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Evaluation of sex differences in patients with ST-elevated myocardial infarction: an observational cohort study in Amsterdam and surrounding region. Neth Heart J 2020; 28:595-603. [PMID: 32529555 PMCID: PMC7596126 DOI: 10.1007/s12471-020-01435-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction Women with ST-elevation myocardial infarction (STEMI) present with different symptoms compared to men. This can result in delays in diagnosis and in the timely treatment of women. The aim of this study is to examine these differences, including the short- and long-term mortality in women and men. Methods This quality registry study included all patients with STEMI who received primary percutaneous coronary intervention in 2015 or 2016 in Amsterdam and the surrounding region. Results Three PCI centres and the Emergency Medical Service in Amsterdam participated. In total, 558 men (71%) and 229 women (29%) were included. Women were on average 7 years older than men (68 vs 61 years, p < 0.001), and suffered more often from hypertension (46% vs 34%, p = 0.002) and monovascular disease (69% vs 57%, p = 0.002). A higher percentage of men were current smokers (41% vs 49%, p = 0.043). Patient delay, system delay and overall ischaemic times were similar in both women and men (medians: 51, 94 and 157 min, respectively). Initiation of treatment was achieved within 90 min after STEMI diagnosis in 85% of patients (87% in women, 85% in men). Thirty-day and 1‑year mortality adjusted hazard ratio for women versus men was 1.60 (95% CI 0.9–3.0) and 1.24 (95% CI 0.8–2.0), respectively. Discussion Recognition of cardiac complaints remains challenging for patients. In the Amsterdam region, time delays and mortality were not significantly different between men and women presenting with STEMI. These results are in contrast to findings in similar registries. This suggests that implementation of current knowledge and national campaigns are effective in increasing awareness of the signs and symptoms suggestive of myocardial infarction.
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Grimfjärd P, Lagerqvist B, Erlinge D, Varenhorst C, James S. Clinical use of cangrelor: nationwide experience from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 5:151-157. [PMID: 30698669 DOI: 10.1093/ehjcvp/pvz002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/28/2018] [Accepted: 01/13/2019] [Indexed: 01/06/2023]
Abstract
AIMS This nationwide study aimed to analyse the first 2 years of routine clinical use of cangrelor in all Swedish patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS This observational Swedish Coronary Angiography and Angioplasty Registry (SCAAR) study identified 915 cangrelor-treated patients. As 899 were ST-segment elevation myocardial infarction (STEMI)-patients undergoing primary PCI, we decided to exclude all non-STEMI patients (n = 16) from the following analysis. We then identified all primary PCI patients, January 2016 to January 2018 (n = 10 816). Excluding hospitals without cangrelor use, tailoring time frames from first cangrelor use per hospital, patients treated with cangrelor (n = 899) were compared with those without cangrelor treatment (n = 4614). A separate analysis was performed for cardiac arrest STEMI patients (n = 273). Cangrelor-use in primary PCI varied greatly between hospitals (4-36%, mean 16%). At variance with randomized trials, cangrelor was used nearly exclusively in STEMI, often with cardiac arrest (19%). Cangrelor was combined with ticagrelor in two-thirds of patients, among which >50% was prehospital. Cangrelor was used more frequently in high-risk patients: left main PCI, thrombus aspiration, and cardiac arrest. Despite cangrelor being used in more high-risk patients, crude definite stent thrombosis rates at 30 days were low and similar in cangrelor (0.7%) and non-cangrelor treated patients (0.8%). CONCLUSION Cangrelor was used nearly exclusively in primary PCI STEMI patients, predominantly with ticagrelor. Despite being used in very high-risk patients, often with cardiac arrest, cangrelor treatment was associated with low stent thrombosis rates.
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Affiliation(s)
- Per Grimfjärd
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Department of Cardiology, Västerås Hospital, Sigtunagatan, 721 89 Västerås, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Box 117, Skåne University Hospital, Block EA, 22100 Lund, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Pfizer AB Sverige, Vetenskapsvägen 10, Sollentuna, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
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153
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Linfante I, Ravipati K, Starosciak AK, Reyes D, Dabus G. Intravenous cangrelor and oral ticagrelor as an alternative to clopidogrel in acute intervention. J Neurointerv Surg 2020; 13:30-32. [PMID: 32414891 DOI: 10.1136/neurintsurg-2020-015841] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAP) is necessary to prevent thromboembolic events during carotid stenting, stent-assisted coil embolization, and implant of flow diverters (FD). However, DAP in the acute phase may be challenging. An intravenous alternative, cangrelor, has rapid onset, short plasma half-life, and more reliable antiplatelet action for acute interventions. The study objective was to evaluate feasibility and safety of IV cangrelor during acute neuroendovascular surgery procedures. METHODS We performed a retrospective analysis of our database of patients treated with stent-assisted coil embolization, FD placement for aneurysmal subarachnoid hemorrhage (aSAH), or stenting for acute internal carotid artery (ICA) occlusion where IV cangrelor was used. Morbidity, mortality, incidence of thromboembolic events, hemorrhages, and 90-day outcomes were reported. RESULTS Ten patients were found in our database from June 2018 through January 2019. Four patients had aSAH, four had middle cerebral artery strokes with tandem lesions, one had an ICA occlusion, and one had a vertebral artery aneurysm. One of the ten patients experienced a thrombotic event. One patient developed new post-procedural bleeding and two had worsening intracranial hemorrhage. Five patients were discharged home in stable condition, two to acute rehabilitation, one to a nursing facility, and two others expired (likely the result of the severe and evolving strokes). Of the eight who were discharged, six (75%) had a good 90-day functional outcome (modified Rankin Scale 0-2). CONCLUSION Acute administration of IV cangrelor with or without oral ticagrelor is a feasible antiplatelet treatment option for acute neuroendovascular procedures.
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Affiliation(s)
- Italo Linfante
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA .,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Kaushik Ravipati
- Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Amy Kathryn Starosciak
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA.,Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Dennys Reyes
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Guilherme Dabus
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
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154
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Milluzzo RP, Franchina GA, Capodanno D, Angiolillo DJ. Selatogrel, a novel P2Y12 inhibitor: a review of the pharmacology and clinical development. Expert Opin Investig Drugs 2020; 29:537-546. [DOI: 10.1080/13543784.2020.1764533] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rocco P. Milluzzo
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Gabriele A. Franchina
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
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155
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Elhorany M, Lenck S, Degos V, Sourour NA, Frasca Polara G, Shotar E, Godier A, Drir M, Mahtout J, Premat K, Alamowitch S, Samson Y, Clarençon F. Cangrelor and Stenting in Acute Ischemic Stroke : Monocentric Case Series. Clin Neuroradiol 2020; 31:439-448. [PMID: 32382875 DOI: 10.1007/s00062-020-00907-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE Cangrelor is an intravenous P2Y12 receptor inhibitor with a rapid onset/offset of action and a short half-life (3-6 min). The objective was to present a preliminary experience regarding the safety and effectiveness using cangrelor, in combination with aspirin, in acute ischemic stroke patients requiring acute stenting. MATERIAL AND METHODS Retrospective analysis for patients who underwent stenting (intracranial and/or extracranial) in the setting of acute ischemic stroke with cangrelor and aspirin as antiplatelet therapy. RESULTS Cangrelor was used in 12 patients, 4 (33%) with extracranial stenting, 6 (50%) with intracranial stenting and 2 (17%) with combined extracranial and intracranial stenting. The mean age was 67 years (44-88) and 9 patients (75%) were female. The median National Institutes of Health Stroke Score at admission was 15 (IQR: 8-22). Of the patients, six (50%) received intravenous thrombolysis. All patients (100%) obtained modified thrombolysis in cerebral infarction score ≥2b. Good clinical outcome, defined as modified Rankin scale score ≤2 at 3‑months follow-up, was observed in 7 patients (58%). None of the patients experienced intraprocedural thromboembolic complications. Postprocedural stent thrombosis after cessation of cangrelor infusion due to emergency craniotomy surgery to manage malignant cerebral infarction occurred in one patient (8%). Of the patients, two (17%) experienced asymptomatic intracranial hemorrhage (ICH), one patient (8%) experienced symptomatic ICH and one (8%) retroperitoneal hematoma was observed, which was managed conservatively. CONCLUSION Cangrelor might be a safe and effective antiplatelet medication owing to its on/off activity for acute stenting in the setting of acute ischemic stroke. Further investigations through randomized studies with larger samples are necessary.
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Affiliation(s)
- Mahmoud Elhorany
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University, Paris VI University, Paris, France.,GRC Biofast, Paris VI University, Paris, France.,Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Stephanie Lenck
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Vincent Degos
- Sorbonne University, Paris VI University, Paris, France.,GRC Biofast, Paris VI University, Paris, France.,Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Nader-Antoine Sourour
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Giulia Frasca Polara
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Eimad Shotar
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France
| | - Anne Godier
- Department of Anesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, INSERM UMRS-1140, Paris Descartes University, Paris, France
| | - Mehdi Drir
- Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Jugurtha Mahtout
- Department of Neuro Intensive Care, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France.,Sorbonne University, Paris VI University, Paris, France
| | - Sonia Alamowitch
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Saint-Antoine University Hospital, Paris, France
| | - Yves Samson
- Sorbonne University, Paris VI University, Paris, France.,Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, 47-83 Boulevard de l'Hôpital, 75013, Paris, France. .,Sorbonne University, Paris VI University, Paris, France. .,GRC Biofast, Paris VI University, Paris, France.
