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Abstract
Cardiovascular disease (CVD) remains the main cause of mortality and morbidity in patients with diabetes. Prevention of CVD in diabetes involves a multifactorial approach that aims to treat the cluster of risk factors including hyperglycemia, dyslipidemia, obesity, hypertension, and hypercoagulation associated with this condition. Antiplatelets reduce the prothrombotic environment in diabetes, but complications of this therapeutic approach include a general risk of bleeding, specifically intracranial hemorrhage, the risk of which increases in the presence of hypertension. Current guidelines recommend the use of antiplatelet agents after tight control of blood pressure, which, in clinical practice, is not always possible. In this review, the evidence for antiplatelet use in diabetes with particular emphasis on patients with associated hypertension is examined. Safe levels of blood pressure with antiplatelet therapy, various studies, and general recommendations for diabetes patients, in light of current evidence, are explored.
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Affiliation(s)
- R. A. Ajjan
- From the Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Peter J. Grant
- From the Division of Cardiovascular and Diabetes Research, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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102
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Capodanno D, Patel A, Dharmashankar K, Ferreiro JL, Ueno M, Kodali M, Tomasello SD, Capranzano P, Seecheran N, Darlington A, Tello-Montoliu A, Desai B, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Different Aspirin Dosing Regimens in Type 2 Diabetes Mellitus Patients With Coronary Artery Disease. Circ Cardiovasc Interv 2011; 4:180-7. [DOI: 10.1161/circinterventions.110.960187] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Patients with type 2 diabetes mellitus (T2DM) have reduced aspirin-induced pharmacodynamic effects. This may be attributed to increased platelet turnover rates resulting in an increased proportion of non–aspirin-inhibited platelets during the daily dosing interval. The hypothesis of this study was that an increase in the frequency of drug administration [twice daily (bid) versus once daily (od)] may provide more effective platelet inhibition in T2DM patients.
Methods and Results—
T2DM patients with stable coronary artery disease were prospectively recruited. Patients modified their aspirin regimen on a weekly basis according to the following scheme: 81 mg/od, 81 mg/bid, 162 mg/od, 162 mg/bid, and 325 mg/od. Pharmacodynamic assessments included light-transmittance aggregometry after arachidonic acid, collagen and adenosine diphosphate stimuli; VerifyNow-Aspirin assay; and serum thromboxane B
2
(TXB
2
) levels. Twenty patients were analyzed. All patients were sensitive and compliant to aspirin irrespective of dose, as assessed by arachidonic acid–induced aggregation. When aspirin was administered once daily, there was no significant effect on platelet reactivity by increasing the once-daily dosing using aspirin-sensitive assays (collagen-induced aggregation and VerifyNow-Aspirin). An increase in aspirin dose by means of a second daily administration was associated with a significant reduction in platelet reactivity assessed by collagen-induced aggregation and VerifyNow-Aspirin between 81 mg/od and 81 mg/bid (
P
<0.05 for both assays) and between 81 mg/od and 162 mg/bid (
P
<0.05 for both assays). There was no impact of aspirin dosing regimens on adenosine diphosphate–induced aggregation. A dose-dependent effect of aspirin was observed on serum TXB
2
levels (
P
=0.003).
Conclusions—
Aspirin dosing regimens are associated with different pharmacodynamic effects in platelets from T2DM patients and stable coronary artery disease, with a twice-daily, low-dose aspirin administration resulting in greater platelet inhibition than once-daily administration as assessed by aspirin-sensitive assays and a dose-dependent effect on serum TXB
2
levels. The clinical implications of a modified aspirin regimen tailored to T2DM patients warrant further investigation.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01201785.
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Affiliation(s)
- Davide Capodanno
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Aasita Patel
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | | | - José Luis Ferreiro
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Masafumi Ueno
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Murali Kodali
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | | | - Piera Capranzano
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Naveen Seecheran
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Andrew Darlington
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | | | - Bhaloo Desai
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
| | - Theodore A. Bass
- From the University of Florida College of Medicine–Jacksonville, Jacksonville, FL
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103
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A case of subacute thrombosis associated with clopidogrel resistance after implantation of a zotarolimus-eluting stent. Heart Vessels 2011; 27:106-9. [DOI: 10.1007/s00380-011-0134-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
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104
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Foo F, Oldroyd KG. Clinical value of antiplatelet therapy in patients with acute coronary syndromes and in percutaneous coronary intervention. Biomark Med 2011; 5:9-30. [PMID: 21319962 DOI: 10.2217/bmm.11.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Dual antiplatelet therapy with aspirin and clopidogrel is recommended in all patients who have had an acute coronary syndrome or who undergo percutaneous coronary intervention to prevent further ischemic events. Resistance or reduced responsiveness to aspirin and/or clopidogrel has been associated with adverse cardiovascular outcomes, including stent thrombosis. There have been significant advances in this field, which aim to overcome antiplatelet resistance, including the development of new antiplatelet agents. The rationale for dual antiplatelet therapy, the impact of suboptimal efficacy and the potential ways of overcoming resistance or variability in response to antiplatelet agents will be reviewed in this article.
