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Ozaki AF, Jackevicius CA, Chong A, Sud M, Fang J, Austin PC, Ko DT. Hospital-Level Variation in Ticagrelor Use in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2022; 11:e024835. [PMID: 35766263 PMCID: PMC9333376 DOI: 10.1161/jaha.121.024835] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Despite improved outcomes associated with ticagrelor compared with clopidogrel in acute coronary syndrome (ACS), many studies have demonstrated slow adoption of ticagrelor in the United States because of its increased cost. Less is known about how ticagrelor is adopted when there is no added cost consideration. Our objectives were to determine patterns of use of ticagrelor, hospital‐level adoption of ticagrelor use, and factors associated with its use after ACS in a publicly funded health care system. Methods and Results We conducted a population‐based cohort study including patients (≥65 years) hospitalized with their first ACS from April 2014 to March 2018 in Ontario, Canada. We determined temporal trends in ticagrelor use and hospital‐level adoption of its use post‐ACS discharge. Using hierarchical regression models, we identified significant predictors of ticagrelor use. There were 23 962 patients with ACS (mean age 76.3 years, 59.7% men) hospitalized in 156 hospitals. Overall ticagrelor use increased from 32.6% in 2014/2015 to 51.8% in 2017/2018. There was substantial variation in ticagrelor use post‐ACS across hospitals, with hospital‐specific prescribing rates ranging from 0% to 83.6%. Lower odds of ticagrelor use was associated with advanced age and the presence of comorbidities. Besides patient factors, being admitted to a rurally located hospital more than halved the odds of being prescribed ticagrelor (odds ratio [OR], 0.49; 95% CI, 0.32–0.77). Being managed by a cardiologist during the index ACS hospitalization was associated with higher odds of having a ticagrelor prescription after ACS (OR, 2.80; 95% CI, 2.36–3.33). Conclusions Ticagrelor use rates varied substantially across hospitals and were strongly associated with physician and hospital factors independent of patient characteristics.
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Roh JW, Kim Y, Lee OH, Im E, Cho DK, Choi D. Successful Primary Percutaneous Coronary Intervention without Stenting: Insight from Optimal Coherence Tomography. Yonsei Med J 2022; 63:399-404. [PMID: 35352892 PMCID: PMC8965435 DOI: 10.3349/ymj.2022.63.4.399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/17/2021] [Accepted: 01/13/2022] [Indexed: 11/27/2022] Open
Abstract
For patients with acute myocardial infarction, current management guidelines recommend implantation of a drug-eluting stent, dual antiplatelet therapy (including potent P2Y12 inhibitors) for at least 1 year, and maintenance of life-long antiplatelet therapy. However, a pilot study showed favorable results with antithrombotic therapy without stent implantation when plaque erosion, not definite plaque rupture, was confirmed using optical coherence tomography (OCT), despite the patients having acute myocardial infarction. Here, we present a case where successful primary percutaneous coronary intervention was performed without stenting with the aid of OCT in a patient with ST-elevation myocardial infarction who developed thrombotic total occlusion of the right coronary artery.
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Passacquale G, Sharma P, Perera D, Ferro A. Antiplatelet therapy in cardiovascular disease: current status and future directions. Br J Clin Pharmacol 2022; 88:2686-2699. [PMID: 35001413 PMCID: PMC9303765 DOI: 10.1111/bcp.15221] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Antiplatelet medications remain a cornerstone of therapy for atherosclerotic cardiovascular and cerebrovascular diseases. In primary prevention (patients with cardiovascular risk factors but no documented events, symptoms or angiographic disease), there is little evidence of benefit of any antiplatelet therapy, and such therapy carries the risk of excess bleeding. Where there is documented disease (secondary prevention), stable patients benefit from long-term antiplatelet monotherapy, aspirin being first choice in those with coronary heart disease and clopidogrel in those with cerebrovascular disease; moreover, recent evidence shows that low-dose rivaroxaban in combination with aspirin confers added benefit, in patients with stable cardiovascular and peripheral arterial disease. In patients with acute cerebrovascular disease, aspirin combined with clopidogrel reduces subsequent risk, while in acute coronary syndrome, dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) confers greater protection than aspirin monotherapy, with prasugrel and ticagrelor offering greater antiplatelet efficacy with faster onset of action than clopidogrel. Although greater antiplatelet efficacy is advantageous in preventing thrombotic events, this must be tempered by increased risk of bleeding which may be a particular issue in certain patient groups, as will be discussed. We will also discuss possible future approaches to personalisation of antiplatelet therapy.
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Hays NM, Balsam LB. Commentary: Prevention of saphenous vein graft disease remains elusive. J Card Surg 2022; 37:571-573. [PMID: 34981862 DOI: 10.1111/jocs.16192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 11/28/2022]
Abstract
One-year outcomes of Ticagrelor Antiplatelet Therapy to Reduce Graft Events and Thrombosis (TARGET), a randomized double-blinded clinical trial comparing post-coronary artery bypass surgery antiplatelet therapy with ticagrelor versus aspirin are published in this issue of the Journal. Although the authors did not detect statistically significant differences in their primary outcome (saphenous vein graft patency at 1 year) and major adverse cardiovascular events, their findings must be interpreted with caution given important limitations in the design and execution of the trial.
