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Abstract
Patients surviving an acute coronary syndrome (ACS) remain at increased risk of ischemic events long term. This paper reviews current evidence and guidelines for oral antiplatelet therapy for secondary prevention following ACS, with respect to decreased risk of ischemic events versus bleeding risk according to individual patient characteristics and risk factors. Specifically, data are reviewed from clinical studies of clopidogrel, prasugrel, ticagrelor and vorapaxar, as well as the results of systematic reviews and meta-analyses looking at the benefits and risks of oral antiplatelet therapy, and the relative merits of shorter versus longer duration of dual antiplatelet therapy, in different patient groups.
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Affiliation(s)
- Jeffrey S Berger
- Division of Cardiology, New York University Langone Medical Center, New York, NY, USA.
- Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY, 10016, USA.
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102
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Design and baseline characteristics of the eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes trial (VERTIS-CV). Am Heart J 2018; 206:11-23. [PMID: 30290289 DOI: 10.1016/j.ahj.2018.08.016] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/31/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ertugliflozin is an inhibitor of sodium-glucose co-transporter-2 (SGLT2), approved in the United States and European Union to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). The VERTIS cardiovascular (CV) outcomes trial (NCT01986881) has a primary objective to demonstrate non-inferiority of ertugliflozin versus placebo on major adverse CV events: time to the first event of CV death, nonfatal myocardial infarction, or nonfatal stroke. Secondary objectives are to demonstrate superiority of ertugliflozin versus placebo on time to: 1) the composite outcome of CV death or hospitalization for heart failure (HF); 2) CV death; and 3) the composite outcome of renal death, dialysis/transplant, or doubling of serum creatinine from baseline. METHODS Patients ≥40 years old with T2DM (HbA1c 7.0-10.5%) and established atherosclerotic cardiovascular disease (ASCVD) of the coronary, cerebral, and/or peripheral arterial systems, were randomized 1:1:1 to once daily double-blind placebo, ertugliflozin 5 mg or 15 mg added to existing therapy. RESULTS 8246 patients were randomized and 8238 received at least 1 dose of investigational product. Mean age was 64.4 years, 11.0% were ≥75 years old, and mean diabetes duration was 12.9 years with screening HbA1c of 8.3%. At entry, coronary artery disease, cerebrovascular disease, and peripheral arterial disease were present in 76.3%, 23.1%, and 18.8% of patients, respectively. HF was present in 23.1%, and Stage 3 kidney disease in 21.6% of patients. CONCLUSION The results from the VERTIS-CV trial will define the CV and renal safety and efficacy of ertugliflozin in patients with T2DM and ASCVD.
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103
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Abstract
The global prevalence of diabetes has risen in adults from 4.7% in 1980 to 8.5% in 2014. 90–95% of adults with diabetes have Type 2 diabetes (T2D). This paper focuses on the diagnosis and treatment of T2D patients who have or are at risk for cardiovascular disease. Hyperglycemia, insulin resistance and excess fatty acids increase oxidative stress, disrupt protein kinase C signaling and increase advanced glycation end-products that result in vascular inflammation, vasoconstriction, thrombosis and atherogenesis. Intensive T2D treatment produces a ≥10% risk reduction in major macrovascular and microvascular events. Glucose-lowering therapies must be individualized. Metformin is an optimal drug for monotherapy. If hemoglobin A1c is not at goal, a sodium-glucose cotransporter-2 inhibitor or a dipeptidyl peptidase-4 inhibitor should be considered for therapy with metformin. Coronary angioplasty/stenting is recommended for diabetic patients with acute myocardial infarctions. Coronary artery bypass grafting is recommended for symptomatic diabetic patients with multivessel disease.
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104
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Rivas Rios JR, Franchi F, Rollini F, Angiolillo DJ. Diabetes and antiplatelet therapy: from bench to bedside. Cardiovasc Diagn Ther 2018; 8:594-609. [PMID: 30498684 DOI: 10.21037/cdt.2018.05.09] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes mellitus (DM) is a metabolic disorder associated with accelerated atherogenesis and an increased risk of atherothrombotic complications. Multiple mechanisms contribute to the pro-thrombotic status which characterizes DM patients underscoring the importance of antiplatelet therapies used for secondary prevention in these patients. For many years, dual antiplatelet therapy (DAPT) with aspirin and the P2Y12 inhibitor clopidogrel has represented the mainstay of treatment following an acute coronary syndrome (ACS) or in patients undergoing percutaneous coronary interventions (PCI). Although DAPT reduces the incidence of atherothrombotic recurrences, these rates remain high in DM patients underscoring the need for more efficacious therapies. Oral platelet P2Y12 receptor inhibitors with enhanced potency, such as prasugrel and ticagrelor, as well as antiplatelet therapies such as vorapaxar inhibiting the thrombin-mediated platelet signaling pathway, constitute treatment opportunities for patients with DM and have shown to be associated with a greater reduction in ischemic recurrences, albeit at the cost of more bleeding. This article reviews currently available antiplatelet agents and delivers an update on the advances and drawbacks of these agents used for secondary prevention in DM patients experiencing an ACS or undergoing PCI.
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Affiliation(s)
- Jose R Rivas Rios
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
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105
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106
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Finamore F, Reny JL, Malacarne S, Fontana P, Sanchez JC. A high glucose level is associated with decreased aspirin-mediated acetylation of platelet cyclooxygenase (COX)-1 at serine 529: A pilot study. J Proteomics 2018; 192:258-266. [PMID: 30240925 DOI: 10.1016/j.jprot.2018.09.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 09/02/2018] [Accepted: 09/17/2018] [Indexed: 01/29/2023]
Abstract
Diabetes is a major risk factor for cardiovascular diseases. Although aspirin is considered a cornerstone of the prevention and treatment of atherothrombotic-related ischemic events, this antiplatelet drug appears to be less effective in patients with poorly controlled diabetes. It has been suggested that the glycation of platelet proteins plays a pivotal role in poor responsiveness to aspirin. However, a direct effect on the critical residue (serine 529, or Ser 529) of the catalytic pocket of cyclooxygenase 1 (COX-1) has never been demonstrated. This pilot study aimed to elucidate the impact of hyperglycaemia on aspirin acetylation of COX-1 using a targeted mass spectrometry approach. We observed that high glucose concentration had a direct impact on the level of acetylation of the COX-1 Ser 529 residue, whereas it's overall acetylation level remained unchanged. Moreover, the functional aspirin-induced inhibition of COX-1 was dose-dependently impaired as glucose concentrations increased. These in vitro findings were in line with data obtained using platelets from diabetic patients. These data provide new insights into the interplay between glucose and aspirin on platelet proteins and their effects on platelet COX-1. They also suggest a potential mechanistic explanation for the phenomenon of poor response to aspirin in diabetic patients. Data are available via ProteomeXchange with identifier PXD011204. SIGNIFICANCE: Deciphering the mutual interplay between glucose and aspirin-mediated acetylation on platelet COX-1, might be of great interest as there is still a lack of information of the mechanism underlying this process that may contribute to the less-than expected response of platelets to aspirin, often observed in diabetes.