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Affiliation(s)
- Fiona Foo
- West of Scotland Regional Heart & Lung Centre, Golden Jubilee National Hospital, Beardmore Street, Glasgow, G81 4HX, UK
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105
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106
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Angiolillo DJ, Badimon JJ, Saucedo JF, Frelinger AL, Michelson AD, Jakubowski JA, Zhu B, Ojeh CK, Baker BA, Effron MB. A pharmacodynamic comparison of prasugrel vs. high-dose clopidogrel in patients with type 2 diabetes mellitus and coronary artery disease: results of the Optimizing anti-Platelet Therapy In diabetes MellitUS (OPTIMUS)-3 Trial. Eur Heart J 2011; 32:838-46. [PMID: 21252171 PMCID: PMC3069388 DOI: 10.1093/eurheartj/ehq494] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims Patients with diabetes mellitus (DM) have increased platelet reactivity and reduced platelet response to clopidogrel compared with patients without DM. Prasugrel, a more potent antiplatelet agent, is associated with greater reductions in ischaemic events compared with clopidogrel, particularly in patients with DM. The aim of this study was to perform serial pharmacodynamic assessments of prasugrel with high-dose clopidogrel in patients with DM. Methods and results Optimizing anti-Platelet Therapy In diabetes MellitUS (OPTIMUS)-3 was a prospective, randomized, double-blind, crossover study in patients with type 2 DM and coronary artery disease (CAD). Patients (n= 35) were randomly assigned to either prasugrel 60 mg loading dose (LD)/10 mg maintenance dose (MD) or clopidogrel 600 mg LD/150 mg MD over two 1-week treatment periods separated by a 2-week washout period. Platelet function was assessed by VerifyNow® P2Y12 assay, light transmission aggregometry, and vasodilator-stimulated phosphoprotein phosphorylation at 0, 1, 4, and 24 h and 7 days. Greater platelet inhibition by VerifyNow® P2Y12 was achieved by prasugrel compared with clopidogrel at 4 h post-LD (least squares mean, 89.3 vs. 27.7%, P< 0.0001; primary endpoint). The difference in platelet inhibition between prasugrel and clopidogrel was significant from 1 h through 7 days (P < 0.0001). Similar results were obtained using all other platelet function measures. Prasugrel resulted in fewer poor responders at all time points irrespective of definition used. Conclusion In patients with type 2 DM and CAD, standard-dose prasugrel is associated with greater platelet inhibition and better response profiles during both the loading and maintenance periods when compared with double-dose clopidogrel. Clinical trial identifier: www.clinicaltrials.gov—NCT00642174
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Affiliation(s)
- Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, 655 W. Eighth Street, Jacksonville, FL 32209, USA.
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107
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Ueno M, Kodali M, Tello-Montoliu A, Angiolillo DJ. Role of Platelets and Antiplatelet Therapy in Cardiovascular Disease. J Atheroscler Thromb 2011; 18:431-42. [DOI: 10.5551/jat.7633] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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108
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Maruyama H, Takeda H, Dembo T, Nagoya H, Kato Y, Fukuoka T, Deguchi I, Horiuchi Y, Tanahashi N. Clopidogrel resistance and the effect of combination cilostazol in patients with ischemic stroke or carotid artery stenting using the VerifyNow P2Y12 Assay. Intern Med 2011; 50:695-8. [PMID: 21467700 DOI: 10.2169/internalmedicine.50.4623] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE The inhibitory response to clopidogrel considerably varies among individuals and clopidogrel resistance is a risk factor for thrombotic events in patients with cardiovascular disease. Based on the platelet aggregation evaluated by the VerifyNow P2Y12 Assay, the present study investigated clopidogrel resistance and the effect of cilostazol addition. METHODS We measured the ability of 20 µM ADP to aggregate platelets using the VerifyNow P2Y12 Assay. Clopidogrel resistance was defined as % inhibition of <20% in this assay. PATIENTS We examined 77 patients (53 men and 24 women, aged 65.8 ± 9.9 years) with ischemic stroke or carotid artery stenting who received clopidogrel (75 mg) for >7 days at our hospital between October 2009 and March 2010. For 62 patients (42 men and 20 women, aged 65.3 ± 9.9 years) 75 mg clopidogrel alone was administered (clopidogrel only group); the other 15 patients (11 men and 4 women, aged 67.9 ± 9.9 years) received 75 mg of clopidogrel plus 100 or 200 mg of cilostazol (cilostazol combination group). RESULTS Clopidogrel resistance was identified in 18 (29%) of the 62 patients in the clopidogrel only group. The percent inhibition was significantly higher in the cilostazol combination group than in the clopidogrel only group (41.7 ± 28.0% vs. 64.9 ± 22.7%, p=0.005). None of the patients in the cilostazol combination group had % inhibition of <20%. CONCLUSION Clopidogrel resistance developed in 29% of patients given clopidogrel alone. The addition of cilostazol to clopidogrel may have intensified platelet inhibition.
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Affiliation(s)
- Hajime Maruyama
- Department of Neurology, International Medical Center, Saitama Medical University, Japan.
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109
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Michelson AD. Advances in antiplatelet therapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:62-69. [PMID: 22160013 DOI: 10.1182/asheducation-2011.1.62] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Because of the central role of platelets in cardiovascular atherothrombosis, there is a well-established therapeutic role for antiplatelet therapy that includes aspirin (a cyclooxygenase 1 [COX1] inhibitor), clopidogrel (an antagonist of the ADP P2Y(12) receptor), and the GPIIb-GPIIIa (αIIbβ3) antagonists. However, there remains a significant incidence of arterial thrombosis in patients treated with currently available antiplatelet therapy. Novel P2Y(12) antagonists such as the recently US Food and Drug Administration (FDA)-approved prasugrel, along with ticagrelor, cangrelor, and elinogrel, have advantages over clopidogrel, including more rapid, less variable, and more complete inhibition of platelet function. Currently ongoing phase 3 studies will determine whether these new P2Y(12) antagonists will result in better and/or more rapid antithrombotic effects than clopidogrel, without an unacceptable increase in hemorrhagic or other side effects, as has been recently reported in some clinical settings for prasugrel and ticagrelor. Antagonists of the thrombin receptor protease-activated receptor 1 (PAR1) are also undergoing phase 3 trials, and many other novel antiplatelet agents are under investigation as antithrombotic agents.
