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Acute myocardial infarction treatments and outcomes in 6.5 million patients with a current or historical diagnosis of cancer in the USA.

美国 650万例目前或历史诊断为癌症的患者的急性心肌梗死治疗和结局。

  • 影响因子:8.07
  • DOI:10.1093/eurheartj/ehz851
  • 作者列表:"Bharadwaj A","Potts J","Mohamed MO","Parwani P","Swamy P","Lopez-Mattei JC","Rashid M","Kwok CS","Fischman DL","Vassiliou VS","Freeman P","Michos ED","Mamas MA
  • 发表时间:2020-06-14

AIMS:The aim of this study is to evaluate temporal trends, treatment, and clinical outcomes of patients who present with an acute myocardial infarction (AMI) and have a current or historical diagnosis of cancer, according to cancer type and presence of metastases. METHODS AND RESULTS:Data from 6 563 255 patients presenting with an AMI between 2004 and 2014 from the US National Inpatient Sample (NIS) database were analysed. A total of 5 966 955 had no cancer, 186 604 had current cancer, and 409 697 had a historical diagnosis of cancer. Prostate, breast, colon, and lung cancer were the four most common types of cancer. Patients with cancer were older with more comorbidities. Differences in invasive treatment were noted, 43.9% received percutaneous coronary intervention (PCI) in patients without cancer, whilst only 21.0% of patients with lung cancer received PCI. Lung cancer was associated with the highest in-hospital mortality [odds ratio (OR) 2.71, 95% confidence interval (CI) 2.62-2.80], major adverse cardiovascular and cerebrovascular complications (OR 2.38, 95% CI 2.31-2.45), and stroke (OR 1.91, 95% CI 1.80-2.02), while colon cancer was associated with highest risk of bleeding (OR 2.82, 95% CI 2.68-2.98). Irrespective of the type of cancer, presence of metastasis was associated with worse in-hospital outcomes, and historical cancer did not adversely impact on survival (OR 0.90, 95% CI 0.89-0.91). CONCLUSION:A concomitant cancer diagnosis is associated with a conservative medical management strategy for AMI, and worse clinical outcomes, compared to patients without cancer. Survival and clinical outcomes in the context of AMI vary significantly according to the type of cancer and metastasis status. The management of this high-risk group is challenging and requires a multidisciplinary and patient-centred approach to improve their outcomes.


目的: 本研究的目的是评估目前或既往诊断为癌症的急性心肌梗死 (AMI) 患者的时间趋势、治疗和临床结局,根据癌症类型和转移的存在。 方法和结果: 分析了来自美国国家住院病人样本 (NIS) 数据库的 6 563 255 例 2004 年至 2014 年间 AMI 患者的数据。共有 5   966   955 没有癌症,186   604 有当前癌症,409   697 有癌症的历史诊断。前列腺癌、乳腺癌、结肠癌和肺癌是最常见的四种癌症。癌症患者年龄较大,合并症较多。有创治疗的差异被注意到,43.9% 的非癌症患者接受经皮冠状动脉介入治疗 (PCI),而只有 21.0% 的肺癌患者接受 PCI。肺癌与最高的住院死亡率 [比值比 (OR) 2.71,95% 置信区间 (CI) 2.62-2.80] 、主要不良心脑血管并发症 (OR 2.38, 95% CI 2.31-2.45) 和卒中 (OR 1.91,95% CI 1.80-2.02),而结肠癌与最高出血风险相关(OR 2.82,95% CI 2.68-2.98)。无论癌症类型如何,转移的存在与较差的住院结局相关,历史癌症对生存率没有不利影响 (OR 0.90,95% CI 0.89-0.91)。 结论: 伴随癌症诊断与 AMI 的保守医疗管理策略相关,与无癌症患者相比,临床结局更差。AMI 背景下的生存率和临床结局因癌症类型和转移状态而异。这个高危人群的管理具有挑战性,需要多学科和以患者为中心的方法来改善他们的结果。



作者列表:["Tavenier AH","Hermanides RS","Fabris E","Lapostolle F","Silvain J","Ten Berg JM","Lassen JF","Bolognese L","Cantor WJ","Cequier Á","Chettibi M","Goodman SG","Hammett CJ","Huber K","Janzon M","Merkely B","Storey RF","Zeymer U","Ecollan P","Collet JP","Willems FF","Diallo A","Vicaut E","Hamm CW","Montalescot G","van 't Hof AWJ","ATLANTIC investigators."]