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Affiliation(s)
- Francesco Finamore
- Translational Biomarker Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Jean-Luc Reny
- Division of Internal Medicine and Rehabilitation, Geneva University Hospitals, Geneva, Switzerland; Geneva Platelet Groupx, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Sarah Malacarne
- Endocrinology, Diabetology and Nutrition Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Pierre Fontana
- Translational Biomarker Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Geneva Platelet Groupx, Faculty of Medicine, University of Geneva, Geneva, Switzerland; Division of Angiology and Haemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Jean-Charles Sanchez
- Translational Biomarker Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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107
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Rodríguez-Azúa R, Quinteros EF, Olate-Briones A, Moore-Carrasco R. Phaseolus vulgaris Exerts an Inhibitory Effect on Platelet Aggregation through AKT Dependent Way. Prev Nutr Food Sci 2018; 23:102-107. [PMID: 30018887 PMCID: PMC6047876 DOI: 10.3746/pnf.2018.23.2.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 03/13/2018] [Indexed: 12/15/2022] Open
Abstract
The Phaseolus vulgaris (common bean), a worldwide vegetable of high consumption, can act as a nutritional supplement in the diet of oversized individuals to reduce weight. Studies have demonstrated the existence of molecules capable of inhibiting the breakdown of carbohydrates via inhibition of both α-amylases and glycosidases. Here, we describe a novel property of the Phaseolus vulgaris: inhibition of thrombotic cardiovascular events. Using assays to test platelet aggregation and secretion, and flow cytometry against the surface expression of P-Selectin. We show that bean extracts significantly reduced adenosine 5′-diphosphate and arachidonic acid induced-platelet aggregation. The mechanism underlying such effect appears to be mediated by AKT, since AKT hypo-phosphorylation decreases the “inside out” activation of platelets. In sum, our results support the hypothesis that common beans are nutritional ingredients that help reduce the risk of cardiovascular diseases associated with platelet hyper-reactivity.
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Affiliation(s)
- Rosio Rodríguez-Azúa
- Centro de Estudios en Alimentos Procesados (CEAP), CONICYT-regional, Gore Maule, Talca R09I2001, Chile
| | - Eduardo Fuentes Quinteros
- Department of Clinical Biochemistry and Immunohematology, Faculty of Health Sciences, University of Talca, Talca 3465548, Chile
| | - Alexandra Olate-Briones
- Department of Clinical Biochemistry and Immunohematology, Faculty of Health Sciences, University of Talca, Talca 3465548, Chile.,Programa de Investigación Asociativa en Cáncer Gástrico (PIA-CG), University of Talca, Talca 3465548, Chile
| | - Rodrigo Moore-Carrasco
- Centro de Estudios en Alimentos Procesados (CEAP), CONICYT-regional, Gore Maule, Talca R09I2001, Chile.,Department of Clinical Biochemistry and Immunohematology, Faculty of Health Sciences, University of Talca, Talca 3465548, Chile.,Programa de Investigación Asociativa en Cáncer Gástrico (PIA-CG), University of Talca, Talca 3465548, Chile
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108
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109
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Prevention of Heart Failure With SGLT-2 Inhibition. J Am Coll Cardiol 2018; 71:2507-2510. [DOI: 10.1016/j.jacc.2018.02.078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 02/22/2018] [Accepted: 02/25/2018] [Indexed: 12/28/2022]
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110
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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111
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Hussain MA, Al-Omran M, Creager MA, Anand SS, Verma S, Bhatt DL. Antithrombotic Therapy for Peripheral Artery Disease. J Am Coll Cardiol 2018; 71:2450-2467. [DOI: 10.1016/j.jacc.2018.03.483] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/16/2018] [Accepted: 03/21/2018] [Indexed: 12/18/2022]
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112
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Arrieta F, Iglesias P, Pedro-Botet J, Becerra A, Ortega E, Obaya JC, Nubiola A, Maldonado GF, Campos MDM, Petrecca R, Pardo JL, Sánchez-Margalet V, Alemán JJ, Navarro J, Duran S, Tébar FJ, Aguilar M, Escobar F. Diabetes mellitus y riesgo cardiovascular. Actualización de las recomendaciones del Grupo de Trabajo de Diabetes y Riesgo Cardiovascular de la Sociedad Española de Diabetes (SED, 2018). CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2018; 30:137-153. [DOI: 10.1016/j.arteri.2018.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 02/28/2018] [Accepted: 03/09/2018] [Indexed: 12/24/2022]
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113
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Chamberlain JJ, Johnson EL, Leal S, Rhinehart AS, Shubrook JH, Peterson L. Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018. Ann Intern Med 2018; 168:640-650. [PMID: 29610837 DOI: 10.7326/m18-0222] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
DESCRIPTION The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. METHODS For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. RECOMMENDATIONS This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.
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Affiliation(s)
- James J Chamberlain
- St. Mark's Hospital and St. Mark's Diabetes Center, Salt Lake City, Utah (J.J.C.)
| | - Eric L Johnson
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota (E.L.J.)
| | | | | | - Jay H Shubrook
- Touro University College of Osteopathic Medicine, Vallejo, California (J.H.S.)
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114
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Gulizia MM, Colivicchi F, Abrignani MG, Ambrosetti M, Aspromonte N, Barile G, Caporale R, Casolo G, Chiuini E, Di Lenarda A, Faggiano P, Gabrielli D, Geraci G, La Manna AG, Maggioni AP, Marchese A, Massari FM, Mureddu GF, Musumeci G, Nardi F, Panno AV, Pedretti RFE, Piredda M, Pusineri E, Riccio C, Rossini R, di Uccio FS, Urbinati S, Varbella F, Zito GB, De Luca L. Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease. Eur Heart J Suppl 2018; 20:F1-F74. [PMID: 29867293 PMCID: PMC5978022 DOI: 10.1093/eurheartj/suy019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.
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Affiliation(s)
- Michele Massimo Gulizia
- U.O.C. di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia e UTIC, Ospedale San Filippo Neri, Roma, Italy
| | | | - Marco Ambrosetti
- Servizio di Cardiologia Riabilitativa, Clinica Le Terrazze Cunardo, Varese, Italy
| | - Nadia Aspromonte
- U.O. Scompenso e Riabilitazione Cardiologica, Polo Scienze Cardiovascolari, Toraciche, Policlinico Agostino Gemelli, Roma, Italy
| | | | - Roberto Caporale
- U.O.C. Cardiologia Interventistica, Ospedale Annunziata, Cosenza, Italy
| | - Giancarlo Casolo
- S.C. Cardiologia, Nuovo Ospedale Versilia, Lido di Camaiore (LU), Italy
| | - Emilia Chiuini
- Specialista Ambulatoriale Cardiologo, ASL Umbria 1, Perugia, Italy
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | | | - Domenico Gabrielli
- ASUR Marche - Area Vasta 4 Fermo, Ospedale Civile Augusto Murri, Fermo, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ferdinando Maria Massari
- U.O.C. Malattie Cardiovascolari "Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | - Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | | | | | - Massimo Piredda
- Centro Cardiotoracico, Divisione di Cardiologia, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Enrico Pusineri
- U.O.C. di Cardiologia, Ospedale Civile di Vigevano, A.S.S.T., Pavia, Italy
| | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, AZ. Ospedaliera S. Anna e S. Sebastiano, Caserta, Italy
| | | | | | - Stefano Urbinati
- U.O.C. Cardiologia, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | | | | | - Leonardo De Luca
- U.O.C. Cardiologia, Ospedale San Giovanni Evangelista, Tivoli, Roma, Italy
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115
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Chaturvedula S, Diver D, Vashist A. Antiplatelet Therapy in Coronary Artery Disease: A Daunting Dilemma. J Clin Med 2018; 7:E74. [PMID: 29642547 PMCID: PMC5920448 DOI: 10.3390/jcm7040074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/05/2018] [Accepted: 04/06/2018] [Indexed: 12/19/2022] Open
Abstract
Percutaneous coronary intervention (PCI) with stenting for the treatment of acute coronary syndrome (ACS) is the contemporary standard of care. Such treatment is followed by dual antiplatelet therapy (DAPT) comprising of aspirin and a P2Y12 inhibitor. The efficacy of this therapy has been well established but the optimal duration of DAPT remains elusive, and has thus far attracted a prodigious deal of scientific attention. The decision regarding DAPT duration can be clinically challenging in the modern era with the evolution of newer stents, more potent antiplatelet agents, and novel anticoagulant drugs in addition to an older patient population with multiple comorbidities. Major societal guidelines have emphasized comprehensive assessment of ischemic and bleeding risk, in turn recommending individualization of DAPT duration, thus encouraging "shared decision making". The following review is aimed at critically evaluating the available evidence to help make these crucial clinical decisions regarding duration of DAPT and triple therapy.