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156
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Chandiramani R, Cao D, Mehran R. Periprocedural anticoagulation in non-ST-segment elevation acute coronary syndrome: time to reassess? ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:556. [PMID: 32411779 PMCID: PMC7214884 DOI: 10.21037/atm.2020.01.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Rishi Chandiramani
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NY, USA
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157
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Abtan J, Ducrocq G, Steg PG, Stone GW, Mahaffey KW, Gibson CM, Hamm CW, Price MJ, Prats J, Deliargyris EN, White HD, Harrington RA, Bhatt DL. Periprocedural Outcomes According to Timing of Clopidogrel Loading Dose in Patients Who Did Not Receive P2Y 12 Inhibitor Pretreatment. Circ Cardiovasc Interv 2020; 12:e007445. [PMID: 30871355 DOI: 10.1161/circinterventions.118.007445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In patients undergoing percutaneous coronary intervention (PCI), who did not receive P2Y12 inhibitor pretreatment, the optimal timing of P2Y12 inhibitor loading dose remains debated. We sought to examine whether the choice of administration of the clopidogrel loading dose before or after the start of PCI had an impact on periprocedural complications, including bleeding. METHODS AND RESULTS The CHAMPION PHOENIX (A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention) double-blind randomized trial compared cangrelor with clopidogrel loading dose at the time of PCI. Pretreatment with clopidogrel before randomization was not permitted per protocol. In the clopidogrel-only group (n=5438), a loading dose was given before (early load [EL]) or after the start of PCI (late load [LL]) according to physician choice. Overall, 3442 (63.3%) patients had EL and 1997 LL (36.7%). Median times were 5 minutes before and 20 minutes after the start of PCI, respectively. EL was more frequently used among patients with ST-segment-elevation myocardial infarction (84.4%) and non-ST-segment-elevation acute coronary syndromes (71.5%) than in stable patients (53.7%). At 48 hours, rates of the primary outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis were similar (6.0% versus 5.4%) for EL versus LL, respectively (odds ratio [OR], 1.11 [95% CI, 0.87-1.41]; P=0.41), and remained so after adjustment for potential confounders, including clinical presentation (OR [95% CI], 1.39 [0.90-2.15]; P=0.14). Compared with clopidogrel, cangrelor consistently reduced the primary outcome in both EL (4.8% versus 6.0%; OR [95% CI], 0.80 [0.64-0.98]) and LL (4.3% versus 5.4%; OR [95% CI], 0.79 [0.59-1.06]; interaction P=0.99). Global Use of Strategies to Open Occluded Coronary Arteries severe/moderate bleeding rates were similar between treatment arms for both EL (OR [95% CI], 1.24 [0.58-2.66]) and LL (OR [95% CI], 2.53 [0.98-6.54]; interaction P=0.25). CONCLUSIONS In a nonrandomized comparison of patients with clopidogrel loading before or after the start of PCI, the rates of periprocedural PCI complications, including bleeding, were similar, as were the benefits of cangrelor, regardless of the timing. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01156571.
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Affiliation(s)
- Jeremie Abtan
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.)
| | - Gregory Ducrocq
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.)
| | - Philippe Gabriel Steg
- Département Hospitalo-Universitaire-Fibrosis, Inflammation, Remodelling, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Université Paris Diderot, Sorbonne Paris Cité, France (J.A., G.D., P.G.S.).,French Alliance for Cardiovascular Clinical Trials-An F-CRIN Network, INSERM U-1148, Paris, France (J.A., G.D., P.G.S.).,NLHI, ICMS, Royal Brompton Hospital, Imperial College, London, United Kingdom (P.G.S.)
| | - Gregg W Stone
- Division of Cardiology, Columbia University Medical Center, Cardiovascular Research Foundation, New York, NY (G.W.S.)
| | - Kenneth W Mahaffey
- Cardiovascular Medicine, Stanford Center for Clinical Research (K.W.M., R.A.H.), Stanford School of Medicine, CA.,Department of Medicine (K.W.M., R.A.H.), Stanford School of Medicine, CA
| | - C Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (C.M.G.)
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.)
| | - Matthew J Price
- Scripps Clinic, Scripps Translational Science Institute, La Jolla, CA (M.J.P.)
| | | | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- Cardiovascular Medicine, Stanford Center for Clinical Research (K.W.M., R.A.H.), Stanford School of Medicine, CA.,Department of Medicine (K.W.M., R.A.H.), Stanford School of Medicine, CA
| | - Deepak L Bhatt
- Cardiovascular Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
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158
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Vaduganathan M, Qamar A, Badreldin HA, Faxon DP, Bhatt DL. Cangrelor Use in Cardiogenic Shock: A Single-Center Real-World Experience. JACC Cardiovasc Interv 2020; 10:1712-1714. [PMID: 28838482 DOI: 10.1016/j.jcin.2017.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
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159
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Cangrelor alleviates bleomycin-induced pulmonary fibrosis by inhibiting platelet activation in mice. Mol Immunol 2020; 120:83-92. [PMID: 32106023 DOI: 10.1016/j.molimm.2020.01.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/15/2020] [Accepted: 01/24/2020] [Indexed: 12/14/2022]
Abstract
Pulmonary fibrosis is a progressive chronic inflammatory lung disease whose pathogenesis is complicated. Platelets and neutrophils play important roles in the progression of pulmonary inflammation. We have reported that cangrelor, a non-sepesific GPR17 antagonist, alleviates pulmonary fibrosis partly by inhibiting macrophage inflammation in mice. Cangrelor is also a well-known anti-platelet agent. To test whether cangrelor mitigated pulmonary fibrosis partly through the inhibition of platelets, bleomycin (BLM) was used to induce pulmonary fibrosis in C57BL/6 J mice. We found that cangrelor (10 mg/kg) not only significantly decreased BLM-induced release of inflammatory cytokines (PF4, CD40 L and MPO), but also decreased the increment of platelets, neutrophils and platelet-neutrophil aggregates in the fibrotic lung and in the peripheral blood of BLM-treated mice. In addition, cangrelor decreased the number of CD40 and MPO double positive neutrophils and the expression level of CD40 in BLM-treated mouse lungs. Based on these results we conclude that cangrelor alleviates BLM-induced lung inflammation and pulmonary fibrosis in mice, partly through inhibition of platelet activation, therefore reducing the infiltration of neutrophils due to the adhesion of platelets and neutrophils mediated by CD40 - CD40 L interaction. Cangrelor could be a potential therapeutic medicine for pulmonary fibrosis.
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160
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Abstract
Inadequate antiplatelet effects can result in substantial morbidity and mortality in patients with acute coronary syndrome and percutaneous coronary intervention (PCI). Cangrelor is a rapid onset and potent intravenous P2Y12 inhibitor that has been shown in large randomized controlled trials to reduce periprocedural complications for PCI compared with clopidogrel, the most commonly used P2Y12 inhibitor. Cangrelor should be considered in the setting of PCI to reduce the risk of periprocedural complications such as myocardial infarction, repeat coronary revascularization and stent thrombosis in patients not yet treated with another P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor. In this review, the importance of adequate P2Y12 inhibition, cangrelor's pharmacology and clinical profiles, and future directions for the cangrelor are discussed.
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Affiliation(s)
- Kent Y Feng
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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161
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Impact of Cangrelor on Coronary Thrombus: Optical Coherence Tomography Assessment. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:700-701. [PMID: 32033895 DOI: 10.1016/j.carrev.2020.01.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 11/23/2022]
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162
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Franchi F, Rollini F, Rivas A, Wali M, Briceno M, Agarwal M, Shaikh Z, Nawaz A, Silva G, Been L, Smairat R, Kaufman M, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Platelet Inhibition With Cangrelor and Crushed Ticagrelor in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circulation 2020; 139:1661-1670. [PMID: 30630341 DOI: 10.1161/circulationaha.118.038317] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The platelet inhibitory effects induced by oral P2Y12 receptor antagonists are delayed in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (P-PCI). In turn, this leads to a gap in platelet inhibition, exposing patients to an increased risk of early thrombotic complications and underscoring the need to define strategies associated with more effective platelet inhibition in the peri-primary percutaneous coronary intervention period. Cangrelor is an intravenous P2Y12 inhibitor with prompt and potent antiplatelet effects. However, to date, there are limited data on the effects of cangrelor used in combination with ticagrelor in patients undergoing primary percutaneous coronary intervention. Moreover, questions have emerged on the potential for drug-drug interactions during the transition from cangrelor to oral P2Y12 inhibitors. METHODS This was a prospective, randomized, double-blind, placebo-controlled pharmacodynamic study conducted in patients undergoing primary percutaneous coronary intervention (n=50) who were randomized to treatment with either cangrelor or matching placebo (bolus followed by 2-hour infusion). All patients received ticagrelor 180-mg loading dose administered as crushed tablets at the time of cangrelor/placebo bolus administration. Pharmacodynamic analyses were performed at 8 time points. Pharmacodynamic effects were measured as P2Y12 reaction units by VerifyNow and platelet reactivity index by vasodilator-stimulated phosphoprotein. RESULTS Compared with placebo, cangrelor was associated with reduced P2Y12 reaction units as early as 5 minutes after bolus, which persisted during the entire duration of drug infusion, including at 30 minutes (63 [32-93] versus 214 [183-245]; mean difference, 152 [95% CI, 108-195]; P<0·001; primary end point). Parallel findings were shown with platelet reactivity index. Accordingly, high on-treatment platelet reactivity rates were reduced with cangrelor. After discontinuation of cangrelor/placebo infusion, there were no differences in levels of platelet reactivity between groups, ruling out a drug-drug interaction when cangrelor and ticagrelor are concomitantly administered. CONCLUSIONS In patients undergoing primary percutaneous coronary intervention, cangrelor is an effective strategy to bridge the gap in platelet inhibition associated with the use of oral P2Y12 inhibition induced by ticagrelor. Ticagrelor can be administered as a crushed formulation concomitantly with cangrelor without any apparent drug-drug interaction. The clinical implications of these pharmacodynamic findings warrant investigation in an adequately powered clinical trial. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT03247738.
