Efficacy and Safety of Low-Molecular-Weight Heparins As An Adjunct to Thrombolysis in Acute ST-Elevation Myocardial Infarction

A 48-hour course of intravenous unfractionated heparin (UFH) is the standard of treatment in conjunction with fibrin-specific thrombolysis in ST-elevation myocardial infarction (STEMI). In recent trials, the efficacy and safety of in-hospital administration of subcutaneous low-molecular-weight heparins (LMWH), previously proven effective in non-ST-elevation acute coronary syndromes, have been investigated in the setting of STEMI. The aim of this review was to evaluate the available evidence supporting the use of LMWH in STEMI

Utilizing enoxaparin in the management of STEMI

The use of enoxaparin in conjunction with thrombolysis in ST-elevation acute myocardial infarction (STEMI), has been recently investigated in several clinical trials. In 8 published open-label studies including about 10,000 patients, in which enoxaparin was compared to either placebo or unfractionated heparin (UFH), a general superiority of enoxaparin on both reinfarction/recurrent angina and patency of the infarct-related artery, was observed. Overall, bleeding rate with enoxaparin was higher than with placebo and comparable to UFH, with the exception of one study where pre-hospital administration induced a doubled incidence of intracranial bleeding in patients older than 75 years. In a recent double-blind, randomized, mega-trial including over 20,000 patients, the superior efficacy on in-hospital and 30-day adverse cardiac events (namely reinfarction), and comparable safety on intracranial bleedings of enoxaparin compared to UFH, was definitively proven

IMPACT OF ANEMIA ON CLINICAL OUTCOME IN PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: INSIGHTS FROM THE AFCAS REGISTRY

OBJECTIVES: Anaemia has an adverse impact on the outcome in the general patient population undergoing percutaneous coronary intervention (PCI). The aim of this study was to analyse the impact of anaemia on the 12-month clinical outcome of patients with atrial fibrillation (AF) undergoing PCI and therefore requiring intense antithrombotic treatment. We hypothesised that anaemia might be associated with a worse outcome and more bleeding in these anticoagulated patients. SETTING: Data were collected from 17 secondary care centres in Europe. PARTICIPANTS: Consecutive patients with AF undergoing PCI were enrolled in the prospective, multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry. Altogether, 929 patients participated in the study. Preprocedural haemoglobin concentration was available for 861 (92.7%; 30% women). The only exclusion criteria were inability or unwillingness to give informed consent. Anaemia was defined as a haemoglobin concentration of <12 g/dL for women and <13 g/dL for men. OUTCOME MEASURES: The primary endpoint was occurrence of major adverse cardiac and cerebrovascular events (MACCE) or bleeding events. RESULTS: 258/861 (30%) patients had anaemia. Anaemic patients were older, more often had diabetes, higher CHA(2)DS(2)-VASc scores, prior history of heart failure, chronic renal impairment and acute coronary syndrome. Anaemic patients had more MACCE than non-anaemic (29.1% vs 19.4%, respectively, p=0.002), and minor bleeding events (7.0% vs 3.3%, respectively, p=0.028), with a trend towards more total bleeding events (25.2% vs 21.7%, respectively, p=0.059). No difference was observed in antithrombotic regimens at discharge. In multivariate analysis, anaemia was an independent predictor of all-cause mortality at 12-month follow-up (hazard ratio 1.62, 95% CI 1.05 to 2.51, p=0.029). CONCLUSIONS: Anaemia was a frequent finding in patients with AF referred for PCI. Anaemic patients had a higher all-cause mortality, more thrombotic events and minor bleeding events. Anaemia seems to be an identification of patients at risk for cardiovascular events and death. TRIAL REGISTRATION: ClinicalTrials.gov number NCT00596570

470 Percutaneous arterial closure devices and ultrasound-guided trans-femoral puncture observational investigation: insights from the PETRONIO registry

Abstract Aims To evaluate the safety of a single and combined use of ultrasound-guided femoral puncture (U) and percutaneous arterial closure devices (P) in femoral artery procedures (FAP) compared to fluoroscopic guidance (F) and manual compression (M) in a large radial-focused interventional centre. U and P, taken individually, have improved safety in femoral arterial access procedures compared to traditional techniques. Methods and results All FAP performed between July 2017 and December 2018 in our centre were divided into three phases: (i) control period with F and M mainly performed; (ii) phase out period where U and P were introduced; and (iii) intervention period where a 6-month expertise on the novel techniques was acquired. The overall population was further stratified into subgroups: F/M, U/M, F/P, and U/P. The primary study endpoint was in-hospital access site bleeding events (BE) according to the BARC criteria. The secondary endpoint was vascular site complications (VASC). 418 procedures (14%) out of 3025 were performed via FA access during the study period. The overall access-site in-hospital BE were 97 (23%). Decreasing rates of BE (phase 1: n = 46, 29%; phase 2: n = 38, 22% e phase 3: n = 13, 15%; P = 0.027) and VASC were observed during the three periods. BE occurred significantly more often in F/M group (F/M: n = 48; 32%; U/M: n = 12, 16%; F/P: n = 18, 21%; U/P: n = 19, 17%; P = 0.008). F/M subgroup was an independent predictor of BE both in multivariable analysis and propensity score matching analysis. Conclusions The introduction of ultrasound-guided femoral puncture and percutaneous arterial closure devices has reduced access site bleeding with a progressive improvement after the first 6 months learning period