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Lv H, Wang J, Zhu Y, Hu Z, Wang Z, Qiao M, Jiang T. Association between osteoporosis or osteopenia and taking antiplatelet agents in general US population of NHANES. Front Endocrinol (Lausanne) 2022; 13:945159. [PMID: 36017309 PMCID: PMC9396674 DOI: 10.3389/fendo.2022.945159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/14/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Osteoporosis (OP) and osteopenia are common bone disorders in old age, and lots of patients suffering from OP or osteopenia need to take antiplatelet agents to treat basic diseases. However, clinical data on the link between osteopenia or OP and antiplatelet agents are limited. METHODS Data in this study were collected and screened from the NHANES from 2013 to 2014 and 2017 to 2018. The variables were extracted from interviews and compared between OP or osteopenia participants and normal. The relationship between OP or osteopenia and taking antiplatelet drugs was analyzed by weighted multivariate logistic regression. RESULTS After excluding individuals who were not eligible and had invalid data, we finally identified 894 participants for inclusion in the study. We found a negative association between OP or osteopenia and taking antiplatelet agents (OR = 0.53; 95% CI, 0.33-0.84; p < 0.05). These results did not change on multiple imputations (OR = 0.32, 95% CI, 0.19-0.56; p <0.01). In the subgroup analyses, the associations were more significant in women (OR = 0.18, 95% CI, 0.05-0.62; p <0.05). CONCLUSION This study demonstrated that the association between OP or osteopenia and taking antiplatelet agents was significant. Therefore, it is necessary to confirm the result by extending further research.
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Heinzmann ACA, Coenen DM, Vajen T, Cosemans JMEM, Koenen RR. Combined Antiplatelet Therapy Reduces the Proinflammatory Properties of Activated Platelets. TH OPEN 2021; 5:e533-e542. [PMID: 34901735 PMCID: PMC8651446 DOI: 10.1055/a-1682-3415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/22/2020] [Indexed: 11/17/2022] Open
Abstract
The cause of atherothrombosis is rupture or erosion of atherosclerotic lesions, leading to an increased risk of myocardial infarction or stroke. Here, platelet activation plays a major role, leading to the release of bioactive molecules, for example, chemokines and coagulation factors, and to platelet clot formation. Several antiplatelet therapies have been developed for secondary prevention of cardiovascular events, in which anticoagulant drugs are often combined. Besides playing a role in hemostasis, platelets are also involved in inflammation. However, it is unclear whether current antiplatelet therapies also affect platelet immune functions. In this study, the possible anti-inflammatory effects of antiplatelet medications on chemokine release were investigated using enzyme-linked immunosorbent assay and on the chemotaxis of THP-1 cells toward platelet releasates. We found that antiplatelet medication acetylsalicylic acid (ASA) led to reduced chemokine (CC motif) ligand 5 (CCL5) and chemokine (CXC motif) ligand 4 (CXCL4) release from platelets, while leukocyte chemotaxis was not affected. Depending on the agonist, α
IIb
β
3
and P2Y
12
inhibitors also affected CCL5 or CXCL4 release. The combination of ASA with a P2Y
12
inhibitor or a phosphodiesterase (PDE) inhibitor did not lead to an additive reduction in CCL5 or CXCL4 release. Interestingly, these combinations did reduce leukocyte chemotaxis. This study provides evidence that combined therapy of ASA and a P2Y
12
or PDE3 inhibitor can decrease the inflammatory leukocyte recruiting potential of the releasate of activated platelets.
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Yazaki Y, Nakamura M, Iijima R, Yasuda S, Kaikita K, Akao M, Ako J, Matoba T, Miyauchi K, Hagiwara N, Kimura K, Hirayama A, Matsui K, Ogawa H. Clinical Outcomes of Rivaroxaban Monotherapy in Heart Failure Patients With Atrial Fibrillation and Stable Coronary Disease: Insights From the AFIRE Trial. Circulation 2021; 144:1449-1451. [PMID: 34694893 DOI: 10.1161/circulationaha.121.055374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Singh PP, Borkar DS, Robbins CB, Kim JS, Birnbaum F, Gomez-Caraballo M, Thomas AS, Fekrat S. Systemic antiplatelet agents and anticoagulants in eyes with branch retinal vein occlusion. Ther Adv Ophthalmol 2021; 13:25158414211040894. [PMID: 34497976 PMCID: PMC8419548 DOI: 10.1177/25158414211040894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/03/2021] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this study was to investigate the effect of systemic antiplatelet agents and anticoagulants on the structural and functional outcomes of eyes with branch retinal vein occlusion (BRVO). Methods A retrospective longitudinal cohort study was performed on BRVO patients evaluated at a single tertiary care referral center between 2009 and 2017. Medical records were reviewed for antiplatelet agent and anticoagulant use including aspirin, clopidogrel, warfarin, rivaroxaban, apixaban, or dabigatran prior to BRVO onset. In addition, optical coherence tomography (OCT) parameters, clinical outcomes, and treatment patterns were also recorded. Results A total of 354 BRVO eyes were identified with a mean follow-up time of 36 months. Antiplatelet or anticoagulant use was associated with presence of cystoid macular edema (CME) at presentation after controlling for potential confounding variables in a multivariate logistic regression. Multivariate regression also revealed an association between foveal hemorrhage at presentation and use of antiplatelet or anticoagulant medications. There were no significant differences in visual acuity or prevalence of CME at the final visit in those with antiplatelet/anticoagulant use compared to those not on these agents. Conclusion Although the use of systemic antiplatelet or anticoagulant agents was associated with increased prevalence of CME and foveal hemorrhage at presentation of BRVO, the use of these medications was not associated with different visual or structural outcomes at the final visit.