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Mustafa Wali
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Maryuri Briceno
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Malhar Agarwal
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Zubair Shaikh
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ahmed Nawaz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Gabriel Silva
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ramez Smairat
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Marc Kaufman
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Theodore A Bass
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
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Abstract
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Arjun Majithia
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
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164
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Affiliation(s)
- David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital Lund, Sweden
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165
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Holm M, Tornvall P, Henareh L, Jensen U, Golster N, Alström P, Santos-Pardo I, Witt N, Fedchenko N, Venetsanos D, Beck O, van der Linden J. The MOVEMENT Trial. J Am Heart Assoc 2020; 8:e010152. [PMID: 30636504 PMCID: PMC6497337 DOI: 10.1161/jaha.118.010152] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Morphine administration is a strong predictor of delayed onset of action of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction, likely because of impaired gastrointestinal motility. The aim of this study was to evaluate whether the peripheral opioid antagonist methylnaltrexone could improve pharmacodynamics and pharmacokinetics of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Methods and Results The MOVEMENT (Methylnaltrexone to Improve Platelet Inhibition of Ticagrelor in Morphine‐Treated Patients With ST‐Segment Elevation Myocardial Infarction) trial was a multicenter, prospective, randomized, controlled trial in patients with ST‐segment–elevation myocardial infarction treated with morphine and ticagrelor. Upon arrival to the catheterization laboratory, patients were randomized to a blinded intravenous injection of either methylnaltrexone (8 or 12 mg according to weight) or 0.9% sodium chloride. The proportion of patients with high on‐treatment platelet reactivity and plasma concentrations of ticagrelor and AR‐C124910XX were assessed at baseline (arrival in the catheterization laboratory) and 1 and 2 hours later. A total of 82 patients received either methylnaltrexone (n=43) or placebo (n=39). Median (interquartile range) time from ticagrelor administration to randomization was 41 (31–50) versus 45.5 (37–60) minutes (P=0.16). Intravenous methylnaltrexone administration did not significantly affect prevalence of high on‐treatment platelet reactivity at 2 hours after inclusion, the primary end point, when compared with placebo (54% versus 51%, P=0.84). Plasma concentrations of ticagrelor and its active metabolite, the prespecified secondary end points, did not differ significantly between the groups over time. There was no significant difference in patient self‐estimated pain between the groups. Conclusions Methylnaltrexone did not significantly improve platelet reactivity or plasma concentrations of orally administered ticagrelor in patients with ST‐segment–elevation myocardial infarction receiving morphine. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02942550.
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Affiliation(s)
- Manne Holm
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,2 Perioperative Medicine and Intensive Care, B31 Karolinska University Hospital Huddinge, Stockholm Sweden
| | - Per Tornvall
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Loghman Henareh
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Ulf Jensen
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nanna Golster
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Patrik Alström
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Irene Santos-Pardo
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nils Witt
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Nikolai Fedchenko
- 3 Unit of Cardiology Department of Clinical Science and Education Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Dimitrios Venetsanos
- 4 Coronary Artery and Vascular Disease Heart and Vascular Theme Department of Medicine Karolinska Institute and Karolinska University Hospital Stockholm Sweden
| | - Olof Beck
- 5 Department of Laboratory Medicine Karolinska Institutet Stockholm Sweden
| | - Jan van der Linden
- 1 Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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166
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Capodanno D, Milluzzo RP, Angiolillo DJ. Intravenous antiplatelet therapies (glycoprotein IIb/IIIa receptor inhibitors and cangrelor) in percutaneous coronary intervention: from pharmacology to indications for clinical use. Ther Adv Cardiovasc Dis 2020; 13:1753944719893274. [PMID: 31823688 PMCID: PMC6906352 DOI: 10.1177/1753944719893274] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oral antiplatelet drugs are crucially important for patients with acute coronary
syndrome or stable coronary artery disease undergoing percutaneous coronary
intervention (PCI). In recent decades, several clinical trials have focused on
reducing periprocedural ischemic events in patients undergoing PCI by means of
more rapid platelet inhibition with the use of intravenous antiplatelet drugs.
Glycoprotein IIb/IIIa receptor inhibitors (GPIs) block the final common pathway
of platelet aggregation and enable potent inhibition in the peri-PCI period. In
recent years, however, the use of GPIs has decreased due to bleeding concerns
and the availability of more potent oral P2Y12 inhibitors. Cangrelor
is an intravenous P2Y12 receptor antagonist. In a large-scale
regulatory trial, cangrelor administration during PCI allowed for rapid, potent
and rapidly reversible inhibition of platelet aggregation, with an anti-ischemic
benefit and no increase in major bleeding. This article aims to provide an
overview of general pharmacology, supporting evidence and current status of
intravenous antiplatelet therapies (GPIs and cangrelor), with a focus on
contemporary indications for their clinical use.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, P.O. Rodolico, Ed. 8, Via Santa Sofia 78, 95123 Catania, Sicilia, Italy
| | - Rocco P Milluzzo
- Division of Cardiology, A.O.U. 'Policlinico-Vittorio Emanuele', University of Catania, Catania, Sicilia, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
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167
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Cangrelor Bridging Within 6 Months of a Drug-Eluting Stent in a Patient for Emergency Cervical Spine Surgery: A Case Report. A A Pract 2019; 13:69-73. [PMID: 30864953 DOI: 10.1213/xaa.0000000000000994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The recommended duration of dual antiplatelet therapy after drug-eluting stent placement presents a dilemma for patients with recent stenting who require urgent or emergency noncardiac surgery. We present the case of a patient with recent drug-eluting stent placement (<6 months) on dual antiplatelet therapy who underwent successful emergency cervical spine surgery with antiplatelet therapy bridged using cangrelor, an intravenous P2Y12 inhibitor antiplatelet agent. Our experience illustrates the multidisciplinary approach to a patient with high thrombotic and bleeding risk who underwent neurosurgery off both aspirin and a P2Y12 inhibitor.
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168
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169
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Sharma RK, Pinto DS. Mind the Gap: Platelet Inhibition in Low‐Risk Acute Coronary Syndrome Undergoing Percutaneous Revascularization. J Am Heart Assoc 2019; 8:e014498. [PMID: 31766972 PMCID: PMC6912963 DOI: 10.1161/jaha.119.014498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ravi K. Sharma
- Cardiovascular Institute Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
| | - Duane S. Pinto
- Cardiovascular Institute Beth Israel Deaconess Medical Center Harvard Medical School Boston MA
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170
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McCarthy CP, Steg G, Bhatt DL. The management of antiplatelet therapy in acute coronary syndrome patients with thrombocytopenia: a clinical conundrum. Eur Heart J 2019; 38:3488-3492. [PMID: 29020292 PMCID: PMC5837661 DOI: 10.1093/eurheartj/ehx531] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Cian P McCarthy
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Gabriel Steg
- Département Hospitalo-Universitaire FIRE, AP-HP, Hôpital Bichat, FACT (French Alliance for Cardiovascular Trials), an F-CRIN Network, Université Paris-Diderot, Sorbonne Paris-Cité, INSERM U-1148, Paris, France
- NHLI, Imperial College, ICMS Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
- Corresponding author. Tel: +1 857 307 1992, Fax: +1 857 307 1955,
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171
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Stone GW, Généreux P, Harrington RA, White HD, Gibson CM, Steg PG, Hamm CW, Mahaffey KW, Price MJ, Prats J, Deliargyris EN, Bhatt DL. Impact of lesion complexity on peri-procedural adverse events and the benefit of potent intravenous platelet adenosine diphosphate receptor inhibition after percutaneous coronary intervention: core laboratory analysis from 10 854 patients from the CHAMPION PHOENIX trial. Eur Heart J 2019; 39:4112-4121. [PMID: 30203006 PMCID: PMC6284164 DOI: 10.1093/eurheartj/ehy562] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023] Open
Abstract
Aims In the CHAMPION PHOENIX trial, the potent, rapidly acting, intravenous platelet adenosine diphosphate receptor antagonist cangrelor reduced the 48-h incidence of major adverse cardiac events (MACE; death, myocardial infarction, stent thrombosis, or ischaemia-driven revascularization) compared with a loading dose of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). We sought to determine whether the efficacy of cangrelor during PCI varies in patients with simple vs. complex target lesion coronary anatomy. Methods and results Blinded angiographic core laboratory analysis was completed in 10 854 of 10 942 (99.2%) randomized patients in CHAMPION PHOENIX (13 418 target lesions). Outcomes were analysed according to the number of angiographic PCI target lesion high-risk features (HRF) present (bifurcation, left main, thrombus, angulated, tortuous, eccentric, calcified, long, or multi-lesion treatment). The number of patients with 0, 1, 2, and ≥3 HRFs was 1817 (16.7%), 3442 (31.7%), 2901 (26.7%), and 2694 (24.8%), respectively. The 48-h MACE rate in clopidogrel-treated patients increased progressively with lesion complexity (from 3.3% to 4.4% to 6.9% to 8.7%, respectively, P < 0.0001). Cangrelor reduced the 48-h rate of MACE by 21% {4.7% vs. 5.9%, odds ratio (OR) [95% confidence interval (95% CI)] 0.79 (0.67, 0.93), P = 0.006} compared with clopidogrel, an effect which was consistent regardless of PCI lesion complexity (Pinteraction = 0.66) and presentation with stable ischaemic heart disease (SIHD) or an acute coronary syndrome (ACS). By multivariable analysis, the number of high-risk PCI characteristics [OR (95% CI) 1.68 (1.20, 2.36), 2.78 (2.00, 3.87), and 3.23 (2.33, 4.48) for 1, 2, and 3 HRFs compared with 0 HRFs, all P < 0.0001] and treatment with cangrelor vs. clopidogrel [OR (95% CI) 0.78 (0.66, 0.92), P = 0.004] were independent predictors of the primary 48-h MACE endpoint. Major bleeding rates were unrelated to lesion complexity and were not increased by cangrelor. Conclusion Peri-procedural MACE after PCI is strongly dependent on the number of treated high-risk target lesion features. Compared with a loading dose of clopidogrel, cangrelor reduced MACE occurring within 48 h after PCI in patients with SIHD and ACS regardless of baseline lesion complexity. The absolute benefit:risk profile for cangrelor will therefore be greatest during PCI in patients with complex coronary anatomy. Clinicaltrials.gov identifier NCT01156571.