Synergic impact of oral anticoagulation control and renal function in determining major adverse events in atrial fibrillation patients undergoing percutaneous coronary intervention: insights from the AFCAS registry

In patients with atrial fibrillation (AF), quality of oral anticoagulation control as well as impaired renal function are associated with adverse outcomes. Our objective was to analyze if there was a synergistic impact of these factors in determining adverse outcomes in AF patients undergoing percutaneous coronary intervention and stent (PCI-S).Post-hoc analysis from the Atrial Fibrillation Undergoing Coronary Artery Stenting (AFCAS) registry. Poor oral anticoagulation control was defined as time in therapeutic range (TTR) < 65%, while impaired renal function as creatinine clearance (CrCl) < 60 ml/min.Of the whole cohort, 448 were eligible for this post-hoc analysis. Of these, 27.9% had TTR < 65%only (Group I), 19.2% had CrCl < 60 ml/min only (Group II), while 13.8% had both conditions (Group III). At follow-up, patients in Group III had a higher rate of major adverse cardiovascular and cerebrovascular events (MACCE) (p = 0.007), while patients in Groups I and III had higher rates of major bleeding. Kaplan-Meier analyses showed that patients in Group III had higher risk for MACCE (LogRank: 14.406, p = 0.003), while Group I and Group III patients had higher risk for major bleeding (LogRank: 12.290, p = 0.006). On Cox regression, presence of both conditions independently increased MACCE risk (p = 0.001), while TTR < 65% alone and the presence of both conditions were independently associated with major bleeding (p = 0.004 and p = 0.028, respectively).There was a synergic impact of oral anticoagulation control and renal function in determining major adverse events in AF patients undergoing PCI-S. Use of poor anticoagulation control and impaired renal function in combination would help identify AF patients undergoing PCI-S at risk for MACCE and/or major bleeding

Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a Joint Position Paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

© The Author 2020. This is a pre-copyedited, author-produced version of an article accepted for publication in European Heart Journal - Cardiovascular Pharmacotherapy following peer review. The version of record [Gorog et al., Antithrombotic therapy in patients with acute coronary syndrome complicated by cardiogenic shock or out-of-hospital cardiac arrest: a Joint Position Paper from the European Society of Cardiology (ESC) Working Group on Thrombosis, in association with the Acute Cardiovascular Care Association (ACCA) and European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Journal - Cardiovascular Pharmacotherapy, pvaa009] is available online at: https://doi.org/10.1093/ehjcvp/pvaa009.Peer reviewedFinal Accepted Versio

Acute, periprocedural and longterm antithrombotic therapy in older adults

The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults. © The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved.info:eu-repo/semantics/publishedVersio

Synergic impact of oral anticoagulation control and renal function in determining major adverse events in atrial fibrillation patients undergoing percutaneous coronary intervention: insights from the AFCAS registry

BACKGROUND: In patients with atrial fibrillation (AF), quality of oral anticoagulation control as well as impaired renal function are associated with adverse outcomes. Our objective was to analyze if there was a synergistic impact of these factors in determining adverse outcomes in AF patients undergoing percutaneous coronary intervention and stent (PCI-S). METHODS: Post-hoc analysis from the Atrial Fibrillation Undergoing Coronary Artery Stenting (AFCAS) registry. Poor oral anticoagulation control was defined as time in therapeutic range (TTR) <65%, while impaired renal function as creatinine clearance (CrCl) <60 ml/min. RESULTS: Of the whole cohort, 448 were eligible for this post-hoc analysis. Of these, 27.9% had TTR <65%only (Group I), 19.2% had CrCl <60 ml/min only (Group II), while 13.8% had both conditions (Group III). At follow-up, patients in Group III had a higher rate of major adverse cardiovascular and cerebrovascular events (MACCE) (p = 0.007), while patients in Groups I and III had higher rates of major bleeding. Kaplan-Meier analyses showed that patients in Group III had higher risk for MACCE (LogRank: 14.406, p = 0.003), while Group I and Group III patients had higher risk for major bleeding (LogRank: 12.290, p = 0.006). On Cox regression, presence of both conditions independently increased MACCE risk (p = 0.001), while TTR <65% alone and the presence of both conditions were independently associated with major bleeding (p = 0.004 and p = 0.028, respectively). CONCLUSIONS: There was a synergic impact of oral anticoagulation control and renal function in determining major adverse events in AF patients undergoing PCI-S. Use of poor anticoagulation control and impaired renal function in combination would help identify AF patients undergoing PCI-S at risk for MACCE and/or major bleeding