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Article ; Online: A Contemporary Review of Antiplatelet Therapies in Current Clinical Practice

Sacchin Arockiam / Brittany Staniforth / Sacha Kepreotis / Annette Maznyczka / Heerajnarain Bulluck

International Journal of Molecular Sciences, Vol 24, Iss 11132, p

2023 Volume 11132

Abstract: Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their ... ...

Abstract	Antiplatelet therapy plays a crucial role in a number of cardiovascular disorders. We currently have a range of antiplatelet agents in our armamentarium. In this review, we aim to summarise the common antiplatelet agents currently available, and their use in clinic practice. We not only highlight recent trials exploring antiplatelet therapy in atherosclerotic cardiovascular disease, but also in trials related to transcatheter aortic valve implantation and coronavirus disease 2019. Inevitably, the antithrombotic benefits of these drugs are accompanied by an increase in bleeding complications. Therefore, an individualised approach to weighing each patient’s thrombotic risk versus bleeding risk is imperative, in order to improve clinical outcomes.
Keywords	antiplatelet therapy ; atherosclerotic vascular disease ; ischaemic heart disease ; acute coronary syndrome ; coronary artery bypass graft surgery ; stroke ; Biology (General) ; QH301-705.5 ; Chemistry ; QD1-999
Language	English
Publishing date	2023-07-01T00:00:00Z
Publisher	MDPI AG
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Defining Peri-Operative Myocardial Injury during Cardiac Surgery Using High-Sensitivity Troponin T

Vikram Sharma / Huili Zheng / Luciano Candilio / Jennifer M. Nicholas / Tim Clayton / Derek M. Yellon / Heerajnarain Bulluck / Derek J. Hausenloy

Journal of Clinical Medicine, Vol 12, Iss 4291, p

2023 Volume 4291

Abstract: Objective: Cut-offs for high-sensitivity troponin (hs-Tn) elevations to define prognostically significant peri-operative myocardial injury (PMI) in cardiac surgery is not well-established. We evaluated the associations between peri-operative high- ... ...

Abstract	Objective: Cut-offs for high-sensitivity troponin (hs-Tn) elevations to define prognostically significant peri-operative myocardial injury (PMI) in cardiac surgery is not well-established. We evaluated the associations between peri-operative high-sensitivity troponin T (hs-TnT) elevations and 1-year all-cause mortality in patients undergoing cardiac surgery. Methods: The prognostic significance of baseline hs-TnT and various thresholds for post-operative hs-TnT elevation at different time-points on 1-year all-cause mortality following cardiac surgery were assessed after adjusting for baseline hs-TnT and EuroSCORE in a post-hoc analysis of the ERICCA trial. Results: 1206 patients met the inclusion criteria. Baseline elevation in hs-TnT >x1 99th percentile upper reference limit (URL) was significantly associated with 1-year all-cause mortality (adjusted hazard ratio 1.90, 95% confidence interval 1.15–3.13). In the subgroup with normal baseline hs-TnT ( n = 517), elevation in hs-TnT at all post-operative time points was associated with higher 1-year mortality, reaching statistical significance for elevations above: ≥100 × URL at 6 h; ≥50 × URL at 12 and 24 h; ≥35 × URL at 48 h; and ≥30 × URL at 72 h post-surgery. Elevation in hs-TnT at 24 h ≥ 50 × URL had the optimal sensitivity and specificity (73% and 75% respectively). When the whole cohort of patients was analysed, including those with abnormal baseline hs-TnT (up to 10 × URL), the same threshold had optimal sensitivity and specificity (66% and 70%). Conclusions: Both baseline and post-operative hs-TnT elevations are independently associated with 1-year all-cause mortality in patients undergoing cardiac surgery. The optimal threshold to define a prognostically significant PMI in our study was ≥50 × URL elevation in hs-TnT at 24 h.
Keywords	peri-operative myocardial injury ; high-sensitivity troponin ; coronary artery bypass graft surgery ; mortality ; Medicine ; R
Subject code	610
Language	English
Publishing date	2023-06-01T00:00:00Z
Publisher	MDPI AG
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Fractional Flow Reserve versus Angiography–Guided Management of Coronary Artery Disease

