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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024; 13:e031606. [PMID: 38804216 PMCID: PMC11255623 DOI: 10.1161/jaha.123.031606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.
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Affiliation(s)
| | - Eric R. Bates
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
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Chodnekar SY, Jain N, Lansiaux E, Panag DS, Gibietis V. Beyond Traditional Pain Relief: A Review of Alternative Analgesics in Myocardial Infarction Patient Management. J Pain Palliat Care Pharmacother 2024; 38:157-169. [PMID: 38329476 DOI: 10.1080/15360288.2024.2304008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024]
Abstract
While morphine is the recommended first-line treatment for pain management in patients with acute coronary syndrome, recent studies have raised concerns about its association with adverse outcomes. Morphine has been found to cause delayed antiplatelet effects, decreased ticagrelor absorption, increased platelet reactivity, and compromised efficacy of dual antiplatelet therapy (DAPT). Alternative analgesics, such as lidocaine, fentanyl, and acetaminophen, have begun to emerge as viable alternatives, each with unique mechanisms and potential benefits. Lidocaine is demonstrated to have superior effects in reducing microvascular obstruction and fewer adverse events compared to fentanyl, despite being less effective in pain reduction. Fentanyl, which shows rapid onset and powerful analgesic properties, may interfere with ticagrelor absorption, potentially affecting platelet inhibition. Acetaminophen, a centrally acting analgesic, emerges as a safer alternative with comparable pain relief efficacy and minimal side effects. The results of multiple clinical trials emphasize the significance of customizing pain management approaches to match individual patient profiles and achieving the optimal balance between pain relief and potential adverse outcomes.
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Affiliation(s)
| | - Nityanand Jain
- Faculty of Medicine, Riga Stradinš University, Riga, Latvia
| | - Edouard Lansiaux
- Faculty of Medicine, Lille University School of Medicine, Lille, France
| | | | - Valdis Gibietis
- Department of Internal Diseases, Riga Stradinš University, Riga, Latvia
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Chen P, Eikelboom JW, Tan C, Zhang W, Xu Y, Bai J, Wang J, Wang T, Gong X, Liu K, Chen X, Wang X, Zhu L, Zhao X, Yang N, Jiang J, Pu J, Zhao B, Chen Z, Li B, Wang G, Lu C, Ying L, Jiang M, Zhu X, Ma J, Dong Z, Li C, Zong J, Zhang F, Zhu J, Huang J, Kong X, Yu H, Li C. Single Bolus r-SAK Before Primary PCI for ST-Segment-Elevation Myocardial Infarction. Circ Cardiovasc Interv 2024; 17:e013455. [PMID: 38258563 DOI: 10.1161/circinterventions.123.013455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND It is uncertain whether adjunctive thrombolysis is beneficial for patients with ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention (PCI) within 120 minutes of presentation. This study was to determine whether in patients presenting with ST-segment-elevation myocardial infarction a single bolus recombinant staphylokinase (r-SAK) before timely PCI leads to improved patency of the infarct-related artery and reduces the infarct size. METHODS This is an open-label, prospective, multicenter, randomized study. We enrolled patients aged 18 to 75 years who were within 12 hours of symptom onset of ST-segment-elevation myocardial infarction and expected to undergo PCI within 120 minutes. Patients were administered loading doses of aspirin and ticagrelor and intravenous heparin and were randomized to receive 5 mg bolus of r-SAK or normal saline intravenously before PCI. The primary end point was Thrombolysis in Myocardial Infarction flow grade 2 to 3 or grade 3 in the infarct-related artery 60 minutes after thrombolysis. The infarct size was detected by cardiac magnetic resonance 5 days after randomization. The safety end point was major bleeding (Bleeding Academic Research Consortium ≥3) during 30-day follow-up. RESULTS A total of 283 patients were screened from 8 centers and 200 were randomized (median age, 58.5 years; 14% female). The median symptom to thrombolysis time was 252.5 (interquartile range, 142.8-423.8) minutes and thrombolysis to coronary arteriography was 50.0 (interquartile range, 37.0-66.0) minutes. Patients randomized to r-SAK compared with normal saline more often had Thrombolysis in Myocardial Infarction flow grade 2 to 3 (69.0% versus 29.0%; P<0.001) and Thrombolysis in Myocardial Infarction flow grade 3 (51.0% versus 18.0%; P<0.001) and had smaller infarct size (21.91±10.84% versus 26.85±12.37%; P=0.016). There was no increase in major bleeding (r-SAK, 1.0% versus control, 3.0%; P=0.616). CONCLUSIONS A single bolus r-SAK before primary PCI for ST-segment-elevation myocardial infarction improves infarct-related artery patency and reduces infarct size without increasing major bleeding. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05023681.
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Affiliation(s)
- Pengsheng Chen
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, Xuzhou Central Hospital, Jiangsu, China (P.C.)
| | - John W Eikelboom
- Department of Medicine, McMaster University or Thrombosis Service, Hamilton General Hospital, ON, Canada (J.W.E.)
| | - Chunyue Tan
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Wenhao Zhang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Yi Xu
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jianling Bai
- Department of Biostatistics, Nanjing Medical University, Jiangsu, China (J.B., H.Y.)
| | - Jun Wang
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Tong Wang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, the First People's Hospital of Yancheng, Jiangsu, China (T.W.)
| | - Xiaoxuan Gong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Kun Liu
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
- Department of Cardiology, the First People's Hospital of Lianyungang, Jiangsu, China (K.L., B.Z.)
| | - Xin Chen
- Department of Cardiology, the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Jiangsu, China (X.C., Z.C.)
| | - Xiaoyan Wang
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.W., B.L.)
| | - Li Zhu
- Department of Cardiology, Taizhou People's Hospital, Jiangsu, China (L.Z., G.W.)
| | - Xin Zhao
- Department of Cardiology, the Second Hospital of Dalian Medical University, Liaoning, China (X. Zhao, C. Lu)
| | - Naiquan Yang
- Department of Cardiology, Huai'an Second People's Hospital Affiliated to Xuzhou Medical University, Jiangsu, China (N.Y., L.Y.)
| | - Jun Jiang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, China (J.J.)
| | - Jun Pu
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China (J.P., M.J.)
| | - Bo Zhao
- Department of Cardiology, the First People's Hospital of Lianyungang, Jiangsu, China (K.L., B.Z.)
| | - Zengguang Chen
- Department of Cardiology, the Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Jiangsu, China (X.C., Z.C.)
| | - Baihong Li
- Department of Cardiology, Affiliated Hospital of Jiangnan University, Wuxi, Jiangsu, China (X.W., B.L.)
| | - Guoyu Wang
- Department of Cardiology, Taizhou People's Hospital, Jiangsu, China (L.Z., G.W.)
| | - Chuan Lu
- Department of Cardiology, the Second Hospital of Dalian Medical University, Liaoning, China (X. Zhao, C. Lu)
| | - Lianghong Ying
- Department of Cardiology, Huai'an Second People's Hospital Affiliated to Xuzhou Medical University, Jiangsu, China (N.Y., L.Y.)
| | - Meng Jiang
- Department of Cardiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, China (J.P., M.J.)
| | - Xiaomei Zhu
- Radiology (Y.X., J.W., X. Zhu), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jiazheng Ma
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Zhou Dong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Chen Li
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jiaxin Zong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Fumin Zhang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Jun Zhu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, China (J. Zhu)
| | - Jun Huang
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Xiangqing Kong
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
| | - Hao Yu
- Department of Biostatistics, Nanjing Medical University, Jiangsu, China (J.B., H.Y.)