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Aminoshariae A, Donaldson M, Horan M, Kulild JC, Baur D. Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques. J Endod 2021; 47:1557-1565. [PMID: 34265324 DOI: 10.1016/j.joen.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this study was to review evidence-based recommendations for the safe perioperative management of patients undergoing endodontic microsurgery who are currently taking antiplatelet or anticoagulant medications. Using the PICO (Population, Intervention, Comparison, Outcome) format, the following scientific question was asked: In patients taking anticoagulant or antiplatelet agents, what is the available evidence in the management of endodontic microsurgery? METHODS MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched to identify current recommendations regarding the management of antiplatelet and anticoagulant medications in the context of outpatient dental surgical procedures. Additionally, the authors hand searched the bibliographies of all relevant articles, the gray literature, and textbooks. Because of the lack of clinical studies and evidence on this subject, articles and guidelines from other organizations and association position statements were included. RESULTS Because any minor surgery can become a major surgery, the treating doctor needs to best assess the risk of bleeding, especially if the surgery is anticipated to take longer than 45 minutes. Every patient should be stratified on a case-by-case basis. Consultation with the patient's physician is highly recommended. CONCLUSIONS In order to maximize the effects of these medications (to prevent thrombosis) while minimizing the potential risks (procedural hemorrhage), clinicians should be aware of the best available evidence when considering continuation or discontinuation of antiplatelet and anticoagulant agents perioperatively for endodontic microsurgery. Ideally, a joint effort from an expert panel for microsurgery would be warranted.
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Use of Antiplatelet Agents Decreases the Positive Predictive Value of Fecal Immunochemical Tests for Colorectal Cancer but Does Not Affect Their Sensitivity. J Pers Med 2021; 11:jpm11060497. [PMID: 34205974 PMCID: PMC8227279 DOI: 10.3390/jpm11060497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 05/19/2021] [Accepted: 05/25/2021] [Indexed: 11/17/2022] Open
Abstract
Previous studies have evaluated the effects of antithrombotic agents on the performance of fecal immunochemical tests (FITs) for the detection of colorectal cancer (CRC), but the results were inconsistent and based on small sample sizes. We studied this topic using a large-scale population-based database. Using the Korean National Cancer Screening Program Database, we compared the performance of FITs for CRC detection between users and non-users of antiplatelet agents and warfarin. Non-users were matched according to age and sex. Among 5,426,469 eligible participants, 768,733 used antiplatelet agents (mono/dual/triple therapy, n = 701,683/63,211/3839), and 19,569 used warfarin, while 4,638,167 were non-users. Among antiplatelet agents, aspirin, clopidogrel, and cilostazol ranked first, second, and third, respectively, in terms of prescription rates. Users of antiplatelet agents (3.62% vs. 4.45%; relative risk (RR): 0.83; 95% confidence interval (CI): 0.78–0.88), aspirin (3.66% vs. 4.13%; RR: 0.90; 95% CI: 0.83–0.97), and clopidogrel (3.48% vs. 4.88%; RR: 0.72; 95% CI: 0.61–0.86) had lower positive predictive values (PPVs) for CRC detection than non-users. However, there were no significant differences in PPV between cilostazol vs. non-users and warfarin users vs. non-users. For PPV, the RR (users vs. non-users) for antiplatelet monotherapy was 0.86, while the RRs for dual and triple antiplatelet therapies (excluding cilostazol) were 0.67 and 0.22, respectively. For all antithrombotic agents, the sensitivity for CRC detection was not different between users and non-users. Use of antiplatelet agents, except cilostazol, may increase the false positives without improving the sensitivity of FITs for CRC detection.
