coronary artery disease

Low dose colchicine taken after an MI or stroke for at least 6 months reduces the risk of subsequent MI or stroke with minimal adverse effects (mostly GI). James W. Mold, MD, MPH

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Rationale
People with cardiovascular disease are at risk of recurrent major adverse cardiovascular events, and chronic low‐grade inflammation may be a major underlying factor. Treatment with low‐dose colchicine has been proposed for the secondary prevention of cardiovascular events in individuals at high cardiovascular risk. A previous Cochrane review showed considerable uncertainty regarding the benefits and harms of this approach.

Objectives
To evaluate the benefits and harms of low‐dose colchicine in the prevention of cardiovascular events in adults with a history of stable CVD or following myocardial infarction or stroke.

Search methods
We conducted a comprehensive search of the literature until February 2025 using Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the drugs@FDA database, references of key papers, and references of included studies.

Eligibility criteria
Randomised controlled trials (RCTs) comparing the use of low‐dose colchicine for a minimum of six months versus any control intervention in patients of any age with cardiovascular disease (i.e. history of stable cardiovascular disease, previous myocardial infarction or stroke).

Outcomes
Our critical outcomes were all‐cause mortality, myocardial infarction, and serious adverse events.

Our important outcomes were cardiovascular mortality, stroke, all‐cause hospitalisations, coronary revascularisation (percutaneous coronary intervention (PCI)/angioplasty or coronary artery bypass graft (CABG)), quality of life, and gastrointestinal adverse events (i.e. diarrhoea, nausea, abdominal pain, or vomiting).

Risk of bias
Two authors independently assessed the risk of bias using the Cochrane RoB2 tool.

Synthesis methods
We conducted meta‐analyses using the random‐effects model. We generated forest plots to facilitate visualisation of the data. We did not perform any subgroup analysis.

We used GRADE to assess the certainty of evidence for all critical outcomes and for cardiovascular mortality, stroke, and coronary revascularisation. This was carried out by two review authors working independently.

Included studies
We included 12 studies involving 22,983 randomised participants. The follow‐up in the studies ranged from 6 to 80 months. Overall, 11,524 participants were assigned to low‐dose colchicine treatment and 11,459 were assigned to a control intervention, which constituted either usual care plus placebo or usual care only. The doses of colchicine used were 0.5 mg once or twice daily. At baseline, the mean age of participants ranged from 57 to 74 years. Most participants (79.4%) were male.

Synthesis of results
There is high‐certainty evidence that low‐dose colchicine treatment reduces the risk of myocardial infarction, with a risk ratio (RR) of 0.74 (95% confidence interval (CI) 0.57 to 0.96; 22,153 participants, 8 studies; I2 = 51%), yielding an absolute risk reduction of 9 fewer events (95% CI 16 fewer to 2 fewer) per 1000 patients, when the myocardial infarction rate is about 4% (36 events per 1000 patients) in the control group.

There is also high‐certainty evidence that low‐dose colchicine reduces the risk of stroke with a RR of 0.67 (95% CI 0.47 to 0.95; 22,483 participants, 10 studies; I2 = 40%), yielding an absolute risk reduction of 8 fewer events (95% CI 12 fewer to 1 fewer) per 1000 patients, when the stroke rate is about 2% (22 events per 1000 patients) in the control group.

There is high‐certainty evidence that the use of low‐dose colchicine does not increase the rate of serious adverse events (RR 0.98, 95% CI 0.94 to 1.02; 15,677 participants, 4 studies; I2 = 0%). However, gastrointestinal adverse events were more common under treatment with colchicine (RR 1.68, 95% CI 1.11 to 2.57; 22,185 participants, 10 studies; I2 = 91%).

For all other outcomes assessed, the evidence is of moderate certainty. Colchicine probably results in little to no difference in all‐cause mortality (RR 1.01, 95% CI 0.84 to 1.21; 22,747 participants, 10 studies; I2 = 1%; moderate‐certainty evidence), in cardiovascular mortality (RR 0.94, 95% CI 0.73 to 1.22; 22,271 participants; 8 studies; I2 = 13%; moderate‐certainty evidence), and coronary revascularisation (RR 0.83, 95% CI 0.64 to 1.08; 13,705 participants, 5 studies; I2 = 40%; moderate‐certainty evidence).

There is no evidence about the benefits or harms of colchicine on quality‐of‐life or on the risk of all‐cause hospitalisation.