| | - Chunjian Li
- Departments of Cardiology (P.C., C.T., W.Z., T.W., X.G., K.L., J.M., Z.D., Chen Li, J. Zong, F.Z., J.H., X.K., Chunjian Li), the First Affiliated Hospital of Nanjing Medical University, China
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Dou J, Gao J, Yang HH, Guo R, Jiang C, Zhou J, Yu X, Guo J, Zhang J, Luo D. Prognosis in Patients with ST-Segment Elevation Myocardial Infarction Reperfused by PHDP: 1-Year MACEs Follow-Up. Clin Appl Thromb Hemost 2024; 30:10760296241271394. [PMID: 39140859 PMCID: PMC11325463 DOI: 10.1177/10760296241271394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024] Open
Abstract
This study explored 1-year follow-up of Parmaco-invasive strategy with half-dose recombinant human prourokinase (PHDP) in patients with acute ST-segment elevation myocardial infarction (STEMI). The follow-up endpoints were major adverse cardiovascular events (MACEs) occurring within 30 days and 1 year, as well as postoperative bleeding events. The study ultimately included 150 subjects, with 75 in the primary percutaneous coronary intervention (PPCI) group and 75 in the PHDP group. This study found that the PHDP group had a shorter FMC-reperfusion time (42.00 min vs 96.00 min, P < 0.001). During PCI, the PHDP group had a lower percutaneous transluminal coronary angioplasty (PTCA) (P = 0.021), intropin (P = 0.002) and tirofiban (P < 0.001) use. And the incidence of intraoperative arrhythmia, malignant arrhythmia, and slow flow/no-reflow was lower in the PHDP group (P < 0.001). At the 30-day follow-up, there was a significantly higher proportion of patients in the PPCI group who were readmitted due to unstable angina (P = 0.037). After 1 year of follow-up, there was no statistically significant difference in MACEs between the two groups (P = 0.500). The incidence of postoperative major bleeding, intracranial bleeding, and minor bleeding did not differ between the PHDP and PPCI groups (P > 0.05). The PHDP facilitates early treatment of infarct-related vessels, shortens FMC-reperfusion time, and does not increase the risk of MACEs.
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Affiliation(s)
- Jie Dou
- School of Medicine, Chengde Medical University, Chengde 067000, Hebei, China
| | - Jie Gao
- School of Medicine, Chengde Medical University, Chengde 067000, Hebei, China
| | - Hui-Hui Yang
- School of Medicine, Chengde Medical University, Chengde 067000, Hebei, China
| | - Ruoling Guo
- School of Medicine, Chengde Medical University, Chengde 067000, Hebei, China
| | - Chao Jiang
- School of Medicine, Chengde Medical University, Chengde 067000, Hebei, China
| | - Jiang Zhou
- Department of Cardiology, Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
| | - Xiaomei Yu
- Department of Cardiology, Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
| | - Jingtao Guo
- Department of Cardiology, Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
| | - Jinlong Zhang
- Department of Cardiology, Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
| | - Donglei Luo
- Department of Cardiology, Chengde Central Hospital/Second Clinical College of Chengde Medical University, Chengde 067000, Hebei, China
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Maqbool S, Ali MS, Rehman A, Ur Rehman ME, Iqbal J, Razzaq A, Kamal A, Shivamadhu SS, Afzal M, Fazal F, Basit J, Khalid SA. Efficacy and Safety Profile of Ticagrelor Versus Clopidogrel in Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS): A Systematic Review and Meta-Analysis. Cureus 2023; 15:e46455. [PMID: 37927743 PMCID: PMC10623206 DOI: 10.7759/cureus.46455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
The utilization of individualized anti-platelet therapy is of paramount significance in this era of cardiovascular advancement. This meta-analysis is also aiming to get more information relating to the effectiveness of ticagrelor versus clopidogrel among patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). A comprehensive literature search was done through various databases like PubMed, Google Scholar, EMBASE, Web of Science, and the Cochrane Database Library from January 15, 2023, to February 23, 2023. After careful screening, eight articles with highly significant variables were involved in the synthesis of this meta-analysis. Data analysis was done through Review Manager (RevMan, Version 5.4; The Cochrane Collaboration, Copenhagen, Denmark). In our study, ticagrelor and clopidogrel were evaluated in 10614 and 14662 patients, respectively. Ticagrelor was significantly superior to Clopidogrel in terms of all-cause mortality (RR 0.79, 95% CI 0.69-0.91, p = 0.001), risk of MI (RR 0.74, 95% CI 0.61-0.89, p = 0.001), and stroke (RR 0.64, 95% CI 0.42-0.98, p = 0.04), but a higher risk of bleeding events was observed with Ticagrelor (RR 1.36, 95% CI 1.04-1.79, p = 0.03). The two regimens were comparable in terms of stent thrombosis. Ticagrelor was found to be best in terms of reducing post-PCI myocardial infarction, stroke, stent thrombosis, and all other mortality events in comparison to Clopidogrel. However, the bleeding events were of significant concern for the utilization of ticagrelor and required further investigations.
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Affiliation(s)
- Shahzaib Maqbool
- Department of Cardiology, Rawalpindi Medical University, Rawalpindi, PAK
| | | | - Abdur Rehman
- Department of Cardiology, Rawalpindi Medical University, Rawalpindi, PAK
| | | | - Javed Iqbal
- Department of Neurosurgery, Mayo Hospital, Lahore, PAK
| | - Azeen Razzaq
- Department of Cardiology, Rawalpindi Medical University, Rawalpindi, PAK
| | - Amer Kamal
- Department of Medicine, The University of Jordan, Amman, JOR
| | | | - Maham Afzal
- Department of Medicine, Fatima Jinnah Medical University, Lahore, PAK
| | - Faizan Fazal
- Department of Cardiology, Rawalpindi Medical University, Rawalpindi, PAK
| | - Jawad Basit
- Department of Cardiology, Rawalpindi Medical University, Rawalpindi, PAK
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. J Am Coll Cardiol 2023; 82:1131-1174. [PMID: 37516946 DOI: 10.1016/j.jacc.2023.03.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
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Dehmer GJ, Grines CL, Bakaeen FG, Beasley DL, Beckie TM, Boyd J, Cigarroa JE, Das SR, Diekemper RL, Frampton J, Hess CN, Ijioma N, Lawton JS, Shah B, Sutton NR. 2023 AHA/ACC Clinical Performance and Quality Measures for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures. Circ Cardiovasc Qual Outcomes 2023; 16:e00121. [PMID: 37499042 DOI: 10.1161/hcq.0000000000000121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Affiliation(s)
| | | | | | | | | | | | | | - Sandeep R Das
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | | | - Binita Shah
- Society for Cardiovascular Angiography and Interventions representative
| | - Nadia R Sutton
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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Huang PY, Shih HM, Huang SW, Pan YC, Huang FW, Chen WK, Yu SH. Comparison of In-Hospital Major Adverse Cardiovascular Events in Patients with Acute Myocardial Infarction Treated with Ticagrelor or Clopidogrel in the Emergency Department: A Propensity Score Matched Retrospective Cohort Study. Healthcare (Basel) 2023; 11:2246. [PMID: 37628444 PMCID: PMC10454921 DOI: 10.3390/healthcare11162246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/28/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) is a standard treatment option for acute myocardial infarction (AMI). The difference between the efficacy of ticagrelor and clopidogrel in the emergency department (ED) before percutaneous coronary intervention (PCI) remains unknown. The present study compared the in-hospital major adverse cardiovascular event (MACE) rates between patients with AMI treated with clopidogrel and those treated with ticagrelor in the ED before PCI. METHODS We retrospectively collected the data of patients diagnosed as having AMI in the ED. Patients were only included if they had successfully received complete DAPT with aspirin and ticagrelor/clopidogrel in the ED and had undergone PCI. The patients were divided into two groups according to their DAPT regimen. The primary outcome was the rate of in-hospital MACEs. The secondary outcomes included an unexpected return to the ED within 72 h, readmission within 14 d, and revascularization. RESULTS A total of 1836 patients were enrolled. Patients in the ticagrelor group had a lower in-hospital MACE rate (3.01% versus 7.51%, p < 0.001) and in-hospital mortality rate (2.15% versus 5.70%, p < 0.001) than those in the clopidogrel group. Multivariate logistic regression analysis revealed ticagrelor was independently associated with a lower risk of in-hospital MACEs (odds ratio [OR]: 0.53, 95% CI: 0.32-0.88, p = 0.013). After propensity score matching, the risk of in-hospital MACEs remained significantly lower in the ticagrelor group (OR 0.42, 95% CI: 0.21-0.85, p = 0.016). CONCLUSION DAPT with ticagrelor and aspirin in the ED before PCI is associated with a lower in-hospital MACE rate among patients with AMI.