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Affiliation(s)
- Surya Chaturvedula
- Department of Cardiology, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
| | - Daniel Diver
- Department of Cardiology, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
- Hoffman Heart and Vascular Institute at St Francis Hospital and Medical Center, Hartford, CT 06105, USA.
| | - Aseem Vashist
- Department of Cardiology, University of Connecticut School of Medicine, Farmington, CT 06030, USA.
- Hoffman Heart and Vascular Institute at St Francis Hospital and Medical Center, Hartford, CT 06105, USA.
- VACT Healthcare System, West Haven, CT 06516, USA.
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116
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Lettino M, Leonardi S, De Maria E, Halvorsen S. Antiplatelet and antithrombotic treatment for secondary prevention in ischaemic heart disease. Eur J Prev Cardiol 2018; 24:61-70. [PMID: 28618904 DOI: 10.1177/2047487317707854] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Platelets play a key role in the pathogenesis of acute coronary syndromes and this is why antiplatelet drugs are essential, both in the acute phase and in the long-term follow-up in preventing recurrent myocardial infarction, stroke and cardiovascular death. Aspirin is the most used agent and still remains the first choice drug for lifelong administration in secondary prevention after myocardial infarction. Dual antiplatelet therapy, targeting more than one pathway of platelet activation, has significantly improved the outcome of patients with acute coronary syndromes despite an increased risk of bleeding complications. The aim of this article is to provide an overview of the evidence from randomized clinical trials with a focus on the best association between aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel or ticagrelor, on the selection of the appropriate agent based on the revascularization strategy and on the optimal duration of such an intensive treatment. We will also provide the latest evidence regarding new antithrombotic agents, such as vorapaxar or low dose rivaroxaban, that could be associated with dual antiplatelet therapy in high risk patients with the aim of further reducing the rate of major ischaemic complications. Finally we will address the issue of patients presenting with atrial fibrillation and a concomitant acute coronary syndrome who frequently need a percutaneous coronary intervention, with a specific focus on the combination therapy of antiplatelet and anticoagulant agents and on the current recommendations of the guidelines.
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Affiliation(s)
- Maddalena Lettino
- 1 Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | | | | | - Sigrun Halvorsen
- 4 Department of Cardiology, Ulleval and University of Oslo, Norway
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Stone JA, Houlden RL, Lin P, Udell JA, Verma S. Cardiovascular Protection in People With Diabetes. Can J Diabetes 2018; 42 Suppl 1:S162-S169. [DOI: 10.1016/j.jcjd.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 10/17/2022]
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118
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Abstract
Cardiovascular disease (CVD) is a significant cause of morbidity and mortality among patients with diabetes mellitus (DM). Increased platelet reactivity among patients with DM contributes to disproportionately high levels of atherothrombotic CVD. Consequently, there has been tremendous interest in exploring the role of antiplatelet therapies in DM to reduce the development of and frequency of future cardiovascular events.
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Affiliation(s)
- Arjun Majithia
- Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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119
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Pechlivani N, Ajjan RA. Thrombosis and Vascular Inflammation in Diabetes: Mechanisms and Potential Therapeutic Targets. Front Cardiovasc Med 2018; 5:1. [PMID: 29404341 PMCID: PMC5780411 DOI: 10.3389/fcvm.2018.00001] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/03/2018] [Indexed: 12/14/2022] Open
Abstract
Cardiovascular disease remains the main cause of morbidity and mortality in patients with diabetes. The risk of vascular ischemia is increased in this population and outcome following an event is inferior compared to individuals with normal glucose metabolism. The reasons for the adverse vascular profile in diabetes are related to a combination of more extensive atherosclerotic disease coupled with an enhanced thrombotic environment. Long-term measures to halt the accelerated atherosclerotic process in diabetes have only partially addressed vascular pathology, while long-term antithrombotic management remains largely similar to individuals without diabetes. We address in this review the pathophysiological mechanisms responsible for atherosclerosis with special emphasis on diabetes-related pathways. We also cover the enhanced thrombotic milieu, characterized by increased platelet activation, raised activity of procoagulant proteins together with compromised function of the fibrinolytic system. Potential new therapeutic targets to reduce the risk of atherothrombosis in diabetes are explored, including alternative use of existing therapies. Special emphasis is placed on diabetes-specific therapeutic targets that have the potential to reduce vascular risk while keeping an acceptable clinical side effect profile. It is now generally acknowledged that diabetes is not a single clinical entity but a continuum of various stages of the condition with each having a different vascular risk. Therefore, we propose that future therapies aiming to reduce vascular risk in diabetes require a stratified approach with each group having a "stage-specific" vascular management strategy. This "individualized care" in diabetes may prove to be essential to improve vascular outcome in this high risk population.
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Affiliation(s)
- Nikoletta Pechlivani
- School of Medicine, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Ramzi A Ajjan
- School of Medicine, Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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120
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Magnuson EA, Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Braunwald E, Sabatine MS, Cohen DJ. Reply: Cost-Effectiveness of Long-Term Ticagrelor in Patients With Prior Myocardial Infarction: Analysis by Subgroups. J Am Coll Cardiol 2018; 71:108. [PMID: 29301623 DOI: 10.1016/j.jacc.2017.10.079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 10/15/2017] [Accepted: 10/19/2017] [Indexed: 11/17/2022]
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121
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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122
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Danielak D, Karaźniewicz-Łada M, Główka F. Ticagrelor in modern cardiology - an up-to-date review of most important aspects of ticagrelor pharmacotherapy. Expert Opin Pharmacother 2017; 19:103-112. [DOI: 10.1080/14656566.2017.1421634] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Karaźniewicz-Łada
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Franciszek Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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123
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Al-Salama ZT, Keating GM, Keam SJ. Ticagrelor: A Review in Long Term Secondary Prevention of Cardiovascular Events. Drugs 2017; 77:2025-2036. [DOI: 10.1007/s40265-017-0844-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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124
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Patti G, Cavallari I, Antonucci E, Calabrò P, Cirillo P, Gresele P, Palareti G, Pengo V, Pignatelli P, Ricottini E, Marcucci R. Prevalence and predictors of dual antiplatelet therapy prolongation beyond one year in patients with acute coronary syndrome. PLoS One 2017; 12:e0186961. [PMID: 29059255 PMCID: PMC5653361 DOI: 10.1371/journal.pone.0186961] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 10/10/2017] [Indexed: 12/15/2022] Open
Abstract
There are limited real-world data on prevalence and predictors of dual antiplatelet therapy (DAPT) prolongation beyond one year after acute coronary syndrome (ACS). We have explored such issue in the START ANTIPLATELET Registry, which is a prospective, observational, multicenter, Italian registry performed in seven Italian cardiology institutions including patients admitted for ACS and followed up to one year. Out of a total population of 840 ACS patients, 596 patients had completed 12-month follow-up being on DAPT. Decision to prolong DAPT beyond one year was taken in 79 patients (13%), whereas in 517 patients DAPT was stopped. The strongest predictors of DAPT continuation were a new cardiovascular events after the index admission event (OR 3.3, 95% CI 1.4-7.7), no bleeding complications (OR 3.2, 95% CI 1.2-8.3) and no anemia during one-year follow-up (OR 2.6, 95% CI 1.1-5.9); other independent predictors were renal failure (OR 2.5, 95% CI 1.3-5.0) and peripheral artery disease (OR 1.8, 95% CI 1.1-3.0). The choice of DAPT prolongation was not correlated with younger ager, presence of diabetes mellitus, coronary angioplasty as initial treatment strategy or type of implanted stent (drug-eluting vs bare metal). In conclusion, this study provides a real-world snapshot on the factors influencing the option to continue DAPT beyond one year after ACS; a low bleeding risk seems to influence the choice to prolong DAPT more than a high ischemic risk.
