European Heart Journal - Cardiovascular Pharmacotherapy最新文献

Background and aims: Extended dual pathway inhibition (DPI) with aspirin and rivaroxaban is recommended in high-risk patients with chronic coronary syndrome (CCS). In the 2024 update of the European Society of Cardiology guidelines on CCS, the high-risk criteria were revised. In the COMPASS cohort, we evaluated net clinical benefit of DPI according to baseline risk as defined by the ESC criteria in CCS patients.

Methods: CCS patients randomized to aspirin alone or DPI (n=15,429) were risk stratified using the 2024 ESC criteria. Endpoints included major adverse cardiovascular events (MACE), all-cause death, fatal/critical organ bleeding, and composite adverse events (MACE and bleeding). Net clinical benefit was the 30-month absolute risk difference combining MACE and bleeding.

Results: High-risk status was associated with higher 30-month incidences of MACE (6.4% vs. 5.0%, HR 1.33, 95% CI 1.09-1.63) and composite adverse events (7.1% vs. 5.7%, HR 1.31 [1.09-1.58]), but not all-cause death or bleeding. DPI reduced MACE (low-risk: HR 0.66 [0.45-0.95]; high-risk: HR 0.77 [0.66.-0.91]; p-value for interaction 0.42) and all-cause death (low-risk: 0.78 [0.53-1.14]; high-risk: HR 0.78 [0.64-0.94], p-value for interaction 0.99). DPI provided similar net clinical benefit in low-risk (30-month risk difference -1.77% [-3.88-0.33], HR 0.79 [0.56-1.11]) and high-risk patients (30-month risk difference -2.06% [-3.20--0.91], HR 0.80 [0.69-0.93]; p-value for interaction 0.94).

Conclusions: In CCS patients, DPI reduced all-cause death and MACE while increasing major bleeding. The 2024 ESC criteria performed poorly in terms of distinguishing patients at high vs. low ischemic risk, making them inadequate to provide guidance for DPI use.

Aims: To assess whether rivaroxaban is associated with a decreased risk of major adverse limb events (MALE), stroke, systemic embolism (SE), and major bleeding (MB) among patients with non-valvular atrial fibrillation (NVAF) and peripheral artery disease (PAD), compared with apixaban.

Methods and results: We conducted a population-based cohort study using the UK Clinical Practice Research Datalink. Patients aged ≥45 years with incident NVAF and PAD who initiated rivaroxaban or apixaban between 2013 and 2021 were included. Primary effectiveness outcomes were MALE, and a composite of ischaemic stroke, transient ischaemic attack (TIA), or SE. The primary safety outcome was MB. The risk of major cardiovascular events (MACE) was assessed as a secondary outcome. Confounding was addressed using propensity score fine stratification and weighting. Weighted Cox proportional hazards models estimated hazard ratios (HRs) with 95% confidence intervals (CIs). The cohort included 6170 new users of rivaroxaban and 9990 new users of apixaban (44% female; mean [SD] age 78.5 [9.2] years). Incidence rates were similar for MALE (6.7 vs. 5.6/1000 person-years; adjusted HR (aHR): 1.20; 95% CI 0.87-1.65), stroke/TIA/SE (24.5 vs. 21.3/1000 person-years; aHR: 1.15; 95% CI 0.97-1.36), and MACE (40.1 vs. 35.9 per 1000 person-years; aHR 1.10: 95% CI 0.94-1.28). Major bleeding rates were higher with rivaroxaban (46.1 vs. 29.8/1000 person-years; aHR: 1.55; 95% CI 1.36-1.77).

Conclusion: In patients with NVAF and PAD, rivaroxaban was associated with a similar risk of MALE and stroke/TIA/SE, but a higher risk of MB compared with apixaban. These findings support apixaban as a potentially safer anticoagulant in this high-risk population.

Post-operative atrial fibrillation (POAF) is common after non-cardiac surgery. Because often transient, there are uncertainties on the associated risk of stroke, possibly driving the need for long-term anticoagulation. We performed a systematic PubMed search until 16 January 2025, related to the incidence of stroke in patients with POAF after non-cardiac surgery. We included papers reporting outcomes, excluding studies only dealing with epidemiology, mechanisms, management, and treatment. We excluded studies reporting on POAF after cardiac surgery. Risk of bias was assessed for each study, and the certainty of evidence was evaluated using the GRADE methodology. We retrieved and included 40 studies (including review papers) for the systematic review. These were then further selected to create a final list of 19 studies included in the meta-analysis. The reported incidence of stroke after POAF was found to be widely variable, ranging between 0.4% and 16.7% at 1 year. Stroke incidence also varies widely according to the type of surgery and patient characteristics. With only three exceptions, all studies, however, reported a risk of stroke higher in the POAF group than in the no-POAF group, with a mean odds ratio of 3.02. POAF on average triples the risk of stroke, with variations related to patient characteristics and type of surgery. Patients after non-cardiac surgery should be monitored at least during hospitalisation to detect POAF. Future studies are necessary to evaluate optimal duration and modalities of monitoring, as well as to assess the relevance of symptomatic vs asymptomatic AF episodes.