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Affiliation(s)
- Alan D Michelson
- Center for Platelet Research Studies, Division of Hematology/Oncology, Children's Hospital Boston, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115-5737, USA.
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110
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Multicenter Randomized Trial Evaluating the Efficacy of Cilostazol on Ischemic Vascular Complications After Drug-Eluting Stent Implantation for Coronary Heart Disease. J Am Coll Cardiol 2011; 57:280-9. [PMID: 21232664 DOI: 10.1016/j.jacc.2010.08.631] [Citation(s) in RCA: 154] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Revised: 08/13/2010] [Accepted: 08/18/2010] [Indexed: 11/23/2022]
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111
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Kakouros N, Rade JJ, Kourliouros A, Resar JR. Platelet function in patients with diabetes mellitus: from a theoretical to a practical perspective. Int J Endocrinol 2011; 2011:742719. [PMID: 21869886 PMCID: PMC3159301 DOI: 10.1155/2011/742719] [Citation(s) in RCA: 109] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Accepted: 06/22/2011] [Indexed: 11/24/2022] Open
Abstract
Patients with diabetes mellitus have an increased prevalence of vascular disease. Pathologic thrombosis associated with atherosclerotic plaque rupture is a major cause of morbidity and mortality. Platelets are intimately involved in the initiation and propagation of thrombosis. Evidence suggests that platelets from patients with type 2 diabetes have increased reactivity and baseline activation compared to healthy controls. We review the pathophysiology of platelet hyperreactivity in DM patients and its implications in clinical practice, with particular focus on acute coronary syndromes, percutaneous coronary intervention, and novel antiplatelet agents.
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Affiliation(s)
- Nicholaos Kakouros
- Johns Hopkins University School of Medicine, and Johns Hopkins Hospital Division of Cardiovascular Disease, Baltimore, MD 21287-073, USA
- *Nicholaos Kakouros:
| | - Jeffrey J. Rade
- Johns Hopkins University School of Medicine, and Johns Hopkins Hospital Division of Cardiovascular Disease, Baltimore, MD 21287-073, USA
| | | | - Jon R. Resar
- Johns Hopkins University School of Medicine, and Johns Hopkins Hospital Division of Cardiovascular Disease, Baltimore, MD 21287-073, USA
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112
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Lee SP, Bae JW, Park KW, Rha SW, Bae JH, Suh JW, Chae IH, Cho MC, Kim HS. Inhibitory Interaction Between Calcium Channel Blocker and Clopidogrel - Efficacy of Cilostazol to Overcome It -. Circ J 2011; 75:2581-2589. [DOI: 10.1253/circj.cj-11-0113] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Seung-Pyo Lee
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University Hospital
| | - Kyung Woo Park
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital
| | | | - Jang-Ho Bae
- Division of Cardiology, Konyang University Hospital
| | - Jung-Won Suh
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - In-Ho Chae
- Cardiovascular Center, Seoul National University Bundang Hospital
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital
| | - Hyo-Soo Kim
- Cardiovascular Center, Department of Internal Medicine, Seoul National University Hospital
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113
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Yamanouchi J, Hato T, Niiya T, Nakagawa K, Kumon Y, Fujiwara H, Yakushijin Y, Yasukawa M. Vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay for platelet response to cilostazol. Platelets 2010; 22:135-42. [DOI: 10.3109/09537104.2010.525976] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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114
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Ye Y, Perez-Polo JR, Birnbaum Y. Protecting against ischemia-reperfusion injury: antiplatelet drugs, statins, and their potential interactions. Ann N Y Acad Sci 2010; 1207:76-82. [PMID: 20955429 DOI: 10.1111/j.1749-6632.2010.05725.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Statins and antiplatelet agents are currently used as therapeutic agents for patients with acute myocardial infarction. Statins limit myocardial infarct size by activating phosphatidylinositol-3-kinase (PI3K), ecto-5'-nucleotidase, Akt/endothelial nitric oxide synthase (eNOS), and the downstream effectors inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2). Inhibition of PI3K, adenosine receptors, eNOS, iNOS, or COX-2 abrogates the protective effects of statins. At >5 mg/kg, aspirin attenuates the myocardial infarct-size-limiting effect of statins. In contrast, the combination of low-dose atoravastatin with either the phosphodiesterase-III inhibitor cilostazol or the adenosine reuptake inhibitor dipyridamole synergistically limits infarct size. Low-dose aspirin with dipyridamole started during ischemia augmented the infarct-size-limiting effects of simvastatin. In contrast, high-dose aspirin blocked the protective effect of simvastatin. The combination of dipyridamole with low-dose aspirin and simvastatin resulted in the smallest infarct size. According to the most current data available, we believe that antiplatelet regimens may require modification for patients who are receiving statins.