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Affiliation(s)
| | | | | | - Paolo Calabrò
- Division of Cardiology, Monaldi Hospital and "Luigi Vanvitelli" University of Campania, Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, School of Medicine, "Federico II" University, Naples, Italy
| | - Paolo Gresele
- Department of Medicine, Division of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | | | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, La Sapienza University of Rome, Rome, Italy
| | | | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Center for Atherothrombotic diseases, University of Florence, Florence, Italy
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125
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126
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Nicosia A, Cernetti C, Cremonesi A, Goktekin O, Sauguet A, Wijns W, Musumeci G. PCR Peripheral @ GISE: a unique educational link between peripheral endovascular solutions and interventional cardiologists. EUROINTERVENTION 2017; 13:e1013-e1017. [PMID: 29033385 DOI: 10.4244/eijv13i9a154] [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: 11/23/2022]
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127
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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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128
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Patrono C, Morais J, Baigent C, Collet JP, Fitzgerald D, Halvorsen S, Rocca B, Siegbahn A, Storey RF, Vilahur G. Antiplatelet Agents for the Treatment and Prevention of Coronary Atherothrombosis. J Am Coll Cardiol 2017; 70:1760-1776. [PMID: 28958334 DOI: 10.1016/j.jacc.2017.08.037] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 08/08/2017] [Accepted: 08/09/2017] [Indexed: 01/06/2023]
Abstract
Antiplatelet drugs provide first-line antithrombotic therapy for the management of acute ischemic syndromes (both coronary and cerebrovascular) and for the prevention of their recurrence. Their role in the primary prevention of atherothrombosis remains controversial because of the uncertain balance of the potential benefits and risks when combined with other preventive strategies. The aim of this consensus document is to review the evidence for the efficacy and safety of antiplatelet drugs, and to provide practicing cardiologists with an updated instrument to guide their choice of the most appropriate antiplatelet strategy for the individual patient presenting with different clinical manifestations of coronary atherothrombosis, in light of comorbidities and/or interventional procedures.
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Affiliation(s)
- Carlo Patrono
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy.
| | - Joao Morais
- Division of Cardiology, Santo Andre's Hospital, Leiria, Portugal
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Jean-Philippe Collet
- Sorbonne Université Paris 6, ACTION Study Group, Institut de Cardiologie Hôpital Pitié-Salpêtrière (APHP), INSERM UMRS 1166, Paris, France
| | | | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ullevål, and University of Oslo, Oslo, Norway
| | - Bianca Rocca
- Department of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Barcelona, Spain
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129
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Magnuson EA, Li H, Wang K, Vilain K, Shafiq A, Bonaca MP, Bhatt DL, Cohen M, Steg PG, Storey RF, Braunwald E, Sabatine MS, Cohen DJ. Cost-Effectiveness of Long-Term Ticagrelor in Patients With Prior Myocardial Infarction: Results From the PEGASUS-TIMI 54 Trial. J Am Coll Cardiol 2017; 70:527-538. [PMID: 28750695 DOI: 10.1016/j.jacc.2017.05.063] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 05/12/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND In patients with a myocardial infarction (MI) 1 to 3 years earlier, treatment with ticagrelor + low-dose aspirin (ASA) reduces the risk of cardiovascular (CV) death, MI, or stroke compared with low-dose aspirin alone, but at an increased risk of major bleeding. OBJECTIVES The authors evaluated cost-effectiveness of ticagrelor + low-dose ASA in patients with prior MI within the prior 3 years. METHODS The authors performed a prospective economic substudy alongside the PEGASUS-TIMI 54 (Prevention of Cardiovascular Events in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin-Thrombolysis In Myocardial Infarction 54) trial, which randomized 21,162 patients to ASA alone, ticagrelor 60 mg twice daily + low-dose ASA, or ticagrelor 90 mg twice daily + low-dose ASA. Medical resource use data were collected over a median 33-month follow-up. Costs were assessed from the U.S. health care system perspective. In-trial data relating to survival, utility, and costs were combined with lifetime projections to evaluate lifetime cost-effectiveness of the Food and Drug Administration-approved lower-dose ticagrelor regimen (60 mg twice daily). RESULTS Hospitalization costs were similar for ticagrelor 60 mg and placebo ($2,262 vs. $2,333; 95% confidence interval for difference -$303 to $163; p = 0.54); after inclusion of a daily ticagrelor 60 mg cost of $10.52, total costs were higher for ticagrelor ($10,016 vs. $2,333; 95% CI: $7,441 to $7,930; p < 0.001). In-trial quality-adjusted life-years (QALYs) were similar (2.28 vs. 2.27; p = 0.34). Over a lifetime horizon, ticagrelor was associated with QALY gains of 0.078 and incremental costs of $7,435, yielding an incremental cost-effectiveness ratio (ICER) of $94,917/QALY gained. Several high-risk groups had more favorable ICERs, including patients with >1 prior MI, multivessel disease, diabetes, renal dysfunction (all with ICERs $50,000 to $70,000/QALY gained), patients age <75 years (ICER = $44,779/QALY gained), and patients with peripheral artery disease (ICER = $13,427/QALY gained). CONCLUSIONS For patients with a history of MI >1 year previously, long-term treatment with ticagrelor 60 mg + low-dose ASA yields a cost-effectiveness ratio suggesting intermediate value based on current guidelines. Ticagrelor appears to provide higher value for patients in several recognized high-risk subgroups. (Prevention of Cardiovascular Events [e.g., Death From Heart or Vascular Disease, Heart Attack, or Stroke] in Patients With Prior Heart Attack Using Ticagrelor Compared to Placebo on a Background of Aspirin [PEGASUS]; NCT01225562).
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Affiliation(s)
- Elizabeth A Magnuson
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri Kansas City, Kansas City, Missouri.