Annette M. Maznyczka / Connor J. Matthews / Jonathan M. Blaxill / John P. Greenwood / Abdul M. Mozid / Jennifer A. Rossington / Murugapathy Veerasamy / Stephen B. Wheatcroft / Nick Curzen / Heerajnarain Bulluck

Journal of Clinical Medicine, Vol 11, Iss 7092, p

A Meta–Analysis of Contemporary Randomised Controlled Trials

2022 Volume 7092

Abstract: Background and Aims: Randomised controlled trials (RCTs) comparing outcomes after fractional flow reserve (FFR)-guided versus angiography-guided management for obstructive coronary artery disease (CAD) have produced conflicting results. We investigated ... ...

Abstract	Background and Aims: Randomised controlled trials (RCTs) comparing outcomes after fractional flow reserve (FFR)-guided versus angiography-guided management for obstructive coronary artery disease (CAD) have produced conflicting results. We investigated the efficacy and safety of an FFR-guided versus angiography-guided management strategy among patients with obstructive CAD. Methods: A systematic electronic search of the major databases was performed from inception to September 2022. We included studies of patients presenting with angina or myocardial infarction (MI), managed with medications, percutaneous coronary intervention, or bypass graft surgery. A meta-analysis was performed by pooling the risk ratio (RR) using a random-effects model. The endpoints of interest were all-cause mortality, MI and unplanned revascularisation. Results: Eight RCTs, with outcome data from 5077 patients, were included. The weighted mean follow up was 22 months. When FFR-guided management was compared to angiography-guided management, there was no difference in all-cause mortality [3.5% vs. 3.7%, RR: 0.99 (95% confidence interval (CI) 0.62–1.60), p = 0.98, heterogeneity (I 2 ) 43%], MI [5.3% vs. 5.9%, RR: 0.93 (95%CI 0.66–1.32), p = 0.69, I 2 42%], or unplanned revascularisation [7.4% vs. 7.9%, RR: 0.92 (95%CI 0.76–1.11), p = 0.37, I 2 0%]. However, the number patients undergoing planned revascularisation by either stent or surgery was significantly lower with an FFR-guided strategy [weighted mean difference: 14 (95% CI 3 to 25)%, p =< 0.001]. Conclusion: In patients with obstructive CAD, an FFR-guided management strategy did not impact on all-cause mortality, MI and unplanned revascularisation, when compared to an angiography-guided management strategy, but led to up to a quarter less patients needing revascularisation.
Keywords	fractional flow reserve ; angiography ; coronary artery disease ; percutaneous coronary intervention ; coronary artery bypass graft surgery ; Medicine ; R
Subject code	610
Language	English
Publishing date	2022-11-01T00:00:00Z
Publisher	MDPI AG
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery

Chenghui Zhou / Heerajnarain Bulluck / Nengxin Fang / Lihuan Li / Derek J. Hausenloy

Scientific Reports, Vol 7, Iss 1, Pp 1-

A Meta analysis

2017 Volume 11

Abstract: Abstract We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of ... ...

Abstract	Abstract We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of 6302 patients were selected and identified. Compared with controls, RIPC significantly reduced the incidence of acute kidney injury (AKI) [odds ratio (OR) = 0.79; P = 0.02; I2 = 38%], and in particular, AKI stage I (OR = 0.65; P = 0.01; I2 = 55%). RIPC significantly shortened mechanical ventilation (MV) duration [weighted mean difference (WMD) = −0.79 hours; P = 0.002; I2 = 53%), and reduced intensive care unit (ICU) stay (WMD = −0.23 days; P = 0.07; I2 = 96%). Univariate meta-regression analyses showed that the major sources of heterogeneity for AKI stage I were age (coefficient = 0.06; P = 0.01; adjusted R2 = 0.86) and proportion of complex surgery (coefficient = 0.02; P = 0.03; adjusted R2 = 0.81). Subsequent multivariate regression and subgroup analyses also confirmed these results. The present meta-analysis suggests that RIPC reduces the incidence of AKI in adults undergoing cardiac surgery and this benefit was more pronounced in younger patients undergoing non-complex cardiac surgery. RIPC may also shorten MV duration and ICU stay. Future RCTs tailored for those most likely to benefit from RIPC warrants further investigation.
Keywords	Medicine ; R ; Science ; Q
Subject code	610 ; 616
Language	English
Publishing date	2017-03-01T00:00:00Z
Publisher	Nature Portfolio
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Comparison of the modified Singapore myocardial infarction registry risk score with GRACE 2.0 in predicting 1-year acute myocardial infarction outcomes

