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Sinha T, Riaz A, Rawat A, Phoo CN, Nageye ME, Chaudhari SS, Wei CR, Amin A. Comparison of Effectiveness and Safety of Dual Antiplatelet Therapy (DAPT) With Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients With Mild-to-Moderate Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e58909. [PMID: 38800328 PMCID: PMC11118889 DOI: 10.7759/cureus.58909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
The aim of this meta-analysis was to assess the effectiveness and safety of the combination of clopidogrel and aspirin in patients with mild ischemic stroke or transient ischemic attack (TIA). The methodologies employed in this meta-analysis strictly followed the commonly used reporting formats for systematic reviews and meta-analyses. The methodologies employed in this meta-analysis strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Until March 25, 2024, we conducted thorough searches on PubMed, EMBASE (Excerpta Medica Database), and the Cochrane Library to locate studies investigating the efficacy and safety of dual antiplatelet therapy (DAPT) in patients with mild or moderate stroke or TIA. Outcomes assessed in this meta-analysis included stroke (including ischemic stroke and hemorrhagic stroke), myocardial infarction, all bleeding events, and moderate to severe bleeding events. A total of 12 studies were included in this meta-analysis. The total number of enrolled patients across these studies was 35,369, with 16,957 receiving DAPT and 18,412 receiving aspirin monotherapy. The risk of developing stroke was significantly lower in patients receiving the combination of clopidogrel and aspirin compared to the aspirin monotherapy group (relative risk (RR): 0.77, 95% confidence interval (CI): 0.72 to 0.83, p-value<0.0001). No significant differences were there in terms of all bleeding events (RR: 1.37, 95% CI: 0.92 to 2.04, p-value: 0.12) and moderate to severe bleeding events (RR: 1.18, 95% CI: 0.86 to 1.63, p-value: 0.30). These findings highlight the importance of carefully weighing the potential benefits against the risks, especially in clinical decision-making for patients with TIA or ischemic stroke. Further research is warranted to elucidate optimal strategies for balancing stroke prevention with bleeding risk mitigation in this patient population.
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Affiliation(s)
- Tanya Sinha
- Medical Education, Tribhuvan University, Kirtipur, NPL
| | - Areeba Riaz
- Medicine, Quiad-e-Azam Medical College, Bahawalpur, PAK
| | - Anurag Rawat
- Interventional Cardiology, Himalayan Institute of Medical Sciences, Dehradun, IND
| | - Chaw N Phoo
- Internal Medicine, University of Medicine, Mandalay, Mandalay, MMR
| | - Maymona E Nageye
- Internal Medicine - Pediatrics, Avalon University School of Medicine, Willemstad, CUW
| | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
| | - Adil Amin
- Cardiology, Pakistan Navy Ship Shifa, Karachi, PAK
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Deguchi I, Osada T, Takahashi S. Efficacy of Treatment with and without Initial Clopidogrel Loading in Branch Atheromatous Disease. Intern Med 2023; 62:2959-2964. [PMID: 36889709 PMCID: PMC10641194 DOI: 10.2169/internalmedicine.1209-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/01/2023] [Indexed: 03/09/2023] Open
Abstract
Objective Despite aggressive therapeutic interventions during the acute phase of branch atheromatous disease (BAD)-type cerebral infarction, many patients, even those with a mild condition at the onset, experience neurological deterioration after hospitalization and develop serious deficits. We compared the therapeutic efficacy of multiple antithrombotic therapies for BAD between patients who received a clopidogrel loading dose (loading group; LG) and those without loading (non-loading group; NLG). Patients Between January 2019 and May 2022, patients with BAD-type cerebral infarction in the lenticulostriate artery admitted within 24 h of the onset were recruited. This study included 95 consecutive patients who received combination argatroban and dual antiplatelet therapy (aspirin and clopidogrel). Methods Patients were classified into the LG and NLG according to whether or not a loading dose of clopidogrel (300 mg) had been administered on admission. Changes in neurological severity [National Institutes of Health Stroke Scale (NIHSS) score] during the acute phase were retrospectively evaluated. Results There were 34 (36%) and 61 (64%) patients in the LG and NLG, respectively. On admission, the median NIHSS score was similar between the groups [LG: 2.5 (2-4) vs. NLG: 3 (2-4), p=0.771]. At 48 h following admission, the median NIHSS scores were 1 (0.25-4), and 2 (1-5) in the LG and NLG, respectively (p=0.045). Early neurological deterioration (END; defined as worsening of the NIHSS score by ≥4 points at 48 h after admission) occurred in 3% of LG and 20% of NLG patients (p=0.028). Conclusion Administration of a clopidogrel loading dose with combination antithrombotic therapy for BAD reduced END.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | - Takashi Osada
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Japan
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Deguchi I, Takahashi S. Pathophysiology and Optimal Treatment of Intracranial Branch Atheromatous Disease. J Atheroscler Thromb 2023; 30:701-709. [PMID: 37183021 PMCID: PMC10322737 DOI: 10.5551/jat.rv22003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Intracranial branch atheromatous disease (BAD) is a pathological condition characterized by the occlusion of a relatively large perforating branch (700-800 µm) near the orifice of a parent artery due to atherosclerotic plaque-based thrombus (microatheroma). BAD is refractory to treatment and follows a course of progressive exacerbation, especially motor paralysis. Uniform treatment for common atherothrombotic cerebral infarction or lacunar infarction does not prevent the progressive exacerbation of BAD, and consequently affects functional prognosis. To date, various combinations of treatments have been investigated and proposed to attenuate the worsening symptoms of BAD. However, no therapy with established efficacy is yet available for BAD. Since it is the most difficult condition to treat in the area of cerebral infarction, the establishment of optimal treatment methods for BAD is keenly awaited. This review presents an overview of the acute treatments available for BAD and discusses the prospects for optimal treatment.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan
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Arnachellen D, Xulu KR, Pillay K, Augustine TN. Breast Tumor Cells Evade the Cytotoxic Action of Anastrozole, Aspirin, and Clopidogrel Cocktail. MICROSCOPY AND MICROANALYSIS : THE OFFICIAL JOURNAL OF MICROSCOPY SOCIETY OF AMERICA, MICROBEAM ANALYSIS SOCIETY, MICROSCOPICAL SOCIETY OF CANADA 2023; 29:1205-1219. [PMID: 37749673 DOI: 10.1093/micmic/ozad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 02/07/2023] [Accepted: 02/22/2023] [Indexed: 09/27/2023]
Abstract
Globally, breast cancer is among the most frequently diagnosed and common cause of death among women. Aromatase inhibitors, such as anastrozole, are one of the first-line therapies used in the treatment of breast cancer in postmenopausal women; however, thromboembolic complications are common. Thus, this study investigated the combined effects of anastrozole and antiplatelet therapies, aspirin and clopidogrel, on breast cancer cytotoxicity and survival in vitro. Breast cancer cell lines (MCF-7 and T47D) were treated with varying Cmax concentrations of anastrozole and/or antiplatelet therapies for 24 h. A wound-healing scratch assay was used to measure migration and the WST-1 assay for cellular proliferation. An autophagy/cytotoxicity dual staining kit was used to assay cell death and survival. Changes in cell morphology were assessed using scanning electron microscopy. Data were analyzed with Statistica software. Our findings showed that sub-phenotypic differences exist between the luminal-A breast cancer cell lines, with T47D cells being more aggressive than MCF-7 cells. Cellular proliferation and migration responded in a dose-dependent manner for the different treatment groups. Notably, anastrozole combined with aspirin and clopidogrel mediated higher levels of cell survival than each agent individually, with autophagy levels being significantly increased in comparison to that induced with antiplatelet therapy alone.
