Apixaban and risk of myocardial infarction: meta-analysis of randomized controlled trials

The coagulation system contributes greatly to the evolution of myocardial infarction (MI). Anticoagulation may reduce the occurrence of MI as monotherapy or with con- comitant use of aspirin. Activated factor X antagonists (anti- Xa) and direct thrombin inhibitors have promising results in various indications in non-inferiority trials. However, results regarding their cardiovascular safety are heterogeneous. We systematically evaluated the risk of MI and mortality in patients receiving the new-generation oral anti-Xa agent apixaban. Electronic databases were searched to find pro- spective, randomized, controlled clinical trials (RCT) that evaluated the clinical impact of apixaban. Efficacy measures included frequency of MI, cardiovascular and overall mor- tality. Outcome parameters of RCTs were pooled with a ran- dom-effects model. Between January 2000 and December 2013, 12 RCTs comprising 54,054 patients were identified. Based on the pooled results, there was no increase in the risk of MI in patients treated with apixaban [odds ratio (OR) 0.90;95 % confidence interval (CI) 0.77–1.05; p = 0.17] com- pared to different controls. Cardiovascular and overall mor- tality with apixaban was comparable to the control groups (OR 0.88; 95 % CI 0.72–1.06; p = 0.18, OR 0.89; 95 % CI 0.77–1.03; p = 0.11, respectively). The pooled risk of major bleeding was lower in the apixaban treated groups (OR 0.84; 95 % CI 0.62–1.12; p = 0.23) however this reached signifi- cant level only in subgroup analysis of trials with anticoagu- lant regimes in the control (OR 0.66; 95 % CI 0.51–0.87; p = 0.003). In a broad spectrum of patients and compared to different controls apixaban treatment was not associated with an increase in MI or mortality

Cardiovascular outcomes in patients treated with sodium-glucose transport protein 2 inhibitors, a network meta-analysis of randomized trials

BackgroundGliflozins altering the sodium-glucose transport protein 2 (SGLT2) in the nephron, represent alone or in combination a promising treatment option for patients with type II diabetes mellitus. In addition to glucose control, these drugs provide benefits including reduced risk of long-term cardiovascular (CV) and renal complications. Several trials evaluated gliflozins in patients with various degrees of cardiac dysfunction with heterogeneous results.ObjectivesWe aimed to perform a comprehensive analysis of the effect of gliflozins on CV outcomes.MethodsSystematic searches of electronic databases were conducted until September 2022. Multiple treatment network meta-analysis was performed in R. Random-effects model was used to combine risk estimates across trials calculating risk ratio (RR) with 95% confidence intervals as summary statistics. The primary endpoint of interest was the rate of heart failure-related hospitalization (HHF) and the composite of HHF with CV mortality (HHF + CVD). Secondary outcomes included major adverse cardiac events (MACE), CV- and overall mortality, myocardial infarction (MI), and stroke.ResultsTwenty-nine studies randomizing 88,418 patients were identified. Gliflozins reduced the risk of HHF (RR: 0.72 [0.69; 0.76]) and HHF + CVD (RR: 0.78 [0.75; 0.82]). The risk of MACE and its component also improved significantly except for stroke. The network analyses did not explore major differences among the individual substances. The only exception was sotagliflozin which appeared to be more effective regarding HHF + CVD, stroke, and MI compared to ertugliflozin, in HHF + CVD and stroke compared to dapagliflozin, and in stroke endpoint compared to empagliflozin.ConclusionOur meta-analysis supports a group effect of gliflozins beneficial in a wide spectrum of patients with a risk of heart failure (HF) development. In addition to the improvement of HF-related outcomes, the risk of major adverse events is also reduced with SGLT2 inhibition.Systematic review registration[www.ClinicalTrials.gov], identifier [CRD42022358078]

Clinical outcomes in patients treated for coronary in-stent restenosis with drug-eluting balloons: Impact of high platelet reactivity.

BACKGROUND: The impact of high platelet reactivity (HPR) on clinical outcomes after elective percutaneous coronary interventions (PCI) with drug-eluting balloons (DEB) due to in-stent restenosis (ISR) is unknown. OBJECTIVE: We sought to evaluate the prognostic importance of HPR together with conventional risk factors in patients treated with DEB. METHODS: Patients treated with DEB due to ISR were enrolled in a single-centre, prospective registry between October 2009 and March 2015. Only patients with recent myocardial infarction (MI) received prasugrel, others were treated with clopidogrel. HPR was defined as an ADP-test >46U with the Multiplate assay and no adjustments were done based on results. The primary endpoint of the study was a composite of cardiovascular mortality, MI, any revascularization or stroke during one-year follow-up. RESULTS: 194 stable angina patients were recruited of whom 90% were treated with clopidogrel. Clinical characteristics and procedural data were available for all patients; while platelet function testing was performed in 152 subjects of whom 32 (21%) had HPR. Patients with HPR had a higher risk for the primary endpoint (HR: 2.45; CI: 1.01-5.92; p = 0.03). The difference was primarily driven by a higher risk for revascularization and MI. According to the multivariate analysis, HPR remained a significant, independent predictor of the primary endpoint (HR: 2.88; CI: 1.02-8.14; p = 0.04), while total DEB length and statin treatment were other independent correlates of the primary outcome. CONCLUSION: HPR was found to be an independent predictor of repeat revascularization and MI among elective patients with ISR undergoing PCI with DEB

