scholarly journals Reflections after TWILIGHT study: a new era in secondary prevention without aspirin?

2021 ◽  
Vol 23 (Supplement_E) ◽  
pp. E45-E50
Author(s):  
Giovanni Occhipinti ◽  
Davide Capodanno
Keyword(s):  
Secondary Prevention ◽  
Enzyme Inhibitor ◽  
Imaging Techniques ◽  
Beta Blockers ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Optimization Strategy ◽  
St Segment Elevation ◽  
Early Withdrawal ◽  
High Bleeding Risk

Abstract Dual antiplatelet therapy (DAPT) is mandatory in patients undergoing percutaneous coronary interventions (PCIs), but carries an increased bleeding risk which must be weighed over the expected antithrombotic benefit. In recent years, DAPT optimization strategy has been enriched by the concept of early withdrawal of aspirin (‘aspirin-free’ strategy). This strategy is supported by the modern advancements in pharmacological and procedural fields (i.e. the availability of P2Y12 receptor inhibitors with a concomitant ‘aspirin-like’ effect), the advocated use of pharmacological non-antiplatelet secondary prevention strategies (i.e. angiotensin-converting enzyme inhibitor, statins, beta-blockers), the use of modern stents and the increasingly widespread use of intra-coronary imaging techniques. In the last few years, five clinical trials (GLOBAL LEADERS, TWILIGHT, STOP-DAPT2, SMART CHOICE, TICO) and their own meta-analysis have been followed, aiming to evaluate the efficacy and safety of different ‘aspirin-free’ strategies. They showed that aspirin withdrawal (1–3 months after PCI), determines a consistent reduction of bleeding risk, without compromising efficacy endpoints. It resulted in a class IIa indication in the 2020 European Society of Cardiology Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation, which suggested the early withdrawal of aspirin in patients undergoing PCI and considered to be at low ischaemic and low bleeding risk, or at high bleeding risk.

scholarly journals Optical Coherence Tomography Facilitating Early Withdrawal of Antiplatelet Agents in a High–Bleeding Risk Patient

2020 ◽  
Vol 2 (8) ◽  
pp. 1186-1191
Author(s):  
Ioannis Gkirdis ◽  
Dimitrios N. Nikas ◽  
Theodora Bampali ◽  
Theofilos M. Kolettis
Keyword(s):  
Optical Coherence Tomography ◽  
Antiplatelet Agents ◽  
Bleeding Risk ◽  
Risk Patient ◽  
Optical Coherence ◽  
Early Withdrawal ◽  
High Bleeding Risk

scholarly journals Bleeding and ischaemic outcomes in patients treated with dual or triple antithrombotic therapy: systematic review and meta-analysis

2019 ◽  
Vol 5 (4) ◽  
pp. 226-236 ◽  
Author(s):  
Paul M Haller ◽  
Patrick Sulzgruber ◽  
Christoph Kaufmann ◽  
Bastiaan Geelhoed ◽  
Juan Tamargo ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Stent Thrombosis ◽  
Antithrombotic Therapy ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Power Calculation ◽  
Coronary Syndrome ◽  
High Bleeding Risk ◽  
Triple Antithrombotic Therapy

Abstract Aims The combination of oral anticoagulation with a P2Y12 inhibitor and aspirin in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is associated with a high bleeding risk. Dual antithrombotic therapy (DAT) with omission of aspirin is a promising option to reduce bleedings, but carries a yet unknown risk of ischaemic events. We therefore sought to systematically review and analyse randomized controlled trials investigating DAT vs. triple antithrombotic therapy (TAT) in patients with AF following PCI and/or acute coronary syndrome (ACS). Methods and results We included four trials with overall 9317 patients (5039 DAT, 4278 TAT) in our analysis. Dual antithrombotic therapy was associated with a significant reduction in thrombolysis in myocardial infarction major bleeding [hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.42–0.65; P = 0.0001], while the composite trial-defined ischaemic endpoint did not differ significantly between DAT and TAT (HR 0.98, 95% CI 0.79–1.22; P = 0.88). There was also no difference regarding the occurrence of myocardial infarction (MI; HR 1.16, 95% CI 0.92–1.46; P = 0.21) or stent thrombosis (HR 1.25, 95% CI 0.69–2.26; P = 0.46). Absolute numbers for MI were 131/4278 (3.1%) with TAT and 182/5039 (3.6%) with DAT, and for stent thrombosis 32/4278 (0.75%) and 52/5039 (1%), respectively. A post hoc power calculation based on the size and event rate of this meta-analysis revealed 80% power to detect a 37% and 100% increase in MI and stent thrombosis, respectively. Conclusion Dual antithrombotic therapy significantly reduces bleedings compared with TAT and seems to have a similar effect in preventing ischaemic endpoints in AF patients post-PCI or ACS. Future investigations are needed to determine its applicability specifically in patients at high risk of ischaemic outcomes.