METHODS:BACKGROUND: Glycoprotein IIb/IIIa inhibitors (GPIs) in combination with clopidogrel improve clinical outcome in ST-elevation myocardial infarction (STEMI); however, finding a balance that minimizes both thrombotic and bleeding risk remains fundamental. The efficacy and safety of GPI in addition to ticagrelor, a more potent P2Y12-inhibitor, have not been fully investigated. METHODS: 1,630 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were analyzed in this subanalysis of the ATLANTIC trial. Patients were divided in three groups: no GPI, GPI administration routinely before primary PCI, and GPI administration in bailout situations. The primary efficacy outcome was a composite of death, myocardial infarction, urgent target revascularization, and definite stent thrombosis at 30 days. The safety outcome was non-coronary artery bypass graft (CABG)-related PLATO major bleeding at 30 days. RESULTS: Compared with no GPI (n = 930), routine GPI (n = 525) or bailout GPI (n = 175) was not associated with an improved primary efficacy outcome (4.2% no GPI vs. 4.0% routine GPI vs. 6.9% bailout GPI; p = 0.58). After multivariate analysis, the use of GPI in bailout situations was associated with a higher incidence of non-CABG-related bleeding compared with no GPI (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.32-6.64; p = 0.03). However, routine GPI use compared with no GPI was not associated with a significant increase in bleeding (OR 1.78, 95% CI 0.88-3.61; p = 0.92). CONCLUSION: Use of GPIs in addition to ticagrelor in STEMI patients was not associated with an improvement in 30-day ischemic outcome. A significant increase in 30-day non-CABG-related PLATO major bleeding was seen in patients who received GPIs in a bailout situation.

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作者列表:["Huang X","Chen S","Redfors B","Zhang Y","Souza CF","Mehran R","Bansilal S","Kirtane AJ","Brener SJ","Feite F","Dangas GD","Ben-Yehuda O","Stone GW"]

METHODS:OBJECTIVES:There are limited data on bivalirudin monotherapy in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) with positive biomarkers of myocardial necrosis (troponin and/or creatine kinase-myocardial band isoenzyme). We sought to evaluate the safety and efficacy of bivalirudin monotherapy in patients with positive biomarkers from the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. PATIENTS AND METHODS:We compared the net adverse clinical events [composite ischemia - (death, myocardial infarction, or unplanned ischemic revascularization) - or noncoronary artery bypass graft surgery (CABG)-related major bleeding] among patients with biomarker-positive NSTE-ACS in the ACUITY trial overall and by antithrombotic strategy. RESULTS:Among 13 819 patients with NSTE-ACS enrolled in ACUITY, 4728 patients presented with positive biomarkers and underwent an early invasive strategy. Of those, 1547 were randomized to heparin plus a glycoprotein IIb/IIIa inhibitor (GPI), 1555 to bivalirudin plus GPI, and 1626 to bivalirudin monotherapy. Compared with biomarker-negative patients, biomarker-positive patients had higher 30-day rates of net adverse clinical events (14.0 vs. 12.4%; P = 0.04), all-cause death (1.3 vs. 0.5%; P = 0.001), cardiac death (1.1 vs. 0.5%; P = 0.005), and non-CABG-related major bleeding (6.5 vs. 5.2%, P = 0.03). At 30 days, bivalirudin monotherapy was associated with significantly less non-CABG-related major bleeding (bivalirudin monotherapy 4.1% vs. bivalirudin plus GPI 8.4% vs. heparin plus GPI 7.1%) with comparable rates of composite ischemia (bivalirudin monotherapy 9.2% vs. bivalirudin plus GPI 9.9% vs. heparin plus GPI 8.4%). In a multivariable model, bivalirudin monotherapy was associated with a significant reduction in non-CABG-related major bleeding but was not associated with an increased risk of death, myocardial infarction, unplanned revascularization or stent thrombosis. CONCLUSION:Compared with heparin plus GPI or bivalirudin plus GPI, bivalirudin monotherapy provides similar protection from ischemic events with less major bleeding at 30 days among patients with NSTE-ACS and positive biomarkers.

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作者列表:["Ravi V","Pulipati P","Vij A","Kodumuri V"]

METHODS:Atrial fibrillation (AF) and concomitant coronary artery disease (CAD) create a therapeutic dilemma as the risk of bleeding with triple antithrombotic therapy (TATT) must be balanced against the risk of ischemic events with double antithrombotic therapy (DATT). The aim of this meta-analysis is to compare the efficacy and safety of DATT versus TATT in AF and CAD. MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched for relevant articles published from inception to May 1, 2019. Studies comparing the safety and efficacy of DATT versus TATT in patients with AF and CAD were included. Among 9 studies, where 6,104 patients received DATT and 7,333 patients received TATT, there was no statistically significant difference in the outcomes of mortality, nonfatal myocardial infarction, stent thrombosis, and stroke. There was a lower rate of major bleeding in DATT (risk ratio [RR] 0.64 [95% confidence interval [CI] 0.54 to 0.75]; p <0.001). There was no significant difference in stent thrombosis (RR 1.52 [95% CI 0.97 to 2.38]; p = 0.07). However, subgroup analysis of trials with direct oral anticoagulant use demonstrated a borderline higher rate of stent thrombosis in DATT (RR 1.66 [95% CI 1.01 to 2.73]; p = 0.05). In conclusion, DATT showed no difference in the outcomes of mortality, stroke, nonfatal myocardial infarction, and stent thrombosis compared with TATT. DATT demonstrated a lower rate of major bleeding. DATT demonstrated a borderline higher rate of stent thrombosis in the subgroup analysis of trials with direct oral anticoagulant which needs to be evaluated in further studies.

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