disruption ◽

Dual Pathway ◽

Artery Disease ◽

Pathway Inhibition

AbstractDespite advances in secondary prevention strategies in patients with cardiovascular disease, the residual risk of recurrent atherothrombotic events remains high. Dual-antiplatelet therapy is the standard of care for secondary prevention in patients with acute coronary syndrome (ACS), whereas single antiplatelet therapy, generally with aspirin, is the standard of care for secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. However, atherosclerotic plaque disruption not only triggers platelet activation but also results in thrombin generation because of tissue factor exposure. Therefore, blocking both pathways by combining antiplatelet therapy with an anticoagulant, or dual pathway inhibition (DPI), has the potential to be more effective than inhibiting either pathway alone. The benefit of DPI has been demonstrated in the ATLAS ACS 2-TIMI 51, COMPASS, and VOYAGER PAD trials, where the combination of rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin significantly reduced the risk of atherothrombotic events compared with aspirin across a broad range of patients, including those with recent ACS, those with chronic CAD and/or PAD, and patients with PAD who have undergone peripheral revascularization. This article provides the rationale for this regimen in more detail, including why the DPI regimen with the rivaroxaban vascular dose was developed for vascular protection in a broad spectrum of patients with atherosclerotic disease.

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Risk for recurrent cardiovascular events and expected risk reduction with optimal treatment one year after an acute coronary syndrome

European Heart Journal ◽

10.1093/ehjci/ehaa946.2969 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

S Zafeiropoulos ◽

I.T Farmakis ◽

A Kartas ◽

A Arvanitaki ◽

A Pagiantza ◽

...

Keyword(s):

Risk Factors ◽

Acute Coronary Syndrome ◽

Risk Reduction ◽

Risk Score ◽

Residual Risk ◽

Stable Phase ◽

Modifiable Risk Factors ◽

Clinical Issue ◽

Coronary Syndrome ◽

One Year

Abstract Background According to the latest ESC Guidelines for chronic coronary syndromes (CCS), patients who suffered an acute coronary syndrome (ACS) pass to a chronic stable phase after one year. In these patients the estimated 10-year risk for recurrent cardiovascular (CV) events varies considerably. We estimated this risk and the expected risk reduction after optimal control. Methods We applied the SMART risk score in 211 patients one year after an ACS to estimate the 10-year risk for recurrent CV events (subsequent non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death). We assessed the distribution of the estimated risk and the potential risk reduction that might be achieved with an optimal guideline-directed management of modifiable risk factors (systolic blood pressure, low-density lipoprotein cholesterol, smoking and body mass index). Results In our cohort, the median SMART score was 16% [interquartile range (IQR), 9.5–26]. If all modifiable risk factors met guideline-recommended targets, median SMART risk score would be 9.4% (IQR, 5.9–17.1), with 52% of the patients at a 10-year risk <10%, while 10% and 11% at 20–30% and >30% risk respectively. The total median reducible risk was 4.7% (IQR, 1.7–8.8). Conclusions The SMART score had a wide distribution among patients with CCS. Noteworthy, one out of five patients will remain at a >20% 10-year risk, even with optimal risk factors management, clearly underlining that residual risk is an unmet clinical issue, which demands individualized patient care. Baseline and total residual risk score Funding Acknowledgement Type of funding source: None

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Role of hsCRP as an indicator of prognosis in acute coronary syndrome

Medpusle International Journal of Medicine ◽

10.26611/102110211 ◽

2019 ◽

Vol 10 (2) ◽

pp. 97-100

Author(s):

Ashok Thaned ◽

◽

Triveni Ayyanna ◽

Sunil K ◽

◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Syndrome

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A review of public acceptance of nature-based solutions: The ‘why’, ‘when’, and ‘how’ of success for disaster risk reduction measures

AMBIO ◽

10.1007/s13280-021-01502-4 ◽

2021 ◽

Cited By ~ 1

Author(s):

Carl C. Anderson ◽

Fabrice G. Renaud

Keyword(s):

Ecosystem Services ◽

Risk Perception ◽

Risk Reduction ◽

Disaster Risk Reduction ◽

Disaster Risk ◽

Public Acceptance ◽

Societal Challenges ◽

Increasing Trend ◽

Risk Reduction Measures

AbstractNature-based solutions (NbS) are increasingly recognized as sustainable approaches to address societal challenges. Disaster risk reduction (DRR) has benefited by moving away from purely ‘grey’ infrastructure measures towards NbS. However, this shift also furthers an increasing trend of reliance on public acceptance to plan, implement and manage DRR measures. In this review, we examine how unique NbS characteristics relate to public acceptance through a comparison with grey measures, and we identify influential acceptance factors related to individuals, society, and DRR measures. Based on the review, we introduce the PA-NbS model that highlights the role of risk perception, trust, competing societal interests, and ecosystem services. Efforts to increase acceptance should focus on providing and promoting awareness of benefits combined with effective communication and collaboration. Further research is required to understand interconnections among identified factors and how they can be leveraged for the success and further uptake of NbS.

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Metabolic Surgery and Cancer Risk: An Opportunity for Mechanistic Research

Cancers ◽

10.3390/cancers13133183 ◽

2021 ◽

Vol 13 (13) ◽

pp. 3183

Author(s):

Edward R. Sauter ◽

Brandy Heckman-Stoddard

Keyword(s):

Weight Loss ◽

Cancer Risk ◽

Risk Reduction ◽

Dramatic Improvement ◽

Role Of Government ◽

Sustained Weight Loss ◽

Historical Role ◽

Cancer Risk Reduction

Metabolic (bariatric) surgery (MBS) is recommended for individuals with a BMI > 40 kg/m2 or those with a BMI 35–40 kg/m2 who have one or more obesity related comorbidities. MBS leads to greater initial and sustained weight loss than nonsurgical weight loss approaches. MBS provides dramatic improvement in metabolic function, associated with a reduction in type 2 diabetes mellitus and cardiovascular risk. While the number of MBS procedures performed in the U.S. and worldwide continues to increase, they are still only performed on one percent of the affected population. MBS also appears to reduce the risk of certain obesity related cancers, although which cancers are favorably impacted vary by study, who benefits most is uncertain, and the mechanism(s) driving this risk reduction are mostly speculative. The goal of this manuscript is to highlight 1) emerging evidence that MBS influences cancer risk, and that the potential benefit appears to vary based on cancer, gender, surgical procedure, and likely other variables; 2) the role of the NIH in MBS research in T2DM and CV risk for many years, and more recently in cancer; and 3) the opportunity for research to understand the mechanism(s) by which MBS influences cancer. There is evidence that women benefit more from MBS than men, that MBS may actually increase the risk of colorectal cancer in both women and men, and there is speculation that the benefit in cancer risk reduction may vary according to which MBS procedure an individual undergoes. Herein, we review what is currently known, the historical role of government, especially the National Institutes of Health (NIH), in driving this research, and provide suggestions that we believe could lead to a better understanding of whether and how MBS impacts cancer risk, which cancers are impacted either favorably or unfavorably, the role of the NIH and other research agencies, and key questions to address that will help us to move the science forward.

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