Authors' conclusions
People with cardiovascular disease using low‐dose colchicine as secondary prevention for at least six months benefit from reduced rates of myocardial infarction and stroke, without an increase in serious adverse events. Moderate‐certainty evidence did not show a benefit from low‐dose colchicine for the risk of mortality (i.e. all‐cause and cardiovascular mortality) or coronary revascularisation rates. Colchicine use was associated with an increased risk of gastrointestinal adverse events, which were typically described as mild and transient in nature. Additional studies are warranted to investigate the benefits and harms of low‐dose colchicine in relevant subgroups and in specific indications, such as long‐term use in individuals with stable coronary artery disease versus limited‐time use following acute coronary syndrome.

Funding
Review author FE was supported by the Margot und Erich Goldschmidt & Peter René Jacobson Foundation. Review author CMS was supported by the Janggen Pöhn Foundation and the Swiss National Science Foundation (MD‐PhD grant Number: 323530_221860).

Registration
This review is based on its protocol, which is available via DOI 10.1002/14651858.CD014808, and a previous review, which is available via DOI 10.1002/14651858.CD011047.pub2.

Author/s:

Fahim Ebrahimi, Ramin Ebrahimi, Maximilian Beer, Christof Manuel Schönenberger, Hannah Ewald, Matthias Briel, Perrine Janiaud, Julian Hirt

Rethinking coronary artery disease: a call to action

Alex Haga — Tue, 08 Apr 2025 13:04:11 +0000

Date Added:

April 8, 2025

Journal/Publication:

The Lancet

Publication Date:

March 31, 2025

URL:

Rethinking coronary artery disease: a call to action

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/S0140-6736(25)00497-0

Keywords

coronary artery disease

heart attack

PMID (1):

40179929

MeSH

coronary artery disease

This commentary summarizes and emphasizes what we have known for years but haven't always practiced. Heart attacks are usually caused by ruptured atheromas, not obstructed arteries. CABGs and PTCA procedures should almost always be used to treat angina. They don't prevent heart attacks. James W. Mold, MD, MPH

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No abstract available.

Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of Randomized Trials

Alex Haga — Mon, 24 Feb 2025 17:49:34 +0000

Date Added:

February 24, 2025

Journal/Publication:

Journal of the American College of Cardiology

Publication Date:

January 17, 2025

URL:

Anticoagulation and Antiplatelet Therapy for Atrial Fibrillation and Stable Coronary Disease: Meta-Analysis of Randomized Trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.jacc.2024.12.030

Keywords

anticoagulants

atrial fibrillation

coronary artery disease

ischemia

platelet aggregation inhibitors

PMID (1):

39918465

MeSH

coronary artery disease

Platelet Aggregation Inhibitors

Atrial Fibrillation* / diagnosis

anticoagulants

A meta-analysis suggesting that patients with atrial fib and stable CAD do better on oral anticoagulants alone than on oral anticoagulants plus an antiplatelet agent. James W. Mold, MD, MPH

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Background: The optimal long-term antithrombotic strategy in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD) remains uncertain. Individual randomized controlled trials (RCTs) had variations in their reported results and were not powered for effectiveness outcomes.

Objectives: This study aimed to pool the results of RCTs comparing the effectiveness and safety of oral anticoagulation (OAC) monotherapy vs OAC plus single antiplatelet therapy (SAPT) in patients with AF and stable CAD.

Methods: We systematically searched PubMed, Embase, and ClinicalTrials.gov until September 09, 2024. The primary effectiveness outcome was a composite of myocardial infarction, ischemic stroke, systemic embolism, or death. The primary safety outcome was major bleeding. We obtained unpublished results from principal investigators of the included RCTs, as needed, to calculate pooled HRs and 95% CIs and to perform prespecified subgroup analyses.

Results: Among 690 screened records, 4 RCTs with 4,092 randomized patients were included (2 using edoxaban, 1 using rivaroxaban, and 1 using any oral anticoagulant; mean age 73.9 years, 20.1% women). The median follow-up durations ranged from 12 to 30 months (overall estimated weighted mean follow-up of 21.9 months). There were no statistically significant differences between OAC monotherapy vs OAC plus SAPT in the primary effectiveness outcome (7.3% vs 8.2%; HR: 0.90; 95% CI: 0.72-1.12), myocardial infarction (1.0% vs 0.7%; HR: 1.51; 95% CI: 0.75-3.04), ischemic stroke (1.9% vs 2.1%; HR: 0.89; 95% CI: 0.57-1.37), all-cause death (4.2% vs 5.3%; HR: 0.94; 95% CI: 0.49-1.80), or cardiovascular death (2.4% vs 3.0%; HR: 0.79; 95% CI: 0.54-1.15). OAC monotherapy was associated with a lower risk of major bleeding than OAC plus SAPT (3.3% vs 5.7%; HR: 0.59; 95% CI: 0.44-0.79). Subgroup analyses did not show significant interactions for effectiveness but suggested that the magnitude of bleeding reduction may be greater among men (Pinteraction = 0.03) and among patients with diabetes mellitus (Pinteraction = 0.04).