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Ye C, Zhang Q, Chao Y, Yin C. Case Report: Effective Treatment for Acute Chlorpyrifos Poisoning Complicated by a Non-ST-Segment Elevation Myocardial Infarction. Front Cardiovasc Med 2021; 8:623708. [PMID: 33996934 PMCID: PMC8119778 DOI: 10.3389/fcvm.2021.623708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Acute myocardial infarction (AMI) is a rare complication of acute organophosphorus pesticide poisoning. Although chlorpyrifos has been widely used as an organophosphate insecticide, a few cases of AMI complicated by chlorpyrifos poisoning have been reported thus far. Hence, a suitable treatment strategy remains to be explored. Case Presentation: Based on the clinical manifestations, medical history, results of an auxiliary examination, and serum biomarkers, a 65-year-old male farmer with complaints of nausea, vomiting, chest tightness, and pain was clearly diagnosed as having a severe chlorpyrifos self-poisoning with acute non-ST-segment elevation MI. Because the patient and his family confirmedly refused a coronary intervention, conservative treatment was used instead. It should be noted that there were some conflicts of the management for chlorpyrifos poisoning and AMI. Although rapid atropinization would contribute to the relief of muscarinic symptoms, it would also lead to an increased heart rate and myocardial oxygen consumption in AMI. Furthermore, the reduction of platelet aggregation, which is necessary for coronary recanalization of an AMI patient, is known to aggravate the gastrointestinal injury caused by poisoning. In this case, these conflicts were properly addressed, which led to an excellent effect and prognosis of the patient. Conclusions: To our knowledge, this is the first case report of acute chlorpyrifos poisoning with AMI. It is emphasized that patients with chest pain or coronary heart disease should be treated with atropine more cautiously because of the possible AMI. Moreover, proper resolution of conflicts in the management for chlorpyrifos poisoning and AMI played contributing roles in patient improvement.
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Santos CMD, Prada L, David C, Costa J, Ferreira JJ, Pinto FJ, Caldeira D. Antithrombotic Therapy Recommendations in the European Society of Cardiology Guidelines: How Robust Are the Randomized Controlled Trials Underpinning Them? TH OPEN 2021; 5:e125-e133. [PMID: 33870076 PMCID: PMC8046518 DOI: 10.1055/s-0041-1725043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 01/18/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction Criticisms have been raised against the sole use of p -value in interpreting results from randomized controlled trials (RCTs). Additional tools have been suggested, like the fragility index (FI), a measure of a trial's robustness/fragility, and derivative measures. The FI is the minimum number of patients who would have to be converted from nonevents to events, in the group with the least events, for a result to lose statistical significance. Objective This study aimed to evaluate RCT supporting European Society of Cardiology (ESC) guidelines regarding antithrombotics, using the FI and FI-related measures. Methods FI, fragility quotient (FQ), and FI minus LTF lost to follow-up (FI - LTF) were calculated for the RCT underpinning recommendations regarding antithrombotic therapy from the updated ESC guidelines. LTF was compared with FI. Results were calculated for the total group of studies, as per guideline and as per recommendation type. Results Overall, 61 studies were included. The median FI was 24.5 (interquartile range [IQR]: 9.0-60.0) and median FQ was 0.0035 (IQR: 0.0019-0.0056). Median FI - LTF was 2.0 (IQR: 0.0-38.0). Twenty (32.8%) of the studies had one primary or main safety outcome with LTF exceeding FI. Peripheral arterial disease guideline and chronic coronary syndrome guideline had the lowest (2.5; IQR: 1.8-3.3) and the highest (48.5; IQR: 23.8-73.0) FI, respectively. Conclusion The median FI suggests robustness of clinical trials evaluating antithrombotic drugs cited in the guidelines, but about one-third of them had LTF larger than FI. This emphasizes the need for assessing trials' robustness when constructing guidelines.
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Joshi RS, Bandgar RR. Incidence of Non-Traumatic Subconjunctival Hemorrhage in an Indian Rural Population. Clin Ophthalmol 2021; 15:183-188. [PMID: 33488067 PMCID: PMC7815081 DOI: 10.2147/opth.s277428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/07/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose To determine the incidence of non-traumatic subconjunctival hemorrhage (NTSH) in Indian rural population and analyze the associated risk factors. Methods The study included patients diagnosed having subconjunctival hemorrhage (SCH) who attended the out-patient department (OPD) of ophthalmology. Demographic characteristics of subjects included age, gender, medical and ocular history, and location of hemorrhage. Results The incidence rate of NTSH in this study was 3.07 per 1000 patients per year attending OPD. The men to women ratio for NTSH was 1.26 (95% CI). The commonest site of presentation was nasal side (n=36, 51.4%). Right eye (n= 37, 54.3%) was affected more than the left eye (n=28, 40%). The analysis showed 24 patients (34.3%) did not have any etiological factor attributable to SCH. Conjunctivochalasis (CCH) was associated in 15 patients (21.4%). An antiplatelet agent was associated with SCH in 7 patients (10%). Other factors associated with SCH were hypertension, leukemia, and anemia (n=6, 8.6%). Conclusion This study indicates that NTSH occurs in 3 out of 1000 individuals per year in the rural population presenting to the OPD. Nasal conjunctiva was commonly involved. CCH was associated with 15 patients. Use of antiplatelet agents, hypertension and blood disorders are associated with the risk of NTSH. Patients presenting for the first time with NTSH should be screened for systemic etiological factors.