Comparative efficacy and safety of anticoagulant strategies for acute coronary syndromes

2015 ◽  
Vol 114 (11) ◽  
pp. 933-944 ◽  
Author(s):  
Felicita Andreotti ◽  
Michalina Kołodziejczak ◽  
Volker Schulze ◽  
Georg Wolff ◽  
Sofia Dias ◽  
...  
Keyword(s):  
Acute Coronary Syndromes ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Minor Bleeding ◽  
Efficacy And Safety ◽  
Comparative Efficacy ◽  
St Segment Elevation ◽  
St Segment ◽  
Coronary Syndromes ◽  
Randomised Controlled

SummaryInternational guidelines differ in strengths of recommendation for anticoagulation strategies in acute coronary syndromes (ACS). We performed a comprehensive network meta-analysis (NMA) of randomised controlled trials (RCTs) to investigate the comparative efficacy and safety of parenteral anticoagulants in ACS. MEDLINE, Cochrane, EM-BASE, Google Scholar, major cardiology websites, and abstracts/presentations were searched. Six treatments were identified: 1) unfractionated heparin (UFH) + glycoprotein IIb/IIIa inhibitor (GPI) [UFH+GPI], 2) UFH±GPI, 3) bivalirudin, 4) low-molecular-weight heparins (LMWHs), 5) otamixaban, and 6) fondaparinux. Prespecified outcomes (death, myocardial infarction [MI], revascularisation, major bleeding [MB], minor bleeding, and stent thrombosis [ST]) were evaluated up to 30 days. Forty-two RCTs involving 117,353 patients were included. No significant differences in mortality rates were found among strategies. Compared to UFH+GPI, bivalirudin reduced the odds of MB but increased the odds of ST and MI. LMWHs vs bivalirudin reduced MI risk at the price of MB excess. UFH±GPI significantly increased the odds of MI vs LMWHs, of ST vs UFH+GPI, and of MB vs bivalirudin. Reduced ST risk with otamixaban vs UFH±GPI and vs bivalirudin was offset by a marked 2.5- to four-fold MB excess. Fondaparinux showed an intermediate profile. Results for ST-segment elevation MI were consistent with the overall findings. Early anticoagulant strategies for ACS differ in efficacy and safety, with UFH+GPI and LMWHs reducing ischaemic but increasing bleeding risk, and bivalirudin reducing MB but increases MI and ST. The findings support individualised therapy based on patients´ bleeding and ischaemic risks.

scholarly journals Tenecteplase in Pulmonary Embolism Patients: A Meta-Analysis and Systematic Review

2021 ◽  
Author(s):  
Zhu Zhang ◽  
Linfeng Xi ◽  
Shuai Zhang ◽  
Yunxia Zhang ◽  
Guohui Fan ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Meta Analysis ◽  
Random Effect ◽  
Random Effect Model ◽  
Bleeding Risk ◽  
Effect Model ◽  
High Bleeding Risk