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Affiliation(s)
- Gregg W Stone
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.,Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
| | - Philippe Généreux
- Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA.,Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA.,Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | | | - Harvey D White
- Cardiovascular Department, Auckland City Hospital, University of Auckland, New Zealand
| | | | - P Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hopital Bichat, Assistance Publique-Hopitaux de Paris, Paris, France
| | - Christian W Hamm
- Kerckhoff Clinic and Thoraxcenter of the University of Giessen, Bad Nauheim, Germany
| | | | | | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
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172
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Chehab O, Abdallah N, Kanj A, Pahuja M, Adegbala O, Morsi RZ, Mishra T, Afonso L, Abidov A. Impact of immune thrombocytopenic purpura on clinical outcomes in patients with acute myocardial infarction. Clin Cardiol 2019; 43:50-59. [PMID: 31710764 PMCID: PMC6954382 DOI: 10.1002/clc.23287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/14/2019] [Accepted: 10/21/2019] [Indexed: 11/29/2022] Open
Abstract
Background Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP. Methods Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS). Results The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05‐1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions. Conclusions Patients with ITP admitted for AMI had a similar in‐hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population.
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Affiliation(s)
- Omar Chehab
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Nadine Abdallah
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Amjad Kanj
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Mohit Pahuja
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Oluwole Adegbala
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Rami Z Morsi
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tushar Mishra
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Luis Afonso
- Department of Internal Medicine, Wayne State University, Detroit, Michigan
| | - Aiden Abidov
- Department of Internal Medicine, Wayne State University, Detroit, Michigan.,Cardiology Section, Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, Michigan
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173
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Guvvala V, Subramanian VC, Anireddy J. Development of a Novel and Scalable Process for the Synthesis of a Key Cangrelor Intermediate. ORG PREP PROCED INT 2019. [DOI: 10.1080/00304948.2019.1677442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Vinodh Guvvala
- Centre for Chemical Science & Technology, Institute of Science & Technology, Jawaharlal Nehru Technological University Hyderabad, Kukatpally, Hyderabad 500 085, India
- Gland Pharma Ltd, Research and Development, D. P. Pally, Hyderabad 500 043, India
| | | | - Jayashree Anireddy
- Centre for Chemical Science & Technology, Institute of Science & Technology, Jawaharlal Nehru Technological University Hyderabad, Kukatpally, Hyderabad 500 085, India
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174
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Katira A, Katira R. Cangrelor. PRACTICAL DIABETES 2019. [DOI: 10.1002/pdi.2249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Arnav Katira
- Sheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - Ravish Katira
- St Helens & Knowsley Teaching Hospitals NHS Trust Whiston UK
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175
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Buccheri S, Capodanno D, James S, Angiolillo DJ. Bleeding after antiplatelet therapy for the treatment of acute coronary syndromes: a review of the evidence and evolving paradigms. Expert Opin Drug Saf 2019; 18:1171-1189. [DOI: 10.1080/14740338.2019.1680637] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Sergio Buccheri
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. “G. Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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176
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Cohen MV, Downey JM. What Are Optimal P2Y12 Inhibitor and Schedule of Administration in Patients With Acute Coronary Syndrome? J Cardiovasc Pharmacol Ther 2019; 25:121-130. [DOI: 10.1177/1074248419882923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Guidelines recommend treatment with a P2Y12 platelet adenosine diphosphate receptor inhibitor in patients undergoing elective or urgent percutaneous coronary intervention (PCI), but the optimal agent or timing of administration is still not clearly specified. The P2Y12 inhibitor was initially used for its platelet anti-aggregatory action to block thrombosis of the recanalized coronary artery or deployed stent. It is now recognized that these agents also offer potent cardioprotection against a reperfusion injury that occurs in the first minutes of reperfusion if platelet aggregation is blocked at the time of reperfusion. But this is difficult to achieve with oral agents which are slowly absorbed and often require time-consuming metabolic activation. Patients with ST-segment elevation myocardial infarction who usually have a large mass of myocardium at risk of infarction seldom have sufficient time for upstream-administered oral agents to achieve a therapeutic P2Y12 level of inhibition by the time of balloon inflation. However, optimal treatment could be assured by initiating an IV cangrelor infusion shortly prior to stenting followed by subsequent post-PCI transition to an oral agent, that is, ticagrelor, once success of the recanalization and absence of need for surgical intervention are confirmed. Not only should this sequence provide optimal protection against infarction, it should also negate bleeding if coronary artery bypass grafting should be required since stopping the cangrelor infusion at any time will quickly restore platelet reactivity. It is anticipated that cangrelor-induced myocardial salvage will help preserve myocardial function and significantly diminish postinfarction heart failure.
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Affiliation(s)
- Michael V. Cohen
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
- Department of Medicine, University of South Alabama College of Medicine, Mobile, AL, USA
| | - James M. Downey
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
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177
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Alexopoulos D, Varlamos C, Mpahara A, Lianos I. P2Y12 inhibitors for the treatment of acute coronary syndrome patients undergoing percutaneous coronary intervention: current understanding and outcomes. Expert Rev Cardiovasc Ther 2019; 17:717-727. [PMID: 31583920 DOI: 10.1080/14779072.2019.1675513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: Inhibition of P2Y12 platelet receptors consists a crucial target of pharmacologic treatment in acute coronary syndrome patients. Several controversial issues however still remain and these are analyzed.Areas covered: The significance of early and strong platelet inhibition in the early phase of STEMI and the role of pretreatment are discussed. Concerns regarding morphine administration are raised. The role of crushing integral tablets to expedite the onset of action of oral P2Y12 inhibitors is emphasized. New data on the intravenous cangrelor are reported. Antiplatelet therapies as adjunct to thrombolysis, as well as the role of de-escalation antiplatelet therapy are analyzed.Expert opinion: Pharmacodynamic studies convincingly demonstrate a gap in the onset of antiplatelet action in STEMI cases, even when prasugrel or ticagrelor loading dose is used. The clinical benefit, however, of the early platelet inhibition and pretreatment is not entirely clear. Morphine delays the onset of action of oral agents, while this is expedited by crushing the integral tablets. Cangrelor devoids of these deficiencies by achieving fast and strong platelet inhibition in all clinical scenarios. Concomitant administration of novel antiplatelet agents with thrombolysis and de-escalation of antiplatelet treatment necessitate further study to reach definite conclusion.
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Affiliation(s)
- Dimitrios Alexopoulos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aikaterini Mpahara
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- 2nd Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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178
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Alexopoulos D, Pappas C, Sfantou D, Xanthopoulou I, Didagelos M, Kikas P, Ziakas A, Tziakas D, Karvounis H, Iliodromitis E. Cangrelor in Ticagrelor-Loaded STEMI Patients Undergoing Primary Percutaneous Coronary Intervention. J Am Coll Cardiol 2019; 72:1750-1751. [PMID: 30261967 DOI: 10.1016/j.jacc.2018.07.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 06/25/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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179
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Bhattad VB, Gaddam S, Lassiter MA, Jagadish PS, Ardeshna D, Cave B, Khouzam RN. Intravenous cangrelor as a peri-procedural bridge with applied uses in ischemic events. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:408. [PMID: 31660307 DOI: 10.21037/atm.2019.07.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cangrelor is a relatively new antiplatelet drug that has been approved for use as an adjunct therapy to percutaneous coronary intervention (PCI) to decrease peri-procedural myocardial infarction (MI), coronary revascularization, and stent thrombosis. Cangrelor is an adenosine triphosphate analogue with a pharmacokinetic mechanism based on a reversible, dose-dependent inhibition adenosine diphosphate (ADP)-induced platelet aggregation. This drug has lately been in the spotlight as a possible bridge therapy for anti-platelet medication prior to cardiac and non-cardiac surgeries. Platelet function is usually restored within sixty minutes of cessation of therapy, thereby decreasing the risk of bleeding while providing adequate pre-procedural coverage to reduce ischemic events. This manuscript reviews the literature on cangrelor and summarizes its role as a peri-procedural bridge.