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Affiliation(s)
- Derushka Arnachellen
- School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa
| | - Kutlwano R Xulu
- School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa
| | - Kiveshen Pillay
- School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa
| | - Tanya N Augustine
- School of Anatomical Sciences, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193, Johannesburg, South Africa
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Feng WH, Chang YC, Lin YH, Chen HL, Chen CY, Lin TH, Lin TC, Chang CT, Kuo HF, Chang HM, Chu CS. P2Y12 Inhibitor Monotherapy versus Conventional Dual Antiplatelet Therapy in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: A Meta-Analysis. Pharmaceuticals (Basel) 2023; 16:232. [PMID: 37259380 PMCID: PMC9958698 DOI: 10.3390/ph16020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/20/2023] [Accepted: 01/27/2023] [Indexed: 08/08/2023] Open
Abstract
P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) in the modern era. Clinical trials have shown that it could lower the risk of bleeding complications without increased ischemic events as compared to standard dual antiplatelet therapy (DAPT). However, the efficacy and safety of this novel approach among patients with acute coronary syndrome (ACS) are controversial because they have a much higher risk for recurrent ischemic events. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with ACS. We conducted a meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12-month DAPT in ACS patients who underwent PCI with stent implantation. PubMed, Embase, the Cochrane library database, ClinicalTrials.gov, and other three websites were searched for data from the earliest report to July 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause mortality, myocardial infarction, stent thrombosis, or stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE), defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. Five randomized controlled trials with a total of 21,034 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy as compared with standard DAPT(OR: 0.59, 95% CI: 0.46-0.75, p < 0.0001) without increasing the risk of MACCE (OR: 0.98, 95% CI: 0.86-1.13, p = 0.82). The NACE was favorable in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.82, 95% CI: 0.73-0.93, p = 0.002). Of note, the overall clinical benefit of P2Y12 inhibitor monotherapy was quite different between ticagrelor and clopidogrel. The incidence of NACE was significantly lower in ticagrelor monotherapy as compared with DAPT (OR: 0.79, 95% CI: 0.68-0.91), but not in clopidogrel monotherapy (OR: 1.14, 95% CI: 0.79-1.63). Both clopidogrel and ticagrelor monotherapy showed a similar reduction in bleeding complications (OR: 0.46, 95% CI: 0.22-0.94; OR: 0.60, 95% CI: 0.44-0.83, respectively). Although statistically insignificant, the incidence of MACCE was numerically higher in clopidogrel monotherapy as compared with standard DAPT (OR: 1.50, 95% CI: 0.99-2.28, p = 0.06). Based on these findings, P2Y12 inhibitor monotherapy with ticagrelor would be a better choice of medical treatment for ACS patients after PCI with stent implantation in the current era.
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Affiliation(s)
- Wen-Han Feng
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan
| | - Yong-Chieh Chang
- Department of Pharmacy, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 801, Taiwan
| | - Yi-Hsiung Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
- Center for Lipid Biosciences, Kaohsiung Medical University Hospital, Kaohsiung 807, Taiwan
- Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Hsiao-Ling Chen
- Institute of Health and Welfare Policy, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Chun-Yin Chen
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
| | - Tsung-Han Lin
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
| | - Tzu-Chieh Lin
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
| | - Ching-Tang Chang
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
| | - Hsuan-Fu Kuo
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
| | - Hsiu-Mei Chang
- Department of Pharmacy, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 801, Taiwan
| | - Chih-Sheng Chu
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 801, Taiwan
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Wang Y, Geng Y, Zhang O, Xu Q, Xue Y, Zhou B, Zhang P. Association between P2Y12 inhibitor reloading and in-hospital outcomes for patients with non-ST-segment elevation acute coronary syndrome already on chronic P2Y12 receptor inhibitors therapy in China: findings from the CCC-ACS (improving care for cardiovascular disease in China-acute coronary syndrome) project. Eur J Med Res 2023; 28:59. [PMID: 36732830 PMCID: PMC9893674 DOI: 10.1186/s40001-023-01025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/20/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The association between P2Y12 receptor inhibitors reloading and in-hospital outcomes in non-ST-segment elevation acute coronary syndrome (NSTEACS) patients who were on chronic P2Y12 receptor inhibitors therapy remained underdetermined. METHODS The Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome (CCC-ACS project) is a national registry active from November 2014 to December 2019. 4790 NSTEACS patients on chronic P2Y12 receptor inhibitors therapy were included. Cox proportional hazard models, Kaplan-Meier curves, and subgroup analyses were conducted. RESULTS The NSTEACS patients who received reloading of P2Y12 receptor inhibitors were younger and had fewer comorbid conditions. The reloading group had a lower risk of major adverse cardiac events (MACE) (0.51% vs. 1.43%, P = 0.007), and all-cause death (0.36% vs. 0.99%, P = 0.028), the risks of myocardial infarction and major bleeding were not significantly different between patients with and without reloading. In survival analysis, a lower cumulative risk of MACE could be identified (Log-rank test, P = 0.007) in reloading group. In the unadjusted Cox model, reloading P2Y12 receptor inhibitors was associated with a decreased risk of MACE [HR, 0.35; 95% CI 0.16-0.78; (P = 0.010)] and all-cause death [HR, 0.37; 95% CI 0.14-0.94; (P = 0.036)]. Reloading of P2Y12 receptor inhibitors was associated with a decreased risk of MACE in most of the subgroups. CONCLUSIONS In NSTEACS patients already taking P2Y12 receptor inhibitors, we observed a decreased risk of in-hospital MACEs and all-cause mortality and did not observe an increased risk of major bleeding, with reloading. The differential profile in the two groups might influence this association and further studies are warranted. CLINICAL TRIAL REGISTRATION https://www. CLINICALTRIALS gov (Unique identifier: NCT02306616, date of first registration: 03/12/2014).
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Affiliation(s)
- Yintang Wang
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
| | - Yu Geng
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
| | - Ou Zhang
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
| | - Qin Xu
- grid.411617.40000 0004 0642 1244China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China ,grid.411617.40000 0004 0642 1244Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yajun Xue
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
| | - Boda Zhou
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
| | - Ping Zhang
- grid.12527.330000 0001 0662 3178Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Changping District, Beijing, 102218 People’s Republic of China
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P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:829-844. [PMID: 35697777 DOI: 10.1038/s41569-022-00725-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 12/15/2022]
Abstract
For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y12 receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y12 inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y12 inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y12 inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y12 inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.
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Galli M, Ortega-Paz L, Franchi F, Rollini F, Angiolillo DJ. Precision medicine in interventional cardiology: implications for antiplatelet therapy in patients undergoing percutaneous coronary intervention. Pharmacogenomics 2022; 23:723-737. [PMID: 35938534 DOI: 10.2217/pgs-2022-0057] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Precision medicine is a medical model that proposes the customization of medical treatments to the individual patient, as opposed to a one-drug-fits-all model. Such a "personalized medicine" approach has been widely adopted in several medical fields, such as cancer medicine, but the implementation of precision medicine in cardiovascular medicine has not been similarly straightforward. Because pharmacogenomics plays an important role in the safety and efficacy of cardiovascular drug therapy, there has been a great interest in the use of tools aiming at personalizing antiplatelet therapy. Moreover, antiplatelet therapy is essential for the treatment of cardiovascular patients to reduce the risk of thrombotic complications, particularly those undergoing percutaneous coronary intervention, but it is inevitably associated with increased bleeding risk. In this review, the authors discuss the rationale, summarize the evidence and discuss the current and future directions for the personalization of antiplatelet treatment regimens in patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Capranzano P, Angiolillo DJ. Basics of Antiplatelet and Anticoagulant Therapy for Cardiovascular Disease. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 110] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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Tyrosine Kinase Inhibitor Sunitinib Delays Platelet-Induced Coagulation: Additive Effects of Aspirin. Thromb Haemost 2021; 122:92-104. [PMID: 34130349 DOI: 10.1055/s-0041-1730312] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sunitinib is a multitarget tyrosine kinase inhibitor (TKI) used for cancer treatment. In platelets, sunitinib affects collagen-induced activation under noncoagulating conditions. We investigated (1) the effects of sunitinib on thrombus formation induced by other TK-dependent receptors, and (2) the effects under coagulating conditions. Cardiovascular disease is a comorbidity in cancer patients, resulting in possible aspirin treatment. Sunitinib and aspirin are associated with increased bleeding risk, and therefore we also investigated (3) the synergistic effects of these compounds on thrombus and fibrin formation. METHODS Blood or isolated platelets from healthy volunteers or cancer patients were incubated with sunitinib and/or aspirin or vehicle. Platelet activation was determined by TK phosphorylation, flow cytometry, changes in [Ca2+]i, aggregometry, and whole blood perfusion over multiple surfaces, including collagen with(out) tissue factor (TF) was performed. RESULTS Sunitinib reduced thrombus formation and phosphatidylserine (PS) exposure under flow on collagen type I and III. Also, sunitinib inhibited glycoprotein VI-induced TK phosphorylation and Ca2+ elevation. Upon TF-triggered coagulation, sunitinib decreased PS exposure and fibrin formation. In blood from cancer patients more pronounced effects of sunitinib were observed in lung and pancreatic as compared to neuroglioblastoma and other cancer types. Compared to sunitinib alone, sunitinib plus aspirin further reduced platelet aggregation, thrombus formation, and PS exposure on collagen under flow with(out) coagulation. CONCLUSION Sunitinib suppresses collagen-induced procoagulant activity and delays fibrin formation, which was aggravated by aspirin. Therefore, we urge for awareness of the combined antiplatelet effects of TKIs with aspirin, as this may result in increased risk of bleeding.