Ching-Hui Sia / Huili Zheng / Junsuk Ko / Andrew Fu-Wah Ho / David Foo / Ling-Li Foo / Patrick Zhan-Yun Lim / Boon Wah Liew / Ping Chai / Tiong-Cheng Yeo / Huay-Cheem Tan / Terrance Chua / Mark Yan-Yee Chan / Jack Wei Chieh Tan / Keith A. A. Fox / Heerajnarain Bulluck / Derek J. Hausenloy

Scientific Reports, Vol 12, Iss 1, Pp 1-

2022 Volume 9

Abstract: Abstract Risk stratification plays a key role in identifying acute myocardial infarction (AMI) patients at higher risk of mortality. However, current AMI risk scores such as the Global Registry of Acute Coronary Events (GRACE) score were derived from ... ...

Abstract	Abstract Risk stratification plays a key role in identifying acute myocardial infarction (AMI) patients at higher risk of mortality. However, current AMI risk scores such as the Global Registry of Acute Coronary Events (GRACE) score were derived from predominantly Caucasian populations and may not be applicable to Asian populations. We previously developed an AMI risk score from the national-level Singapore Myocardial Infarction Registry (SMIR) confined to ST-segment elevation myocardial infarction (STEMI) patients and did not include non-STEMI (NSTEMI) patients. Here, we derived a modified SMIR risk score for both STEMI and NSTEMI patients and compared its performance to the GRACE 2.0 score for predicting 1-year all-cause mortality in our multi-ethnic population. The most significant predictor of 1-year all-cause mortality in our population using the GRACE 2.0 score was cardiopulmonary resuscitation on admission (adjusted hazards ratio [HR] 6.50), while the most significant predictor using the SMIR score was age 80–89 years (adjusted HR 7.78). Although the variables used in the GRACE 2.0 score and SMIR score were not exactly the same, the c-statistics for 1-year all-cause mortality were similar between the two scores (GRACE 2.0 0.841 and SMIR 0.865). In conclusion, we have shown that in a multi-ethnic Asian AMI population undergoing PCI, the SMIR score performed as well as the GRACE 2.0 score.
Keywords	Medicine ; R ; Science ; Q
Subject code	310
Language	English
Publishing date	2022-08-01T00:00:00Z
Publisher	Nature Portfolio
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Benefits and Harms of Extending the Duration of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Drug-Eluting Stents

Chun Shing Kwok / Heerajnarain Bulluck / Alisdair D. Ryding / Yoon K. Loke

The Scientific World Journal, Vol

A Meta-Analysis

2014 Volume 2014

Keywords	Science ; Q ; Science (General) ; Q1-390
Publishing date	2014-01-01T00:00:00Z
Publisher	Hindawi Publishing Corporation
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Interrogation of the infarcted and salvaged myocardium using multi-parametric mapping cardiovascular magnetic resonance in reperfused ST-segment elevation myocardial infarction patients

Derek J. Hausenloy / Mei Xing Lim / Mervyn H. H. Chan / Valeria Paradies / Rohin Francis / Tushar Kotecha / Daniel S. Knight / Marianna Fontana / Peter Kellman / James C. Moon / Heerajnarain Bulluck

Scientific Reports, Vol 9, Iss 1, Pp 1-

2019 Volume 8

Abstract: Abstract We used multi-parametric cardiovascular magnetic resonance (CMR) mapping to interrogate the myocardium following ST-segment elevation myocardial infarction (STEMI). Forty-eight STEMI patients underwent CMR at 4 ± 2 days. One matching short-axis ... ...