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Affiliation(s)
- Venugopal B Bhattad
- Department of Internal Medicine, Division of Cardiovascular Diseases, East Tennessee State University, Johnson City, TN, USA
| | - Sathvika Gaddam
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Margaret A Lassiter
- Cardiovascular Clinical Pharmacy Department, Johnson City Medical Center, Johnson City, TN, USA
| | | | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
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180
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Capranzano P, Francaviglia B, Angiolillo DJ. Pharmacodynamics During Transition Between Platelet P2Y 12 Inhibiting Therapies. Interv Cardiol Clin 2019; 8:321-340. [PMID: 31445718 DOI: 10.1016/j.iccl.2019.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Several platelet P2Y12 inhibiting agents, both oral and intravenous, are available for clinical use. The oral P2Y12 inhibitors comprise clopidogrel, prasugrel, and ticagrelor. Cangrelor is the only intravenous P2Y12 inhibitor. Numerous pharmacodynamic studies have been performed to assess the impact of P2Y12 inhibitor switching on platelet reactivity profiles and to define the optimal strategy if switching is needed, with the goal of minimizing the risk of having inadequate platelet inhibition due to potential drug-drug interactions occurring during the drug overlap phase. This article provides an overview of pharmacodynamic studies assessing switching between P2Y12 inhibitors and recommendations on switching modalities based on these findings.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, CAST Policlinico Hospital, University of Catania, S. Sofia n. 78, Catania 95123, Italy.
| | - Bruno Francaviglia
- Division of Cardiology, CAST Policlinico Hospital, University of Catania, S. Sofia n. 78, Catania 95123, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL 32209, USA
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Groves EM, Bhatt DL, Steg PG, Deliargyris EN, Stone GW, Gibson CM, Hamm CW, Mahaffey KW, White HD, Angiolillo DJ, Prats J, Harrington RA, Price MJ. Incidence, Predictors, and Outcomes of Acquired Thrombocytopenia After Percutaneous Coronary Intervention: A Pooled, Patient-Level Analysis of the CHAMPION Trials (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition). Circ Cardiovasc Interv 2019; 11:e005635. [PMID: 29632238 DOI: 10.1161/circinterventions.117.005635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The influence of cangrelor on the incidence and outcomes of post-percutaneous coronary intervention (PCI) thrombocytopenia is not defined. We aimed to explore the incidence, predictors, and clinical impact of thrombocytopenia after PCI in cangrelor-treated patients. METHODS AND RESULTS This was a pooled, patient-level analysis of the CHAMPION trials (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), which compared cangrelor with clopidogrel for prevention of thrombotic complications during and after PCI. Acquired thrombocytopenia was defined as either a drop in platelet count to <100 000 after PCI or a drop of >50% between baseline and a follow-up. The main efficacy outcome was major adverse cardiac events. The primary safety outcome was noncoronary artery bypass grafting-related Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-defined severe bleeding at 48 hours. Patients (23 783) were enrolled, and 3009 (12.7%) received a GPI (glycoprotein IIb/IIIa inhibitor). Acquired thrombocytopenia occurred in 200 patients (0.8%). The adjusted rate of major adverse cardiovascular events at 48 hours was significantly higher in patients who developed thrombocytopenia compared with those who did not (odds ratio, 3.00; 95% confidence interval, 1.89-4.69; P<0.001), as was major bleeding (odds ratio, 14.71; 95% confidence interval, 5.96-36.30; P<0.001). GPI use was the strongest independent predictor of acquired thrombocytopenia (odds ratio, 2.93; 95% confidence interval, 2.15-3.97; P<0.0001). There was no difference in the rate of acquired thrombocytopenia in patients randomized to cangrelor or clopidogrel. CONCLUSIONS Acquired thrombocytopenia after PCI is strongly associated with substantial early morbidity and mortality, as well as major bleeding. GPI use is a significant predictor of thrombocytopenia. Cangrelor is not associated with acquired thrombocytopenia, and its clinical efficacy and safety is consistent irrespective of thrombocytopenia occurrence. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00305162, NCT00385138, and NCT01156571.
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Affiliation(s)
- Elliott M Groves
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Deepak L Bhatt
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Philippe Gabriel Steg
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Efthymios N Deliargyris
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Gregg W Stone
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - C Michael Gibson
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Christian W Hamm
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Kenneth W Mahaffey
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Harvey D White
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Dominick J Angiolillo
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Jayne Prats
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Robert A Harrington
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Matthew J Price
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.).
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Xiang Q, Pang X, Liu Z, Yang G, Tao W, Pei Q, Cui Y. Progress in the development of antiplatelet agents: Focus on the targeted molecular pathway from bench to clinic. Pharmacol Ther 2019; 203:107393. [PMID: 31356909 DOI: 10.1016/j.pharmthera.2019.107393] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 07/10/2019] [Indexed: 12/22/2022]
Abstract
Antiplatelet drugs serve as a first-line antithrombotic therapy for the management of acute ischemic events and the prevention of secondary complications in vascular diseases. Numerous antiplatelet therapies have been developed; however, currently available agents are still associated with inadequate efficacy, risk of bleeding, and variability in individual response. Understanding the mechanisms of platelet involvement in thrombosis and the clinical development process of antiplatelet agents is critical for the discovery of novel agents. The functions of platelets in thrombosis are regulated by two major mechanisms: the interaction between surface receptors and their ligands, and the downstream intracellular signaling pathways. Recently, most of the progress made in antiplatelet drug development has been achieved with P2Y receptor antagonists. Additionally, the usage of GP IIb/IIIa receptor antagonists has decreased, because it is associated with a higher risk of bleeding and thrombocytopenia. Agents targeting other platelet surface receptors such as PARs, TP receptor, EP3 receptor, GPIb-IX-V receptor, P-selectin, as well as intracellular signaling factors, such as PI3Kβ, have been evaluated in an attempt to develop the next generation of antiplatelet drugs, reduce or eliminate interpatient variability of drug efficacy and significantly lower the risk of drug-induced bleeding. The aim of this review is to describe the pathways of platelet activation in thrombosis, and summarize the development process of antiplatelet agents, as well as the preclinical and clinical evaluations performed on these agents.
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Affiliation(s)
- Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Xiaocong Pang
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China
| | - Zhenming Liu
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Guoping Yang
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Weikang Tao
- Center of Clinical Pharmacology, The Third Xiangya Hospital, Central South University, Research Center of Drug Clinical Evaluation of Central South University, 138 TongZiPo Road, Changsha, Hunan 410013, China
| | - Qi Pei
- Shanghai Hengrui Pharmaceuticals Co., 279 Wenjing Road, Shanghai, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6, Da Hong Luo Chang Street, Xicheng District, Beijing 100034, China.
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183
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Olivier CB, Bhatt DL, Leonardi S, Stone GW, Gibson CM, Steg PG, Hamm CW, Wilson MD, Mangum S, Price MJ, Prats J, White HD, Lopes RD, Harrington RA, Mahaffey KW. Central Adjudication Identified Additional and Prognostically Important Myocardial Infarctions in Patients Undergoing Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2019; 12:e007342. [PMID: 31296081 DOI: 10.1161/circinterventions.118.007342] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the CHAMPION PHOENIX trial, cangrelor reduced the primary composite end point of death, myocardial infarction (MI), ischemia-driven revascularization, or stent thrombosis at 48 hours. This study aimed to explore the impact of event adjudication and the prognostic importance of MI reported by a clinical events committee (CEC) or site investigators (SIs). METHODS AND RESULTS Data from the CHAMPION PHOENIX trial of patients undergoing elective or nonelective percutaneous coronary intervention were analyzed. A CEC systematically identified and adjudicated MI using predefined criteria, a computer algorithm to identify suspected events, and semilogarithmic plots to review biomarker changes. Thirty-day death was modeled using baseline characteristics. Of 10 942 patients, 462 (4.2%) patients had at least 1 MI by 48 hours identified by the CEC (207 [3.8%] cangrelor; 255 [4.7%] clopidogrel; odds ratio [OR] 0.80; 95% CI, 0.67-0.97; P=0.022), and 143 patients had at least 1 MI by 48 hours reported by the SI (60 [1.1%] cangrelor; 83 [1.5%] clopidogrel; OR, 0.72; 95% CI, 0.52-1.01; P=0.053). Of the 462 MIs identified by the CEC, 92 (20%) were reported by SI, and 370 (80%) were not. Of the 143 MI reported by the SI, 51 (36%) were not confirmed by CEC. All categories were associated with an increased adjusted risk for 30-day death (CEC: OR, 5.35; 95% CI, 2.56-11.2; P<0.001; SI: 9.08 [4.01-20.5]; P<0.001; CEC and SI: 10.9 [3.23-36.6]; P<0.001; CEC but not SI: 4.69 [1.94-11.3]; P<0.001; SI but not CEC: 15.4 [5.26-44.9]; P<0.001). CONCLUSIONS In patients undergoing percutaneous coronary intervention, CEC procedures identified 3 times as many MIs as the SI reported. Compared with clopidogrel, cangrelor significantly reduced MIs identified by the CEC with a qualitatively similar relative risk reduction in MIs reported by the SI. MIs identified by CEC or reported by SI were independently associated with worse 30-day death. Central adjudication identified additional, prognostically important events. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT01156571.
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Affiliation(s)
- Christoph B Olivier
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, CA (C.B.O., K.W.M.).,Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Germany (C.B.O.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Sergio Leonardi
- University of Pavia, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy (S.L.)
| | - Gregg W Stone
- Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.)
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Division of Cardiology, Boston, MA (C.M.G.)
| | - Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular Clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, Paris, France, and NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.)
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.)
| | - Matthew D Wilson
- Duke University Medical Center, Durham, NC (M.D.W., S.M., R.D.L.)
| | - Stacey Mangum
- Duke University Medical Center, Durham, NC (M.D.W., S.M., R.D.L.)
| | - Matthew J Price
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, CA (M.J.P.)
| | | | - Harvey D White
- Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.)
| | - Renato D Lopes
- Duke University Medical Center, Durham, NC (M.D.W., S.M., R.D.L.)
| | - Robert A Harrington
- Department of Medicine, Stanford University School of Medicine, Stanford, CA (R.A.H.)
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, CA (C.B.O., K.W.M.)