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Affiliation(s)
- Po-Yao Huang
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
- Department of Public Health, China Medical University, Taichung 40402, Taiwan
| | - Szu-Wei Huang
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Yan-Cheng Pan
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
| | - Fen-Wei Huang
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
| | - Wei-Kung Chen
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Shao-Hua Yu
- Department of Emergency Medicine, China Medical University Hospital, Taichung 40402, Taiwan
- School of Medicine, College of Medicine, China Medical University, Taichung 40402, Taiwan
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Ueapornpanith P, Buranakiti B, Chotayaporn T, Phrommintikul A, Yoodee V. Safety outcomes of ticagrelor among patients with STE-ACS post streptokinase therapy-a retrospective observational study. PLoS One 2023; 18:e0289721. [PMID: 37540686 PMCID: PMC10403104 DOI: 10.1371/journal.pone.0289721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/23/2023] [Indexed: 08/06/2023] Open
Abstract
From the restriction of access to primary percutaneous coronary intervention, about 46% of patients with ST-elevation acute coronary syndrome (STE-ACS) received fibrinolytic therapy as a reperfusion strategy; streptokinase is frequently used in Thailand. Despite the guidelines recommending potent P2Y12 inhibitors among these patients, the data are limited, especially among patients with STE-ACS post streptokinase therapy. The study was proposed to describe factors for P2Y12 inhibitors selection and evaluate outcomes of pharmacoinvasively treated STE-ACS receiving ticagrelor compared with clopidogrel in Thailand. We performed a retrospective observational study of patients with STE-ACS post streptokinase therapy followed by percutaneous coronary intervention (PCI) with coronary stent placement and receiving ticagrelor or clopidogrel as P2Y12 inhibitor treatment from January 2017 to June 2021. The primary outcomes described factors for P2Y12 inhibitor selection and evaluated safety outcomes with inverse probability weight (IPW) adjustment. The secondary outcome was a composite of all-cause death, myocardial infarction and stroke. The median time from streptokinase therapy to initiating ticagrelor in the switch group was 25.7 (IQR, 1.9-4.4) hours. The factors related to switching from clopidogrel to ticagrelor included young age, history of coronary artery disease (CAD), dose of streptokinase and use of intravascular imaging. Any bleeding events occurred among 83 patients (41.71%) in the switch group and 83 patients (41.09%) in the no switch group (adjusted HR 1.04, 95% CI 0.75-1.44; p = 0.826). The composite of efficacy outcomes occurred in 6 patients in the switch group (3.02%) and 12 patients (5.94%) in the no switch group (adjusted HR 0.57, 95% CI 0.21-1.57; p = 0.279). Conclusion: In real practice, ticagrelor switching among patients with STE-ACS post streptokinase therapy did not differ regarding safety outcomes and composite of efficacy outcomes compared with clopidogrel.
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Affiliation(s)
| | | | | | - Arintaya Phrommintikul
- Faculty of Medicine, Department of Internal Medicine, Division of Cardiology, Chiang Mai University, Chiang Mai, Thailand
| | - Voratima Yoodee
- Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
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10
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Cantor WJ, Tan M, Berwanger O, Lavi S, White HD, Nicolau JC, Dehghani P, Tajer CD, Lopes RD, Moia DDF, Nicholls SJ, Parkhomenko A, Averkov O, Brass N, Lutchmedial S, Malaga G, Damiani LP, Piegas LS, Granger CB, Goodman SG. Morphine and clinical outcomes in patients with ST segment elevation myocardial infarction treated with fibrinolytic and antiplatelet therapy: Insights from the TREAT trial. Am Heart J 2022; 251:1-12. [PMID: 35533724 DOI: 10.1016/j.ahj.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 02/22/2022] [Accepted: 05/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Morphine is commonly used to relieve pain, anxiety and dyspnea in STEMI but it lowers blood pressure and delays the activity of oral antiplatelet agents. The impact of morphine on clinical outcomes remains unknown. This analysis was performed to determine if morphine use was associated with increased risk of adverse clinical events among STEMI patients treated with fibrinolytic therapy and clopidogrel or ticagrelor. METHODS In the Ticagrelor in Patients with ST Elevation Myocardial Infarction Treated with Pharmacological Thrombolysis (TREAT) study, 3799 STEMI patients treated with fibrinolysis were randomized to receive clopidogrel or ticagrelor. Morphine use was left to the discretion of the treating physicians. In this pre-specified analysis, we evaluated clinical outcomes based on the use and timing of morphine administration. Outcomes were stratified by randomized treatment group. Multivariable analysis was performed using Inverse Probability Treatment Weighting (IPTW) weighting. RESULTS Morphine was used in 53% of patients. After adjustment using IPTW weighting, morphine use was associated with higher hazard of reinfarction at 7 days (HR 4.9, P = .0006) and 30 days (HR 1.7, P = .04), and lower hazard of major bleeding (HR 0.37, P = .006). There was no significant difference in mortality at any time point. CONCLUSIONS Among patients with STEMI treated with fibrinolytic therapy, morphine use was associated with a higher risk of early reinfarction and a lower risk of major bleeding but no difference in mortality. CLINICAL TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02298088.