Abstract	Abstract We used multi-parametric cardiovascular magnetic resonance (CMR) mapping to interrogate the myocardium following ST-segment elevation myocardial infarction (STEMI). Forty-eight STEMI patients underwent CMR at 4 ± 2 days. One matching short-axis slice of native T1 map, T2 map, late gadolinium enhancement (LGE), and automated extracellular volume fraction (ECV) maps per patient were analyzed. Manual regions-of-interest were drawn within the infarcted, the salvaged and the remote myocardium. A subgroup analysis was performed in those without MVO and with ≤75% transmural extent of infarct. For the whole cohort, T1, T2 and ECV in both the infarcted and the salvaged myocardium were significantly higher than in the remote myocardium. T1 and T2 could not differentiate between the salvaged and the infarcted myocardium, but ECV was significantly higher in the latter. In the subgroup analysis of 15 patients, similar findings were observed for T1 and T2. However, there was only a trend towards ECVsalvage being higher than ECVremote. In the clinical setting, current native T1 and T2 methods with the specific voxel sizes at 1.5 T could not differentiate between the infarcted and salvaged myocardium, whereas ECV could differentiate between the two. ECV was also higher in the salvaged myocardium when compared to the remote myocardium.
Keywords	Medicine ; R ; Science ; Q
Subject code	610
Language	English
Publishing date	2019-06-01T00:00:00Z
Publisher	Nature Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Benefits and Harms of Extending the Duration of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Drug-Eluting Stents

Chun Shing Kwok / Heerajnarain Bulluck / Alisdair D. Ryding / Yoon K. Loke

The Scientific World Journal, Vol

A Meta-Analysis

2014 Volume 2014

Abstract: Background. The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is unclear. Methods. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating risk of adverse events ... ...

Abstract	Background. The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is unclear. Methods. We conducted a systematic review and meta-analysis of randomized controlled trials evaluating risk of adverse events in participants receiving different durations of DAPT following insertion of drug-eluting stents. Results. Five trials were included, but only four had data suitable for meta-analysis (n=8,231 participants). No significant increase in the composite endpoint of death and nonfatal myocardial infarction was observed with earlier cessation of DAPT in any instance when compared to longer durations of DAPT (RR 0.64 95% CI 0.25–1.63 for 3 versus 12 months, RR 1.09 95% CI 0.84–1.41 for 6 versus 12 months and, RR 0.64 95% CI 0.35–1.16 for 12 versus 24 months). Pooled results showed a significantly lower risk of major bleeding (RR 0.48 95% CI 0.25–0.93) and total bleeding (RR 0.30 95% CI 0.16–0.54) for shorter compared to longer duration of DAPT. Subgroup analysis based on age, prior diabetes, and prior ACS failed to show any group where longer durations were consistently better than shorter ones. Conclusions. There are no cardiovascular or mortality benefits associated with extended duration of DAPT, but the risk of major bleeding was significantly lower with shorter lengths of therapy.
Keywords	Technology ; T ; Medicine ; R ; Science ; Q
Subject code	610
Language	English
Publishing date	2014-01-01T00:00:00Z
Publisher	Hindawi Limited
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Association between smoking status and outcomes in myocardial infarction patients undergoing percutaneous coronary intervention

Ching-Hui Sia / Junsuk Ko / Huili Zheng / Andrew Fu-Wah Ho / David Foo / Ling-Li Foo / Patrick Zhan-Yun Lim / Boon Wah Liew / Ping Chai / Tiong-Cheng Yeo / Huay-Cheem Tan / Terrance Chua / Mark Yan-Yee Chan / Jack Wei Chieh Tan / Heerajnarain Bulluck / Derek J. Hausenloy

Scientific Reports, Vol 11, Iss 1, Pp 1-

2021 Volume 9

Abstract: Abstract Smoking is one of the leading risk factors for cardiovascular diseases, including ischemic heart disease and hypertension. However, in acute myocardial infarction (AMI) patients, smoking has been associated with better clinical outcomes, a ... ...