| | - Haiyan Li
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Kaijun Wang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Ali Shafiq
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Marc P Bonaca
- Thrombosis In Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Deepak L Bhatt
- Thrombosis In Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marc Cohen
- Cardiovascular Division, Department of Medicine, Newark Beth Israel Medical Center, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Trials, Département Hospitalo-Universitaire Fibrosis, Inflammation, Remodeling, Hôpital Bichat, Assistance Publique-Hôpitaux de Pars, INSERM Unité 1148, Paris, France; Université Paris-Diderot, Sorbonne Paris Cité, Paris, France
| | - Robert F Storey
- Department of Cardiovascular Science, University of Sheffield, Sheffield, United Kingdom
| | - Eugene Braunwald
- Thrombosis In Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marc S Sabatine
- Thrombosis In Myocardial Infarction (TIMI) Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David J Cohen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri Kansas City, Kansas City, Missouri
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130
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Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN, Badimon L, Vranckx P, Agewall S, Andreotti F, Antman E, Barbato E, Bassand JP, Bugiardini R, Cikirikcioglu M, Cuisset T, De Bonis M, Delgado V, Fitzsimons D, Gaemperli O, Galiè N, Gilard M, Hamm CW, Ibanez B, Iung B, James S, Knuuti J, Landmesser U, Leclercq C, Lettino M, Lip G, Piepoli MF, Pierard L, Schwerzmann M, Sechtem U, Simpson IA, Uva MS, Stabile E, Storey RF, Tendera M, Van de Werf F, Verheugt F, Aboyans V. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur J Cardiothorac Surg 2017; 53:34-78. [DOI: 10.1093/ejcts/ezx334] [Citation(s) in RCA: 172] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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131
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Valgimigli M, Bueno H, Byrne RA, Collet JP, Costa F, Jeppsson A, Jüni P, Kastrati A, Kolh P, Mauri L, Montalescot G, Neumann FJ, Petricevic M, Roffi M, Steg PG, Windecker S, Zamorano JL, Levine GN, Badimon L, Vranckx P, Agewall S, Andreotti F, Antman E, Barbato E, Bassand JP, Bugiardini R, Cikirikcioglu M, Cuisset T, De Bonis M, Delgado V, Fitzsimons D, Gaemperli O, Galiè N, Gilard M, Hamm CW, Ibanez B, Iung B, James S, Knuuti J, Landmesser U, Leclercq C, Lettino M, Lip G, Piepoli MF, Pierard L, Schwerzmann M, Sechtem U, Simpson IA, Uva MS, Stabile E, Storey RF, Tendera M, Van de Werf F, Verheugt F, Aboyans V, Windecker S, Aboyans V, Agewall S, Barbato E, Bueno H, Coca A, Collet JP, Coman IM, Dean V, Delgado V, Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P, Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh T, Piepoli MF, Ponikowski P, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Zamorano JL, Windecker S, Aboyans V, Agewall S, Barbato E, Bueno H, Coca A, Collet JP, Coman IM, Dean V, Delgado V, Fitzsimons D, Gaemperli O, Hindricks G, Iung B, Jüni P, Katus HA, Knuuti J, Lancellotti P, Leclercq C, McDonagh T, Piepoli MF, Ponikowski P, Richter DJ, Roffi M, Shlyakhto E, Simpson IA, Zamorano JL, Roithinger FX, Aliyev F, Stelmashok V, Desmet W, Postadzhiyan A, Georghiou GP, Motovska Z, Grove EL, Marandi T, Kiviniemi T, Kedev S, Gilard M, Massberg S, Alexopoulos D, Kiss RG, Gudmundsdottir IJ, McFadden EP, Lev E, De Luca L, Sugraliyev A, Haliti E, Mirrakhimov E, Latkovskis G, Petrauskiene B, Huijnen S, Magri CJ, Cherradi R, Ten Berg JM, Eritsland J, Budaj A, Aguiar CT, Duplyakov D, Zavatta M, Antonijevic NM, Motovska Z, Fras Z, Montoliu AT, Varenhorst C, Tsakiris D, Addad F, Aydogdu S, Parkhomenko A, Kinnaird T. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS. Eur Heart J 2017; 39:213-260. [DOI: 10.1093/eurheartj/ehx419] [Citation(s) in RCA: 1697] [Impact Index Per Article: 242.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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132
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Long-term outcome and risk assessment in premature acute myocardial infarction: A 10-year follow-up study. Int J Cardiol 2017; 240:37-42. [DOI: 10.1016/j.ijcard.2017.03.146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 03/22/2017] [Accepted: 03/31/2017] [Indexed: 11/23/2022]
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133
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Cavender MA, White WB, Jarolim P, Bakris GL, Cushman WC, Kupfer S, Gao Q, Mehta CR, Zannad F, Cannon CP, Morrow DA. Serial Measurement of High-Sensitivity Troponin I and Cardiovascular Outcomes in Patients With Type 2 Diabetes Mellitus in the EXAMINE Trial (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care). Circulation 2017; 135:1911-1921. [DOI: 10.1161/circulationaha.116.024632] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
Abstract
Background:
We aimed to describe the relationship between changes in high-sensitivity cardiac troponin I (hsTnI) and cardiovascular outcomes.
Methods:
The EXAMINE trial (Examination of Cardiovascular Outcomes With Alogliptin Versus Standard of Care) was a phase IIIb clinical outcomes trial designed to evaluate the cardiovascular safety of alogliptin, a nonselective dipeptidyl peptidase 4 inhibitor. Patients with type 2 diabetes mellitus, glycohemoglobin between 6.5% and 11% (or between 7% and 11% if they were on insulin), and a recent acute coronary syndrome (between 15 and 90 days before randomization) were eligible for the trial. hsTnI was measured using the Abbott ARCHITECT assay at baseline and 6 months in patients randomized in the EXAMINE trial. This analysis was restricted to patients randomized ≥30 days after qualifying acute coronary syndrome to mitigate the potential for persistent hsTnI elevation after acute coronary syndrome (n=3808). The primary end point of the trial was cardiovascular death, myocardial infarction, or stroke. Cardiovascular death or heart failure was a prespecified, adjudicated secondary end point.
Results:
At baseline, hsTnI was detectable (≥1.9 ng/L) in 93% of patients and >99
th
percentile upper reference limit in 16%. There was a strong relationship between increasing hsTnI, both at baseline and 6 months, and the incidence of cardiovascular events through 24 months (
P
<0.001 for each). Patients with undetectable hsTnI at baseline and 6 months were at the lowest risk of future cardiovascular events. Stable patients with hsTnI ≥99th percentile upper reference limit at 6 months were at increased risk of cardiovascular death, myocardial infarction, or stroke compared with patients with hsTnI <99 percentile upper reference limit irrespective of whether hsTnI was newly elevated (28.1% versus 8.8%; adjusted hazard ratio, 2.65; 95% confidence interval, 1.64–4.28;
P
<0.001) or persistently so (22.5% versus 8.8%; adjusted hazard ratio, 1.90; 95% confidence interval, 1.33–2.70;
P
<0.001). Alogliptin neither increased nor decreased the risk of cardiovascular events compared with placebo in patients with high baseline hsTnI (22.3% versus 23.0%; hazard ratio, 0.87; 95% confidence interval, 0.60–1.25;
P
=0.44).
Conclusions:
Serial assessment of hsTnI revealed a substantial proportion of patients with type 2 diabetes mellitus without clinically recognized events had dynamic or persistently elevated values and were at high risk of recurrent events. hsTnI may have a role in personalizing preventive strategies in patients with diabetes mellitus based on risk.
Clinical Trial Registration:
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00968708.
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Affiliation(s)
- Matthew A. Cavender
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - William B. White
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Petr Jarolim
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - George L. Bakris
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - William C. Cushman
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Stuart Kupfer
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Qi Gao
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Cyrus R. Mehta
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Faiez Zannad
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - Christopher P. Cannon
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
| | - David A. Morrow
- From University of North Carolina, Chapel Hill (M.A.C.); Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington (W.B.W.); Department of Pathology (P.J.) and TIMI Study Group (D.A.M.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA; University of Chicago, IL (G.L.B.); Memphis Veterans Affairs Medical Center, University of Tennessee College of Medicine (W.C.C.); Takeda Development Center Americas, Inc., Deerfield, IL (S.K.); Baim Institute for Clinical
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134
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Verdoia M, Nardin M, Rolla R, Marino P, Bellomo G, Suryapranata H, De Luca G. Immature platelet fraction and the extent of coronary artery disease: A single centre study. Atherosclerosis 2017; 260:110-115. [DOI: 10.1016/j.atherosclerosis.2017.03.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/27/2017] [Accepted: 03/30/2017] [Indexed: 02/08/2023]
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135
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Sweeny JM, Angiolillo DJ, Franchi F, Rollini F, Waksman R, Raveendran G, Dangas G, Khan ND, Carlson GF, Zhao Y, Teng R, Mehran R. Impact of Diabetes Mellitus on the Pharmacodynamic Effects of Ticagrelor Versus Clopidogrel in Troponin-Negative Acute Coronary Syndrome Patients Undergoing Ad Hoc Percutaneous Coronary Intervention. J Am Heart Assoc 2017; 6:JAHA.117.005650. [PMID: 28356282 PMCID: PMC5533039 DOI: 10.1161/jaha.117.005650] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background Diabetes mellitus (DM) is associated with enhanced platelet reactivity and impaired response to oral antiplatelet therapy, including clopidogrel. This post hoc analysis investigated the pharmacodynamic effects of ticagrelor versus clopidogrel loading dose (LD) in troponin‐negative acute coronary syndrome patients with or without DM undergoing percutaneous coronary intervention in the Ad Hoc PCI study. Methods and Results Patients randomized (1:1) to receive ticagrelor 180 mg LD or clopidogrel 600 mg LD were assessed by diabetic status. Platelet reactivity (P2Y12 reaction units [PRU] on VerifyNow® assay) was measured pre‐LD, at 0.5, 2, and 8 hours post‐LD, and at the end of the percutaneous coronary intervention. The primary endpoint was PRU levels 2 hours post‐LD; secondary endpoints included rates of high on‐treatment platelet reactivity (PRU≥208). Of 100 randomized patients, 51 received ticagrelor (DM, n=20; non‐DM, n=31) and 49 clopidogrel (DM, n=16; non‐DM, n=33). At 2 hours post‐LD, mean (SD) PRU levels in DM patients were 130.1 (111.7) with ticagrelor versus 287.6 (71.9) with clopidogrel (mean [95%CI] difference −157.5 [−225.3, −89.8]; P<0.001); in non‐DM patients, they were 75.3 (75.7) versus 243.0 (72.4) (mean difference −167.7 [−207.1, −128.3]; P<0.001). High on‐treatment platelet reactivity rates at 2 hours post‐LD were also significantly (P<0.001) reduced with ticagrelor versus clopidogrel in DM and non‐DM patients. Between‐treatment differences for PRU and high on‐treatment platelet reactivity were not significant at earlier time points but were at 8 hours post‐LD (P<0.001). Conclusions Compared with clopidogrel, ticagrelor achieved faster, enhanced platelet inhibition and reduced high on‐treatment platelet reactivity rates, in DM and non‐DM patients. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01603082.