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K Anderson M, C Pickens R, Davis J, H Baker E, H Baker E, B Martinie J, Vrochides D. Antiplatelet therapy after pancreaticoduodenectomy with portal vein resection as the optimal preventative strategy for maintaining primary vein patency. INTERNATIONAL JOURNAL OF HEPATOBILIARY AND PANCREATIC DISEASES 2021. [DOI: 10.5348/100096z04ma2021ra] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Predictors of Clopidogrel Hyper-Responsiveness in Neuro-Interventional Procedures. J Stroke Cerebrovasc Dis 2020; 30:105420. [PMID: 33161351 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105420] [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: 08/04/2020] [Revised: 10/09/2020] [Accepted: 10/18/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Hyper-responsiveness to clopidogrel abnormally inhibits platelet aggregation and increases hemorrhagic complications. The present study investigated clinical factors related to clopidogrel hyper-responsiveness in neuro-interventional procedures. METHODS Two hundred twenty-four patients receiving clopidogrel for coil embolization to treat unruptured cerebral aneurysm or carotid artery stenting to treat carotid artery stenosis at the internal carotid artery origin were retrospectively reviewed for their P2Y12 reactivity unit (PRU) values and clinical characteristics. Hyper-responsiveness to clopidogrel was defined as a PRU of <95. RESULTS The mean PRU was 218.2 ± 77.8. Hyper-responsiveness to clopidogrel was observed in 12 patients (5.4%). Hyper-responsiveness was observed in younger patients, patients with a lower concentration of hemoglobin A1c, and patients with a higher low-density lipoprotein cholesterol (LDL-C) concentration compared with non-hyper-responsive patients (P = 0.01, P < 0.01, P < 0.01, respectively). On analysis of concomitant drugs, the patients in the hyper-responsive group were less frequently administered calcium channel blockers (CCBs) compared with the non-hyper-responsive group (P = 0.01). No significant differences in the usage of proton pump inhibitors or statins were observed. A LDL-C concentration of >120 mg/dL and no usage of CCBs were significant independent predictors of hyper-responsiveness to clopidogrel with a multivariate analysis (OR; 6.16, 95% CI, 1.57-26.64, P = 0.01, OR; 0.09, 95% CI, 0.01-0.82, P = 0.03, respectively). CONCLUSION The present study shows that a higher LDL-C concentration and no usage of CCBs are independent predictors of clopidogrel hyper-responsiveness. These results are useful to predict perioperative hemorrhagic complications. Considering dose reduction of clopidogrel or alternative drugs in high risk cases is necessary to prevent perioperative hemorrhagic complications.
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Baber U, Zafar MU, Dangas G, Escolar G, Angiolillo DJ, Sharma SK, Kini AS, Sartori S, Joyce L, Vogel B, Farhan S, Gurbel P, Gibson CM, Fuster V, Mehran R, Badimon JJ. Ticagrelor With or Without Aspirin After PCI: The TWILIGHT Platelet Substudy. J Am Coll Cardiol 2020; 75:578-586. [PMID: 32057371 DOI: 10.1016/j.jacc.2019.11.056] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 11/20/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND An evolving strategy in the setting of percutaneous coronary intervention (PCI) involves withdrawal of acetylsalicylic acid (ASA), or aspirin, while maintaining P2Y12 inhibition. However, the pharmacodynamic effects of this approach on blood thrombogenicity and platelet reactivity remain unknown. OBJECTIVES This study sought to compare the antithrombotic potency of ticagrelor alone versus ticagrelor plus ASA among high-risk patients undergoing PCI with drug-eluting stents. METHODS This was a mechanistic substudy within the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial, which randomized patients undergoing PCI to ticagrelor plus placebo versus ticagrelor plus ASA following 3 months of dual antiplatelet therapy. Substudy participants were enrolled after randomization, at which time ex vivo assays to quantify thrombus size under dynamic flow conditions and platelet reactivity were performed. Pharmacodynamic assessments were repeated 1 to 6 months thereafter. The primary endpoint was thrombus size at the post-randomization visit with platelet reactivity following stimuli to arachidonic acid, collagen, adenosine diphosphate, and thrombin as secondary endpoints. Results were analyzed using analysis of covariance. RESULTS A total of 51 patients were enrolled, among whom 42 underwent perfusion assays at baseline and follow-up with a median time between studies of 1.5 months. The adjusted mean difference in post-randomization thrombus area was similar between groups: -218.2 μm2 (95% confidence interval [CI]: -575.9 to 139.9 μm2; p = 0.22). Markers sensitive to cyclo-oxygenase-1 blockade, including platelet reactivity in response to arachidonic acid (mean difference: 10.9 U; 95% CI: 1.9 to 19.9 U) and collagen (mean difference: 9.8 U; 95% CI: 0.8 to 18.8 U) stimuli were higher among patients receiving placebo, whereas levels of platelet reactivity were similar with adenosine diphosphate and thrombin. CONCLUSIONS Among high-risk patients receiving drug-eluting stents, the antithrombotic potency of ticagrelor monotherapy is similar to that of ticagrelor plus ASA with respect to ex vivo blood thrombogenicity, whereas markers sensitive to cyclo-oxygenase-1 blockade are increased in the absence of ASA. (Platelet Substudy of the TWILIGHT Trial; NCT04001374).
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Affiliation(s)
- Usman Baber
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - M Urooj Zafar
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George Dangas
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ginés Escolar
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | - Samin K Sharma
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Annapoorna S Kini
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lauren Joyce
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Birgit Vogel
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Serdar Farhan
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul Gurbel
- Inova Center for Thrombosis Research and Translational Medicine, Falls Church, Virginia
| | - C Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts
| | - Valentin Fuster
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Juan J Badimon
- Atherothrombosis Research Unit, Icahn School of Medicine at Mount Sinai, New York, New York
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Lee CH, Franchi F, Angiolillo DJ. Clopidogrel drug interactions: a review of the evidence and clinical implications. Expert Opin Drug Metab Toxicol 2020; 16:1079-1096. [PMID: 32835535 DOI: 10.1080/17425255.2020.1814254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Patients with cardiovascular disease are commonly affected by a number of comorbidities leading to a high prevalence of polypharmacy. Polypharmacy increases the probability of drug-drug interactions (DDIs). Amongst these, DDIs involving clopidogrel, the most commonly utilized platelet P2Y12 inhibitor, is a topic of potential clinical concern. AREAS COVERED This article reviews DDIs between clopidogrel and drugs which are widely used in clinical practice. In particular, drugs shown to interfere with the pharmacodynamic and pharmacokinetic effects of clopidogrel and the clinical implications of these findings are reviewed. These drugs include inhibitors of gastric acid secretion, statins, calcium channel blockers, antidiabetic agents, and antimicrobial agents. For the references, we searched PubMed, EMBASE, or the Cochrane Library. EXPERT OPINION Clopidogrel-drug interactions are common. Most of these DDIs are limited to laboratory findings showing an impact on clopidogrel-induced antiplatelet effects. While variability in clopidogrel-induced antiplatelet effects is known to affect clinical outcomes, with high platelet reactivity being associated with thrombotic complications among patients undergoing coronary stenting, most studies assessing the clinical implications of clopidogrel-drug interactions have not shown to significantly affect outcomes. However, awareness of these DDIs remains important for optimizing the selection of concomitant therapies.