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Ye F, Li J, Wang T, Lan K, Li H, Yin H, Guo T, Zhang X, Yang T, Liang J, Wu X, Li Q, Sheng W. Efficacy and Safety of Antiplatelet Agents for Adult Patients With Ischemic Moyamoya Disease. Front Neurol 2021; 11:608000. [PMID: 33519687 PMCID: PMC7844095 DOI: 10.3389/fneur.2020.608000] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022] Open
Abstract
Background: The use of antiplatelet agents in ischemic moyamoya disease (MMD) is controversial. This study aimed to investigate the effectiveness and safety of antiplatelet therapy compared with conservative treatment and surgical revascularization in ischemic MMD patients. Methods: Ischemic MMD patients were retrospectively enrolled from eight clinical sites from January 2013 to December 2018. Follow-up was performed through clinical visits and/or telephone interviews from first discharge to December 2019. The primary outcome was the episodes of further ischemic attacks, and the secondary outcome was the individual functional status. Risk factors for future stroke were identified by the LASSO-Cox regression model. Propensity score matching was applied to assemble a cohort of patients with similar baseline characteristics using the TriMatch package. Results: Among 217 eligible patients, 159 patients were included in the analyses after a 1:1:1 propensity score matching. At a mean follow-up of 33 months, 12 patients (7.5%) developed further incident cerebral ischemic events (surgical:antiplatelet:conservative = 1:3:8; p = 0.030), 26 patients (16.4%) developed a poor functional status (surgical:antiplatelet:conservative = 7:12:7; p = 0.317), and 3 patients (1.8%) died of cerebral hemorrhage (surgical:antiplatelet:conservative = 1:2:0; p = 0.361). The survival curve showed that the risk of further cerebral ischemic attacks was lowest with surgical revascularization, while antiplatelet therapy was statistically significant for preventing recurrent risks compared with conservative treatment (χ2 = 8.987; p = 0.011). No significant difference was found in the functional status and bleeding events. The LASSO-Cox regression model revealed that a family history of MMD (HR = 6.93; 95% CI: 1.28-37.52; p = 0.025), a past history of stroke or transient ischemic attack (HR = 4.35; 95% CI: 1.09-17.33; p = 0.037), and treatment (HR = 0.05; 95% CI: 0.01-0.32; p = 0.001) were significantly related to the risk of recurrent strokes. Conclusions: Antiplatelet agents were effective and safe in preventing further cerebral ischemic attacks in adult patients with ischemic MMD. They may be a replacement therapy for patients with surgical contraindications and for patients prior to revascularization.
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Validation of an HPLC-MS/MS Method for the Determination of Plasma Ticagrelor and Its Active Metabolite Useful for Research and Clinical Practice. Molecules 2021; 26:molecules26020278. [PMID: 33429903 PMCID: PMC7827928 DOI: 10.3390/molecules26020278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022] Open
Abstract
Ticagrelor is an antiplatelet agent which is extensively metabolized in an active metabolite: AR-C124910XX. Ticagrelor antagonizes P2Y12 receptors, but recently, this effect on the central nervous system has been linked to the development of dyspnea. Ticagrelor-related dyspnea has been linked to persistently high plasma concentrations of ticagrelor. Therefore, there is a need to develop a simple, rapid, and sensitive method for simultaneous determination of ticagrelor and its active metabolite in human plasma to further investigate the link between concentrations of ticagrelor, its active metabolite, and side effects in routine practice. We present here a new method of quantifying both molecules, suitable for routine practice, validated according to the latest Food and Drug Administration (FDA) guidelines, with a good accuracy and precision (<15% respectively), except for the lower limit of quantification (<20%). We further describe its successful application to plasma samples for a population pharmacokinetics study. The simplicity and rapidity, the wide range of the calibration curve (2–5000 µg/L for ticagrelor and its metabolite), and high throughput make a broad spectrum of applications possible for our method, which can easily be implemented for research, or in daily routine practice such as therapeutic drug monitoring to prevent overdosage and occurrence of adverse events in patients.
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Conti V, Corbi G, Manzo V, Sellitto C, Iannello F, Esposito S, De Bellis E, Iannaccone T, Filippelli A. The role of pharmacogenetics for antithrombotic therapy management: new achievements and barriers yet to overcome. Curr Med Chem 2020; 28:6675-6703. [PMID: 33390104 DOI: 10.2174/0929867328666201231124715] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/30/2020] [Accepted: 11/14/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Pharmacogenetics investigates the response to pharmacological treatments based on individual genetic background. Actually, numerous pharmacogenetic tests help to predict the response to drugs used in different medical areas, contributing to the so-called personalized medicine. OBJECTIVE This review aims to update the available data on the genotype-guided treatment with both the anticoagulant and antiplatelet agents. Moreover, it shed light on the pitfalls still contrasting the implementation of cardiovascular pharmacogenetics. METHODS A review of the literature on the studies investigating the effects of the genotype-guided anticoagulant and antiplatelet treatment was performed. RESULTS Considering the large use of antithrombotic drugs, pharmacogenetics has particular importance in this field. Several polymorphisms influence the response to both anticoagulant and antiplatelet agents, and tests, based on their identification, are now available. CONCLUSIONS Recent randomized clinical trials demonstrated that pharmacogenetics might successfully contribute to optimizing the antiplatelet therapy also in patients particularly complicated to treat. However, despite accumulating evidence on the utility and feasibility of some pharmacogenetics tests, several barriers still contrast their implementation into clinical practice.