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Affiliation(s)
- Yumei Ye
- Department of Biochemistry and Molecular Biology, The University of Texas Medical Branch, Galveston, Texas, USA
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115
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Lee K, Kim JY, Yoo BS, Yoon J, Hong MK, Ahn MS, Choe H, Lee SH. Cilostazol augments the inhibition of platelet aggregation in clopidogrel low-responders. J Thromb Haemost 2010; 8:2577-9. [PMID: 20723027 DOI: 10.1111/j.1538-7836.2010.04019.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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116
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Ferreiro JL, Cequier ÁR, Angiolillo DJ. Oral Antiplatelet Therapy in Patients with Diabetes Mellitus and Acute Coronary Syndromes. Trends Cardiovasc Med 2010; 20:211-7. [DOI: 10.1016/j.tcm.2011.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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117
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Morel O, Kessler L, Ohlmann P, Bareiss P. Diabetes and the platelet: Toward new therapeutic paradigms for diabetic atherothrombosis. Atherosclerosis 2010; 212:367-76. [DOI: 10.1016/j.atherosclerosis.2010.03.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2009] [Revised: 03/05/2010] [Accepted: 03/18/2010] [Indexed: 01/21/2023]
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118
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Ferreiro JL, Cequier ÁR, Angiolillo DJ. Antithrombotic therapy in patients with diabetes mellitus and coronary artery disease. Diab Vasc Dis Res 2010; 7:274-88. [PMID: 20921091 DOI: 10.1177/1479164110383995] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Currently approved antiplatelet treatment strategies have proved successful for reducing cardiovascular adverse events in patients with CAD. However, despite the use of recommended antiplatelet treatment strategies, the presence of DM has been consistently associated with a negative impact on outcomes and a high rate of adverse cardiovascular events continue to occur in patients with DM. The elevated prevalence of low response to standard oral antiplatelet agents contribute to these impaired outcomes. Thus, the search for more potent antiplatelet treatment strategies is warranted in high-risk patients, such as those with DM. The present manuscript provides an overview on the current status of knowledge on currently available antiplatelet agents, focusing on the benefits and limitations of these therapies in DM patients, and evaluating the potential role of new antithrombotic agents and treatment strategies currently under development to overcome these limitations.
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Affiliation(s)
- José Luis Ferreiro
- IDIBELL-Hospital Universitari de Bellvitge, Department of Cardiology, Interventional Cardiology Unit, L'Hospitalet de Llobregat, Barcelona, Spain
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119
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Mangiacapra F, Patti G, Peace A, Gatto L, Vizzi V, Ricottini E, D'Ambrosio A, Muller O, Barbato E, Di Sciascio G. Comparison of platelet reactivity and periprocedural outcomes in patients with versus without diabetes mellitus and treated with clopidogrel and percutaneous coronary intervention. Am J Cardiol 2010; 106:619-23. [PMID: 20723634 DOI: 10.1016/j.amjcard.2010.04.015] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 04/15/2010] [Accepted: 04/15/2010] [Indexed: 11/17/2022]
Abstract
The effect of periprocedural platelet reactivity and clinical outcomes in diabetic patients taking clopidogrel and undergoing percutaneous coronary intervention (PCI) is unclear. The aim of the present study was to prospectively evaluate the influence of diabetes mellitus (DM) on platelet reactivity measured by the VerifyNow P2Y12 assay and on periprocedural outcomes in patients receiving clopidogrel and undergoing PCI. A total of 285 consecutive clopidogrel-treated patients undergoing elective PCI were included. Platelet function analysis was performed using the VerifyNow P2Y12 assay. High platelet reactivity (HPR) after clopidogrel was defined as a platelet reaction unit value > or =240. Cardiac biomarkers were measured before and 8 and 24 hours after intervention. Patients with DM had significantly higher platelet reactivity before PCI compared to nondiabetics (214 +/- 83 vs 193 +/- 68 platelet reaction units, p = 0.02). HPR was more frequently observed in diabetics (36% vs 22%, p = 0.01) before PCI. Patients with DM had an increased incidence of periprocedural myocardial infarction (MI; 11% vs 4%, p = 0.04). When the entire population was divided by the presence or absence of DM and HPR, patients with DM and HPR presented the highest incidence of periprocedural MI (p for trend = 0.0008). HPR was an independent predictor of periprocedural MI (odds ratio 8.34, 95% confidence interval 2.60 to 26.76, p = 0.0003). In conclusion, patients with DM undergoing PCI have higher platelet reactivity at the time of PCI despite adequate clopidogrel pretreatment and subsequently worse periprocedural outcomes. Point-of-care platelet function testing may help to identify patients at higher risk of periprocedural MI.
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Affiliation(s)
- Fabio Mangiacapra
- Department of Cardiovascular Sciences, Campus Bio-Medico University, Rome, Italy.
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120
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Sobieraj-Teague M, Eikelboom JW. Point-of-care testing for assessment of adequacy of oral antiplatelet therapy in patients with cardiovascular disease. Future Cardiol 2010; 6:289-99. [PMID: 20462336 DOI: 10.2217/fca.10.20] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Studies with recently introduced point-of-care (POC) platelet function tests have shown that individuals are variably responsive to aspirin and clopidogrel therapy, and that hyporesponsiveness to antiplatelet therapy is associated with an increased risk of cardiovascular events. However, the currently available POC tests have undergone only limited clinical evaluation and clinicians are uncertain about the best POC test, the optimal cut-off point to define hyporesponsiveness in different patient populations and clinical settings, the appropriate management of patients demonstrating hyporesponsiveness and the cost effectiveness of adjusting treatment on the basis of the results of POC platelet function testing. Several large randomized controlled trials currently underway are examining whether adjusting antiplatelet therapy on the basis of a POC test result can improve patient-important outcomes. Until these issues are resolved, POC testing to monitor antiplatelet therapy will largely remain a research tool and patients should continue to receive oral antiplatelet therapy without routine monitoring at doses that have been demonstrated to be effective in randomized controlled trials.