Abstract OBJECTIVE: To assess the efficacy and safety of tenecteplase in patients with pulmonary embolism (PE). METHODS: We completed the literature search on May 31, 2021 using PubMed, EMBASE and the Web of Science. Analyses were conducted according to PE risk stratification, study design and duration of follow-up. The pooled risk ratios (RRs) and its 95% confident intervals (CIs) for death and major bleeding were calculated using a random-effect model.RESULTS: A total of six studies, with four randomized controlled trials (RCTs) and two cohort studies, were included in this study out of the 160 studies retrieved. For patients with high-risk PE, tenecteplase increased 30-day survival rate (16% vs 6%; P=0.005) and did not increase the incidence of bleeding (6% vs 5%; P=0.73). For patients with intermediate-risk PE, four RCTs suggested that tenecteplase reduced right ventricular insufficiency at 24h early in the onset and the incidence of hemodynamic failure without affecting mortality in a short/long-term [<30 days RR=0.83, 95% CI (0.47, 1.46);≥30 days RR=1.04, 95% CI (0.88, 1.22)]. However, tenecteplase was associated with high bleeding risk [<30 days RR=1.79, 95% CI (1.61, 2.00); ≥30 days RR=1.28, 95% CI (0.62, 2.64)].CONCLUSIONS: Tenecteplase may represent a promising candidate for patients with intermediate/high risk PE. Furthermore, tenecteplase may be preferable in the COVID-19 pandemic due to its all-at-once administration.

Cardioprotection in patients with cancer undergoing chemotherapy: A network meta-analysis.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e12008-e12008
Author(s):  
Pragnan Kancharla ◽  
Alexander Ivanov
Keyword(s):  
Randomized Clinical Trials ◽  
Enzyme Inhibitor ◽  
Left Ventricular Systolic Dysfunction ◽  
Beta Blockers ◽  
Meta Analysis ◽  
Systolic Dysfunction ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Patients With Cancer

e12008 Background: Introduction of anthracycline or trastuzumab based regimen for various types of cancer during the past two decades led to substantial improvement in life expectancy, yet resulting in increased prevalence of unintended side effects. Left ventricular systolic dysfunction is a known complication of the currently employed chemotherapy regimens with anthracycline or trastuzumab which not only affects patient’s cardiac outcome but also limits their therapeutic opportunities, especially continuation or reintroduction of chemotherapy treatment. We aimed to perform comprehensive network meta analysis to synthesize data from randomized clinical trials (RCT) comparing all modern regimens to prevent cardiotoxicity in such patients. Methods: We performed a comprehensive search of pubmed, embase, google scholar and TRIP database for all RCT comparing cardioprotective effects of medication in patients with various types of cancer on chemotherapy with either an anthracycline or trastuzumab based regimen from 1997 to 2019. Left ventricular ejection fraction (LVEF) was measured by transthoracic echocardiogram or cardiac magnetic resonance imaging. Patients treated with either Angiotensin Converting Enzyme-Inhibitor(ACE) or Angiotensin receptor blocker(ARB) were combined into one group. Primary outcome was change in LVEF between start and end of the chemotherapy. Network meta-analyses were conducted using consistency and inconsistency models. Results: A total of 16 studies with 1459 patients were included in the analysis where either an Anthracycline or Trastuzumab based chemotherapy regimen was administered. 369 patients received beta blockers(BB), 351 received either an ACE or ARB, 61 received a combination of BB and either an ACE or ARB, 20 received a statin and 657 were given a placebo. The primary cancer was breast cancer in 8 studies, one each of lymphoma, blood cancers and remaining 6 being mixed. Mean age was 48.81 years. Compared to patients on placebo there was a significant cardioprotective effect (smaller reduction in LVEF) noted with ACE/ARB (beta coef 5.2 (1.5-8.9), p<0.01), BB(beta coef 4.62 (0.8-7.8), p<0.02), and spironolactone beta coef 12.9 (1.9-23.4), p<0.03) There was an evidence of inconsistency with all p>0.3, other than in spironolactone arm as there were suggestion of inconsistency with p<0.01 likely due to the presence of single study. Conclusions: BB and ACE/ARB are associated with reduction in cardiotoxicity in patients with cancer undergoing cancer chemotherapy with an anthracycline or trastuzumab based regimen.

Sign in / Sign up

Export Citation Format

Share Document