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Affiliation(s)
| | | | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Ron Waksman
- MedStar Washington Hospital Center, Washington, DC
| | | | - George Dangas
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY
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136
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Thomas MR, Angiolillo DJ, Bonaca MP, Ajjan RA, Judge HM, Rollini F, Franchi F, Ahsan AJ, Bhatt DL, Kuder JF, Steg PG, Cohen M, Muthusamy R, Sabatine MS, Storey RF. Consistent platelet inhibition with ticagrelor 60 mg twice-daily following myocardial infarction regardless of diabetes status. Thromb Haemost 2017; 117:940-947. [PMID: 28300867 DOI: 10.1160/th16-09-0703] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/09/2017] [Indexed: 01/03/2023]
Abstract
Diabetes increases cardiovascular risk and reduces pharmacodynamic response to some oral antiplatelet drugs. This study aimed to determine whether ticagrelor 60 mg twice daily (bid) provided potent and consistent platelet inhibition in patients with vs without diabetes in the PEGASUS-TIMI 54 platelet function substudy. Out of 180 patients studied, 58 patients were randomised to and had received at least four weeks of ticagrelor 60 mg bid, with 20 (34 %) having diabetes, 58 patients received ticagrelor 90 mg bid, with 12 (21 %) having diabetes, and 64 patients received placebo, with 18 (28 %) having diabetes. Blood was sampled pre- and 2 hours post-maintenance dose. In patients treated with ticagrelor 60 mg bid, on-treatment platelet reactivity to ADP, as determined by light transmission aggregometry (LTA), VerifyNow and VASP, was similar in patients with vs without diabetes (LTA post-dose, ADP 20 µM: 29 ± 14 vs 34 ± 10 %, respectively; p = 0.19). A consistent inhibitory effect of ticagrelor 60 mg bid was observed pre- and post-dose regardless of diabetes status, even in insulin-treated patients. Patients with diabetes did not have an increased incidence of high platelet reactivity in either ticagrelor group. Platelet reactivity was similar in patients with diabetes treated with ticagrelor 60 mg vs 90 mg bid. Pharmacokinetics of ticagrelor were not affected by diabetes status. In conclusion, ticagrelor 60 mg bid is equally effective at reducing platelet reactivity in patients with and without diabetes, yielding a consistently high level of platelet inhibition regardless of diabetes status.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Robert F Storey
- Prof. Robert F. Storey, MD DM FESC, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK, E-mail:
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Barillà F, Pelliccia F, Borzi M, Camici P, Cas LD, Di Biase M, Indolfi C, Mercuro G, Montemurro V, Padeletti L, Filardi PP, Vizza CD, Romeo F. Optimal duration of dual anti-platelet therapy after percutaneous coronary intervention: 2016 consensus position of the Italian Society of Cardiology. J Cardiovasc Med (Hagerstown) 2017; 18:1-9. [PMID: 27635937 DOI: 10.2459/jcm.0000000000000434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Definition of the optimal duration of dual anti-platelet therapy (DAPT) is an important clinical issue, given the large number of patients having percutaneous coronary intervention (PCI), the costs and risks of pharmacologic therapy, the consequences of stent thrombosis, and the potential benefits of DAPT in preventing ischaemic outcomes beyond stent thrombosis. Nowadays, the rationale for a prolonged duration of DAPT should be not only the prevention of stent thrombosis, but also the prevention of ischaemic events unrelated to the coronary stenosis treated with index PCI. A higher predisposition to athero-thrombosis may persist for years after an acute myocardial infarction, and even stable patients with a history of prior myocardial infarction are at high risk for major adverse cardiovascular events. Recently, results of pre-specified post-hoc analyses of randomized clinical trials, including the PEGASUS-TIMI 54 trial, have shed light on strategies of DAPT in various clinical situations, and should impact the next rounds of international guidelines, and also routine practice. Accordingly, the 2015 to 2016 the Board of the Italian Society of Cardiology addressed newer recommendations on duration of DAPT based on most recent scientific information. The document states that physicians should decide duration of DAPT on an individual basis, taking into account ischaemic and bleeding risks of any given patient. Indeed, current controversy surrounding optimal duration of DAPT clearly reflects the fact that, nowadays, a one size fits all strategy cannot be reliably applied to patients treated with PCI. Indeed, patients usually have factors for both increased ischaemic and bleeding risks that must be carefully evaluated to assess the benefit/risk ratio of prolonged DAPT. Personalized management of DAPT must be seen as a dynamic prescription with regular re-evaluations of the risk/benefit to the patient according to changes in his/her clinical profile. Also, in order to derive more benefit than harm from new treatments, a multi-parametric approach using several risk scores of the ischaemic and bleeding risks might improve the process of risk factor characterization. In patients with high ischaemic risk, particularly those with a history of myocardial infarction, the benefits of extended DAPT (particularly with ticagrelor up to 3 years) are likely to outweigh the risks.
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Affiliation(s)
- Francesco Barillà
- aDepartment of Cardiovascular Sciences, Sapienza University bDepartment of Cardiovascular Disease, Tor Vergata University of Rome, Rome cCardiothoracic and Vascular Department, Vita-Salute University, Milan dDepartment of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia eDepartment of Medical & Surgical Sciences, University of Foggia, Foggia fDivision of Cardiology, Department of Medical and Surgical Sciences, 'Magna Graecia' University, Catanzaro gDepartment of Medical Sciences 'Mario Aresu', University of Cagliari, Cagliari hHeart and Vessels Department, University of Florence, Florence iDepartment of Advanced Biomedical Sciences, Federico II University, Naples, Italy
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Silber S. [Secondary prevention after myocardial infarction with prolonged dual anti-platelet therapy (DAPT). A new therapeutic concept]. MMW Fortschr Med 2017; 159:49-52. [PMID: 28321726 DOI: 10.1007/s15006-017-9389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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139
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Cavallari I, Bonaca MP. Antiplatelet Therapy for Secondary Prevention After Acute Myocardial Infarction. Interv Cardiol Clin 2017; 6:119-129. [PMID: 27886815 DOI: 10.1016/j.iccl.2016.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Patients with prior myocardial infarction (MI) are at long-term heightened risk for recurrent ischemic events. Several large randomized controlled trials have demonstrated the benefit of more intensive antiplatelet strategies for long-term secondary prevention of cardiovascular death, recurrent MI, and stroke in patients with a history of MI at a cost of increased bleeding. The bleeding risk associated with long-term intensive antiplatelet strategies requires careful patient selection and involvement of patients in shared decision making regarding risks and benefits of therapy. Clinical characteristics, adherence to therapy, and integrated risk scores may aid clinicians in translating clinical trials into individualized therapy.
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Affiliation(s)
- Ilaria Cavallari
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 350 Longwood Avenue, Boston, MA 02115, USA
| | - Marc P Bonaca
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, 350 Longwood Avenue, Boston, MA 02115, USA.