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Affiliation(s)
- Warren J Cantor
- Department of Medicine, Southlake Regional Health Centre, University of Toronto, 581 Davis Drive, Newmarket, Toronto, Ontario L3Y 2P6, Canada.
| | - Mary Tan
- Department of Medicine, Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Otavio Berwanger
- Academic Research Organization (ARO), Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Shahar Lavi
- Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Harvey D White
- Department of Medicine, Cardiovascular Services, Auckland City Hospital, Auckland, New Zealand
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Payam Dehghani
- Department of Medicine, Prairie Vascular Research Network and Saskatchewan Health Authority, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Carlos D Tajer
- Department of Medicine, Hospital de Alta Complejidad El Cruce, Buenos Aires, Argentina
| | - Renato D Lopes
- Department of Medicine, Duke Clinical Research Institute, Durham, NC, United States; Department of Medicine, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Diogo D F Moia
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | - Stephen J Nicholls
- Department of Medicine, Monash Cardiovascular Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Parkhomenko
- Department of Medicine, Emergency Cardiology Department, Institute of Cardiology, Kiev, Ukraine
| | - Oleg Averkov
- Department of Medicine, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Neil Brass
- Department of Medicine, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Sohrab Lutchmedial
- Department of Medicine, New Brunswick Heart Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Germán Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Lucas P Damiani
- Clinical Operations, Research Institute, Heart Hospital (HCor), São Paulo, Brazil
| | | | | | - Shaun G Goodman
- Department of Medicine, Canadian Heart Research Centre (CHRC) and Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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11
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Barcelona R. Best Practices in Pharmacotherapy for Acute Coronary Syndromes. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Numerous advances have been made in the therapy of acute coronary syndromes. Despite these advances, acute coronary syndromes still cause significant morbidity and mortality. Decisions as to the best therapy vary depending on other patient factors, such as age, need for chronic anticoagulation, tolerability of medications, and the degree of myocardial damage. Recent evidence suggests that a shorter duration of therapy may be beneficial in decreasing bleeding events without compromising benefits of preventing ischemic complications. For those who have an indication for chronic anticoagulation, less intensive therapy may also be beneficial, again without increasing ischemic complications. Data regarding agents that inhibit the renin–angiotensin–aldosterone system are available and these data are reviewed. Knowledge of the pharmacology, potency, and pharmacokinetics of drugs, as well as adverse drug events, may direct clinicians in choosing the optimal pharmacotherapy strategy for their patients.
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Affiliation(s)
- Robert Barcelona
- Cardiac Intensive Care Unit, University Hospitals Cleveland Medical Center, Cleveland, OH
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12
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Tao L, Ren S, Zhang L, Liu W, Zhao Y, Chen C, Mao X, Chen Z, Gu X. A Review of the Role of the Antiplatelet Drug Ticagrelor in the Management of Acute Coronary Syndrome, Acute Thrombotic Disease, and Other Diseases. Med Sci Monit 2022; 28:e935664. [PMID: 35570383 PMCID: PMC9121774 DOI: 10.12659/msm.935664] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/09/2022] [Indexed: 11/20/2022] Open
Abstract
P2Y12 inhibitors, including aspirin, are key components of dual-antiplatelet therapy (DAPT), which is the optimal therapeutic strategy for preventing arterial thrombosis in patients with acute coronary syndromes (ACS) who underwent stent implantation. Ticagrelor is a cyclopentyl-triazole pyrimidine antiplatelet drug that was the first reversible oral P2Y12 receptor antagonist. Compared with clopidogrel, ticagrelor exerts a faster onset and offset of function by reversible and selective inhibition of platelet aggregation in ACS patients, including those with coronary artery blood revascularization. Despite improvement in stent materials, stent thrombosis (ST) due to high on-treatment platelet reactivity (HPR) to clopidogrel continues to occur. In addition to antiplatelet aggregation, ticagrelor displays pleiotropic cardioprotective effects, including improving coronary blood flow, reducing myocardial necrosis after an ischemic event, and anti-inflammatory effects. The benefits of ticagrelor over clopidogrel were consistent in the PLATO results, with lower incidence of the primary endpoint. Also, in 2020, the findings from the phase 3 THALES trial (NCT03354429) showed that aspirin combined with 90 mg of ticagrelor significantly reduced the rates of stroke and death compared with aspirin alone in patients with AIS or TIA. Here, we review recent research on the superiority of ticagrelor over clopidogrel, discuss the pharmacological mechanism, and present future perspectives. This review aims to present the roles of ticagrelor in the management of acute coronary syndrome, acute thrombotic disease, and other diseases.
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13
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Scanavini-Filho MA, Berwanger O, Matthias W, Aguiar MO, Chiang HP, Azevedo L, Baracioli LM, Lima FG, Furtado RHM, Dalcoquio TF, Menezes FR, Ferrari AG, de Luca F, Giugliano RP, Goodman S, Nicolau JC. Effects of Ticagrelor and Clopidogrel on Coronary Microcirculation in Patients with Acute Myocardial Infarction. Adv Ther 2022; 39:1832-1843. [PMID: 35218519 PMCID: PMC8989815 DOI: 10.1007/s12325-022-02061-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 01/25/2022] [Indexed: 11/27/2022]
Abstract
Introduction Clopidogrel has been demonstrated to be effective in improving coronary microcirculation (CM) among patients with ST-elevation myocardial infarction (STEMI) treated with fibrinolytics. Ticagrelor is a more potent adenosine diphosphate (ADP) receptor blocker proven to be superior to clopidogrel among patients with acute coronary syndromes. The present study aimed to compare the effects of ticagrelor and clopidogrel on CM in patients with STEMI treated with fibrinolytics. Methods The present study prospectively included 48 patients participating in the TREAT trial, which randomly assigned patients with STEMI undergoing fibrinolysis to ticagrelor versus clopidogrel. The primary endpoint of this study was the evaluation of the CM using the global myocardial perfusion score index (global MPSI) obtained by myocardial contrast echocardiography (MCE). Platelet aggregation to ADP was evaluated by Multiplate® and expressed as area under the curve (AUC). Results The global MPSI demonstrated no differences between the groups [mean 1.4 (1.2–1.5) in the ticagrelor group and 1.2 (1.2–1.5) in the clopidogrel group (p = 0.41)]. Platelet aggregability was lower in the ticagrelor group (18.1 ± 9.7 AUC), compared to the clopidogrel group (26.1 ± 12.5 AUC, p = 0.01). Conclusion We found no improvement in coronary microcirculation with ticagrelor compared to clopidogrel among patients with STEMI treated with fibrinolytics, despite the fact that platelet aggregation to ADP was lower with ticagrelor. Clinical Trials Registration NCT03104062. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-022-02061-0.
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Affiliation(s)
- Marco Antonio Scanavini-Filho
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Otavio Berwanger
- Hospital Israelita Albert Einstein, 627 Albert Einstein Ave, São Paulo, SP 05652-900 Brazil
| | - Wilson Matthias
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Miguel O. Aguiar
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Hsu P. Chiang
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Luciene Azevedo
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Luciano M. Baracioli
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Felipe G. Lima
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Remo H. M. Furtado
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Talia F. Dalcoquio
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Fernando R. Menezes
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Aline G. Ferrari
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Fabio de Luca
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
| | - Robert P. Giugliano
- Brigham and Women’s Hospital, Harvard Medical School, 350 Longwood Ave, Boston, MA 02215 USA
| | - Shaun Goodman
- St. Michael’s Hospital, University of Toronto, 36 Queen St E, Toronto, ON M5B 1W8 Canada
| | - José C. Nicolau
- Instituto do Coracao do Hospital das Clinicas da FMUSP, 44 Dr Enéas Carvalho de Aguiar Ave, São Paulo, SP 05403-000 Brazil
- Rua Mato Grosso 306, CJ 713, São Paulo, SP 01239-040 Brazil
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14
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Saven H, Zhong L, McFarlane IM. Co-prescription of Dual-Antiplatelet Therapy and Proton Pump Inhibitors: Current Guidelines. Cureus 2022; 14:e21885. [PMID: 35273851 PMCID: PMC8901154 DOI: 10.7759/cureus.21885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/13/2022] Open
Abstract
Dual-antiplatelet therapy (DAPT) prevents thrombotic complications associated with coronary artery disease, acute coronary syndrome, and stent thrombosis following the percutaneous coronary intervention or coronary artery bypass grafting. When initiating DAPT, the risk of thrombosis must be balanced with the increased risk of upper gastrointestinal bleed (UGIB). Proton-pump inhibitors (PPIs) are concurrently prescribed with DAPT to reduce bleeding risk. In this review, we discuss the benefits and potential complications of DAPT/PPI co-prescription. The only large international randomized control trial (RCT), Clopidogrel and the Optimization of Gastrointestinal Events Trial (COGENT), shows robust evidence that PPIs are a safe and effective method to reduce the risk of bleeding in patients on DAPT. However, more large-scale RCTs are needed to study potential long-term effects and draw a stronger conclusion on this topic.