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121
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Garg S, Serruys PW. Coronary Stents. J Am Coll Cardiol 2010; 56:S1-42. [PMID: 20797502 DOI: 10.1016/j.jacc.2010.06.007] [Citation(s) in RCA: 307] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 06/01/2010] [Accepted: 06/15/2010] [Indexed: 01/07/2023]
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122
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Old and New Molecular Mechanisms Associated with Platelet Resistance to Antithrombotics. Pharm Res 2010; 27:2365-73. [DOI: 10.1007/s11095-010-0209-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 06/28/2010] [Indexed: 12/22/2022]
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123
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Gajos G, Rostoff P, Undas A, Piwowarska W. Effects of polyunsaturated omega-3 fatty acids on responsiveness to dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: the OMEGA-PCI (OMEGA-3 fatty acids after pci to modify responsiveness to dual antiplatelet therapy) study. J Am Coll Cardiol 2010; 55:1671-8. [PMID: 20394870 DOI: 10.1016/j.jacc.2009.11.080] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/19/2009] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The purpose of this study was to investigate whether omega-3 polyunsaturated fatty acids (PUFAs) are able to modify platelet responsiveness to dual antiplatelet therapy in stable coronary artery disease patients undergoing percutaneous coronary intervention (PCI). BACKGROUND Although previous studies have suggested antiplatelet properties of omega-3 polyunsaturated fatty acids, it is unknown whether they can enhance platelet inhibition on standard aspirin and clopidogrel treatment. METHODS The OMEGA-PCI (OMEGA-3 Fatty Acids After PCI to Modify Responsiveness to Dual Antiplatelet Therapy) study was an investigator-initiated, prospective, single-center, double-blind, placebo-controlled, randomized study. Patients receiving standard dual antiplatelet therapy (aspirin 75 mg/day and clopidogrel 600 mg loading dose followed by 75 mg/day) were randomly assigned to receive the addition of 1 g of omega-3 ethyl esters (n = 33) or placebo (n = 30) for 1 month. Platelet function was measured serially by light transmission aggregometry (adenosine diphosphate and arachidonic acid [AA] were used as agonists) and assessment of the phosphorylation status of the vasodilator-stimulated phosphoprotein at baseline, 12 h, 3 to 5 days, and 30 days after randomization. RESULTS The P2Y(12) reactivity index was significantly lower, by 22.2%, after 1 month of treatment with omega-3 polyunsaturated fatty acids compared with placebo when used in addition to dual antiplatelet therapy (p = 0.020). Maximal platelet aggregation induced by 5 and 20 micromol/l adenosine diphosphate was lower by 13.3% (p = 0.026) and 9.8% (p = 0.029), respectively, after 1 month of treatment with omega-3 polyunsaturated fatty acids compared with placebo. Platelet aggregation after AA stimulation was low and did not change significantly throughout the study. There were no cases of aspirin resistance during follow-up that was suggestive of good compliance with the medication. CONCLUSIONS The addition of omega-3 ethyl esters to the combination of aspirin and clopidogrel significantly potentiates platelet response to clopidogrel after percutaneous coronary intervention.
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Affiliation(s)
- Grzegorz Gajos
- Department of Coronary Disease, John Paul II Hospital, Cracow, Poland.
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Impact of inflammatory state and metabolic control on responsiveness to dual antiplatelet therapy in type 2 diabetics after PCI: prognostic relevance of residual platelet aggregability in diabetics undergoing coronary interventions. Clin Res Cardiol 2010; 99:743-52. [DOI: 10.1007/s00392-010-0179-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2010] [Accepted: 05/20/2010] [Indexed: 10/19/2022]
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125
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Price MJ. The Evidence Base for Platelet Function Testing in Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2010; 3:277-83; discussion 283. [DOI: 10.1161/circinterventions.109.928861] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew J. Price
- From the Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, Calif
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126
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Angiolillo DJ, Ferreiro JL. Platelet adenosine diphosphate P2Y12 receptor antagonism: benefits and limitations of current treatment strategies and future directions. Rev Esp Cardiol 2010; 63:60-76. [PMID: 20089227 DOI: 10.1016/s1885-5857(10)70010-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Platelet P2Y12 receptor antagonism with clopidogrel has represented a major advancement in the pharmacological management of patients with atherothrombotic disease, in particular those with acute coronary syndromes and undergoing percutaneous coronary interventions. Despite the benefit associated with clopidogrel therapy in these high risk settings, laboratory and clinical experience have led to identify some of its caveats, among which its wide range of platelet inhibitory response is the most relevant. Genetic, cellular and clinical factors are implied in variability in response to clopidogrel. Importantly, pharmacodynamic findings have shown to have important prognostic implications, underscoring the need for more optimal antiplatelet treatment strategies. The aim of this manuscript is to provide an overview on the current status and future directions in P2Y12 receptor antagonism, with particular emphasis on interindividual variability in response to clopidogrel and strategies, including novel antiplatelet agents, to improve platelet P2Y12 inhibition.
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Affiliation(s)
- Dominick J Angiolillo
- University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida 32209, USA.