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Majithia A, Bhatt DL. Optimal Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. Interv Cardiol Clin 2016; 6:25-37. [PMID: 27886820 DOI: 10.1016/j.iccl.2016.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Dual antiplatelet therapy (DAPT) is an essential component of treatment in patients with coronary artery disease treated with percutaneous coronary intervention (PCI). Recommendations for duration of DAPT after PCI should consider patient-specific risk, clinical presentation, stent characteristics, and procedural factors. Prolonged DAPT results in a reduction of stent thrombosis (ST) and myocardial infarction (MI) at the cost of increased bleeding. Studies of shorter-duration DAPT demonstrate similar mortality, MI, ST, and less bleeding when compared with longer DAPT duration. We review current evidence for strategies of prolonged DAPT and abbreviated DAPT following PCI.
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Affiliation(s)
- Arjun Majithia
- Landsman Heart and Vascular Center, Lahey Hospital and Medical Center, 41 Burlington Mall Road, Burlington, MA 01805, USA
| | - Deepak L Bhatt
- Heart & Vascular Center, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Bardají A, Leal M, Arrarte V, Garcia-Moll X, Pérez de Isla L, Bueno H. Extended dual antiplatelet therapy after acute coronary syndrome in Spain: Results from the EPICOR study. Cardiovasc Ther 2016; 35. [PMID: 27885830 DOI: 10.1111/1755-5922.12237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/02/2016] [Accepted: 11/20/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Real-world, country-specific studies of dual antiplatelet therapy (DAPT) duration among survivors of acute coronary syndrome (ACS) are important for improving long-term prognosis. AIMS To investigate DAPT duration after hospital discharge for ACS in Spain. RESULTS Data from patients enrolled in the Spanish cohort of the EPICOR (long-tErm follow-up of antithrombotic management Patterns In acute CORonary syndrome patients) study (NCT01171404) were analyzed for changes to antithrombotic medication up to 2 years postdischarge according to index event diagnosis and patient characteristics. Deaths, coronary events, and bleeding events were analyzed over the same period. Overall, a high proportion of patients remained on DAPT at 2 years (53.1%). Among patients who experienced any on-treatment bleeding event, almost two-thirds remained on DAPT at the end of follow-up. Patients >65 years, diabetic, or those that were medically managed were more likely to continue with DAPT until 2 years following discharge. At 2 years, the incidence of bleeding events requiring hospitalization was low compared with the incidence of coronary events (1.4% vs 6.6%). There was a numerical reduction in coronary events, but no increase in bleeding events, with DAPT continuation compared with single antiplatelet therapy. CONCLUSIONS More than half of patients in this unselected cohort study remained on DAPT at 2 years following discharge for ACS. Continuation with DAPT was greater among patients with additional cardiovascular risk factors, which suggests that treating physicians in Spain prioritizes ischemic risk reduction over bleeding risk in patients with ACS, according to patient's risk profile.
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Affiliation(s)
- Alfredo Bardají
- Servicio de Cardiología, Hospital Universitario de Tarragona Joan XXIII, IISPV, Universidad Rovira Virgili, Tarragona, Spain
| | | | - Vicente Arrarte
- Servicio de Cardiología, Hospital General Universitario, Alicante, Spain
| | - Xavier Garcia-Moll
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Leopoldo Pérez de Isla
- Department of Cardiology, Clinical Hospital San Carlos, Health Research Institute, San Carlos, Madrid, Spain.,Universidad Complutense de Madrid, Madrid, Spain
| | - Héctor Bueno
- Universidad Complutense de Madrid, Madrid, Spain.,Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Instituto de investigación i+12 and Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
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Eisen A, Bhatt DL. Optimal duration of dual antiplatelet therapy after acute coronary syndromes and coronary stenting. Heart 2016; 103:871-884. [PMID: 27888209 DOI: 10.1136/heartjnl-2015-309022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Alon Eisen
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
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145
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Gargiulo G, Windecker S, da Costa BR, Feres F, Hong MK, Gilard M, Kim HS, Colombo A, Bhatt DL, Kim BK, Morice MC, Park KW, Chieffo A, Palmerini T, Stone GW, Valgimigli M. Short term versus long term dual antiplatelet therapy after implantation of drug eluting stent in patients with or without diabetes: systematic review and meta-analysis of individual participant data from randomised trials. BMJ 2016; 355:i5483. [PMID: 27811064 PMCID: PMC5094199 DOI: 10.1136/bmj.i5483] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare clinical outcomes between short term (up to 6 months) and long term (12 months) dual antiplatelet therapy (DAPT) after placement of a drug eluting stent in patients with and without diabetes. DESIGN Individual participant data meta-analysis. Cox proportional regression models stratified by trial were used to assess the impact of diabetes on outcomes. DATA SOURCE Medline, Embase, and Cochrane databases and proceedings of international meetings searched for randomised controlled trials comparing durations of DAPT after placement of a drug eluting stent. Individual patient data pooled from six DAPT trials. PRIMARY OUTCOME Primary study outcome was one year risk of major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, or definite/probable stent thrombosis. All analyses were conducted by intention to treat. RESULTS Six trials including 11 473 randomised patients were pooled. Of these patients, 3681 (32.1%) had diabetes and 7708 (67.2%) did not (mean age 63.7 (SD 9.9) and 62.8 (SD 10.1), respectively), and in 84 (0.7%) the information was missing. Diabetes was an independent predictor of MACE (hazard ratio 2.30, 95% confidence interval 1.01 to 5.27; P=0.048 At one year follow-up, long term DAPT was not associated with a decreased risk of MACE compared with short term DAPT in patients with (1.05, 0.62 to 1.76; P=0.86) or without (0.97, 0.67 to 1.39; P=0.85) diabetes (P=0.33 for interaction). The risk of myocardial infarction did not differ between the two DAPT regimens (0.95, 0.58 to 1.54; P=0.82; for those with diabetes and 1.15, 0.68 to 1.94; P=0.60; for those without diabetes (P=0.84 for interaction). There was a lower risk of definite/probable stent thrombosis with long term DAPT among patients with (0.26, 0.09 to 0.80; P=0.02) than without (1.42, 0.68 to 2.98; P=0.35) diabetes, with positive interaction testing (P=0.04 for interaction), although the landmark analysis showed a trend towards benefit in both groups. Long term DAPT was associated with higher rates of major or minor bleeding, irrespective of diabetes (P=0.37 for interaction). CONCLUSIONS Although the presence of diabetes emerged as an independent predictor of MACE after implantation of a drug eluting stent, compared with short term DAPT, long term DAPT did not reduce the risk of MACE but increased the risk of bleeding among patients with stents with and without diabetes.