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Ramondou P, Hersant J, Fouquet O, Sempore WY, Abraham P, Henni S. Current-Induced Vasodilation Specifically Detects, and Correlates With the Time Since, Last Aspirin Intake: An Interventional Study of 830 Patients. J Cardiovasc Pharmacol Ther 2020; 26:269-278. [PMID: 33161777 DOI: 10.1177/1074248420971165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Galvanic current-induced vasodilation (CIV) is impaired in patients under low-dose aspirin (ASA; ≤ 500 mg/day), but potential covariates and the impact of the time since the last ASA intake are unknown. OBJECTIVES We used tissue viability imaging (TiVi) in patients at risk of cardiovascular disease and examined its association with self-reported treatments. PATIENTS/METHODS We recorded the age, gender, height, weight, smoking status, and use of 14 different drug categories in 822 patients either with known peripheral artery disease or at risk thereof. The difference between TiVi arbitrary units (TAUs) where stimulation was applied and an adjacent skin area was recorded, as well as the time since the last ASA intake. Step-by-step regression analysis was used to determine the factors that affect CIV amplitude. RESULTS AND CONCLUSIONS CIV was 28.2 ± 22.9 vs. 14.6 ± 18.0 TAUs (P < 0.001) in patients treated with ASA (n = 287) and not treated with ASA (n = 535), respectively. The main determinants of CIV amplitude, by order of importance, were: aspirin intake, diabetes mellitus, age, and male sex. In ASA-treated patients, the main determinants were diabetes mellitus, time since the last ASA intake, male gender, and age. Non-invasive determination of the physiological effects of low-dose ASA is feasible in routine clinical practice. It could be a clinical approach to provide objective evidence of ASA intake, and potentially could be used to test adherence to treatment in ASA-treated patients.
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Guan S, Xu X, Li Y, Li J, Guan M, Wang X, Jing Q, Huo Y, Han Y. Impact of Diabetes Mellitus on Antithrombotic Management Patterns and Long-Term Clinical Outcomes in Patients With Acute Coronary Syndrome: Insights From the EPICOR Asia Study. J Am Heart Assoc 2020; 9:e013476. [PMID: 33164633 PMCID: PMC7763726 DOI: 10.1161/jaha.119.013476] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Long‐term use of antiplatelet agents after acute coronary syndrome in diabetic patients is not well known. Here, we describe antiplatelet use and outcomes in such patients enrolled in the EPICOR Asia (Long‐Term Follow‐up of Antithrombotic Management Patterns in Acute Coronary Syndrome Patients in Asia) registry. Methods and Results EPICOR Asia is a prospective, observational study of 12 922 patients with acute coronary syndrome surviving to discharge, from 8 countries/regions in Asia. The present analysis included 3162 patients with diabetes mellitus (DM) and 9602 patients without DM. The impact of DM on use of antiplatelet agents and events (composite of death, myocardial infarction, and stroke, with or without any revascularization; individual components, and bleeding) was evaluated. Significant baseline differences were seen between patients with DM and patients without DM for age, sex, body mass index, cardiovascular history, angiographic findings, and use of percutaneous coronary intervention. At discharge, ≈90% of patients in each group received dual antiplatelet therapy. At 2‐year follow‐up, more patients with DM tended to still receive dual antiplatelet therapy (60% versus 56%). DM was associated with increased risk from ischemic but not major bleeding events. Independent predictors of the composite end point of death, myocardial infarction, and stroke in patients with DM were age ≥65 years and use of diuretics at discharge. Conclusions Antiplatelet agent use is broadly comparable in patients with DM and patients without DM, although patients with DM are more likely to be on dual antiplatelet therapy at 2 years. Patients with DM are at increased risk of ischemic events, suggesting an unmet need for improved antithrombotic treatment. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01361386.
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Ribeiro-Filho J, Yahouédéhou SCMA, Pitanga TN, Santana SS, Adorno EV, Barbosa CG, Ferreira JRD, Pina ETG, Neres JSDS, Leite IPR, Lyra IM, Goncalves MS. An evaluation of ticagrelor for the treatment of sickle cell anemia. Expert Rev Hematol 2020; 13:1047-1055. [PMID: 32972255 DOI: 10.1080/17474086.2020.1817736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Ticagrelor is an antiplatelet agent approved for the treatment of patients with an acute coronary syndrome or a history of myocardial infarction. Considering the evidence demonstrating that ticagrelor-mediated inhibition of platelet activation and aggregation have beneficial effects in the treatment of thrombotic conditions, clinical studies have been conducted to evaluate the use of this drug for the treatment of sickle cell disease (SCD), demonstrating satisfactory tolerability and safety. AREAS COVERED Clinical investigation has characterized the pharmacokinetic and pharmacodynamical profile, as well as the efficacy and safety of ticagrelor to prevent painful vaso-occlusive crisis (painful episodes and acute chest syndrome) in SCD patients. EXPERT OPINION While phase 1 and 2 clinical trials demonstrated satisfactory tolerability and safety, the conclusion of phase 3 clinical trials is crucial to prove the efficacy of ticagrelor as a therapeutic option for the treatment of SCD. Thus, it is expected that ticagrelor, especially in combination with other drugs, will improve the clinical profile and quality of life of patients with SCD.