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Affiliation(s)
- Chang Hoon Lee
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA.,Division of Cardiology, Department of Internal Medicine, Veterans Health Service Medical Center , Seoul, Korea
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville , Jacksonville, FL, USA
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Yan P, Zhang Y, Ma C, Liang F, Zhu H, Jiang C. Application of the Willis Covered Stent in the treatment of intracranial unruptured aneurysms in internal carotid artery: A retrospective single-center experience. J Clin Neurosci 2020; 78:222-227. [DOI: 10.1016/j.jocn.2020.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/04/2020] [Accepted: 04/08/2020] [Indexed: 11/28/2022]
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Franchi F, Rollini F, Faz G, Rivas JR, Rivas A, Agarwal M, Briceno M, Wali M, Nawaz A, Silva G, Shaikh Z, Maaliki N, Fahmi K, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Baber U, Mehran R, Jennings LK, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Vorapaxar in Prior Myocardial Infarction Patients Treated With Potent Oral P2Y 12 Receptor Inhibitors With and Without Aspirin: Results of the VORA-PRATIC Study. J Am Heart Assoc 2020; 9:e015865. [PMID: 32306797 PMCID: PMC7428520 DOI: 10.1161/jaha.120.015865] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
Background Vorapaxar as an adjunct to dual antiplatelet therapy (DAPT) reduces thrombotic events in patients with prior myocardial infarction at the expense of increased bleeding. Withdrawal of aspirin has emerged as a bleeding reduction strategy. The pharmacodynamic effects of vorapaxar with potent P2Y12 inhibitors as well as the impact of dropping aspirin is unexplored and represented the aim of the VORA-PRATIC (Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor) study. Methods and Results Post-myocardial infarction patients (n=130) on standard DAPT (aspirin+prasugrel or ticagrelor) were randomized to 1 of 3 arms: (1) triple therapy: aspirin+prasugrel/ticagrelor+vorapaxar; (2) dual therapy (drop aspirin): prasugrel/ticagrelor+vorapaxar; (3) DAPT: aspirin+prasugrel/ticagrelor. Pharmacodynamic assessments were performed at 3 time points (baseline and 7 and 30 days). Vorapaxar reduced CAT (collagen-ADP-TRAP)-induced platelet aggregation, a marker of platelet-mediated global thrombogenicity (triple therapy versus DAPT at 30 days: mean difference=-27; 95% CI,-35 to -19; P<0.001; primary end point). This effect was attenuated but still significant in the absence of aspirin (dual therapy versus DAPT at 30 days: mean difference=-15; 95% CI,-23 to -7; P<0.001; between-group comparisons, P<0.05). Vorapaxar abolished TRAP-induced aggregation (P<0.001), without affecting thrombin generation and clot strength. There were no differences in markers of P2Y12 reactivity. Markers sensitive to aspirin-induced effects increased (P<0.001) in the dual-therapy arm. Conclusions In post-myocardial infarction patients treated with potent P2Y12 inhibitors, vorapaxar reduces platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin and without affecting markers of P2Y12 reactivity or clot kinetics. The clinical implications of these PD observations warrant future investigation. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02545933.
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Affiliation(s)
| | | | - Gabriel Faz
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Andrea Rivas
- University of Florida College of Medicine–JacksonvilleFL
| | - Malhar Agarwal
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Mustafa Wali
- University of Florida College of Medicine–JacksonvilleFL
| | - Ahmed Nawaz
- University of Florida College of Medicine–JacksonvilleFL
| | - Gabriel Silva
- University of Florida College of Medicine–JacksonvilleFL
| | - Zubair Shaikh
- University of Florida College of Medicine–JacksonvilleFL
| | - Naji Maaliki
- University of Florida College of Medicine–JacksonvilleFL
| | - Kerolos Fahmi
- University of Florida College of Medicine–JacksonvilleFL
| | - Latonya Been
- University of Florida College of Medicine–JacksonvilleFL
| | | | | | - Daniel Soffer
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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Abstract
An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the "no-reflow phenomenon," which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.
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High mean platelet volume to platelet count ratio as a predictor on poor outcomes after CABG. Gen Thorac Cardiovasc Surg 2019; 68:459-466. [PMID: 31515731 DOI: 10.1007/s11748-019-01202-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 09/04/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To determine the effect of mean platelet volume (MPV) to platelet count (PC) ratio on postoperative poor outcomes, early mortality and long-term survival rate in patients undergoing CABG. METHODS Between February 2016 and September 2018, all patients undergoing CABG in our department were retrospectively reviewed. A total of 213 consecutive patients were included in the study. RESULTS Mean age was 61.5 ± 9.7 years and mean follow-up of all patients was 1.4 ± 0.5 years. All patients were divided into two groups as high and low MPV/PC ratio in terms of 3.825 of cut-off point. 72 patients had a high MPV/PC ratio, whereas, 141 patients had low MPV/PC ratio. The rates of reoperation for early vein-graft occlusion, low cardiac output syndrome and respiratory complication were significantly higher in group 1 (p = 0.03, 0.04 and 0.01). The mean hospital length of stay was higher in group 1 (p = 0.03). MPV/PC ratio for reoperation for early vein-graft occlusion; MPV and ejection fraction for low cardiac output syndrome; hyperlipidemia, chronic renal failure history and MPV/PC ratio for sepsis; male gender, CRF history and CPB time for atrial fibrillation; age, congestive heart failure history, myocardial infarction history and CPB time for the early mortality were found to be independent predictors. Peripheral arterial diseases, USAP and MPV/PC ratio were found to be independent predictors for the late mortality. CONCLUSIONS A high MPV/PC ratio is associated with early vein-graft occlusion and poor postoperative outcomes in the early period after CABG. Furthermore, it has a negative effect on late survival.
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Pharmacodynamic Effects of Vorapaxar in Patients With and Without Diabetes Mellitus: Results of the OPTIMUS-5 Study. JACC Basic Transl Sci 2019; 4:763-775. [PMID: 31998847 PMCID: PMC6978557 DOI: 10.1016/j.jacbts.2019.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Abstract
Vorapaxar reduces thrombotic cardiovascular events in patients with atherosclerotic disease, with enhanced effects in those with DM. Adjunctive vorapaxar therapy reduces platelet-mediated thrombogenicity without affecting clot kinetics in both patients with and those without DM having prior MI/PAD on dual antiplatelet therapy with aspirin and clopidogrel. The pharmacodynamic effects of vorapaxar occur via selective blockade of the PAR-1 on the platelet membrane without apparent interplay with other platelet signaling pathways. Aspirin withdrawal, which leaves patients on a background of clopidogrel and vorapaxar, increases markers specific to COX-1–mediated blockade, leading to an increase in platelet-mediated global thrombogenicity, particularly among patients with DM.
Vorapaxar reduces thrombotic cardiovascular events at the expense of increased bleeding. However, the differential pharmacodynamic (PD) effects of vorapaxar according to diabetes mellitus (DM) status are unknown. Moreover, although withdrawal of aspirin has emerged as a bleeding reduction strategy, the PD effects of stopping aspirin in patients treated with vorapaxar also are unknown. In this prospective PD investigation, vorapaxar was associated with reduced platelet-mediated thrombogenicity without affecting clot kinetics irrespective of DM status. However, platelet-mediated thrombogenicity increased after aspirin withdrawal, particularly among patients with DM. (Optimizing anti-Platelet Therapy In diabetes MellitUS-5 Study [OPTIMUS-5]; NCT02548650)
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Key Words
- ADP, adenosine diphosphate
- CAT, collagen-related peptide + adenosine diphosphate + thrombin receptor activating peptide
- CI, confidence interval
- COX, cyclooxygenase
- DAPT, dual antiplatelet therapy
- DM, diabetes mellitus
- LTA, light transmittance aggregometry
- MI, myocardial infarction
- MPA, maximum platelet aggregation
- PAD, peripheral arterial disease
- PAR, protease-activated receptor
- PD, pharmacodynamic
- TRAP, thrombin receptor activating peptide
- TXB2, thromboxane B2
- VASP, vasodilator-stimulated phosphoprotein
- dual antiplatelet therapy
- o.d., once daily
- pharmacodynamics
- platelets
- thrombin
- vorapaxar
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Ye MB, Chen YL, Wang Q, An J, Ye F, Jing P. Aspirin plus clopidogrel versus aspirin mono-therapy for ischemic stroke: a meta-analysis. SCAND CARDIOVASC J 2019; 53:169-175. [PMID: 31112048 DOI: 10.1080/14017431.2019.1620962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Objectives. Stroke is a common condition after a transient ischemic attack (TIA) or minor ischemic stroke (IS). Adding clopidogrel to aspirin may yield more beneficial outcomes than aspirin mono-therapy; meanwhile, the risk of bleeding in the acute phase remains poorly understood. Therefore, there is increasing emphasis on the risks and benefits of clopidogrel with aspirin compared with aspirin mono-therapy in an effort to treat TIA/IS. Design. We searched several electronic databases, including PubMed, Cochrane, and Embase, to identify eligible randomized controlled trials (RCTs) based on the index words comparing dual-antiplatelet therapy to aspirin mono-therapy for secondary stroke prevention updated to December, 2018. Results. A total of 11 RCTs met our inclusion criteria. The pooled analysis showed that clopidogrel plus aspirin was associated with a trend toward a reduction in recurrent IS (RR = 0.72, 95%CI = 0.65-0.81, p < .001), but not the recurrent stroke rate (RR = 0.81, 95% CI = 0.63-1.03, p = .09) than aspirin mono-therapy. There were differences in bleeding episodes (RR = 1.81, 95%CI = 1.65-1.99, p < .001), moderate-severe major bleeding (RR = 1.64, 95% CI = 1.24-2.16, p = .0005), or mild bleeding (RR = 2.25, 95%CI = 1.54-3.31, p < .001) between the study groups. Meanwhile, no benefit of reducing the risk of intracranial hemorrhage with dual-antiplatelet therapy was found in TIA/IS patients (RR = 1.44, 95% CI = 0.95-2.19, p = .09). Conclusions. The addition of clopidogrel to aspirin for patients with TIA or IS appeared to significantly reduce the risk of IS recurrence with a possible increase in the risk of bleeding compared with aspirin alone.