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184
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Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI. J Am Coll Cardiol 2019; 74:83-99. [DOI: 10.1016/j.jacc.2019.05.016] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
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Yong CM, Sundaram V, Abnousi F, Olivier CB, Yang J, Stone GW, Steg PG, Michael Gibson C, Hamm CW, Price MJ, Deliargyris EN, Prats J, White HD, Harrington RA, Bhatt DL, Mahaffey KW. The efficacy and safety of cangrelor in single vessel vs multivessel percutaneous coronary intervention: Insights from CHAMPION PHOENIX. Clin Cardiol 2019; 42:797-805. [PMID: 31254472 PMCID: PMC6727881 DOI: 10.1002/clc.23221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/18/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The intravenous, rapidly acting P2Y12 inhibitor cangrelor reduces the rate of ischemic events during PCI with no significant increase in severe bleeding. However, the efficacy and safety of cangrelor compared with clopidogrel in patients treated with single vessel (SV)-percutaneous coronary intervention (PCI) or multivessel (MV)-PCI remains unexplored. METHODS We studied the modified intention-to-treat population of patients from the CHAMPION PHOENIX trial who were randomized to either cangrelor or clopidogrel. We used logistic regression and propensity score matching to evaluate the effect of cangrelor compared with clopidogrel on the primary efficacy outcome (composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) at 48 hours. The safety outcome was moderate or severe Global Utilization of Streptokinase and tPA for Occluded Arteries bleeding at 48 hours. HYPOTHESIS Cangrelor is as efficacious and safe as clopidogrel in both SV and MV PCI. RESULTS Among 10 854 patients, 9204 (85%) underwent SV- and 1650 (15%) MV-PCI. After adjustment, cangrelor was associated with similar reductions vs clopidogrel in the primary efficacy outcome in patients undergoing SV-PCI (4.5% vs 5.2%; odds ratio [OR] 0.81 [0.66-0.98]) or MV-PCI (6.1% vs 9.8%, OR 0.59 [0.41-0.85]; Pint 0.14). Similar results were observed after propensity score matching (SV-PCI: 5.5% vs 5.9%, OR 0.93 [0.74-1.18]; MV-PCI: 6.2% vs 8.9%, OR 0.67 [0.44-1.01]; Pint 0.17). There was no evidence of heterogeneity in the treatment effect of cangrelor compared with clopidogrel for the safety outcome. CONCLUSIONS In patients undergoing SV- or MV-PCI, cangrelor was associated with similar relative risk reductions in ischemic complications and no increased risk of significant bleeding compared with clopidogrel, which highlights the expanding repertoire of options for use in complex PCI.
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Affiliation(s)
- Celina M. Yong
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare SystemPalo AltoCalifornia,Division of Cardiovascular MedicineStanford University School of MedicineStanfordCalifornia
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of MedicineStanford University School of MedicineStanfordCalifornia
| | - Freddy Abnousi
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare SystemPalo AltoCalifornia
| | - Christoph B. Olivier
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia,Department of Cardiology and Angiology IHeart Center Freiburg University, Faculty of Medicine, University of FreiburgFreiburgGermany
| | - Jaden Yang
- Quantitative Sciences Unit, Department of MedicineStanford University School of MedicineStanfordCalifornia
| | - Gregg W. Stone
- Cardiovascular Research FoundationColumbia University Medical CenterNew YorkNew York
| | - Philippe G. Steg
- DHU (Département Hospitalo‐Universitaire)‐FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP‐HPb (Assistance Publique‐Hôpitaux de Paris)Université Paris‐Diderot, Sorbonne‐Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F‐CRIN network, INSERM U‐1148ParisFrance,NLHI, ICMSRoyal Brompton Hospital, Imperial CollegeLondonUK
| | - C. Michael Gibson
- Beth Israel Deaconess Medical Center, Division of CardiologyHarvard Medical School, BostonBostonMassachusetts
| | | | - Matthew J. Price
- Scripps Clinic and Scripps Translational Science InstituteLa JollaCalifornia
| | | | | | - Harvey D. White
- Auckland City HospitalUniversity of AucklandAucklandNew Zealand
| | - Robert A. Harrington
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular CenterHarvard Medical SchoolBostonMassachusetts
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia
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186
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Asher E, Tal S, Mazin I, Abu-Much A, Sabbag A, Katz M, Regev E, Chernomordik F, Guetta V, Segev A, Elian D, Barbash I, Fefer P, Narodistky M, Beigel R, Matetzky S. Effect of Chewing vs Swallowing Ticagrelor on Platelet Inhibition in Patients With ST-Segment Elevation Myocardial Infarction: A Randomized Clinical Trial. JAMA Cardiol 2019; 2:1380-1384. [PMID: 29071332 DOI: 10.1001/jamacardio.2017.3868] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Importance Dual anti-platelet therapy represents standard care for treating patients with ST-segment elevation myocardial infarction (STEMI). Ticagrelor is a direct-acting P2Y12 inhibitor and, unlike clopidogrel and prasugrel, does not require metabolic activation. Objective To evaluate whether chewing a loading dose (LD) of ticagrelor, 180 mg, vs traditional oral administration of an equal dose enhances platelet inhibition at 30 minutes and 1 hour after LD administration in patients with STEMI. Design, Setting, and Participants A randomized clinical trial was conducted in adults aged 30 to 87 years from May to October 2016 in a large tertiary care center. Analyses were intention-to-treat. Interventions Fifty patients with STEMI were randomized to either chewing an LD of ticagrelor, 180 mg, or standard oral administration of an equal dose. Main Outcomes and Measures P2Y12 reaction units were evaluated using VerifyNow (Accumentrics) at baseline, 30 minutes, 1 hour, and 4 hours after LD. Results Baseline characteristics were similar in both groups. The mean (SD) of P2Y12 reaction units in the chewing group compared with the standard group at baseline, 30 minutes, 1 hour, and 4 hours after ticagrelor LD were 224 (33) vs 219 (44) (95% CI, -16.77 to 27.73; P = .26), 168 (78) vs 230 (69) (95% CI, -103.77 to -19.75; P = .003), 106 (90) vs 181 (89) (95% CI, -125.15 to -26.29; P = .005), and 43 (41) vs 51 (61) (95% CI, -36.34 to 21.14; P = .30), respectively. Platelet reactivity in the chewing group was significantly reduced by 24% at 30 minutes after LD (95% CI, 19.75 to 103.77; P = .001). The relative inhibition of platelet aggregation in the chewing vs the standard group were 51% vs 10% (95% CI, 13.69 to 67.67; P = .005) at 1 hour and 81% vs 76% (95% CI, -12.32 to 16.79; P = .24) at 4 hours, respectively. Major adverse cardiac and cardiovascular event rate at 30 days was low (4%) and occurred in 1 patient in each group (95% CI, 0.06 to 16.93; P > .99). Conclusions and Relevance Chewing an LD of ticagrelor, 180 mg, in patients with STEMI is feasible and facilitates better early platelet inhibition compared with a standard oral LD. Larger studies are warranted to see if our preliminary findings translate into clinical outcomes. Trial Registration clinicaltrials.gov Identifier: NCT02725099.
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Affiliation(s)
- Elad Asher
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Shir Tal
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Israel Mazin
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Arsalan Abu-Much
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Avi Sabbag
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Moshe Katz
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Ehud Regev
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Fernando Chernomordik
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Victor Guetta
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Amit Segev
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Dan Elian
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Israel Barbash
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Paul Fefer
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Michael Narodistky
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Roy Beigel
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
| | - Shlomi Matetzky
- Leviev Heart Center, Sheba Medical Center, Tel Aviv University, Tel Hashomer, Israel
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187
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Tamez H, Pinto DS, Kirtane AJ, Litherland C, Yeh RW, Dangas GD, Mehran R, Deliargyris EN, Ortiz G, Gibson CM, Stone GW. Effect of Short Procedural Duration With Bivalirudin on Increased Risk of Acute Stent Thrombosis in Patients With STEMI: A Secondary Analysis of the HORIZONS-AMI Randomized Clinical Trial. JAMA Cardiol 2019; 2:673-677. [PMID: 28249084 DOI: 10.1001/jamacardio.2016.5669] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Importance Bivalirudin has been associated with reduced bleeding and mortality during primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI). However, increased rates of acute stent thrombosis (AST) have been noted when bivalirudin is discontinued at the end of the procedure, which is perhaps related to this medication's short half-life. Objectives To evaluate the clinical effect of procedure duration on AST when either bivalirudin or heparin plus glycoprotein IIb/IIIa receptor inhibitor (GPI) is used. Design, Setting, and Participants An ad hoc analysis of the Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) clinical trial was performed between March 1, 2015, and April 30, 2016, on patients who underwent primary percutaneous coronary intervention with stents and were randomized 1:1 to bivalirudin or heparin plus GPI. Defined as the difference between the patient's arrival at the catheterization laboratory and the patient's final angiogram. Participants included 3602 patients with STEMI, aged 18 years or older, who were undergoing primary percutaneous coronary intervention and presenting less than 12 hours from symptom onset. Main Outcomes and Measures Clinical events committee-adjudicated definite AST (occurring ≤24 hours after percutaneous coronary intervention). Results Among patients included in this analysis, procedure time was identified in 1286 receiving bivalirudin and 1412 receiving heparin plus GPI. Shorter procedures were defined as the lowest quartile of duration (<45 minutes). Patients undergoing shorter procedures were younger and less likely to be hypertensive and smokers. Shorter procedures were less complicated with fewer stents implanted, less multivessel stenting, less thrombus, and less no-reflow. An increased risk of definite AST was associated with shorter than with longer procedures with bivalirudin (7 [2.1%] vs 7 [0.7%]; relative risk, 2.87; 95% CI, 1.01-8.17; P = .04) but not with heparin plus GPI (0 vs 3 [0.3%]; P = .30). Conclusions and Relevance Despite less procedural complexity, shorter primary percutaneous coronary intervention time was associated with an increased risk of AST in patients treated with bivalirudin but not patients treated with heparin plus GPI, possibly because of the rapid offset of bivalirudin's antithrombotic effect during a window of limited oral antiplatelet action. Trial Registration clinicaltrials.gov Identifier: NCT00433966.