Conclusions: In patients with AF and stable CAD, OAC monotherapy, compared with OAC plus SAPT, was not associated with a statistically significant increased risk of ischemic events but resulted in a significantly reduced risk of bleeding.

Author/s:

Sina Rashedi, Mohammad Keykhaei, Alyssa Sato, Philippe Gabriel Steg

Management of Atrial Fibrillation

Erin Blanchette — Mon, 18 Nov 2024 14:34:46 +0000

Date Added:

November 18, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

November 14, 2024

URL:

Management of Atrial Fibrillation

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.19565

Keywords

atrial fibrillation

coronary artery disease

PMID (1):

39541112

MeSH

atrial fibrillation

Atrial Fibrillation* / diagnosis

Platelet Aggregation Inhibitors

Mitral Valve Stenosis

Atrial Appendage

coronary artery disease

heart failure

stroke

2023 guidelines from the ACC/AHA/ACCP/HRS on treatment of patients with atrial fibrillation. James W. Mold, MD, MPH

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Atrial fibrillation has a lifetime prevalence of 15% to 40% and predisposes patients to stroke and cardiac dysfunction. This JAMA Clinical Guidelines Synopsis focuses on recommendations for long-term management of AF, including new paradigms for rhythm control and stroke risk reduction.

Author/s:

Francis J Alenghat, Jason T Alexander, Gaurav A Upadhyay

Initial Invasive or Conservative Strategy for Stable Coronary Disease

John Bayhi — Thu, 02 Apr 2020 18:30:58 +0000

Date Added:

April 2, 2020

Journal/Publication:

The New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

March 30, 2020

Issue:

Online ahead of print

URL:

Initial Invasive or Conservative Strategy for Stable Coronary Disease

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/nejmoa1915922

Keywords

coronary artery disease

cardiac ischemia

cardiac interventions

PMID (1):

32227755

MeSH

myocardial infarction

coronary artery disease

Once again, opening up coronary arteries by whatever invasive method does not prevent heart attacks any better than medical management. CABG and PTCA should be reserved for patients with clinically significant angina unresponsive to medical management and possibly those with critical LAD stenosis or CHF with 3-vessel disease. James W. Mold, MD, MPH

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Background: Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain.

Methods: We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction.

Results: Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, -1.8 percentage points; 95% CI, -4.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32).

Conclusions: Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA ClinicalTrials.gov number, NCT01471522.).

Author/s:

Maron, DJ, Hochman, JS, Reynolds, HR, Bangalore, S, O'Brien, SM, Boden, WE, Chaitman, BR, Senior, R, Lopez-Sendon, J, Alexander, KP, Lopes, RD, Shaw, LJ, Berger, JS, Newman, JD, Sidhu, MS, Goodman, SG, Ruzyllo, W, Gosselin, G, Maggioni, AP, White, HD, Bhargava, B, Min, JK, Mancini, GBJ, Berman, DS, Picard, MH, Kwong, RY, Ali, ZA, Mark, DB, Spertus, JA, Krishnan, MN, Elghamaz, A, Moorthy, N, Hueb, WA, Demkow, M, Mavromatis, K, Bockeria, O, Peteiro, J, Miller, TD, Szwed, H, Doerr, R, Keltai, M, Selvanayagam, JB, Steg, PG, Held, C, Kohsaka, S, Mavromichalis, S, Kirby, R, Jeffries, NO, Harrell, FE Jr, Rockhold, FW, Broderick, S, Ferguson, TB Jr, Williams, DO, Harrington, RA, Stone, GW, Rosenberg, Y, ISCHEMIA Research Group

The Underappreciated Problem of Cardiac Disease in Women

John Bayhi — Wed, 20 Nov 2019 20:25:01 +0000

Date Added:

November 20, 2019

Journal/Publication:

JN Learning

Publisher:

American Medical Association

Publication Date:

November 18, 2019

URL:

The Underappreciated Problem of Cardiac Disease in Women

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Web Page

Keywords

coronary artery disease

coronary microvascular dysfunction

audio

podcast

This is a 10 ½ minute audiotape on the incidence, consequences, evaluation, and management of coronary microvascular dysfunction in women. James W. Mold, MD, MPH

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Barbra Streisand and Noel Bairey Merz, MD, director of the Streisand Women’s Heart Center at Cedars-Sinai in Los Angeles, California, discuss the problem of cardiovascular disease in women and especially coronary microvascular disease, which causes an unusual presentation of cardiac ischemic disease in women.