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127
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128
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Affiliation(s)
- Kevin Croce
- From the Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School and VA Boston Healthcare System, Boston, Mass
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129
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130
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Jeong YH, Hwang JY, Kim IS, Park Y, Hwang SJ, Lee SW, Kwak CH, Park SW. Adding cilostazol to dual antiplatelet therapy achieves greater platelet inhibition than high maintenance dose clopidogrel in patients with acute myocardial infarction: Results of the adjunctive cilostazol versus high maintenance dose clopidogrel in patients with AMI (ACCEL-AMI) study. Circ Cardiovasc Interv 2010; 3:17-26. [PMID: 20118150 DOI: 10.1161/circinterventions.109.880179] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal platelet inhibition is an important therapeutic adjunct in patients acute myocardial infarction (AMI) undergoing coronary stenting. Whether adjunctive cilostazol to dual antiplatelet therapy (triple antiplatelet therapy) can inhibit enhanced platelet reactivity in patients with AMI yet has not been determined. The aim of this study was to assess the degree of platelet inhibition by triple antiplatelet therapy in patients with AMI. METHODS AND RESULTS Immediately after emergency room arrival, patients with AMI received clopidogrel (600-mg loading dose, followed by 75 mg daily) and aspirin (300-mg loading dose and 200 mg daily throughout the study period). After patients underwent coronary stenting (n=90), they were randomly assigned to 1 of 3 groups before discharge: standard group, clopidogrel of 75 mg daily (n=30); high maintenance dose (MD) group, clopidogrel of 150 mg daily (n=30); and triple group, adjunctive cilostazol of 100 mg twice daily to clopidogrel of 75 mg daily (n=30). Platelet reactivity was assessed at predischarge and 30-day follow-up by conventional aggregometry and the VerifyNow P2Y12 assay. Predischarge platelet reactivities were similar in the 3 groups. At 30-day follow-up, inhibition of maximal aggregation with 20 microM ADP stimuli was 6.0% in the standard group, 19.1% in the high-MD group, and 42.4% in the triple group (P<0.001), whereas inhibition of late aggregation with 20microM ADP stimuli was 10.8%, 38.1%, and 66.4%, respectively (P<0.001). Similar results were demonstrated when 5 microM ADP was used. Furthermore, percent changes of P2Y12 reaction unit were significantly different among regimens (10.6% in the standard group, 30.7% in the high-MD group, and 43.0% in the triple group; P<0.001). With respect to high-postclopidogrel platelet reactivity (prespecified as 20 microM ADP-induced maximal aggregation >50% of light transmission), fewer patients in the triple group (13.3%) met the criteria as compared with those in the standard (76.7%) and high-MD groups (56.7%) at 30-day follow-up (P<0.001). In the triple group, there were more potent and consistent platelet inhibitions by all parameters as compared with the high-MD group except for percent changes of P2Y12 reaction unit (P=0.071). CONCLUSIONS Among patients with AMI undergoing coronary stenting, triple antiplatelet therapy results in a greater antiplatelet effect at 30 days as compared with a high-MD clopidogrel or standard dual antiplatelet therapy.
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Affiliation(s)
- Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
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131
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Affiliation(s)
- Dominick J. Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Masafumi Ueno
- Department of Medicine, Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Shinya Goto
- Department of Medicine Division of Cardiology, Tokai University School of Medicine
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132
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Inhibición del receptor plaquetario P2Y12 de adenosina difosfato plaquetario: efectos beneficiosos y limitaciones de las estrategias terapéuticas actuales y perspectivas futuras. Rev Esp Cardiol 2010. [DOI: 10.1016/s0300-8932(10)70010-5] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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133
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Fu Q, Yokoyama N, Takada K, Ishikawa S, Isshiki T. Comparison of Platelet P2Y12 ADP Receptor-Mediated Pathway Inhibition in Triple Versus Dual Antiplatelet Therapy as Assessed by VASP-Phosphorylation in Japanese Patients Undergoing Coronary Stenting. Int Heart J 2010; 51:303-7. [DOI: 10.1536/ihj.51.303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Qiang Fu
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Naoyuki Yokoyama
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Kaoru Takada
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Shuichi Ishikawa
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
| | - Takaaki Isshiki
- Division of Cardiology, Department of Internal Medicine, Teikyo University School of Medicine
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Abstract
Clinical manifestations of atherothrombotic disease, such as acute coronary syndromes, cerebrovascular events, and peripheral arterial disease, are major causes of mortality and morbidity worldwide. Platelet activation and aggregation are ultimately responsible for the progression and clinical presentations of atherothrombotic disease. The current standard of care, dual oral antiplatelet therapy with aspirin and the P2Y(12) adenosine diphosphate (ADP) receptor inhibitor clopidogrel, has been shown to improve outcomes in patients with atherothrombotic disease. However, aspirin and P2Y(12) inhibitors target the thromboxane A(2) and the ADP P2Y(12) platelet activation pathways and minimally affect other pathways, while agonists such as thrombin, considered to be the most potent platelet activator, continue to stimulate platelet activation and thrombosis. This may help explain why patients continue to experience recurrent ischaemic events despite receiving such therapy. Furthermore, aspirin and P2Y(12) receptor antagonists are associated with bleeding risk, as the pathways they inhibit are critical for haemostasis. The challenge remains to develop therapies that more effectively inhibit platelet activation without increasing bleeding complications. The inhibition of the protease-activated receptor-1 (PAR-1) for thrombin has been shown to inhibit thrombin-mediated platelet activation without increasing bleeding in pre-clinical models and small-scale clinical trials. PAR-1 inhibition in fact does not interfere with thrombin-dependent fibrin generation and coagulation, which are essential for haemostasis. Thus PAR-1 antagonism coupled with existing dual oral antiplatelet therapy may potentially offer more comprehensive platelet inhibition without the liability of increased bleeding.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine -Jacksonville, Shands Jacksonville, 655 West 8th St, Jacksonville, FL 32209, USA.