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Affiliation(s)
- Mao-Bin Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Yan-Lin Chen
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Qin Wang
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Jun An
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Fei Ye
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
| | - Ping Jing
- a Department of Neurology, The Central Hospital of Wuhan, Tongji Medical College , Huazhong University of Science and Technology , Wuhan , China
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Secondary Prevention with Antithrombotic Therapies in Stable Ischemic Heart Disease Patients: a Review. Curr Cardiol Rep 2019; 21:56. [DOI: 10.1007/s11886-019-1152-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Capodanno D, Mehran R, Valgimigli M, Baber U, Windecker S, Vranckx P, Dangas G, Rollini F, Kimura T, Collet JP, Gibson CM, Steg PG, Lopes RD, Gwon HC, Storey RF, Franchi F, Bhatt DL, Serruys PW, Angiolillo DJ. Aspirin-free strategies in cardiovascular disease and cardioembolic stroke prevention. Nat Rev Cardiol 2018; 15:480-496. [DOI: 10.1038/s41569-018-0049-1] [Citation(s) in RCA: 152] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
PURPOSE OF REVIEW Despite the benefits of surgical coronary revascularization, patients continue to be at risk for ischemic events in the years that follow coronary artery bypass graft surgery (CABG), mandating the role for postoperative secondary preventive therapy. The purpose of this review was to present a summary on the subject of secondary prevention after CABG, including an overview of a recently published scientific statement, and highlight the newest studies in the field. RECENT FINDINGS Aspirin and statin therapy continue to be the mainstay of secondary prevention after CABG, although newer antiplatelet and lipid-lowering medicines are being actively studied for their potential benefits. Other important elements to secondary prevention after CABG include the aggressive management of hypertension, smoking cessation, and the initiation of cardiac rehabilitation. SUMMARY Secondary prevention is an essential component of postoperative care after CABG. Instituting preventive therapies after surgery optimizes graft patency and helps patients achieve the highest level of physical health and quality of life following CABG.
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Zhao G, Zhou M, Ma C, Huo Y, Smith SC, Fonarow GC, Ge J, Han Y, Liu J, Hao Y, Liu J, Wang X, Taubert KA, Morgan L, Zhao D, Nie S. In-Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75 Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC-ACS (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) Project. J Am Heart Assoc 2018; 7:e008100. [PMID: 29602767 PMCID: PMC5907592 DOI: 10.1161/jaha.117.008100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/01/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Elderly patients with acute coronary syndrome (ACS) are at high risk for ischemic and bleeding events. This study aimed to evaluate the clinical effectiveness and safety of dual loading antiplatelet therapy for patients 75 years and older undergoing percutaneous coronary intervention for ACS. METHODS AND RESULTS The Improving Care for Cardiovascular Disease in China-ACS project was a collaborative study of the American Heart Association and Chinese Society of Cardiology. A total of 5887 patients 75 years and older with ACS who had percutaneous coronary intervention and received dual antiplatelet therapy with aspirin and P2Y12 inhibitors (clopidogrel or ticagrelor) between November 2014 and June 2017 were enrolled. The primary effectiveness and safety outcomes were in-hospital major adverse cardiovascular events and major bleeding. Hazard ratios (HRs) of in-hospital outcomes with different loading statuses of antiplatelet therapy were estimated using Cox proportional hazard models with multivariate adjustment. A propensity score-matched analysis was also conducted. Compared with patients receiving a dual nonloading dose, patients taking a dual loading dose had increased risks of both major adverse cardiovascular events (HR, 1.66, 95% confidence interval, 1.13-2.44; [P=0.010]) and major bleeding (HR, 2.34, 95% confidence interval, 1.75-3.13; [P<0.001]). Among 3284 propensity score-matched patients, a dual loading dose was associated with a 1.36-fold risk of major adverse cardiovascular events (HR, 1.36; 95% confidence interval, 0.88-2.11 [P=0.168]) and a 2.08-fold risk of major bleeding (HR, 2.08; 95% confidence interval, 1.47-2.93 [P<0.001]). CONCLUSIONS A dual loading dose of antiplatelet therapy was associated with increased major bleeding risk but not with decreased major adverse cardiovascular events risk among patients 75 years and older undergoing percutaneous coronary intervention for ACS in China. CLINICAL TRIAL REGISTRATION URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02306616.
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Affiliation(s)
- Guanqi Zhao
- Emergency & Critical Care Center, Beijing Anzhen Hospital Capital Medical University, Beijing, China
| | - Mengge Zhou
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital Capital Medical University, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, CA
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yaling Han
- General Hospital of Shenyang Military Region, Shenyang, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiao Wang
- Emergency & Critical Care Center, Beijing Anzhen Hospital Capital Medical University, Beijing, China
| | - Kathryn A Taubert
- Department of International Science, American Heart Association International, Basel, Switzerland
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, TX
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital Capital Medical University Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Shaoping Nie
- Emergency & Critical Care Center, Beijing Anzhen Hospital Capital Medical University, Beijing, China
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Brouns SLN, van Geffen JP, Heemskerk JWM. High-throughput measurement of human platelet aggregation under flow: application in hemostasis and beyond. Platelets 2018. [DOI: 10.1080/09537104.2018.1447660] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Sanne L. N. Brouns
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Johanna P. van Geffen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Johan W. M. Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Lauver DA, Hollenberg P, Zhang H. CYP-independent inhibition of platelet aggregation in rabbits by a mixed disulfide conjugate of clopidogrel. Thromb Haemost 2017; 112:1304-11. [DOI: 10.1160/th14-04-0388] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 07/25/2014] [Indexed: 01/27/2023]
Abstract
SummaryDual antiplatelet therapy with clopidogrel and aspirin has been the standard of care in the United States for patients with acute coronary syndromes (ACS) and/or undergoing percutaneous coronary interventions (PCI). However, the effectiveness of clopidogrel varies significantly among different sub-populations due to inter-individual variability. In this study we examined the antiplatelet potential of a novel mixed disulfide conjugate of clopidogrel with the aim to overcome the inter-individual variability. In the metabolic studies using human liver microsomes and cDNA-expressed P450s, we confirmed that multiple P450s are involved in the bioactivation of 2-oxoclopidogrel to H4, one of the diastereomers of the pharmacologically active metabolite (AM) possessing antiplatelet activity. Results from kinetic studies demonstrated that 2C19 is the most active in converting 2-oxoclopidogrel to H4 with a catalytic efficiency of 0.027 µM-1min-1 in the reconstituted system. On the basis of this finding, we were able to biosynthesise the conjugate of clopidogrel with 3-nitropyridine-2-thiol, referred to as clopNPT, and examined its antiplatelet activity in male New Zealand white rabbits. After administration as intravenous bolus at 2 mg/kg, the clopNPT conjugate was rapidly converted to the AM leading to the inhibition of platelet aggregation (IPA). Analyses of the blood samples drawn at various time points showed that intravenous administration of clopNPT led to ~70% IPA within 1 hour and the IPA persisted for more than 3 hours. Since the antiplatelet activity of clopNPT does not require bioactivation by P450s, the mixed disulfide conjugate of clopidogrel has the potential to overcome the inter-individual variability in clopidogrel therapy.