Adherencia és perzisztencia jelentősége az orális antikoaguláns kezelés során

A megfelelő antikoaguláns terápia nélkülözhetetlen a pitvarfibrillációban szenvedő betegek stroke-prevenciója szempontjából. A direkt hatású orális antikoagulánsok bizonyított és jelentős előnyei miatt fokozatosan felváltották a K-vitamin-antagonisták alkalmazását. A gyógyszerek randomizált klinikai vizsgálatokban kimutatott hatékonysága mellett, a klinikai gyakorlatban a terápia hatásosságának meghatározó faktora a kezeléshez tartozó perzisztencia és adherencia. Irodalmi áttekintésünk során az antikoaguláns kezelések ismertetése mellett, az adherenciát befolyásoló faktorokat azonosítottuk, továbbá azokat figyelembe vevő stratégiákat kerestünk. Összefoglaló ismertetésünk alapján az optimális antikoaguláns terápia kiválasztásakor a hosszú távon is eredményes stroke-prevenció érdekében, célszerű a kezelés tolerálhatóságának mérlegelése, továbbá a beteg igényeit szem előtt tartó személyre szabott terápia megválasztása

A pitvarfibrilláció diagnosztikájának, antikoaguláns-kezelésének és a betegadherencia fenntartásának modern gyakorlata

A pitvarfibrilláció (PF) a leggyakoribb tartós szívritmuszavar, azonban az esetek egyharmadában a beteg tünetmentes marad. A nem diagnosztizált és alulkezelt pitvarfibrilláció hozzájárul az ischaemiás stroke kialakulásához, ezért a PF szûrése magában hordozza a korai ritmuskezelés, a stroke és a halálozás megelôzésének lehetôségét. Ennek kapcsán az utóbbi évtizedben jelentôs elôrelépések tanúi voltunk a mindennapi használatban lévô digitális eszközök fejlôdése terén. Ezek új lehetôségeket nyújthatnak a szívritmuszavar idôben történô felismerésében. A korai diagnosztikát és az ideális gyógyszeres kezelés beállítását követôen a megfelelô terápia elengedhetetlen része a betegadherencia fenntartása. A páciens bevonása a döntési folyamatba és az antikoaguláció lehetôségeinek vele való megbeszélése („közös döntéshozatal”) kulcsfontosságú a beteg szükségleteinek megfelelô felméréséhez és az adherencia növeléséhez. Cikkünk célja, hogy naprakész gyakorlati útmutatást nyújtson a digitális eszközök szívritmuszavar esetén történô megfelelô alkalmazásához, valamint összefoglaló áttekintést adjon a mindennapi gyakorlatban használt antikoagulánsokkal kapcsolatos adherencia növelésének kihívásairól

Results of the platelet function test, frequency of high platelet reactivity and its relation to clinical endpoints.

<p><b>A:</b> A scatter plot of platelet reactivity with the Multiplate device in all patients. Values are presented as median {25% percentile, 75% percentile}, ADP reactivity presents as U. <b>B:</b> Percent of the platelet function tested cases with percent of HPR and no HPR patients in the total cohort based on the platelet reactivity values. <b>C:</b> Impact of platelet reactivity on MACE. <b>D:</b> Impact of platelet reactivity on MI. Values are presented as HR [95% CI]. *: asterisk marks hazard ratios from multivariate Cox regression analyses. ADP = adenosine diphosphate; AUC = area under the curve; HPR = high platelet reactivity; MACE = major adverse cardiovascular event; MI = myocardial infarction; HR = hazard ratio; CI = confidence interval.</p

Baseline characteristics of the patient population.

<p>Baseline characteristics of the patient population.</p

Antithrombotic Therapy for Secondary Prevention in Patients with Non-Cardioembolic Stroke or Transient Ischemic Attack: A Systematic Review

Stroke embodies one of the leading causes of death and disability worldwide. We aimed to provide a comprehensive insight into the effectiveness and safety of antiplatelet agents and anticoagulants in the secondary prevention of ischemic stroke or transient ischemic attack. A systematic search for randomized controlled trials, comparing antiplatelet or anticoagulant therapy versus aspirin or placebo among patients with ischemic stroke or transient ischemic attack, was performed in order to summarize data regarding the different regimens. Keyword-based searches in the MEDLINE, EMBASE, and Cochrane Library databases were conducted until the 1st of January 2021. Our search explored 46 randomized controlled trials involving ten antiplatelet agents, six combinations with aspirin, and four anticoagulant therapies. The review of the literature reflects that antiplatelet therapy improves outcome in patients with ischemic stroke or transient ischemic attack. Monotherapy proved to be an effective and safe choice, especially in patients with a high risk of bleeding. Intensified antiplatelet regimens further improve stroke recurrence; however, bleeding rate increases while mortality remains unaffected. Supplementing the clinical judgment of stroke treatment, assessment of bleeding risk is warranted to identify patients with the highest benefit of treatment intensification

Event free survival of the patients based on the platelet reactivity during the follow up period.

<p><b>A:</b> Event free survival of the patients with and without HPR based on the consensus cut-off value. <b>B, C:</b> Event free survival of the patients based on the ROC curve analysis identified two potential cut-off values. Event rates at one year are shown for each group as Kaplan-Meier estimates. HPR = high platelet reactivity; ADP = adenosine diphosphate.</p

Clinical and procedural predictors of MACE at one year.

<p>Clinical and procedural predictors of MACE at one year.</p