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135
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Kim JY. Strategy for the treatment of clopidogrel low responsiveness in diabetes mellitus and stent implantation. Korean Circ J 2009; 39:459-61. [PMID: 19997540 PMCID: PMC2790128 DOI: 10.4070/kcj.2009.39.11.459] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jang-Young Kim
- Department of Cardiology, Wonju College of Medicine, Yonsei University, Wonju, Korea
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136
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Tamhane U, Meier P, Chetcuti S, Chen KY, Rha SW, Grossman MP, Gurm H. Efficacy of cilostazol in reducing restenosis in patients undergoing contemporary stent based PCI: a meta-analysis of randomised controlled trials. EUROINTERVENTION 2009; 5:384-93. [PMID: 19736165 DOI: 10.4244/v5i3a60] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Cilostazol has been associated with reduction in restenosis in patients undergoing coronary and peripheral arterial angioplasty. Our objective was to evaluate the impact of cilostazol on restenosis in patients undergoing contemporary PCI with bare metal (BMS) or drug eluting stents (DES) and treated with aspirin and thienopyridine. METHODS AND RESULTS Ten randomised trials (n=2,809 patients) comparing triple antiplatelet therapy (aspirin, thienopyridine and cilostazol) with standard dual antiplatelet therapy were included. Summary risk ratios for restenosis, late loss, target lesion revascularisation (TLR) and target vessel revascularisation (TVR) were calculated using fixed-effects models. Cilostazol was associated with a significant reduction in late loss in BMS (mean difference 0.24 mm, 95% CI 0.15-0.33, p<0.001) and DES groups (mean difference 0.12 mm, 95% CI 0.07-0.18, p<0.001). Cilostazol therapy was associated with a significant reduction in angiographic restenosis (Odds ratio [OR] 0.52, 95% CI 0.41- 0.66, p<0.001) with consistent benefits in patients treated with BMS (OR 0.49, 95% CI 0.35-0.70, p<0.001) or DES (OR 0.54, 95% CI 0.38-0.76, p=0.001). Addition of cilostazol to dual antiplatelet therapy was associated with a significant reduction in TLR (OR 0.38, 95% CI 0.25-0.58, p<0.001), with no difference in subacute stent thrombosis (OR 1.91, 95% CI 0.33-11.08, p=0.47), or major bleeding (OR 0.87, 95% CI 0.44-1.74, P=0.69) but with an increased risk of skin rash (OR 3.67, 95% CI 1.86-7.24, p<0.001). CONCLUSIONS Cilostazol in addition to dual antiplatelet therapy is associated with a reduction in angiographic restenosis in patients undergoing stent based PCI. This inexpensive drug may be particularly beneficial in patients who are at high risk of restenosis and it should undergo further evaluation in large, definitive randomised controlled trials.
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Affiliation(s)
- Umesh Tamhane
- University of Michigan Cardiovascular Medicine, VA Ann Arbor Health Care System, Ann Arbor, MI, USA
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138
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Angiolillo DJ, Suryadevara S. Aspirin and clopidogrel: efficacy and resistance in diabetes mellitus. Best Pract Res Clin Endocrinol Metab 2009; 23:375-88. [PMID: 19520310 DOI: 10.1016/j.beem.2008.12.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Diabetes mellitus patients are characterized by enhanced platelet reactivity which exposes them to an increased risk of atherothrombotic events in the setting of acute coronary syndromes or percutaneous coronary interventions. Although aspirin and clopidogrel, used either solely or in combination, are associated with improved clinical outcomes in high-risk patients, diabetics patients treated with antiplatelet agents remain at higher risk of recurrent ischemic events. Recent laboratory findings suggest that this observation may be related to a reduced responsiveness or 'resistance' to these agents. In this chapter the efficacy of currently available oral antiplatelet agents in preventing ischemic events is reviewed. In addition, the antiplatelet 'resistance' phenomenon in the diabetic population and its impact on clinical outcomes is summarized. Finally, future developments in the field directed towards individualized treatment strategies and novel antiplatelet agents are examined.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL 32209, USA.
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140
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Grove EL, Kristensen SD. Update on oral antiplatelet therapy: principles, problems and promises. Future Cardiol 2009; 5:247-58. [DOI: 10.2217/fca.09.10] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Platelets are major players in arterial thrombosis, and antiplatelet therapy has a clear clinical benefit in the treatment and prevention of cardiovascular events. In particular, aspirin and clopidogrel have become cornerstones in the treatment of patients with atherothrombosis. However, despite the proven efficacy of antiplatelet drugs, cardiovascular events remain an important cause of morbidity and mortality in these patients. Furthermore, a considerable variability in platelet reactivity during treatment with established oral antiplatelet therapy has prompted the search for novel drugs against platelet-dependent thrombosis. Possible benefits of upcoming drugs include a more efficient platelet inhibition and a reversible effect on platelet function. Aspirin, clopidogrel, prasugrel, ticagrelor, terutroban, E5555, SCH 530348 and cilostazol are discussed. This review highlights the rationale for important oral antiplatelet drugs in development and provides clinical perspectives on their pharmacological advantages and challenges.
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Affiliation(s)
- Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark
| | - Steen D Kristensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Brendstrupgaardsvej 100, 8200 Aarhus N, Denmark
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Cola C, Brugaletta S, Martín Yuste V, Campos B, Angiolillo DJ, Sabaté M. Diabetes mellitus: a prothrombotic state implications for outcomes after coronary revascularization. Vasc Health Risk Manag 2009; 5:101-19. [PMID: 19436654 PMCID: PMC2672443 DOI: 10.2147/vhrm.s4248] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Coronary stent thrombosis is a serious problem in the drug-eluting stent era. Despite aggressive antiplatelet therapy during and after percutaneous coronary intervention (PCI), the incidence of sub-acute stent thrombosis remains approximately 0.5%–2%, which may represent a catastrophic clinical situation. Both procedural factors and discontinuation of antiplatelet therapy are normally associated with this event. We report on simultaneous stent thromboses of two drug-eluting stents implanted in two different vessels, which resulted in a life-threatening clinical condition. Possible contributing factors that led to synergistic thrombotic effects are discussed.