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Katz M, Regev E, Sabbag A, Mazin I, Abu-Much A, Kukuy A, Mazo A, Erez A, Berkovitch A, Narodistky M, Barbash I, Segev A, Beigel R, Matetzky S, Asher E, Frydman S. Chewing versus Swallowing Ticagrelor to Accelerate Platelet Inhibition in Acute Coronary Syndrome - the CHEERS study. Thromb Haemost 2017; 117:727-733. [DOI: 10.1160/th16-09-0728] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 12/31/2016] [Indexed: 12/26/2022]
Abstract
SummaryIt was the study objective to evaluate whether chewing a 180 mg loading dose of ticagrelor versus an equal dose of traditional oral administration, enhances inhibition of platelet aggregation 1 hour (h) after administering a ticagrelor loading dose in non-ST elevation myocardial infarction (NSTEMI) patients. Dual anti-platelet therapy represents standard care for treating NSTEMI patients. Ticagrelor is a direct acting P2Y12 inhibitor and, unlike clopidogrel and prasugrel, does not require metabolic activation. Fifty NSTEMI patients were randomised to receive either a chewing loading dose of 180 mg ticagrelor or an equal standard oral dose of ticagrelor. Platelet reactivity was evaluated by VerifyNow at baseline, 1 and 4 h post-loading dose. Results are reported in P2Y12 reaction units. Patients then continued to receive standard 90 mg oral ticagrelor twice daily. Baseline characteristics did not differ between the two groups. P2Y12 reaction units in the chewing group compared with the standard group at 0, 1 and 4 h after ticagrelor loading dose were: 245 vs 239 (p=0.59), 45 vs 130 (p=0.001) and 39 vs 60 (p=0.12), respectively, corresponding to a relative inhibition of platelet aggregation of 83 % vs only 47 % at 1 h (p< 0.001), and 84 % vs 77 % (p=0.59) at 4 h. Major adverse cardiac and cardiovascular events at 30 days were low (2 %), occurring in only one patient in the standard group. In conclusion, chewing a 180 mg ticagrelor loading dose is feasible and facilitates both faster and improved early inhibition of platelet aggregation in NSTEMI patients, compared with a standard oral-loading dose.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Abstract
PURPOSE OF REVIEW This review aims to summarize and discuss safety and effectiveness of the long-term use of ticagrelor in patients with coronary artery disease (CAD). RECENT FINDINGS Ticagrelor is an orally administered, direct, and reversible inhibitor of the P2Y12-platelet receptor. Long-term use of ticagrelor in patients with previous myocardial infarction (MI) has been investigated in the PEGASUS-TIMI-54 trial. Overall, 21,162 patients with a spontaneous MI 1 to 3 years before randomization were randomly assigned to ticagrelor 90 mg bid, ticagrelor 60 mg bid, or placebo. Compared with placebo, both doses of ticagrelor showed that they were capable of significantly reducing the primary efficacy endpoint, although with a significant increase in TIMI major bleeding. Intracranial hemorrhage or fatal bleeding did not differ across groups. These findings establish clear benefit of DAPT extension with ticagrelor beyond 1 year of treatment, which comes with a tradeoff of clinically meaningful bleeding. Altogether, current evidence suggests that the duration of DAPT remains a patient-by-patient decision based on thrombotic and bleeding risk profiles.
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Affiliation(s)
- Sara Ariotti
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
- Department of Advanced Biomedical Sciences, University Federico II, Naples, Italy
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
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31
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Florian P, Wonerow P, Harder S, Kuczka K, Dubar M, Graff J. Anti-GPVI Fab SAR264565 effectively blocks GPVI function in ex vivo human platelets under arterial shear in a perfusion chamber. Eur J Clin Pharmacol 2017; 73:949-956. [PMID: 28523478 DOI: 10.1007/s00228-017-2264-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/03/2017] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Glycoprotein VI (GPVI) is the major platelet receptor for collagen-mediated platelet adhesion and activation. SAR264565 is an anti-GPVI-Fab, binds to GPVI with high affinity, and blocks GPVI function in human platelets in vitro. METHODS The effect of SAR26456 on platelet responsiveness in the blood of 21 healthy male subjects was investigated using Sakariassen's ex vivo thrombogenesis perfusion chamber model on a collagen-coated surface under conditions mimicking arterial flow. Ex vivo effects of SAR264565 (10 and 100 μg/mL) were investigated before administration of aspirin or clopidogrel to study subjects (baseline), after aspirin (2× 300 mg) administration alone, and after combined aspirin (2× 300 mg)/clopidogrel (600 mg) administration. Additional ex vivo and in vitro platelet tests were also performed. RESULTS Addition of SAR264565 to the perfusion chamber dose-dependently reduced platelet and fibrin deposition, reaching statistical significance at 100 μg/mL (415 ± 67 compared to 137 ± 36 platelets/cm2, [p < 0.01] and fibrin 0.095 ± 0.014 compared to 0.032 ± 0.008 μg/cm2, [p < 0.001]). Aspirin administration caused an additive and dose-dependent reduction of SAR264565-induced platelet and fibrin deposition. Combined aspirin/clopidogrel administration did not lead to additional SAR264565-induced inhibition of platelet or fibrin deposition. CONCLUSION GPVI antagonism by the anti-GPVI-Fab fragment SAR264565 dose-dependently inhibits platelet adhesion and fibrin formation on a collagen surface under arterial shear. Additive inhibition is observed after prior aspirin administration with no further amplification on top of a combination of aspirin with clopidogrel. Ex vivo antiplatelet tests confirmed a selective inhibiting effect of SAR264565 on collagen-induced platelet activation.
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Affiliation(s)
- Peter Florian
- Sanofi-Aventis Deutschland GmbH, R&D, Industriepark Hoechst, Frankfurt am Main, Germany
| | - Peter Wonerow
- Sanofi-Aventis Deutschland GmbH, R&D, Industriepark Hoechst, Frankfurt am Main, Germany
| | - Sebastian Harder
- Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - Karina Kuczka
- Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - Michel Dubar
- Clinical Pharmacology and Exploratory Department, Sanofi-Aventis Recherche, Chilly-Mazarin, France
| | - Jochen Graff
- Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
- Clinical Trial Centre Rhine-Main (KSRM) at the Pharmazentrum Frankfurt/ZAFES, Institute of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
- Fraunhofer Institute for Molecular Biology and Applied Ecology IME, Project Group Translational Medicine and Pharmacology TMP, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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32
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Gurbel PA, Tantry US. GEMINI-ACS-1: toward unearthing the antithrombotic therapy cornerstone for acute coronary syndromes. Lancet 2017; 389:1773-1775. [PMID: 28325639 DOI: 10.1016/s0140-6736(17)30760-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA 22042, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA; Duke University School of Medicine, Durham, NC, USA.
| | - Udaya S Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA 22042, USA
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33
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Wadowski PP, Eichelberger B, Kopp CW, Pultar J, Seidinger D, Koppensteiner R, Lang IM, Panzer S, Gremmel T. Disaggregation Following Agonist-Induced Platelet Activation in Patients on Dual Antiplatelet Therapy. J Cardiovasc Transl Res 2017; 10:359-367. [PMID: 28425039 PMCID: PMC5585279 DOI: 10.1007/s12265-017-9746-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 04/11/2017] [Indexed: 01/09/2023]
Abstract
Disaggregation as the difference between maximal and final platelet aggregation by light transmission aggregometry indicates the stability of platelet aggregates. We evaluated the extent of disaggregation after platelet stimulation with adenosine diphosphate (ADP), arachidonic acid (AA), collagen, epinephrine, and thrombin receptor-activating peptide (TRAP)-6 in 323 patients on dual antiplatelet therapy with daily aspirin and clopidogrel (group 1), prasugrel (group 2), or ticagrelor (group 3) therapy. All patients in group 1 underwent elective angioplasty and stenting, whereas all patients included in groups 2 and 3 suffered from acute coronary syndromes (STEMI or NSTEMI) and underwent urgent PCI. Significant differences between maximal and final platelet aggregation were observed with all agonists throughout the groups (all p<0.001). Disaggregation was highest using AA (clopidogrel 36.5%; prasugrel/ticagrelor 100%) and ADP (clopidogrel 21.7%; prasugrel/ticagrelor 100%). In contrast, low disaggregation was observed after platelet stimulation with collagen and TRAP-6 in clopidogrel-treated patients, and after platelet stimulation with collagen and epinephrine in prasugrel- and ticagrelor-treated patients. In conclusion, pathways of platelet activation that are not inhibited by standard antiplatelet therapy allow persisting platelet aggregation and may at least in part be responsible for adverse ischemic events.