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Affiliation(s)
- Hannah Saven
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Lynna Zhong
- Internal Medicine, State University of New York (SUNY) Downstate College of Medicine, New York, USA
| | - Isabel M McFarlane
- Internal Medicine, State University of New York (SUNY) Downstate Medical Center, New York, USA
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15
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Li X, Jia Z, Yan Y. Ticagrelor for prevention of stroke and cognitive impairment in patients with vascular high-risk factors: A meta-analysis of randomized controlled trials. Int J Cardiol 2022; 353:96-102. [PMID: 35114201 DOI: 10.1016/j.ijcard.2022.01.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/05/2022] [Accepted: 01/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND In recent randomized controlled studies, the prevention of stroke and cognitive function of ticagrelor has been controversial. We conducted a meta-analysis to compare ticagrelor with other antiplatelet treatment in patients with vascular high-risk factors disease, defined as acute coronary syndrome, stroke or transient ischemic attack, coronary artery disease or peripheral artery disease. METHODS We searched the PubMed, Embase, and Cochrane libraries for published randomized controlled trials and additional available data from ClinicalTrials.gov. The primary outcome was related adverse stroke events and the secondary outcome was cognitive function related adverse events. The outcomes were statistically analyzed using Peto odds ratio. RESULTS 12 RCTs with 105,654 patients were included in meta-analysis. Primary outcomes: all stroke (OR 0.84, 95%CI 0.78-0.90, P < 0.001); Secondary outcomes: ischemic stroke (OR 0.83, 95%CI 0.77-0.90, P < 0.001), transient ischemic attack (OR 0.78, 95%CI 0.62-0.97, P = 0.029), intracranial hemorrhage (OR 1.33, 95%CI 1.09-1.61, P = 0.005), Parkinson's disease (OR 0.30, 95%CI 0.12-0.72, P = 0.007), dementia (OR 0.31, 95%CI 0.13-0.77, P = 0.012), dizziness (OR: 1.39, 95%CI 1.03-1.87, P = 0.032), insomnia (OR 1.45, 95%CI 1.05-2.00, P = 0.026). CONCLUSIONS Ticagrelor may provide more favorable outcomes for all stroke, ischemic stroke, and transient ischemic attack prevention in patients with vascular high-risk factors. However, this benefit may come with the cost of intracranial hemorrhage, dizziness and insomnia. Ticagrelor may reduce the risk of dementia and Parkinson's disease, although available data are limited.
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Affiliation(s)
- Xiaohui Li
- School of Life Science and Enginering, Handan University, People's Republic of China
| | - Zetian Jia
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, People's Republic of China
| | - Yaqi Yan
- Department of Cardiology, The First Hospital of Handan of Hebei Province, Handan 056000, People's Republic of China.
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16
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 596] [Impact Index Per Article: 298.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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17
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Faour A, Collins N, Williams T, Khan A, Juergens CP, Lo S, Walters DL, Chew DP, French JK. Reperfusion After Fibrinolytic Therapy (RAFT): An open-label, multi-centre, randomised controlled trial of bivalirudin versus heparin in rescue percutaneous coronary intervention. PLoS One 2021; 16:e0259148. [PMID: 34699549 PMCID: PMC8547635 DOI: 10.1371/journal.pone.0259148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/04/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The safety and efficacy profile of bivalirudin has not been examined in a randomised controlled trial of patients undergoing rescue PCI. OBJECTIVES We conducted an open-label, multi-centre, randomised controlled trial to compare bivalirudin with heparin ± glycoprotein IIb/IIIa inhibitors (GPIs) in patients undergoing rescue PCI. METHODS Between 2010-2015, we randomly assigned 83 patients undergoing rescue PCI to bivalirudin (n = 42) or heparin ± GPIs (n = 41). The primary safety endpoint was any ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) bleeding at 90 days. The primary efficacy endpoint was infarct size measured by peak troponin levels as a multiple of the local upper reference limit (Tn/URL). Secondary endpoints included periprocedural change in haemoglobin adjusted for red cells transfused, TIMI (Thrombolysis in Myocardial Infarction) bleeding, ST-segment recovery and infarct size determined by the Selvester QRS score. RESULTS The trial was terminated due to slow recruitment and futility after an interim analysis of 83 patients. The primary safety endpoint occurred in 6 (14%) patients in the bivalirudin group (4.8% GPIs) and 3 (7.3%) in the heparin ± GPIs group (54% GPIs) (risk ratio, 1.95, 95% confidence interval [CI], 0.52-7.3, P = 0.48). Infarct size was similar between the two groups (mean Tn/URL, 730 [±675] for bivalirudin, versus 984 [±1585] for heparin ± GPIs, difference, 254, 95% CI, -283-794, P = 0.86). There was a smaller decrease in the periprocedural haemoglobin level with bivalirudin than heparin ± GPIs (-7.5% [±15] versus -14% [±17], difference, -6.5%, 95% CI, -0.83-14, P = 0.0067). The rate of complete (≥70%) ST-segment recovery post-PCI was higher in patients randomised to heparin ± GPIs compared with bivalirudin. CONCLUSIONS Whether bivalirudin compared with heparin ± GPI reduces bleeding in rescue PCI could not be determined. Slow recruitment and futility in the context of lower-than-expected bleeding event rates led to the termination of this trial (ANZCTR.org.au, ACTRN12610000152022).
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Affiliation(s)
- Amir Faour
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Collins
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Trent Williams
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Arshad Khan
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Craig P. Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Darren L. Walters
- University of Queensland, Brisbane, Queensland, Australia
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Derek P. Chew
- Department of Cardiology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - John K. French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute and Western Sydney University, Sydney, New South Wales, Australia
- * E-mail:
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19
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Welsh RC, Shavadia JS, Zheng Y, Tyrrell BD, Leung R, Bainey KR. Ticagrelor or clopidogrel dual antiplatelet therapy following a pharmacoinvasive strategy in ST-segment elevation myocardial infarction. Clin Cardiol 2021; 44:1543-1550. [PMID: 34405422 PMCID: PMC8571547 DOI: 10.1002/clc.23716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 01/30/2023] Open
Abstract
Objectives To describe and evaluate outcomes in STEMI patients sustained on clopidogrel compared to those switched to ticagrelor following fibrinolysis. Background World‐wide, many STEMI patients cannot achieve timely PCI and therefore require fibrinolysis. Although comparable 30‐day and 1‐year safety was shown with clopidogrel or ticagrelor in the TREAT study, there is paucity of long‐term outcomes in pharmacoinvasive treated STEMI. Methods We conducted an observational cohort study evaluating consecutive pharmacoinvasive STEMI patients treated in a network, comparing those switched to ticagrelor to those sustained on clopidogrel. The primary efficacy composite was one‐year all‐cause death, recurrent myocardial infarction, and stroke with major bleeding and intracranial hemorrhage (ICH) as the safety outcomes. Multivariable Cox regression model was used to examine the association between P2Y12 inhibitor and outcomes with inverse probability weighting. Results Of 1426 pharmacoinvasive STEMI patients, 28% (n = 396) were converted to ticagrelor at a mean of 9.9 h after fibrinolysis with comparable GRACE Risk Scores (median; 158 vs 157, p0.352). The primary composite occurred in 3.5% of ticagrelor and 7.0% of clopidogrel treated patients (p0.014). Following adjustment, ticagrelor was associated with a 54% lower composite outcome (adjusted HR 0.46, 95% confidence interval 0.26–0.84). Major bleeding 6.3% vs 6.1% (NS) and ICH 0.0% vs 0.2% (NS) were similar. Conclusions In a prospective STEMI cohort, switching to ticagrelor compared with sustaining clopidogrel following fibrinolysis pharmacoinvasive reperfusion reduced recurrent ischemic events at 1‐year with no differences in major bleeding or ICH. Aligned with randomized data, these findings provide support to switch pharmaco‐invasively treated STEMI patients.