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Affiliation(s)
- Clarissa Cola
- Department of Cardiology, Interventional Cardiology Unit, Sant Pau University Hospital, Barcelona, Spain
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Han Y, Li Y, Wang S, Jing Q, Wang Z, Wang D, Shu Q, Tang X. Cilostazol in addition to aspirin and clopidogrel improves long-term outcomes after percutaneous coronary intervention in patients with acute coronary syndromes: a randomized, controlled study. Am Heart J 2009; 157:733-9. [PMID: 19332203 DOI: 10.1016/j.ahj.2009.01.006] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 01/06/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cilostazol has been widely used to prevent peripheral vascular events, and its antiplatelet mechanisms may different from aspirin and clopidogrel. We hypothesized that cilostazol in addition to aspirin and clopidogrel effectively reduces systemic ischemic events after percutaneous coronary intervention (PCI) in high-risk patients. METHODS In this prospective study, 1,212 patients with acute coronary syndromes were randomly assigned to receive either standard dual-antiplatelet treatment with aspirin and clopidogrel (n = 608) or triple-antiplatelet therapy with the addition of a 6-month course of cilostazol (n = 604) after successful PCI. The primary end point was a composite of cardiac death, nonfatal myocardial infarction, stroke, or target vessel revascularization (TVR) at 1 year after randomization. The secondary end points were TVR and hemorrhagic events. RESULTS Triple-antiplatelet treatment was associated with a significantly lower incidence of the primary end points (10.3% vs 15.1%; P = .011). The need for TVR was similar between patients who received triple- and dual-antiplatelet treatment (7.9% vs 10.7%; P = .10). Multivariate analysis showed that female patients and clinically or angiographically high-risk patients benefited more from the triple-antiplatelet treatment. There were no significant differences between the 2 regimens in terms of the risks for major and minor bleeding. CONCLUSIONS For patients with acute coronary syndromes, triple-antiplatelet therapy consisting of cilostazol, aspirin, and clopidogrel reduced long-term cardiac and cerebral events after PCI, especially for patients with high-risk profiles.
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143
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Angiolillo DJ. Antiplatelet therapy in diabetes: efficacy and limitations of current treatment strategies and future directions. Diabetes Care 2009; 32:531-40. [PMID: 19336638 PMCID: PMC2660456 DOI: 10.2337/dc08-2064] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Dominick J. Angiolillo
- From the Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
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Randomized Comparison of Adjunctive Cilostazol Versus High Maintenance Dose Clopidogrel in Patients With High Post-Treatment Platelet Reactivity. J Am Coll Cardiol 2009; 53:1101-9. [PMID: 19324253 DOI: 10.1016/j.jacc.2008.12.025] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Revised: 12/02/2008] [Accepted: 12/08/2008] [Indexed: 11/20/2022]
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Abstract
Patients who have acute coronary syndromes or are undergoing percutaneous coronary intervention receive antiplatelet therapy to reduce the risk of atherothrombotic complications. Current guidelines favor the use of aspirin in combination with clopidogrel based on the results of a number of large-scale clinical trials. Aspirin alone is a relatively weak antiplatelet agent because it inhibits only one of many paths to platelet activation. By blockade of an adjunctive signaling pathway, the addition of clopidogrel to aspirin leads to synergistic platelet inhibitory effects. Dual antiplatelet therapy reduces the number of patients who experience adverse cardiovascular outcomes by 20% over aspirin alone. Nevertheless, approximately 10% of patients experience further atherothrombotic events, even while receiving dual antiplatelet therapy. Variability in individual responsiveness, including "resistance," has been attributed to the occurrence of these events. This article discusses variability in individual responses to oral antiplatelet therapy and its implications for clinical outcomes.
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Angiolillo DJ. Pruebas de función plaquetaria en la práctica clínica: ¿estamos preparados para que pasen a la primera línea? Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)70151-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hoshino K, Horiuchi H, Tada T, Tazaki J, Nishi E, Kawato M, Ikeda T, Yamamoto H, Akao M, Furukawa Y, Shizuta S, Toma M, Tamura T, Saito N, Doi T, Ozasa N, Jinnai T, Takahashi K, Watanabe H, Yoshikawa Y, Nishimoto N, Ouchi C, Morimoto T, Kita T, Kimura T. Clopidogrel Resistance in Japanese Patients Scheduled forPercutaneous Coronary Intervention. Circ J 2009; 73:336-42. [DOI: 10.1253/circj.cj-08-0559] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kozo Hoshino
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hisanori Horiuchi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Tomohisa Tada
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Eiichiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Mitsunori Kawato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Tomoyuki Ikeda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Hiromi Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masaharu Akao
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Satoshi Shizuta
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Toshihiro Tamura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Naritatsu Saito
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takahiro Doi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Toshikazu Jinnai
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kanako Takahashi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Haruyo Watanabe
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yuka Yoshikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Naoko Nishimoto
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Chiho Ouchi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeshi Morimoto
- Center for Medical Education, Graduate School of Medicine, Kyoto University
| | - Toru Kita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
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Angiolillo DJ, Suryadevara S, Capranzano P, Zenni MZ, Guzman LA, Bass TA. Antiplatelet drug response variability and the role of platelet function testing: A practical guide for interventional cardiologists. Catheter Cardiovasc Interv 2009; 73:1-14. [DOI: 10.1002/ccd.21782] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Chhatriwalla AK, Bhatt DL. Should dual antiplatelet therapy after drug-eluting stents be continued for more than 1 year? Circ Cardiovasc Interv 2008; 1:217-25. [DOI: 10.1161/circinterventions.108.811380] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Adnan K. Chhatriwalla
- From the Division of Cardiovascular Medicine (A.K.C.), Cleveland Clinic, Cleveland, Ohio; and the Division of Cardiology (D.L.B.), VA Boston Health Care System and Brigham and Women’s Hospital, Boston, Mass
| | - Deepak L. Bhatt
- From the Division of Cardiovascular Medicine (A.K.C.), Cleveland Clinic, Cleveland, Ohio; and the Division of Cardiology (D.L.B.), VA Boston Health Care System and Brigham and Women’s Hospital, Boston, Mass
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Bhatt DL. Resisting the Temptation to Oversimplify Antiplatelet Resistance⁎⁎Editorials published in JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology. JACC Cardiovasc Interv 2008; 1:660-2. [DOI: 10.1016/j.jcin.2008.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 09/15/2008] [Indexed: 11/29/2022]
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