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Affiliation(s)
- Hector Tamez
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Duane S Pinto
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ajay J Kirtane
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York3Associate Editor, JAMA Cardiology
| | - Claire Litherland
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Guillermo Ortiz
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - C Michael Gibson
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Gregg W Stone
- Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
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188
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Dervan LA, Watson RS. The Fragility of Using p Value Less Than 0.05 As the Dichotomous Arbiter of Truth. Pediatr Crit Care Med 2019; 20:582-583. [PMID: 31162357 DOI: 10.1097/pcc.0000000000001949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Leslie A Dervan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington, Seattle, WA Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington; and Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, WA
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189
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Lu H, Guan W, Zhou Y, Tang Z, Bao H. Cangrelor or Clopidogrel in Patients with Type 2 Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. Diabetes Ther 2019; 10:937-950. [PMID: 30905057 PMCID: PMC6531549 DOI: 10.1007/s13300-019-0593-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION With recent advances in interventional cardiology where percutaneous coronary intervention (PCI) has become the most preferred invasive strategy and with advances in adjunctive pharmacotherapy, several newer oral P2Y12 inhibitors have reached the market. In this analysis, we aimed to compare the cardiovascular outcomes and bleeding events which were associated with the use of cangrelor versus clopidogrel in patients with type 2 diabetes mellitus (T2DM) 48 h after PCI. METHODS The electronic databases MEDLINE (PubMed), www.ClinicalTrials.gov , EMBASE, and Cochrane central were searched for relevant publications comparing canagrelor with clopidogrel during PCI. Patients with T2DM were extracted. Adverse cardiovascular outcomes and bleeding events at 48 h follow-up were considered as the end points. This meta-analysis was carried out with the latest RevMan software (5.30). Odds ratios (OR) and 95% confidence intervals (CI) were used to represent the data. RESULTS This analysis consisted of a total number of 5031 participants with T2DM (enrolled between the years 2006 and 2012). Compared to clopidgrel, use of cangrelor in these patients with T2DM was not associated with significantly different primary end point (OR 0.94, 95% CI 0.75-1.16; P = 0.55), myocardial infarction (OR 0.96, 95% CI 0.76-1.20; P = 0.71), all-cause death (OR 0.70, 95% CI 0.25-1.96; P = 0.49), ischemia-driven revascularization (OR 0.66, 95% CI 0.32-1.36; P = 0.26), and stent thrombosis (OR 0.45, 95% CI 0.17-1.17; P = 0.10). Thrombolysis in myocardial infarction (TIMI)-defined major and minor bleedings were similarly manifested: (OR 1.02, 95% CI 0.38-2.74; P = 0.96) and (OR 1.39, 95% CI 0.70-2.79; P = 0.35), respectively. Global use of strategies to open occluded arteries (GUSTO)-defined moderate and severe bleeding were also not significantly different: (OR 1.36, 95% CI 0.70-2.67; P = 0.37) and (OR 1.21, 95% CI 0.41-3.59; P = 0.74), respectively. However, GUSTO-defined mild bleeding and acute catheterization and urgent intervention triage strategy (ACUITY)-defined major and minor bleedings were significantly in favor of clopidogrel in comparison to cangrelor in these patients with T2DM: (OR 1.28, 95% CI 1.09-1.50; P = 0.003), (OR 1.43, 95% CI 1.05-1.94; P = 0.02), and (OR 1.23, 95% CI 1.04-1.46; P = 0.02), respectively. Other bleeding outcomes were not significantly different. CONCLUSIONS In these patients with T2DM, cangrelor was comparable to clopidogrel in terms of efficacy at 48 h following PCI. However, it was associated with significantly higher mild GUSTO bleeding and major and minor ACUITY bleeding, therefore requiring further workups on its safety side. This hypothesis should be explored further and confirmed in other forthcoming trials based strictly on patients with T2DM.
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Affiliation(s)
- Hongtao Lu
- Jingzhou Central Hospital of Cardiology, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, People's Republic of China
| | - Wenjun Guan
- Jingzhou Central Hospital of Cardiology, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, People's Republic of China
| | - Yanhua Zhou
- Department of Hematology, Jingzhou First People's Hospital, The First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| | - Zhangui Tang
- Institute of Cardiovascular Disease, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hong Bao
- Jiangling County People's Hospital of Cardiology, Jingzhou, Hubei, People's Republic of China.
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190
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Morici N, Nava S, Sacco A, Viola G, Oreglia J, Meani P, Oliva F, Ranucci M, Leonardi S, Rossini R. Acute myocardial infarction complicating ischemic stroke: is there room for cangrelor? Platelets 2019; 31:120-123. [PMID: 31066332 DOI: 10.1080/09537104.2019.1609663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Acute myocardial infarction (AMI) complicating ischemic stroke is a well known and undertreated event. A conservative management is not infrequent in these settings, due to the fear of hemorrhagic complications related to antithrombotic therapy. Notably, an invasive approach with a primary percutaneous coronary intervention (PCI) has been shown to be associated with a lower in-hospital mortality in patients with concomitant ischemic stroke and AMI. The optimal antiplatelet regimen in these cases has been not clearly defined, yet. We report two cases of patients with AMI complicating ischemic stroke, successfully treated with cangrelor infusion, which was started during PCI and maintained up to 48 h at bridge therapy dosage (0.75 mcg/kg/min). Both patients underwent successful PCI in the acute phase, and neither ischemic nor hemorrhagic complications occurred during in-hospital stay.
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Affiliation(s)
- Nuccia Morici
- Unità di Cure Intensive Cardiologiche, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.,Department of Clinical Sciences and Community, Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Nava
- Division of Invasive Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Alice Sacco
- Unità di Cure Intensive Cardiologiche, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giovanna Viola
- Unità di Cure Intensive Cardiologiche, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Jacopo Oreglia
- Division of Invasive Cardiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Meani
- Unità di Cure Intensive Cardiologiche, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fabrizio Oliva
- Unità di Cure Intensive Cardiologiche, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and ICU, IRCCS Policlinico San Donato, San Donato Milanese Milan, Italy
| | - Sergio Leonardi
- Coronary Care Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
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191
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Ilnicki D, Wyderka R, Nowicki P, Sołtowska A, Adamowicz J, Ciapka A, Jaroch J. A 64-year-old man suffering from ST-elevation myocardial infarction and severe thrombocytopenia: Procedures in the case of a patient not fitting the guidelines. SAGE Open Med Case Rep 2019; 7:2050313X19840520. [PMID: 31057796 PMCID: PMC6452426 DOI: 10.1177/2050313x19840520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 03/06/2019] [Indexed: 11/26/2022] Open
Abstract
The objective of this case report is to present how the chronic condition
significantly complicates life-saving procedures and influences further
treatment decisions. A 64-year-old man suffering from arterial hypertension and
immune thrombocytopenic purpura presented to the Emergency Department with
anterior ST-elevation myocardial infarction. An immediate coronary angiography
was performed where critical stenosis of the proximal left anterior descending
was found. It was followed by primary percutaneous intervention with bare metal
stent. In first laboratory results, extremely low platelet count was found
(13 × 109/L). Consulting haematologist advised the use of single
antiplatelet therapy and from the second day of hospitalisation only clopidogrel
was prescribed. On the sixth day of hospital stay, patient presented acute chest
pain with ST elevation in anterior leads. Emergency coronary angiography
confirmed acute stent thrombosis and aspiration thrombectomy was performed. It
was therefore agreed to continue dual antiplatelet therapy for 4 weeks. As there
are no clinical trials where patients with low platelet count are included, all
therapeutic decisions must be made based on clinician’s experience and experts’
consensus. Both the risk of haemorrhagic complications and increased risk of
thrombosis must be taken into consideration when deciding on patient’s
treatment.
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Affiliation(s)
- Dawid Ilnicki
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland
| | - Rafał Wyderka
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland
| | - Przemysław Nowicki
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland
| | - Alicja Sołtowska
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland.,Department of Clinical Nursing, Wroclaw Medical University, Wroclaw, Poland
| | - Jakub Adamowicz
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland.,Department of Clinical Nursing, Wroclaw Medical University, Wroclaw, Poland
| | - Adam Ciapka
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland
| | - Joanna Jaroch
- Department of Cardiology, T. Marciniak Specialized Hospital, Wroclaw, Poland.,Department of Clinical Nursing, Wroclaw Medical University, Wroclaw, Poland
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192
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Rossini R, Tarantini G, Musumeci G, Masiero G, Barbato E, Calabrò P, Capodanno D, Leonardi S, Lettino M, Limbruno U, Menozzi A, Marchese UOA, Saia F, Valgimigli M, Ageno W, Falanga A, Corcione A, Locatelli A, Montorsi M, Piazza D, Stella A, Bozzani A, Parolari A, Carone R, Angiolillo DJ. A Multidisciplinary Approach on the Perioperative Antithrombotic Management of Patients With Coronary Stents Undergoing Surgery: Surgery After Stenting 2. JACC Cardiovasc Interv 2019. [PMID: 29519377 DOI: 10.1016/j.jcin.2017.10.051] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Perioperative management of antithrombotic therapy in patients treated with coronary stents undergoing surgery remains poorly defined. Importantly, surgery represents a common reason for premature treatment discontinuation, which is associated with an increased risk in mortality and major adverse cardiac events. However, maintaining antithrombotic therapy to minimize the incidence of perioperative ischemic complications may increase the risk of bleeding complications. Although guidelines provide some recommendations with respect to the perioperative management of antithrombotic therapy, these have been largely developed according to the thrombotic risk of the patient and a definition of the hemorrhagic risk specific to each surgical procedure, key to defining the trade-off between ischemia and bleeding, is not provided. These observations underscore the need for a multidisciplinary collaboration among cardiologists, anesthesiologists, hematologists and surgeons to reach this goal. The present document is an update on practical recommendations for standardizing management of antithrombotic therapy management in patients treated with coronary stents (Surgery After Stenting 2) in various types of surgery according to the predicted individual risk of thrombotic complications against the anticipated risk of surgical bleeding complications. Cardiologists defined the thrombotic risk using a "combined ischemic risk" approach, while surgeons classified surgeries according to their inherent hemorrhagic risk. Finally, a multidisciplinary agreement on the most appropriate antithrombotic treatment regimen in the perioperative phase was reached for each surgical procedure.