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Affiliation(s)
- Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jay S Shavadia
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Raymond Leung
- Cardiology, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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20
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Roule V, Schwob L, Briet C, Lemaitre A, Bignon M, Ardouin P, Sabatier R, Blanchart K, Beygui F. Residual platelet reactivity, thrombus burden and myocardial reperfusion in patients treated by PCI after successful pre-hospital fibrinolysis compared to primary PCI. J Thromb Thrombolysis 2021; 50:858-866. [PMID: 32306289 DOI: 10.1007/s11239-020-02113-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We compared residual platelet reactivity and post PCI atherothrombotic burden using OFDI in patients successfully treated by primary PCI versus pharmacoinvasive approach (PI) defined as PCI after successful pre-hospital fibrinolysis. Despite pre-hospital P2Y12-inhibitor loading dose, high rates of high on-treatment platelet reactivity were found at the time of PCI in both groups. Primary PCI patients had higher post stenting thrombus burden and lower rates of final normal myocardial blush grade compared to PI. These findings support the use of a pharmacoinvasive reperfusion strategy especially when primary PCI cannot be timely performed.
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Affiliation(s)
- Vincent Roule
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France. .,UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Normandie Univ, Caen, 14000, France.
| | - Lin Schwob
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | - Clément Briet
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | - Adrien Lemaitre
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | - Mathieu Bignon
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | - Pierre Ardouin
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | - Rémi Sabatier
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France
| | | | - Farzin Beygui
- CHU de Caen Normandie, Service de Cardiologie, Caen, 14000, France.,UNICAEN, EA 4650 Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, Normandie Univ, Caen, 14000, France
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21
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Akkaif MA, Ng ML, Sk Abdul Kader MA, Daud NAA, Sha'aban A, Ibrahim B. A review of the effects of ticagrelor on adenosine concentration and its clinical significance. Pharmacol Rep 2021; 73:1551-1564. [PMID: 34283374 DOI: 10.1007/s43440-021-00309-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/05/2021] [Accepted: 07/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Ticagrelor is an oral antiplatelet drug that can reversibly bind to the platelet P2Y12 receptor. Ticagrelor is metabolized mainly by CYP3A4 and produces a rapid blood concentration-dependent platelet inhibitory effect. Unlike other P2Y12 receptor antagonists, many clinical features of ticagrelor are not related to P2Y12 receptor antagonism. PURPOSE This review aims to gather existing literature on the clinical effects of ticagrelor after inhibiting adenosine uptake. METHODOLOGY The current study reviewed literature related to the effects of ticagrelor on adenosine metabolism. The review also examined the drug's biological effects and clinical characteristics to see how it could be used in a clinical setting. RESULTS Many studies have shown that ticagrelor can inhibit equilibrative nucleoside transporter 1 (ENT1). This inhibition leads to intracellular adenosine uptake, increased adenosine half-life and plasma concentration levels and an enhanced adenosine-mediated biological effect. CONCLUSIONS Based on the studies reviewed, it was found that ticagrelor essentially inhibits adenosine absorption of adenosine into cells through ENT1, which increases the concentration in the blood and subsequently increases the protection of the heart muscle by adenosine. It also prevents platelet aggregation, and extends the biological effects of coronary arteries. Moreover, it leads to a lower mortality rate in acute coronary syndrome (ACS) patients.
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Affiliation(s)
- Mohammed Ahmed Akkaif
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Penang, Malaysia
| | - Mei Li Ng
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200, Gelugor, Penang, Malaysia
| | | | - Nur Aizati Athirah Daud
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Penang, Malaysia
| | - Abubakar Sha'aban
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800, Gelugor, Penang, Malaysia
| | - Baharudin Ibrahim
- Faculty of Pharmacy, University of Malaya, 50603, Kuala Lumpur, Malaysia.
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22
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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23
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Krittanawong C, Hahn J, Kayani W, Jneid H. Fibrinolytic Therapy in Patients with Acute ST-elevation Myocardial Infarction. Interv Cardiol Clin 2021; 10:381-390. [PMID: 34053624 DOI: 10.1016/j.iccl.2021.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Fibrinolytic agents provide an important alternative therapeutic strategy in individuals presenting with ST-elevation myocardial infarction (STEMI). Ultimately, primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for most patients with STEMI, including elderly patients and patients with coronavirus disease 2019 (COVID-19) infection. Fibrinolytic therapy should always be considered when timely primary PCI cannot be delivered appropriately. Clinicians should promptly recognize the signs of fibrinolytic therapy failure and consider rescue PCI. When fibrinolytics are used, coronary angiography and revascularization should not be conducted within the initial 3 hours after fibrinolytic administration.
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Affiliation(s)
- Chayakrit Krittanawong
- Section of Cardiology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Joshua Hahn
- Section of Cardiology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Waleed Kayani
- Section of Cardiology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA; Interventional Cardiology Fellowship Program, Interventional Cardiology Research, Baylor College of Medicine, Interventional Cardiology, The Michael E. DeBakey VA Medical Center, MEDVAMC - 2002 Holcombe Boulevard, Cardiology 3C-320C, Houston, TX 77030, USA.
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24
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Affiliation(s)
- Petr Kala
- University Hospital Brno, Faculty of Medicine of Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic
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25
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Hamilos M, Kanakakis J, Anastasiou I, Karvounis C, Vasilikos V, Goudevenos J, Michalis L, Koutouzis M, Tsiafoutis I, Raisakis K, Stakos D, Hahalis G, Vardas P. Ticagrelor versus clopidogrel in patients with STEMI treated with thrombolysis: the MIRTOS trial. EUROINTERVENTION 2021; 16:1163-1169. [PMID: 32715996 PMCID: PMC9724948 DOI: 10.4244/eij-d-20-00268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS We aimed to demonstrate whether coronary microvascular function is improved after ticagrelor administration compared to clopidogrel administration in STEMI subjects undergoing thrombolysis. METHODS AND RESULTS MIRTOS is a multicentre study of ticagrelor versus clopidogrel in STEMI subjects treated with fibrinolysis. We enrolled 335 patients <75 years old with STEMI eligible for thrombolysis, of whom 167 were randomised to receive clopidogrel and 168 to receive ticagrelor together with thrombolysis. Primary outcome was the difference in post-PCI corrected TIMI frame count (CTFC). All clinical events were recorded in a three-month follow-up period. From the 335 patients who were randomised, 259 underwent PCI (129 clopidogrel and 130 ticagrelor) and 154 angiographies were analysable for the study primary endpoint. No significant difference was found between the clopidogrel (n=85) and ticagrelor (n=69) groups for CTFC (24.33±17.35 vs 28.33±17.59, p=0.10). No significant differences were observed in MACE and major bleeding events between randomisation groups (OR 2.0, 95% CI: 0.18-22.2, p=0.99). CONCLUSIONS Thrombolysis with ticagrelor in patients <75 years old was not able to demonstrate superiority compared to clopidogrel in terms of microvascular injury, while there was no difference between the two groups in MACE and major bleeding events. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02429271. EudraCT Number 2014-004082-25.