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Affiliation(s)
- Giuseppe Gargiulo
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
| | - Bruno R da Costa
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Fausto Feres
- Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Martine Gilard
- Department of Cardiology, CHU de la Cavale Blanche, Brest, France
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Antonio Colombo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Tullio Palmerini
- Dipartimento Cardio-Toraco-Vascolare, University of Bologna, Bologna, Italy
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, CH-3010 Bern, Switzerland
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Ajjan RA. Coronary thrombosis in diabetes: Are we doing enough? Diab Vasc Dis Res 2016; 13:445-448. [PMID: 27555606 DOI: 10.1177/1479164116663795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- R A Ajjan
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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147
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Vilahur G, Gutiérrez M, Casani L, Varela L, Capdevila A, Pons-Lladó G, Carreras F, Carlsson L, Hidalgo A, Badimon L. Protective Effects of Ticagrelor on Myocardial Injury After Infarction. Circulation 2016; 134:1708-1719. [PMID: 27789556 DOI: 10.1161/circulationaha.116.024014] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/08/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The P2Y12 receptor antagonist ticagrelor has been shown to be clinically superior to clopidogrel. Although the underlying mechanisms remain elusive, ticagrelor may exert off-target effects through adenosine-related mechanisms. We aimed to investigate whether ticagrelor reduces myocardial injury to a greater extent than clopidogrel after myocardial infarction (MI) at a similar level of platelet inhibition and to determine the underlying mechanisms. METHODS Pigs received the following before MI induction: (1) placebo-control; (2) a loading dose of clopidogrel (600 mg); (3) a loading dose of ticagrelor (180 mg); or (4) a loading dose of ticagrelor followed by an adenosine A1/A2-receptor antagonist [8-(p-sulfophenyl)theophylline, 4 mg/kg intravenous] to determine the potential contribution of adenosine in ticagrelor-related cardioprotection. Animals received the corresponding maintenance doses of the antiplatelet agents during the following 24 hours and underwent 3T-cardiac MRI analysis. Platelet inhibition was monitored by ADP-induced platelet aggregation. In the myocardium, we assessed the expression and activation of proteins known to modulate edema formation, including aquaporin-4 and AMP-activated protein kinase and its downstream effectors CD36 and endothelial nitric oxide synthase and cyclooxygenase-2 activity. RESULTS Clopidogrel and ticagrelor exerted a high and consistent antiplatelet effect (68.2% and 62.2% of platelet inhibition, respectively, on challenge with 20 μmol/L ADP) that persisted up to 24 hours post-MI (P<0.05). All groups showed comparable myocardial area-at-risk and cardiac worsening after MI induction. 3T-Cardiac MRI analysis revealed that clopidogrel- and ticagrelor-treated animals had a significantly smaller extent of MI than placebo-control animals (15.7 g left ventricle and 12.0 g left ventricle versus 22.8 g left ventricle, respectively). Yet, ticagrelor reduced infarct size to a significantly greater extent than clopidogrel (further 23.5% reduction; P=0.0026), an effect supported by troponin-I assessment and histopathologic analysis (P=0.0021). Furthermore, in comparison with clopidogrel, ticagrelor significantly diminished myocardial edema by 24.5% (P=0.004), which correlated with infarct mass (r=0.73; P<0.001). 8-(p-Sulfophenyl)theophylline administration abolished the cardioprotective effects of ticagrelor over clopidogrel. At a molecular level, aquaporin-4 expression decreased and the expression and activation of AMP-activated protein kinase signaling and cyclooxygenase-2 increased in the ischemic myocardium of ticagrelor- versus clopidogrel-treated animals (P<0.05). These protein changes were not observed in those animals administered the adenosine receptor blocker 8-(p-sulfophenyl)theophylline. CONCLUSIONS Ticagrelor, beyond its antiplatelet efficacy, exerts cardioprotective effects by reducing necrotic injury and edema formation via adenosine-dependent mechanisms.
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Affiliation(s)
- Gemma Vilahur
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Manuel Gutiérrez
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Laura Casani
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Lourdes Varela
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Antoni Capdevila
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Guillem Pons-Lladó
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Francesc Carreras
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Leif Carlsson
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Alberto Hidalgo
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.)
| | - Lina Badimon
- From Cardiovascular Research Center (CSIC-ICCC), IIB-HSCSP, Barcelona, Spain (G.V., L.C., L.V., L.B.); Radiology Unit, Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (M.G., A.C., A.H.); Cardiology Unit. Hospital de la Santa Creu i Sant Pau (HSCSP), Barcelona, Spain (G.P.-L., F.C.); Cardiovascular and Metabolic Diseases, Innovative Medicines and Early Development Biotech Unit, AstraZeneca, Mölndal, Sweden (L.C.); and Cardiovascular Research Chair UAB (Autonomous University of Barcelona), Spain (L.B.).
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148
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Rosa GM, Bianco D, Valbusa A, Massobrio L, Chiarella F, Brunelli C. Pharmacokinetics and pharmacodynamics of ticagrelor in the treatment of cardiac ischemia. Expert Opin Drug Metab Toxicol 2016; 12:1491-1502. [PMID: 27715344 DOI: 10.1080/17425255.2016.1244524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Gian Marco Rosa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Daniele Bianco
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Alberto Valbusa
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Laura Massobrio
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Francesco Chiarella
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Division of Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
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149
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Franchi F, Rollini F, Aggarwal N, Hu J, Kureti M, Durairaj A, Duarte VE, Cho JR, Been L, Zenni MM, Bass TA, Angiolillo DJ. Pharmacodynamic Comparison of Prasugrel Versus Ticagrelor in Patients With Type 2 Diabetes Mellitus and Coronary Artery Disease: The OPTIMUS (Optimizing Antiplatelet Therapy in Diabetes Mellitus)-4 Study. Circulation 2016; 134:780-92. [PMID: 27559041 DOI: 10.1161/circulationaha.116.023402] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/05/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with diabetes mellitus (DM) are at increased risk of atherothrombotic events, underscoring the importance of effective platelet inhibiting therapies. Prasugrel and ticagrelor reduce thrombotic complications to a greater extent than clopidogrel. Subgroup analyses of pivotal clinical trials testing prasugrel and ticagrelor versus clopidogrel showed DM patients to have benefits that were consistent with the overall trial populations, although the magnitude of the ischemic risk reduction appeared to be enhanced with prasugrel. Whether these findings may be attributed to differences in the pharmacodynamic profiles of these drugs in DM patients remains poorly explored and represented the aim of this study. METHODS In this prospective, randomized, double-blind, double-dummy, crossover pharmacodynamic study, aspirin-treated DM patients (n=50) with coronary artery disease were randomly assigned to receive prasugrel (60 mg loading dose [LD]/10 mg maintenance dose once daily) or ticagrelor (180 mg LD/90 mg maintenance dose twice daily) for 1 week. Pharmacodynamic assessments were conducted using 4 different assays, including VerifyNow P2Y12, vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate, which allowed us to explore ADP- and non-ADP-induced (arachidonic acid-, collagen-, thrombin receptor-activating, peptide-induced) platelet signaling pathways. The acute (baseline, 30 minutes, and 2 hours post-LD) and maintenance (1 week) effects of therapy were assessed. The primary end point of the study was the comparison of P2Y12 reaction units determined by VerifyNow P2Y12 at 1 week between prasugrel and ticagrelor. RESULTS ADP- and non-ADP-induced measures of platelet reactivity reduced significantly with both prasugrel and ticagrelor LD and maintenance dose. P2Y12 reaction units defined by VerifyNow were similar between prasugrel and ticagrelor at 30 minutes and 2 hours post-LD. At 1 week, P2Y12 reaction units were significantly lower with ticagrelor than with prasugrel (52 [32-72] versus 83 [63-103]; least-square means difference: -31; 95% confidence interval, -57 to -4; P=0.022; primary end point). Pharmacodynamic assessments measured by vasodilator-stimulated phosphoprotein, light transmittance aggregometry, and Multiplate were similar between prasugrel and ticagrelor at each time point, including at 1 week. Rates of high on-treatment platelet reactivity were similar between groups with all assays at all time points. CONCLUSIONS In DM patients with coronary artery disease, ticagrelor exerts similar or greater inhibition of ADP-induced platelet reactivity in comparison with prasugrel in the acute and chronic phases of treatment, whereas the inhibition of measures of non-ADP-induced platelet reactivity was not significantly different between the 2 agents. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01852214.
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Affiliation(s)
- Francesco Franchi
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Fabiana Rollini
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Niti Aggarwal
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Jenny Hu
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Megha Kureti
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Ashwin Durairaj
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Valeria E Duarte
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Jung Rae Cho
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Latonya Been
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Martin M Zenni
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Theodore A Bass
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL
| | - Dominick J Angiolillo
- From the Division of Cardiology, University of Florida College of Medicine-Jacksonville, FL.
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150
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Domanski MJ. Dual Antiplatelet Therapy in the Prevention of Recurrent Ischemic Events ∗. J Am Coll Cardiol 2016; 67:2741-2743. [DOI: 10.1016/j.jacc.2016.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022]
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