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Affiliation(s)
- Roberta Rossini
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy.
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Giuseppe Musumeci
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Giulia Masiero
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Paolo Calabrò
- Division of Cardiology, Department of Cardio-Thoracic Sciences, Università degli Studi della Campania "Luigi Vanvitelli," Naples, Italy
| | - Davide Capodanno
- Division of Cardiology, Cardio-Thoracic-Vascular Department, Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele, Catania, Italy; Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Leonardi
- Coronary Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Maddalena Lettino
- Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | - Ugo Limbruno
- U.O.C. Cardiologia, Azienda USL Toscana Sudest, Grosseto, Italy
| | - Alberto Menozzi
- Unità Operativa di Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - U O Alfredo Marchese
- U.O.C. Cardiologia Interventistica, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thoraco-Vascular Department, University Hospital of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Marco Valgimigli
- Swiss Cardiovascular Centre Bern, Bern University Hospital, Bern, Switzerland
| | - Walter Ageno
- Degenza Breve Internistica e Centro Trombosi ed Emostasi, Dipartimento di Medicina e Chirurgia, Università dell'Insubria, Varese, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Antonio Corcione
- Department of Anaesthesia and Critical Care, AORN Dei Colli, Naples, Italy
| | - Alessandro Locatelli
- Dipartimento Emergenze e Aree Critiche, Ospedale Santa Croce e Carle, Cuneo, Italy
| | - Marco Montorsi
- Dipartimento di Chirurgia Generale, Humanitas Research Hospital and University, Milano, Italy
| | - Diego Piazza
- Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Andrea Stella
- Chirurgia Vascolare, Università di Bologna, Ospedale Sant'Orsola-Malpighi, Bologna, Italy
| | - Antonio Bozzani
- UOC Chirurgia Vascolare, Dipartimento di Scienze Chirurgiche, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Policlinico San Donato IRCCS, University of Milano, Milan, Italy
| | - Roberto Carone
- Azienda Ospedaliera Universitaria Città della salute e della scienza, Torino, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida, College of Medicine-Jacksonville, Jacksonville, Florida
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193
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Effects of Cangrelor as Adjunct Therapy to Percutaneous Coronary Intervention. Am J Cardiol 2019; 123:1228-1238. [PMID: 30738570 DOI: 10.1016/j.amjcard.2019.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 11/21/2022]
Abstract
Percutaneous coronary intervention (PCI) in patients with angiographic evidence of intracoronary thrombus is associated with in-hospital and 30-day adverse clinical outcomes. Cangrelor, a direct, rapid-onset acting intravenous P2Y12 receptor inhibitor, has been proved to be effective by reducing peri-PCI ischemic complications in subjects who underwent PCI. This study aimed to assess the angiographic and in-hospital clinical outcomes in all-comer patients receiving cangrelor immediately before PCI at a tertiary care center. The study analyzed consecutive unselected subjects treated with cangrelor at the time the decision was made to proceed with PCI. At the end of the procedure, all patients were transitioned to oral antiplatelet therapy. The target lesion angiographic assessment of Thrombolysis in myocardial infarction flow grade (TIMI-Flow), TIMI-thrombus grade (TIMI-Thrombus), myocardial blush grade, and TIMI-myocardial perfusion grade (TMPG) was performed before and post-PCI. Clinical events were recorded during the procedure and at discharge. In total, 223 patients (244 lesions) were included in the analysis (106, 97, and 20 patientswith TIMI-Flow 0/1, TIMI-Flow 2/3, and cardiogenic shock, respectively). The overall mean age was 63 ± 12 years, 70% men and 38% with diabetes mellitus. Acute myocardial infarction was the main presentation (72%). The use of cangrelor improved TIMI-Flow, MGB, TMPG, and TIMI-Thrombus in patients with initial TIMI-Flow 0 to 2. Major bleeding rate was 2.0%. In conclusion, cangrelor was effective and safe in restoring TIMI-Flow 3, reducing thrombus burden and improving myocardial blush grade and TMPG when administered to unselected subjects who underwent PCI. Therefore, cangrelor should be considered in patients presenting with intracoronary thrombus before intervention.
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194
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Elderly Patients with ST-Segment Elevation Myocardial Infarction: A Patient-Centered Approach. Drugs Aging 2019; 36:531-539. [DOI: 10.1007/s40266-019-00663-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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195
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Adjuvant antithrombotic therapy in ST-elevation myocardial infarction: A narrative review. Rev Port Cardiol 2019; 38:289-297. [DOI: 10.1016/j.repc.2018.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/08/2018] [Accepted: 05/13/2018] [Indexed: 11/21/2022] Open
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196
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Meta-Analysis of the Role of Cangrelor for Patients Undergoing Percutaneous Coronary Intervention. Am J Cardiol 2019; 123:1069-1075. [PMID: 30654930 DOI: 10.1016/j.amjcard.2018.12.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/19/2018] [Accepted: 12/20/2018] [Indexed: 02/01/2023]
Abstract
Inhibition of the P2Y12 receptor by an oral P2Y12 inhibitor with loading doses along with Cyclooxygenase-1 inhibition by aspirin is considered a first-line treatment strategy in patients with the acute coronary syndrome and patients undergoing percutaneous coronary intervention (PCI). Limitations associated with oral P2Y12 receptor inhibitors include a requirement for in vivo conversion (thienopyridines), delayed onset of action, suboptimal inhibition, irreversible inhibition (thienopyridines), and delayed offset. In the acute setting, therapy with potent platelet inhibitors that have a fast onset and offset is desirable to attenuate thrombotic complications. Cangrelor, an intravenous agent, is an adenosine triphosphate analog, selectively and explicitly blocking P2Y12 receptor-mediated platelet activation. Cangrelor has been studied in a series of CHAMPION trials. A patient-level, meta-analysis of all 3 phase III trials (24,910 patients), demonstrated that cangrelor significantly reduced the rate of the composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 hours and 30 days compared with clopidogrel, with no significant increase in major bleeding. It is approved for clinical use in patients undergoing PCI to reduce the risk of myocardial infarction, repeat revascularization, and stent thrombosis in patients who have not been treated with a P2Y12 platelet inhibitor and are not being given a GPIIbIIIa inhibitor. In conclusion, patients unable to take oral medications undergoing emergent/urgent PCI and those who had recent PCI with drug eluting stent in need for urgent cardiac or noncardiac surgery are potential candidates for cangrelor.
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197
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Abstract
"Periprocedural myocardial infarction (MI) occurs infrequently in the current era of percutaneous coronary interventions (PCI) and is associated with an increased risk of mortality and morbidity. Periprocedural MI can occur due to acute side branch occlusion, distal embolization, slow flow or no reflow phenomenon, abrupt vessel closure, and nonidentifiable mechanical processes. Therapeutic strategies to reduce the risk of periprocedural MI include dual antiplatelet therapy, intravenous cangrelor in the periprocedural setting, intravenous glycoprotein IIb/IIIa inhibitor in high-risk patients, anticoagulation with unfractionated heparin, low-molecular-weight heparin or bivalirudin, and embolic protection devices during saphenous vein graft interventions."
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Affiliation(s)
- David W Lee
- Division of Interventional Cardiology, University of North Carolina, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599, USA.
| | - Matthew A Cavender
- Division of Interventional Cardiology, University of North Carolina, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599, USA
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198
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Caldeira D, Pereira H. Adjuvant antithrombotic therapy in ST-elevation myocardial infarction: A narrative review. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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199
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Gasecka A, Konwerski M, Pordzik J, Soplińska A, Filipiak KJ, Siller-Matula JM, Postuła M. Switching between P2Y12 antagonists – From bench to bedside. Vascul Pharmacol 2019; 115:1-12. [DOI: 10.1016/j.vph.2019.01.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 01/01/2019] [Accepted: 01/12/2019] [Indexed: 01/14/2023]
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200
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Guvvala V, Chidambaram Subramanian V, Anireddy JS. A study on structural characterization of degradation products of cangrelor using LC/QTOF/MS/MS and NMR. J Pharm Biomed Anal 2019; 170:327-334. [PMID: 30978606 DOI: 10.1016/j.jpba.2019.03.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 11/16/2022]
Abstract
A complete degradation study was performed on cangrelor drug substance as per the ICH guidelines. The study reveals that a total of six degradation products (DP-1 to DP-6) were found and out of these, three unknown degradation products (DP-1, DP-5 and DP-6) were not reported in the literature. Based on the degradation study, the drug substance cangrelor was found to be sensitive towards acidic, basic and oxidative conditions. Besides, it was stable under thermal and photolytic stress conditions. The degradation products were characterized by using advanced LC/QTOF and MS/MS analysis. Further, the structures were characterized by NMR studies. The identified degradation products of cangrelor are valuable for cangrelor manufacturing process and quality control.
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Affiliation(s)
- Vinodh Guvvala
- Centre for Chemical Science & Technology, Institute of Science & Technology, JNTUH, Kukatpally, Hyderabad, 500 085, India; Gland Pharma Ltd, Research and Development, D.P.Pally, Hyderabad, 500 043, India.
| | | | - Jaya Shree Anireddy
- Centre for Chemical Science & Technology, Institute of Science & Technology, JNTUH, Kukatpally, Hyderabad, 500 085, India
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