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Affiliation(s)
- Michalis Hamilos
- University Hospital of Heraklion, Stavrakia-Voutes, Crete 71100, Greece
| | - John Kanakakis
- Clinical Therapeutics, Alexandra Hospital, University of Athens, Athens, Greece
| | - Ioannis Anastasiou
- Department of Cardiology, University Hospital of Heraklion, Crete, Greece
| | | | | | - John Goudevenos
- 1st Cardiology Department, Ioannina University Hospital, Ioannina, Greece
| | - Lampros Michalis
- 2nd Cardiology Department, Ioannina University Hospital, Ioannina, Greece
| | | | | | | | - Dimitrios Stakos
- Cardiology Department, Democritus University of Thrace, Alexandroupolis, Greece
| | - George Hahalis
- Cardiology Department, Patras University Hospital, Rio, Greece
| | - Panos Vardas
- Hellenic Cardiovascular Research Society (HCRS), Athens, Greece
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26
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Tan JW, Chew DP, Abdul Kader MAS, Ako J, Bahl VK, Chan M, Park KW, Chandra P, Hsieh IC, Huan DQ, Johar S, Juzar DA, Kim BK, Lee CW, Lee MKY, Li YH, Almahmeed W, Sison EO, Tan D, Wang YC, Yeh SJ, Montalescot G. 2020 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y 12 Receptor Antagonists in the Asia-Pacific Region. Eur Cardiol 2021; 16:e02. [PMID: 33708263 PMCID: PMC7941380 DOI: 10.15420/ecr.2020.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/04/2020] [Indexed: 01/01/2023] Open
Abstract
The unique characteristics of patients with acute coronary syndrome in the Asia-Pacific region mean that international guidelines on the use of dual antiplatelet therapy (DAPT) cannot be routinely applied to these populations. Newer generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) have demonstrated improved clinical outcomes compared with clopidogrel. However, low numbers of Asian patients participated in pivotal studies and few regional studies comparing DAPTs have been conducted. This article aims to summarise current evidence on the use of newer generation P2Y12 inhibitors in Asian patients with acute coronary syndrome and provide recommendations to assist clinicians, especially cardiologists, in selecting a DAPT regimen. Guidance is provided on the management of ischaemic and bleeding risks, including duration of therapy, switching strategies and the management of patients with ST-elevation and non-ST-elevation MI or those requiring surgery. In particular, the need for an individualised DAPT regimen and considerations relating to switching, de-escalating, stopping or continuing DAPT beyond 12 months are discussed.
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Affiliation(s)
- Jack Wc Tan
- National Heart Centre Singapore
- Sengkang General Hospital Singapore
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | | | - Junya Ako
- Kitasato University and Hospital Tokyo, Japan
| | - Vinay K Bahl
- All India Institute of Medical Sciences New Delhi, India
| | - Mark Chan
- National University Hospital Singapore
| | - Kyung Woo Park
- Seoul National University Hospital Internal Medicine Seoul, South Korea
| | | | | | - Do Quang Huan
- Heart Institute of Ho Chi Minh City Ho Chi Minh, Vietnam
| | | | | | | | - Cheol Whan Lee
- Asan Medical Center, University of Ulsan Seoul, South Korea
| | | | - Yi-Heng Li
- National Cheng King University Hospital Tainan, Taiwan
| | | | - Eric Oliver Sison
- University of the Philippines-Philippine General Hospital Manila, Philippines
| | | | - Yu-Chen Wang
- China Medical University Hospital Taichung City, Taiwan
| | | | - Gilles Montalescot
- Sorbonne University Paris, France
- ACTION Study Group France
- Pitié-Salpêtrière Hospital (AP-HP) Paris, France
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27
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Sun J, Leng P, Sun C, Xu W, Zhao Z, Li X, Zhang X, Li J. Should CYP2C19 Genotyping Be Recommended as a Straight Forward Approach to Optimize Clopidogrel Utilization in Patients with Ischemic Stroke Complicated by Type 2 Diabetes Mellitus? Pharmgenomics Pers Med 2020; 13:645-653. [PMID: 33262635 PMCID: PMC7698285 DOI: 10.2147/pgpm.s279719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There have been few studies on CYP2C19 genotypes and clopidogrel response associated with ischemic stroke (IS), especially IS complicated by type 2 diabetes mellitus (T2DM). This study aimed to investigate the possible association between CYP2C19 polymorphisms and high on-treatment platelet reactivity (HTPR) in IS patients with T2DM in China. PATIENTS AND METHODS A total of 426 consecutive IS patients with T2DM were enrolled in this case-control study and they were divided into HTPR group and non-HTPR group according to the ADP-induced platelet inhibition (PIADP) assessed by thromboelastography (TEG). Genotypes were detected by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Various clinical and demographic data were also recorded. The association between CYP2C19 genetic variants and platelet function was assessed. RESULTS Carriers of CYP2C19*2 heterozygous and mutant homozygous genotypes showed significantly lower PIADP than non-carriers (27.2% vs 38.3%, p < 0.001; 27.41% vs 38.3%, p = 0.012, respectively). Compared with the control group, the CYP2C19*2 A allele was more frequent in the HTPR group (34.51% vs 25.82%, p = 0.002). The carriage of CYP2C19*2 mutant allele was significantly associated with increased risk of HTPR (odds ratio (OR) = 1.94, 95% confidence interval (CI) = 1.32-2.85). There was no significant correlation between CYP2C19*3 or *17 genotypes and HTPR risk. CONCLUSION CYP2C19*2 mutant allele was associated with attenuated platelet response to clopidogrel and increased risk of HTPR in IS patients with T2DM, suggesting that CYP2C19*2 polymorphism might be an important predictor of HTPR in this high-risk population.