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Affiliation(s)
- Patricia P Wadowski
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Christoph W Kopp
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Joseph Pultar
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Daniela Seidinger
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Renate Koppensteiner
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Simon Panzer
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- Division of Angiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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34
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Jones LM, Coffey RA, Natwa MP, Bailey JK. The use of intravenous tPA for the treatment of severe frostbite. Burns 2017; 43:1088-1096. [PMID: 28159151 DOI: 10.1016/j.burns.2017.01.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/02/2016] [Accepted: 01/07/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE tPA and anticoagulation for treatment of severe frostbite have been reported suggesting differences in imaging techniques, route of tPA administration and management of patients after tPA infusion. This is a report of our results following a protocol of Tc-99m scanning, intravenous tPA administration, followed by either systemic anticoagulation or antiplatelet therapy. METHODS Patients admitted to our burn center between February 13, 2015 and February 13, 2016 for frostbite who met inclusion criteria were treated with Tc-99m scan and intravenous tPA followed by systemic anticoagulation or antiplatelet therapy. Inclusion criteria included rewarming had not started more than 24h prior to the scan and no contraindications to the use of tPA. RESULTS Fifteen patients met inclusion criteria and 12 were treated according to the protocol. Nine received scans with 2 showing normal perfusion. Seven displayed perfusion defects and received intravenous tPA. Five recovered fully after tPA. Two who showed improved but abnormal scans after tPA experienced bleeding complications necessitating stopping heparin/Coumadin. Those two went on to partial amputation of digits. CONCLUSION The use of intra-arterial or intravenous tPA along with angiography or Tc-99m scanning followed by systemic anticoagulation or antiplatelet therapy may be beneficial to patients suffering frostbite.
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Affiliation(s)
- Larry M Jones
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Rebecca A Coffey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - Mona P Natwa
- Department of Radiology, Division of Nuclear Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
| | - J Kevin Bailey
- Department of Surgery, Division of Critical Care, Trauma and Burn, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
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35
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Batty JA, Dunford JR, Dangas GD, Kunadian V. Oral Antiplatelet Agents in PCI. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Jonathan A. Batty
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
- The Royal Victoria Infirmary; Newcastle upon Tyne NHS Foundation Trust; Newcastle upon Tyne UK
| | - Joseph R. Dunford
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
| | - George D. Dangas
- Department of Cardiology; Mount Sinai Medical Center; New York NY USA
| | - Vijay Kunadian
- Institute of Cellular Medicine; Newcastle University; Newcastle upon Tyne UK
- Freeman Hospital; Newcastle upon Tyne Hospital NHS Foundation Trust; Newcastle upon Tyne UK
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36
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Capranzano P, Angiolillo DJ. Basics of Antiplatelet and Anticoagulant Therapy for Cardiovascular Disease. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
- Piera Capranzano
- Cardiovascular Department, Ferrarotto Hospital; University of Catania; Catania Italy
| | - Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology; University of Florida College of Medicine-Jacksonville; Jacksonville FL USA
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37
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A terapêutica antitrombótica: atual e em desenvolvimento. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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38
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Kumana CR, Cheung G, Lauder IJ, Cheung BMY. Long-Term Combination Therapy with Aspirin and Clopidogrel. J Cardiovasc Pharmacol Ther 2016; 9:223-5. [PMID: 15678241 DOI: 10.1177/107424840400900402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The possible additive antiplatelet effects of aspirin and clopidogrel have been explored in the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) and Management of Atherothrombosis with Clopidogrel in High Risk Patients (MATCH) studies. To assess the overall absolute beneficial and/or harmful impact of aspirin and clopidogrel combination therapy compared with monotherapy with either drug, we analyzed the results from both trials in terms of number needed to treat per year. Treating between 35 and 204 at-risk patients for 1 year with combination therapy appeared to prevent 1 patient from experiencing an adverse primary cardiovascular outcome; whereas, about 1 in 63 such patients appeared liable to major bleeding during that period. We determined that the evidence to date indicates no overall advantage for combination therapy with anti-platelet drugs in preference to monotherapy.
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Affiliation(s)
- C R Kumana
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, Hong Kong
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39
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Tsoumani ME, Tatsidou PT, Ntalas IV, Goudevenos JA, Tselepis AD. Dynamic platelet adhesion in patients with an acute coronary syndrome: The effect of antiplatelet therapy. Platelets 2016; 27:812-820. [DOI: 10.1080/09537104.2016.1192113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Maria E. Tsoumani
- Department of Chemistry, Laboratory of Biochemistry, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Prokopia T. Tatsidou
- Department of Chemistry, Laboratory of Biochemistry, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Ioannis V. Ntalas
- Department of Cardiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - John A. Goudevenos
- Department of Cardiology, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Alexandros D. Tselepis
- Department of Chemistry, Laboratory of Biochemistry, School of Medicine, University of Ioannina, Ioannina, Greece
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40
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Bonello L, Laine M, Thuny F, Paganelli F, Lemesle G, Roch A, Kerbaul F, Dignat-George F, Berbis J, Frere C. Platelet reactivity in patients receiving a maintenance dose of P2Y12-ADP receptor antagonists undergoing elective percutaneous coronary intervention. Int J Cardiol 2016; 216:190-3. [PMID: 27179310 DOI: 10.1016/j.ijcard.2016.04.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/14/2016] [Accepted: 04/29/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND P2Y12-ADP receptor blockade during percutaneous coronary intervention (PCI) is critical to prevent thrombotic events. In patients under chronic P2Y12 blockers, the use of additional loading dose (LD) before an elective PCI is debated. We aimed to investigate the rate of high on-treatment platelet reactivity (HTPR) in patients undergoing elective PCI during chronic clopidogrel or ticagrelor therapy. METHODS AND RESULTS We performed a sub-group analysis of a randomized trial comparing ticagrelor and clopidogrel in acute coronary syndrome (ACS) patients undergoing PCI. Multi-vessel disease patients requiring a staged PCI one month after the ACS were included. The VASP (vasodilatatory phosphoprotein) index, which is a specific and reproducible platelet assay to measure P2Y12-ADP receptor activity, was used to assess the biological efficacy of the maintenance dose (MD) of ticagrelor and clopidogrel before PCI. Forty-one patients in each group of randomization required a staged PCI. They were similar regarding the baseline demographic, clinical and angiographic characteristics. The mean VASP index in the ticagrelor group was 20.7±8.8% compared to 51.8±17% in the clopidogrel group (p<0.001) before PCI. No patients had a VASP index ≥50% in the ticagrelor group compared to 56% in the clopidogrel group (p<0.001). Following PCI the rate of peri-procedural MI was higher in the clopidogrel group (p=0.02). CONCLUSIONS Unlike clopidogrel MD, ticagrelor MD achieves an optimal PR inhibition in all patients during a staged PCI.
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Affiliation(s)
- Laurent Bonello
- Département de Cardiologie, Hôpital Universitaire Nord de Marseille, Assistance-Publique Hôpitaux de Marseille, Marseille, France; Vascular Research Center of Marseille, INSERM UMR-S 1076, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France.
| | - Marc Laine
- Département de Cardiologie, Hôpital Universitaire Nord de Marseille, Assistance-Publique Hôpitaux de Marseille, Marseille, France; MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France
| | - Franck Thuny
- Département de Cardiologie, Hôpital Universitaire Nord de Marseille, Assistance-Publique Hôpitaux de Marseille, Marseille, France; Vascular Research Center of Marseille, INSERM UMR-S 1076, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France
| | - Franck Paganelli
- Département de Cardiologie, Hôpital Universitaire Nord de Marseille, Assistance-Publique Hôpitaux de Marseille, Marseille, France; Vascular Research Center of Marseille, INSERM UMR-S 1076, Aix-Marseille Université, Marseille, France
| | - Gilles Lemesle
- MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France; Département de Cardiologie, Hôpital Universitaire de Lilles, Lilles, France
| | - Antoine Roch
- MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France; Service d'accueil des Urgences, Assistance Publique-Hôpitaux de Marseille, Nord, Marseille, France
| | - François Kerbaul
- MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France; UMR MD2, Aix-Marseille Université, Marseille, France; Pole RUSH, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Françoise Dignat-George
- Vascular Research Center of Marseille, INSERM UMR-S 1076, Aix-Marseille Université, Marseille, France
| | - Julie Berbis
- Department of Biostatistics, Aix-Marseille Université, Marseille, France
| | - Corinne Frere
- Vascular Research Center of Marseille, INSERM UMR-S 1076, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Academic association for Research and Studies in Cardiology, Marseille, France
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Gurbel PA, Jeong YH, Navarese EP, Tantry US. Platelet-Mediated Thrombosis. Circ Res 2016; 118:1380-91. [DOI: 10.1161/circresaha.115.307016] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/17/2016] [Indexed: 11/16/2022]
Abstract
The pivotal role that platelets play in thrombosis and resultant ischemic event occurrences in patients with high-risk coronary artery disease is well established. This role provides the fundamental basis for the current wide implementation of dual antiplatelet therapy with aspirin and a P2Y
12
receptor inhibitor. The development of user friendly point-of-care methods to assess platelet reactivity to adenosine diphosphate has increased the frequency of platelet function testing in clinical practice. Recent large observational studies have established an independent relation between the results of point-of-care platelet function testing and clinical event occurrence in patients undergoing coronary artery stenting. However, prospective, randomized trials have failed to demonstrate that personalized antiplatelet therapy based on point-of-care assessment of platelet function is effective in reducing ischemic event occurrences. Important limitations were associated with these trials. In addition, the concept of a therapeutic window of P2Y
12
receptor reactivity with an upper threshold associated with ischemic event occurrence and a lower threshold associated with bleeding has also been proposed. In the absence of strong prospective evidence to support personalized antiplatelet therapy, clinical decision making about antiplatelet therapy rests on the large body of observational data and the fundamental importance of platelet physiology in catastrophic event occurrence in patients with high-risk coronary artery disease.