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Management of Bleeding Events Associated with Antiplatelet Therapy: Evidence, Uncertainties and Pitfalls. J Clin Med 2020; 9:jcm9072318. [PMID: 32708228 PMCID: PMC7408739 DOI: 10.3390/jcm9072318] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022] Open
Abstract
Bleeding complications are common in patients treated with antiplatelet agents (APA), but their management relies on poor evidence. Therefore, practical guidelines and guidance documents are mainly based on expert opinion. The French Working Group on Perioperative Haemostasis provided proposals in 2018 to enhance clinical decisions regarding the management of APA-treated patients with a bleeding event. In light of these proposals, this review discusses the evidence and uncertainties of the management of patients with a bleeding event while on antiplatelet therapy. Platelet transfusion is the main option as an attempt to neutralise the effect of APA on primary haemostasis. Nevertheless, efficacy of platelet transfusion to mitigate clinical consequences of bleeding in patients treated with APA depends on the type of antiplatelet therapy, the time from the last intake, the mechanism (spontaneous versus traumatic) and site of bleeding and the criteria of efficacy (in vitro, in vivo). Specific antidotes for APA neutralisation are needed, especially for ticagrelor, but are not available yet. Despite the amount of information that platelet function tests are expected to give, little data support the clinical benefit of using such tests for the management of bleeding events in patients treated or potentially treated with APA.
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Laborde C, Barben J, Mihai AM, Nuss V, Vovelle J, d’Athis P, Jouanny P, Putot A, Manckoundia P. Impact of Age, Multimorbidity and Frailty on the Prescription of Preventive Antiplatelet Therapy in Older Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124541. [PMID: 32599756 PMCID: PMC7344555 DOI: 10.3390/ijerph17124541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/22/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022]
Abstract
Platelet aggregation inhibitors (PAI) have widely proven their efficiency for the prevention of ischemic cardiovascular events. We aimed to describe PAI prescription in an elderly multimorbid population and to determine the factors that influence their prescription, including the impact of age, comorbidities and frailty, evaluated through a comprehensive geriatric assessment. This cross-sectional study included all patients admitted to the acute geriatric department of a university hospital from November 2016 to January 2017. We included 304 consecutive hospitalized patients aged 88.7 ± 5.5 years. One third of the population was treated with PAI. A total of 133 (43.8%) patients had a history of cardiovascular disease, 77 of whom were on PAI. For 16 patients, no indication was identified. The prescription or the absence of PAI were consistent with medical history in 61.8% of patients. In the multivariate analysis, among the 187 patients with an indication for PAI, neither age (odds ratio (OR) = 1.00; 95% confidence interval (CI): [0.91-1.08], per year of age), nor comorbidities (OR = 0.97; 95% CI: [0.75-1.26], per point of Charlson comorbidity index), nor cognitive disorders (OR = 0.98; 95% CI [0.91-1.06] per point of Mini Mental State Examination), nor malnutrition (OR = 1.07; 95% CI [0.96-1.18], per g/L of albumin) were significantly associated with the therapeutic decision. PAI were less prescribed in primary prevention situations, in patients taking anticoagulants and in patients with a history of bleeding. In conclusion, a third of our older comorbid population of inpatients was taking PAI. PAI prescription was consistent with medical history for 61.8% of patients. Age, multimorbidity and frailty do not appear to have a significant influence on therapeutic decision-making. Further research is needed to confirm such a persistence of cardiovascular preventive strategies in frail older patients from other settings and to assess whether these strategies are associated with a clinical benefit in this specific population.
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Png WY, Wong XY, Kwan YH, Lin YY, Tan DSY. Perspective on CYP2C19 genotyping test among patients with acute coronary syndrome - a qualitative study. Future Cardiol 2020; 16:655-662. [PMID: 32524842 DOI: 10.2217/fca-2020-0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Identify factors patients consider regarding CYP2C19 genotyping test to guide choice of antiplatelet therapy. Patients & methods: Patient's perception and attitude toward use of CYP2C19 genotyping test was gathered according to an interview guide. Thematic analysis was conducted. Results: A total of 14 patients were interviewed. The main factors found to influence uptake of CYP2C19 genotyping test are, convenience of genotyping test (n = 4), physician's recommendation (n = 11), prior explanation of genetic testing by medical personnel (n = 5) and inclination toward clopidogrel, with three sub-factors; less frequent dosing (n = 3), lower cost (n = 7) and lower risk of bleeding (n = 9). Conclusion: This study provided the information needed to develop a discrete choice experiment to empirically quantify patients' preference and willingness to pay for genetic testing and to simulate uptake.