Primary Prevention of Cardiovascular Disease

John Bayhi — Sat, 05 Oct 2019 14:48:41 +0000

Date Added:

October 5, 2019

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

October 4, 2019

URL:

Primary Prevention of Cardiovascular Disease

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2019.15915

Keywords

CAD

coronary artery disease

guidelines

American Heart Association

American College of Cardiology

CVD

cardiovascular disease

primary prevention

PMID (1):

31584604

The most recent ACC/AHA Guideline regarding primary prevention of coronary artery disease. James W. Mold, MD, MPH

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Atherosclerotic CVD remains the leading cause of death for people of most racial/ethnic groups. In 2010, the AHA suggested metrics of ideal cardiovascular health in 7 domains (blood pressure, physical activity, cholesterol, diet, weight, smoking, and blood glucose). There have since been multiple related guideline updates and scientific statements. In 2017, the ACC/AHA Task Force on Clinical Practice Guidelines commissioned an updated guideline integrating existing and new recommendations into a unified and “user-friendly” document on primary prevention of ASCVD.

Author/s:

Jain, A, Davis, AM

Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation

John Bayhi — Thu, 12 Sep 2019 13:06:34 +0000

Date Added:

September 12, 2019

Journal/Publication:

The American Journal of Cardiology

Publisher:

Elsevier Inc.

Publication Date:

September 15, 2019

Issue:

Volume:

124

Pages:

879-885

URL:

Meta-Analysis of Oral Anticoagulant Monotherapy as an Antithrombotic Strategy in Patients With Stable Coronary Artery Disease and Nonvalvular Atrial Fibrillation

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.amjcard.2019.05.072

Keywords

atrial fibrillation

coronary artery disease

CAD

myocardial infarction

stroke

PMID (1):

31311662

MeSH

atrial fibrillation

coronary artery disease

Percutaneous Coronary Intervention

myocardial infarction

anticoagulants

stroke

This systematic review found that it is unwise to add low-dose aspirin to warfarin in patients with CAD and non-valvular atrial fibrillation (no benefit; more bleeding). James W. Mold, MD, MPH

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Guidelines recommend oral anticoagulant (OAC) monotherapy without antiplatelet therapy (APT) in patients with nonvalvular atrial fibrillation (AF) with stable coronary artery disease (CAD) of >1 year after myocardial infarction or percutaneous coronary intervention. More evidences are required for the safety and efficacy of OAC monotherapy compared with OAC plus APT. PubMed, EMBASE, and Cochrane Database of Systematic Reviews were systematically searched up to February 2019. Nonrandomized studies and randomized clinical trials comparing OAC monotherapy with OAC plus single APT (SAPT) for patients with stable CAD and nonvalvular AF. The primary end point was major adverse cardiovascular events (composite of ischemic or thrombotic events) and secondary outcomes included major bleeding, stroke, all-cause death, and net adverse events (composite of ischemic, thrombotic, or bleeding events). From 6 trials, 8,855 patients were included. There was no significant difference in major adverse cardiovascular event in patients with AF treated using OAC plus SAPT compared with those treated with OAC monotherapy (hazard ratio [HR] 1.09; 95% confidence interval [CI] 0.92 to 1.29). OAC plus SAPT was associated with a significantly higher risk of major bleeding compared with OAC monotherapy (HR 1.61; 95% CI 1.38 to 1.87), as well as in terms of net adverse event (HR 1.21; 95% CI 1.02 to 1.43). There were no significant differences in rates of stroke and all-cause death. In conclusion, in this meta-analysis, OAC monotherapy and OAC plus SAPT treatment showed similar effectiveness, but OAC monotherapy was significantly associated with a lower risk of bleeding compared with OAC plus SAPT in patients with nonvalvular AF and stable CAD.

Author/s:

Lee, SR, Rhee, TM, Kang, DY, Choi, EK, Oh, S, Lip, GYH