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Affiliation(s)
- Paul A. Gurbel
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Young-Hoon Jeong
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Eliano P. Navarese
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
| | - Udaya S. Tantry
- From the Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, VA (P.A.G., E.P.N., U.S.T.); and Clinical Trial Center, Gyeongsang National University Hospital, Gyeongsangnam-do, Korea (Y.-H.J.)
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Abstract
Platelets play a key role in mediating stent thrombosis, which is the major cause of ischemic events immediately after percutaneous coronary intervention (PCI). Antiplatelet therapy is therefore the cornerstone of antithrombotic therapy after PCI. However, the use of antiplatelet agents increases bleeding risk, with more potent antiplatelet agents further increasing bleeding risk. In the past 5 years, potent and fast-acting P2Y12 inhibitors have augmented the antiplatelet armamentarium available to interventional cardiologists. This article reviews the preclinical and clinical data surrounding these new agents, and discusses the significant questions and controversies that still exist regarding the optimal antiplatelet strategy.
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Affiliation(s)
| | - Sunil V Rao
- Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA.
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Abd-Alaziz A. Plavix versus Low Dose Aspirin Impact on Blood Flow of the Uterine Artery in Women with Unexplained Recurrent Miscarriage. JOURNAL OF GYNECOLOGICAL RESEARCH AND OBSTETRICS 2016; 2:010-013. [DOI: 10.17352/jgro.000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Abstract
The shear rate and corresponding shear stress have impacts on arterial thrombus formation. In particular, the effects of increasing concentration of platelets at the vessel wall and activation of platelets at this site increase the growth and stability of the thrombi which may result in a fatal narrowing of the arterial lumen. The efficacy of many antithrombotic agents is shear dependent as well. It is apparent that there is a need for a point-of-care device to rapidly monitor the risk for arterial thrombosis and to optimize antithrombotic therapy in vitro. The present review focuses on the essential role of shear rate on arterial thrombus formation in native human blood drawn directly from an antecubital vein.
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Brandler ES, Sharma M. Early dual antiplatelet therapy in stroke: should we take the CHANCE? ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:177. [PMID: 26366394 DOI: 10.3978/j.issn.2305-5839.2015.07.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 07/16/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Ethan S Brandler
- 1 Department of Emergency Medicine, Associate Director, Emergency Medical Services, State University of New York at Stony Brook, NY, USA ; 2 Department of Community Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar 143001, India
| | - Mohit Sharma
- 1 Department of Emergency Medicine, Associate Director, Emergency Medical Services, State University of New York at Stony Brook, NY, USA ; 2 Department of Community Medicine, Government Medical College and Guru Nanak Dev Hospital, Amritsar 143001, India
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Jurk K. Analysis of platelet function and dysfunction. Hamostaseologie 2014; 35:60-72. [PMID: 25482925 DOI: 10.5482/hamo-14-09-0047] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/21/2014] [Indexed: 12/17/2022] Open
Abstract
Although platelets act as central players of haemostasis only their cross-talk with other blood cells, plasma factors and the vascular compartment enables the formation of a stable thrombus. Multiple activation processes and complex signalling networks are responsible for appropriate platelet function. Thus, a variety of platelet function tests are available for platelet research and diagnosis of platelet dysfunction. However, universal platelet function tests that are sensitive to all platelet function defects do not exist and therefore diagnostic algorithms for suspected platelet function disorders are still recommended in clinical practice. Based on the current knowledge of human platelet activation this review evaluates point-of-care related screening tests in comparison with specific platelet function assays and focuses on their diagnostic utility in relation to severity of platelet dysfunction. Further, systems biology-based platelet function methods that integrate global and specific analysis of platelet vessel wall interaction (advanced flow chamber devices) and post-translational modifications (platelet proteomics) are presented and their diagnostic potential is addressed.
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Affiliation(s)
- K Jurk
- Priv.-Doz. Dr. rer. nat. Kerstin Jurk, Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131 Mainz, Germany, E-mail:
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Rollini F, Tello-Montoliu A, Patel R, Darlington A, Wilson RE, Franchi F, Muñiz-Lozano A, Desai B, Bender N, Sakariassen KS, Angiolillo DJ. Pharmacodynamic effects of EV-077 in patients with diabetes mellitus and coronary artery disease on aspirin or clopidogrel monotherapy: results of an in vitro pilot investigation. J Thromb Thrombolysis 2014; 37:131-8. [PMID: 23943337 DOI: 10.1007/s11239-013-0979-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Patients with diabetes mellitus (DM) have increased propensity to generate thromboxane A2 (TXA2) and other eicosanoids which can contribute to their heightened platelet reactivity. EV-077 is a potent thromboxane receptor antagonist and thromboxane synthase inhibitor and thus represents an attractive therapy in patients with DM. However, the effects of EV-077 on pharmacodynamic (PD) profiles in patients with DM and coronary artery disease (CAD) while on antiplatelet therapy is poorly explored and represented the aim of this in vitro pilot investigation. Patients with DM and stable CAD (n = 10) on low-dose aspirin (81 mg/day) were enrolled and then switched to clopidogrel (75 mg/day) monotherapy for 7-10 days. PD assessments were conducted while on aspirin and on clopidogrel using light transmittance aggregometry following stimuli with U-46619 [TXA2 stable analogue (7 μM)], arachidonic acid [AA (1 mM)], collagen (3 μg/mL) and adenosine diphosphate [ADP (5 μM and 20 μM)] with and without in vitro EV-077. EV-077 completely inhibited U-46619-stimulated platelet aggregation (p = 0.005 for both aspirin and clopidogrel) and also showed a significant reduction of collagen-induced aggregation (aspirin p = 0.008; clopidogrel p = 0.005). EV-077 significantly reduced AA-induced platelet aggregation in clopidogrel (p = 0.009), but not aspirin (p = 0.667) treated patients. Ultimately, EV-077 significantly reduced ADP-mediated platelet aggregation in both aspirin (ADP 5 μM p = 0.012; ADP 20 μM p = 0.032) and clopidogrel (ADP 5 μM p = 0.007; ADP 20 μM p = 0.008) treated patients. In conclusion, in DM patients with CAD on aspirin or clopidogrel monotherapy, in vitro EV-077 exerts potent platelet inhibitory effects on multiple platelet signaling pathways. These data support that EV-077 has only additive platelet inhibiting effects on top of standard antiplatelet therapies. These findings warrant further investigation in ex vivo settings.
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Affiliation(s)
- Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
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Alexopoulos D. p2y12 receptor inhibitors in acute coronary syndromes: from the research laboratory to the clinic and vice versa. Cardiology 2014; 127:211-9. [PMID: 24458006 DOI: 10.1159/000357399] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022]
Abstract
The P2Y12 receptor plays a pivotal role in platelet activation and aggregation through a complex cascade of actions. Laboratory and clinical data have convincingly shown the benefit of P2Y12 inhibition combined with aspirin in patients with acute coronary syndrome (ACS)/undergoing percutaneous coronary intervention (PCI). Newer agents - like prasugrel, ticagrelor, and cangrelor - provide more consistent, faster, and stronger platelet inhibition than clopidogrel. In large clinical trials newer agents have resulted in fewer ischemic complications (though with increased bleeding potential) than clopidogrel. High-risk subpopulations like ST-segment elevation myocardial infarction, diabetes, chronic kidney disease, elderly, and low body weight patients have been identified. A 'return to the laboratory' has been observed recently, with several pharmacodynamic studies being performed particularly in these cohorts. This interplay between research laboratory and clinical data may lead to a more efficient and safer use of P2Y12 inhibitors.
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Capranzano P, Ferreiro JL, Angiolillo DJ. Prasugrel in acute coronary syndrome patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2014; 7:361-9. [DOI: 10.1586/erc.09.4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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