Antiplatelet agents and anticoagulants are a mainstay for the prevention and treatment of thrombosis. However, despite advances in antithrombotic therapy, a fundamental challenge is the side effect ...of bleeding. Improved understanding of the mechanisms of haemostasis and thrombosis has revealed new targets for attenuating thrombosis with the potential for less bleeding, including glycoprotein VI on platelets and factor XIa of the coagulation system. The efficacy and safety of new agents are currently being evaluated in phase III trials. This Review provides an overview of haemostasis and thrombosis, details the current landscape of antithrombotic agents, addresses challenges with preventing thromboembolic events in patients at high risk and describes the emerging therapeutic strategies that may break the inexorable link between antithrombotic therapy and bleeding risk.
Moderate or severe coronary artery calcification reduces vascular compliance and is associated with increased adverse clinical outcomes, including myocardial infarction (MI), target lesion ...revascularization (TLR), and death, in patients who underwent percutaneous coronary intervention (PCI).1,2 Stent underexpansion is believed to be a major cause of the increased risk of adverse outcomes after PCI, leading to the development of several devices designed to increase the compliance of calcified arteries, including rotational atherectomy (RA), orbital atherectomy, excimer laser atherectomy, scoring balloons, and intravascular lithotripsy.3 RA, which works by forward advancement of a rotating abrasive burr, has been in use for more than 3 decades, initially for “debulking” but more recently for “plaque modification” to enable optimal stent expansion. The results showed that there was an increased rate of slow flow/no reflow in the UA group but, otherwise, no significant difference in the procedural success or procedural complications, including coronary dissection, perforation, or side branch closure among the 3 groups. ...the clinical outcomes at 1 year showed higher rates of MI (adjusted hazard ratio adj HR 2.23, 95% confidence interval CI 1.13 to 4.42), TLR (adj HR 1.82, 95% CI 1.15 to 2.89), and death or MI (adj HR 1.79, 95% CI 1.01 to 3.17) in the NSTEMI than in the CCS group.
Abstract Atherosclerosis is rare in internal thoracic arteries (ITA) even in patients with severe atherosclerotic coronary artery (ACA) disease. To explore cellular differences, ITA SMC from 3 ...distinct donors and ACA SMC from 3 distinct donors were grown to sub-confluence and growth arrested for 48 h. Proliferation and thrombospondin-1 (TSP1) production were determined using standard techniques. ITA SMC were larger, grew more slowly and survived more passages than ACA SMC. ACA SMC had a more pronounced proliferative response to 10% serum than ITA SMC. Both ACA SMC and ITA SMC proliferated in response to exogenous TSP1 (12.5 µg/ml and 25 µg/ml) and platelet derived growth factor-BB (PDGF-BB; 20 ng/ml) but TSP1- and PDGF-BB-induced proliferation were partially inhibited by anti-TSP1 antibody A4.1, microRNA-21(miR-21)-3p inhibitors and miR-21-5p inhibitors in each of the 3 ACA SMC lines, but not in any of the ITA SMC lines. PDGF-BB stimulated TSP1 production in ACA SMC but not in ITA SMC but there was no increase in TSP1 levels in conditioned media in either SMC type. In summary, there are significant differences in morphology, proliferative capacity and in responses to TSP1 and PDGF-BB in SMC derived from ITA compared to SMC derived from ACA.
BACKGROUND:Sex differences are known to exist in the management of older patients presenting with acute myocardial infarction (AMI). Few studies have examined the incidence and risk factors of AMI ...among young patients, or whether clinical management differs by sex.
METHODS:The Atherosclerosis Risk in Communities (ARIC) Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified by physician review, using a validated algorithm. Medications and procedures were abstracted from the medical record. Our study population was limited to young patients aged 35 to 54 years.
RESULTS:From 1995 to 2014, 28 732 weighted hospitalizations for AMI were sampled among patients aged 35 to 74 years. Of these, 8737 (30%) were young. The annual incidence of AMI hospitalizations increased for young women but decreased for young men. The overall proportion of AMI admissions attributable to young patients steadily increased, from 27% in 1995 to 1999 to 32% in 2010 to 2014 (P for trend=0.002), with the largest increase observed in young women. History of hypertension (59% to 73%, P for trend<0.0001) and diabetes mellitus (25% to 35%, P for trend<0.0001) also increased among young AMI patients. Compared to young men, young women presenting with AMI were more often black and had a greater comorbidity burden. In adjusted analyses, young women had a lower probability of receiving lipid-lowering therapies (relative risk RR=0.87; 95% confidence interval CI, 0.80–0.94), nonaspirin antiplatelets (RR=0.83; 95% CI, 0.75–0.91), beta blockers (RR=0.96; 95% CI, 0.91–0.99), coronary angiography (RR=0.93; 95% CI, 0.86–0.99) and coronary revascularization (RR = 0.79; 95% CI, 0.71–0.87). However, 1-year all-cause mortality was comparable for women versus men (HR=1.10; 95% CI, 0.83–1.45).
CONCLUSIONS:The proportion of AMI hospitalizations attributable to young patients increased from 1995 to 2014 and was especially pronounced among women. History of hypertension and diabetes among young patients admitted with AMI increased over time as well. Compared with young men, young women presenting with AMI had a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these changes is needed to improve care of young patients with AMI.
The incidence of acute myocardial infarction is increasing in younger age groups, with differences in treatment and outcomes based on gender. ST-elevation myocardial infarction (STEMI) in young ...adults, however, is incompletely understood as most of the current studies were performed in homogenous populations, did not focus on STEMI, and lack direct comparisons with older adults. We performed a retrospective observational study using the Statewide Planning And Research Cooperative System for all admissions in New York State with a principal diagnosis of STEMI from 2011 to 2018. There were 58,083 STEMIs with the majority being male (68.2%) and non-Hispanic White (64.8%), with an average age of 63.9 ± 13.9 years. Of these, 8,494 (14.6%) occurred in patients aged <50 years. The proportion of STEMIs in women increased with age, from 19.2% in the <50-year-old age group to 48.9% in the ≥70-year-old age group. Young adults with STEMI had greater prevalence of obesity, current tobacco use, other substance use, and major psychiatric disorders, were more likely to receive revascularization, and had lower 1-year mortality than older age groups. Revascularization was associated with at least a 3 times lower odds ratio of 1-year mortality in all age groups. In conclusion, young adults with STEMI had a unique set of risk factors and co-morbidities and were more likely to undergo revascularization than older age groups. In all age groups, female gender was associated with a higher burden of co-morbidities, decreased use of revascularization, and increased 1-year mortality.
•In 58,083 STEMIs from 2011 to 2018 in the Statewide Planning And Research Cooperative System database of New York State, adults aged <50 years displayed a differing risk factor panel than older adults, with a higher prevalence of obesity; major psychiatric disorders; and tobacco, alcohol, cocaine, and cannabis use.•Across all ages, female gender was associated with a higher burden of risk factors and co-morbidities, decreased receipt of percutaneous coronary intervention, and increased 1-year mortality.•There are important gender and age differences in the risk factors for ST-Elevation Myocardial Infarction. Preventive efforts to reduce ST-Elevation Myocardial Infarction occurrence in younger patients will need to consider these differences.
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