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Hecht JP, LaDuke ZJ, Cain-Nielsen AH, Hemmila MR, Wahl WL. Effect of Preinjury Oral Anticoagulants on Outcomes Following Traumatic Brain Injury from Falls in Older Adults. Pharmacotherapy 2020; 40:604-613. [PMID: 32515829 DOI: 10.1002/phar.2435] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Warfarin has been the oral anticoagulant of choice for the treatment of thromboembolic disease. However, upward of 50% of all new anticoagulant prescriptions are now for direct oral anticoagulants (DOAC). Despite this, outcome data evaluating preinjury anticoagulants remain scarce following traumatic brain injury (TBI). Our study objective is to determine the effects of preinjury anticoagulation on outcomes in older adults with TBI. METHODS Patient data were obtained from 29 level 1 and 2 trauma centers from 2012 to June 30, 2018. Overall, 8312 patients who were aged 65 years or older, suffering a ground level fall, and with an Abbreviated Injury Scale (AIS) head score of ≥ 3 were identified. Patients were excluded if they presented with no signs of life or a traumatic mechanism besides ground level fall. Statistical comparisons were made using multivariable analyses with anticoagulant/antiplatelet use as the independent variable. RESULTS Of the total patients with TBI, 3293 were on antiplatelet agents (AP), 669 on warfarin, 414 on warfarin + AP, 188 on DOACs, 116 on DOAC + AP, and 3632 on no anticoagulant. There were 185 (27.7%) patients on warfarin and 43 (22.9%) on a DOAC with a combined outcome of mortality or hospice as compared to 575 (15.8%) in the no anticoagulant group (p<0.001). After adjusting for patient factors, there was an increased risk of mortality or hospice in the warfarin (OR 1.60; 95% CI 1.27-2.01) and DOAC group (OR 1.67; 95% CI 1.07-2.59) as compared to no anticoagulant. Warfarin + AP was associated with an increased risk of mortality or hospice (OR 1.61; 95% CI 1.18-2.21) that was not seen with DOAC + AP (OR 0.93; 95% CI 0.46-1.87) as compared to no anticoagulant. CONCLUSIONS In older adults with TBI, preinjury treatment with warfarin or DOACs resulted in an increased risk of mortality or hospice whereas preinjury AP therapy did not increase risk. Future studies are needed with larger sample sizes to directly compare TBI outcomes associated with preinjury warfarin versus DOAC use.
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Hannachi N, Ogé-Ganaye E, Baudoin JP, Fontanini A, Bernot D, Habib G, Camoin-Jau L. Antiplatelet Agents Have a Distinct Efficacy on Platelet Aggregation Induced by Infectious Bacteria. Front Pharmacol 2020; 11:863. [PMID: 32581813 PMCID: PMC7291881 DOI: 10.3389/fphar.2020.00863] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 05/26/2020] [Indexed: 02/01/2023] Open
Abstract
Platelets are the cornerstone of hemostasis. However, their exaggerated aggregation induces deleterious consequences. In several diseases, such as infectious endocarditis and sepsis, the interaction between platelets and bacteria leads to platelet aggregation. Despite platelet involvement, no antiplatelet therapy is currently recommended in these infectious diseases. We aimed here, to evaluate, in vitro, the effect of antiplatelet drugs on platelet aggregation induced by two of the bacterial pathogens most involved in infectious endocarditis, Staphylococcus aureus and Streptococcus sanguinis. Blood samples were collected from healthy donors (n = 43). Treated platelet rich plasmas were incubated with three bacterial strains of each species tested. Platelet aggregation was evaluated by Light Transmission Aggregometry. CD62P surface exposure was evaluated by flow cytometry. Aggregate organizations were analyzed by scanning electron microscopy. All the strains tested induced a strong platelet aggregation. Antiplatelet drugs showed distinct effects depending on the bacterial species involved with different magnitude between strains of the same species. Ticagrelor exhibited the highest inhibitory effect on platelet activation (p <0.001) and aggregation (p <0.01) induced by S. aureus. In the case of S. sanguinis, platelet activation and aggregation were better inhibited using the combination of both aspirin and ticagrelor (p <0.05 and p <0.001 respectively). Aggregates ultrastructure and effect of antiplatelet drugs observed by scanning electron microscopy depended on the species involved. Our results highlighted that the effect of antiplatelet drugs depended on the bacterial species involved. We might recommend therefore to consider the germ involved before introduction of an optimal antiplatelet therapy.
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Chrysohoou C, Magkas N, Antoniou CK, Manolakou P, Laina A, Tousoulis D. The Role of Antithrombotic Therapy in Heart Failure. Curr Pharm Des 2020; 26:2735-2761. [PMID: 32473621 DOI: 10.2174/1381612826666200531151823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.
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