Abstract	Abstract Smoking is one of the leading risk factors for cardiovascular diseases, including ischemic heart disease and hypertension. However, in acute myocardial infarction (AMI) patients, smoking has been associated with better clinical outcomes, a phenomenon termed the “smoker’s paradox.” Given the known detrimental effects of smoking on the cardiovascular system, it has been proposed that the beneficial effect of smoking on outcomes is due to age differences between smokers and non-smokers and is therefore a smoker’s pseudoparadox. The aim of this study was to evaluate the association between smoking status and clinical outcomes in ST-segment elevation (STEMI) and non-STEMI (NSTEMI) patients treated by percutaneous coronary intervention (PCI), using a national multi-ethnic Asian registry. In unadjusted analyses, current smokers had better clinical outcomes following STEMI and NSTEMI. However, after adjusting for age, the protective effect of smoking was lost, confirming a smoker’s pseudoparadox. Interestingly, although current smokers had increased risk for recurrent MI within 1 year after PCI in both STEMI and NSTEMI patients, there was no increase in mortality. In summary, we confirm the existence of a smoker’s pseudoparadox in a multi-ethnic Asian cohort of STEMI and NSTEMI patients and report increased risk of recurrent MI, but not mortality, in smokers.
Keywords	Medicine ; R ; Science ; Q
Subject code	610 ; 616
Language	English
Publishing date	2021-03-01T00:00:00Z
Publisher	Nature Portfolio
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: The Lipid Paradox is present in ST-elevation but not in non-ST-elevation myocardial infarction patients

Ching-Hui Sia / Huili Zheng / Andrew Fu-Wah Ho / Heerajnarain Bulluck / Jun Chong / David Foo / Ling-Li Foo / Patrick Zhan Yun Lim / Boon Wah Liew / Huay-Cheem Tan / Tiong-Cheng Yeo / Terrance Siang Jin Chua / Mark Yan-Yee Chan / Derek J. Hausenloy

Scientific Reports, Vol 10, Iss 1, Pp 1-

Insights from the Singapore Myocardial Infarction Registry

2020 Volume 13

Abstract: Abstract Lowering low-density lipoprotein (LDL-C) and triglyceride (TG) levels form the cornerstone approach of cardiovascular risk reduction, and a higher high-density lipoprotein (HDL-C) is thought to be protective. However, in acute myocardial ... ...

Abstract	Abstract Lowering low-density lipoprotein (LDL-C) and triglyceride (TG) levels form the cornerstone approach of cardiovascular risk reduction, and a higher high-density lipoprotein (HDL-C) is thought to be protective. However, in acute myocardial infarction (AMI) patients, higher admission LDL-C and TG levels have been shown to be associated with better clinical outcomes - termed the ‘lipid paradox’. We studied the relationship between lipid profile obtained within 72 hours of presentation, and all-cause mortality (during hospitalization, at 30-days and 12-months), and rehospitalization for heart failure and non-fatal AMI at 12-months in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients treated by percutaneous coronary intervention (PCI). We included 11543 STEMI and 8470 NSTEMI patients who underwent PCI in the Singapore Myocardial Infarction Registry between 2008–2015. NSTEMI patients were older (60.3 years vs 57.7 years, p < 0.001) and more likely to be female (22.4% vs 15.0%, p < 0.001). In NSTEMI, a lower LDL-C was paradoxically associated with worse outcomes for death during hospitalization, within 30-days and within 12-months (all p < 0.001), but adjustment eliminated this paradox. In contrast, the paradox for LDL-C persisted for all primary outcomes after adjustment in STEMI. For NSTEMI patients, a lower HDL-C was associated with a higher risk of death during hospitalization but in STEMI patients a lower HDL-C was paradoxically associated with a lower risk of death during hospitalization. For this endpoint, the interaction term for HDL-C and type of MI was significant even after adjustment. An elevated TG level was not protective after adjustment. These observations may be due to differing characteristics and underlying pathophysiological mechanisms in NSTEMI and STEMI.
Keywords	Medicine ; R ; Science ; Q
Subject code	610
Language	English
Publishing date	2020-04-01T00:00:00Z
Publisher	Nature Publishing Group
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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