Coronary Artery Calcium for Personalized Allocation of Aspirin in Primary Prevention of Cardiovascular Disease in 2019: The Multi-Ethnic Study of Atherosclerosis (MESA).
冠状动脉钙个性化分配阿司匹林在心血管疾病一级预防中的应用 2019年: 动脉粥样硬化的多种族研究 (MESA)。
- 作者列表："Cainzos-Achirica M","Miedema MD","McEvoy JW","Al Rifai M","Greenland P","Dardari Z","Budoff M","Blumenthal RS","Yeboah J","Duprez DA","Mortensen MB","Dzaye O","Hong J","Nasir K","Blaha MJ
:Background: Recent American College of Cardiology/American Heart Association (ACC/AHA) Primary Prevention Guidelines recommended considering low-dose aspirin therapy only among adults 40-70 years of age who are at higher atherosclerotic cardiovascular disease (ASCVD) risk but not at high risk of bleeding. However, it remains unclear how these patients are best identified. The present study aimed to assess the value of coronary artery calcium (CAC) for guiding aspirin allocation for primary prevention using 2019 aspirin meta-analysis data on CVD relative risk reduction (RRR) and bleeding risk. Methods: The study included 6,470 participants from the Multi-Ethnic Study of Atherosclerosis (MESA). ASCVD risk was estimated using the Pooled Cohort Equations (PCE) and 3 strata were defined: <5%, 5-20% and >20%. All participants underwent CAC scoring at baseline and CAC scores were stratified as =0, 1-99, ≥100 and ≥400. A 12% RRR in CVD events was used for 5-year number needed to treat (NNT5) calculations, and a 42% relative risk increase in major bleeding events was used for 5-year number needed to harm (NNH5) estimations. Results: Only 5% of MESA participants would qualify for aspirin consideration for primary prevention according to ACC/AHA guidelines and using >20% estimated ASCVD risk to define "higher risk". Benefit/harm calculations were restricted to aspirin-naïve participants <70 years not at high risk of bleeding (N=3,540). The overall NNT5 with aspirin to prevent one CVD event was 476 and the NNH5 was 355. The NNT5 was also greater than or similar to the NNH5 among estimated ASCVD risk strata. Conversely, CAC≥100 and CAC≥400 identified subgroups in which NNT5 was lower than NNH5. This was true both overall (for CAC≥100, NNT5=140 vs NNH5=518) as well as within ASCVD risk strata. Also, CAC=0 identified subgroups in which the NNT was much higher than the NNH5 (overall, NNT5=1,190 vs NNH5=567). Conclusions: CAC may be superior to the PCE to inform allocation of aspirin in primary prevention. Implementation of current 2019 ACC/AHA guideline recommendations together with the use of CAC for further risk assessment may result in a more personalized, safer allocation of aspirin in primary prevention. Confirmation of these findings in experimental settings is needed.
: 背景: 最近美国心脏病学会/美国心脏协会 (ACC/AHA) 一级预防指南建议仅在 40-70 岁的动脉粥样硬化性心血管疾病 (ASCVD) 风险较高但出血风险不高的成年人中考虑低剂量阿司匹林治疗。然而，目前还不清楚如何最好地确定这些患者。本研究旨在使用 2019 个阿司匹林降低 CVD 相对风险 (RRR) 的荟萃分析数据，评估冠状动脉钙化 (CAC) 指导阿司匹林分配用于一级预防的价值和出血风险。方法: 该研究包括 6,470 名来自动脉粥样硬化多种族研究 (MESA) 的参与者。使用合并队列方程 (PCE) 估计 ASCVD 风险，定义 3 个分层: <5% 、 5-20% 和> 20%。所有参与者在基线时进行 CAC 评分，CAC 评分分层为 = 0 、 1-99 、 ≥ 100 和 ≥ 400。CVD 事件中的 12% RRR 用于治疗所需的 5 年数量 (NNT5) 计算,对 5 年需要伤害次数 (NNH5) 的估计采用了 42% 的大出血事件相对风险增加。结果: 根据 ACC/AHA 指南，只有 5% 的 MESA 参与者有资格考虑阿司匹林进行一级预防，并使用> 20% 的估计 ASCVD 风险来定义 “高风险”。效益/危害计算仅限于阿司匹林初治参与者 <70 岁，出血风险不高 (N = 3,540)。阿司匹林预防 1 次 CVD 事件的总体 NNT5 为 476，NNH5 为 355。在估计的 ASCVD 危险度地层中，NNT5 也大于或类似于 NNH5。相反，CAC≥ 100 和 CAC≥ 400 确定了 NNT5 低于 nnh5 的亚组。总体 (cac5 ≥ 100，NNT5 = 140 vs NNH5 = 518) 以及 ASCVD 风险分层内都是如此。同样，CAC = 0 确定了 NNT 远高于 NNH5 的亚组 (总体而言，NNT5 = 1,190 vs NNH5 = 567)。结论: 在阿司匹林一级预防中，CAC 可能优于 PCE。实施当前的 2019 ACC/AHA 指南建议以及使用 CAC 进行进一步风险评估可能导致阿司匹林在一级预防中更个性化、更安全的分配。需要在实验环境中确认这些发现。
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.
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.
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.