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Affiliation(s)
- Jialin Sun
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Ping Leng
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Chen Sun
- Department of Pharmacy, Qingdao Municipal Hospital, Qingdao266003, Shandong, People’s Republic of China
| | - Wen Xu
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Zhenhuan Zhao
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Xiao Li
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Xiaolei Zhang
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
| | - Jing Li
- Department of Pharmacy, The Affiliated Hospital of Qingdao University, Qingdao266003, Shandong, People’s Republic of China
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28
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Wang N, Zhang M, Su H, Huang Z, Lin Y, Zhang M. Fibrinolysis is a reasonable alternative for STEMI care during the COVID-19 pandemic. J Int Med Res 2020; 48:300060520966151. [PMID: 33108941 PMCID: PMC7645389 DOI: 10.1177/0300060520966151] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE No data are available to develop uniform recommendations for reperfusion therapies in ST-segment elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to fill the evidence gap regarding STEMI reperfusion strategy during the COVID-19 era. METHODS Clinical characteristics and outcomes for 17 patients with STEMI who received fibrinolysis during the COVID-19 pandemic were compared with 20 patients who received primary percutaneous coronary intervention (PPCI), and were further compared with another 41 patients who received PPCI in the pre-COVID-19 period. RESULTS In patients with STEMI, fibrinolysis achieved a comparable in-hospital and 30-day primary composite end point, as compared with those who received PPCI during the COVID-19 pandemic. No major bleeding was detected in either group. Compared patients with STEMI who received PPCI in the pre-COVID-19 period, we found a remarkable extension of chest pain onset-to-first medical contact (FMC) and FMC-to-wire crossing times, significantly increased number and length of stents, and much worse thrombolysis in myocardial infarction flow in patients with STEMI who received PPCI during the COVID-19 pandemic. CONCLUSION Owing to its considerable efficacy and safety and advantages in conserving medical resources, we recommend fibrinolysis as a reasonable alternative for STEMI care during the COVID-19 pandemic.
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Affiliation(s)
- Nan Wang
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Zhang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Biological Targeted Therapy of the Ministry of Education, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huajun Su
- Department of Cardiology, Union Jiangbei Hospital, Wuhan, China
| | - Zhonglue Huang
- Department of Cardiology, Union Jiangbei Hospital, Wuhan, China
| | - Yongbo Lin
- Department of Cardiology, People's Hospital of Dongxihu District, Wuhan, China
| | - Min Zhang
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Key Laboratory of Biological Targeted Therapy of the Ministry of Education, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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29
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Fei Y, Lam CK, Cheung BMY. Efficacy and safety of newer P2Y 12 inhibitors for acute coronary syndrome: a network meta-analysis. Sci Rep 2020; 10:16794. [PMID: 33033323 PMCID: PMC7545197 DOI: 10.1038/s41598-020-73871-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/31/2020] [Indexed: 12/13/2022] Open
Abstract
Whether newer P2Y12 inhibitors are more efficacious and safer than clopidogrel and whether there is a superior one remain uncertain. We compared the effect of P2Y12 inhibitors on clinical outcomes in patients with acute coronary syndrome (ACS). Randomized controlled trials comparing clopidogrel, prasugrel, ticagrelor, or cangrelor, in combination with aspirin were searched. Sixteen trials with altogether 77,896 patients were included. Compared to clopidogrel, cardiovascular mortality was reduced with prasugrel (OR 0.85, 95% CI 0.75–0.97) and ticagrelor (0.82, 0.73–0.93). Myocardial infarction (0.75, 0.63–0.89) and major adverse cardiovascular events (0.80, 0.69–0.94) were reduced by prasugrel. Stent thrombosis was reduced by prasugrel (0.49, 0.38–0.63), ticagrelor (0.72, 0.57–0.90), and cangrelor (0.59, 0.43–0.81). It was reduced more by prasugrel than ticagrelor (0.69, 0.51–0.93). There were more major bleeds with prasugrel (1.24, 1.05–1.48). Thrombolysis in Myocardial Infarction (TIMI) major bleeding was increased with prasugrel compared to clopidogrel (1.36, 1.11–1.66) and ticagrelor (1.33, 1.06–1.67). TIMI minor bleeding was increased with prasugrel (1.44, 1.16–1.77) and cangrelor (1.47, 1.01–2.16) compared to clopidogrel while it was increased with prasugrel compared to ticagrelor (1.32, 1.01–1.72). Prasugrel is preferable to those ACS patients at low bleeding risk to reduce cardiovascular events whereas ticagrelor is a relatively safe antiplatelet drug of choice for most patients.
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Affiliation(s)
- Yue Fei
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, 102 Pokfulam Road, Hong Kong, China
| | - Cheuk Kiu Lam
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, 102 Pokfulam Road, Hong Kong, China
| | - Bernard Man Yung Cheung
- Division of Clinical Pharmacology and Therapeutics, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, 102 Pokfulam Road, Hong Kong, China. .,State Key Laboratory of Pharmaceutical Biotechnology, The University of Hong Kong, Pokfulam, Hong Kong, China. .,Institute of Cardiovascular Science and Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China.
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30
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Yin Q, Zhao B, Zhu J, Fei Y, Shen W, Liang B, Zhu X, Li Y. JLX001 improves myocardial ischemia-reperfusion injury by activating Jak2-Stat3 pathway. Life Sci 2020; 257:118083. [PMID: 32673665 DOI: 10.1016/j.lfs.2020.118083] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/22/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
AIMS To investigate the preclinical pharmacodynamics and mechanism of JLX001 against myocardial ischemia reperfusion (MI/R) for clinical application. MATERIALS AND METHODS In vivo, SD rats were given intragastric administration for 5 days, and the MI/R model was established by ligating/releasing the left anterior descending coronary artery. In vitro, the oxygen-glucose deprivation/reperfusion (OGD/R) model was established after the drug was pre-incubated for 24 h in H9C2 cells. The infract size was determined by TTC staining. Left ventricular function of MI/R rats was detected by echocardiography. The level of histopathological score was determined by hematoxylin-eosin (HE) staining. The level of superoxide dismutase (SOD), malondialdehyde (MDA), creatine kinase (CK), lactic dehydrogenase (LDH), tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) were determined by relevant kits. The level of apoptosis was measured by Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) and Hoechst staining. The expression of p-Jak2, p-Stat3, Bax, Bcl-2, TNF-α, IL-1β protein were determined by western blot. KEY FINDINGS JLX001 can significantly improve left ventricular function, reduce myocardial infract size, histopathological score, the level of MDA, CK, LDH, TNF-α, IL-1β and the expression of Bax protein, significantly increase the activity of SOD, Bcl-2 protein expression, p-Jak2 protein expression, p-Stat3 protein expression in rat heart tissues and H9C2 cells. These effects can be reversed by AG490 which is a specific inhibitor of Jak2-Stat3 pathway. SIGNIFICANCE JLX001 can alleviate MI/R injury by inhibiting myocardial apoptosis, inflammation, and oxidative stress via Jak2-Stat3 pathway in vivo and in vitro.
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Affiliation(s)
- Qiyang Yin
- State key laboratory of Nature Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, PR China
| | - Bo Zhao
- State key laboratory of Nature Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, PR China
| | - Jianping Zhu
- State key laboratory of Nature Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, PR China
| | - Yuxiang Fei
- State key laboratory of Nature Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, PR China
| | - Weiyang Shen
- School of Sciences, China Pharmaceutical University, Nanjing 210009, PR China
| | - Bingwen Liang
- Jiangsu Jinglixin Pharmaceutical Technology Company Limited, Nanjing 211100, PR china
| | - Xiong Zhu
- School of Sciences, China Pharmaceutical University, Nanjing 210009, PR China.
| | - Yuman Li
- State key laboratory of Nature Medicines, School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, PR China.
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Li YH, Lee CH, Huang WC, Wang YC, Su CH, Sung PH, Chien SC, Hwang JJ. 2020 Focused Update of the 2012 Guidelines of the Taiwan Society of Cardiology for the Management of ST-Segment Elevation Myocardial Infarction. ACTA CARDIOLOGICA SINICA 2020; 36:285-307. [PMID: 32675921 PMCID: PMC7355116 DOI: 10.6515/acs.202007_36(4).20200619a] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/19/2020] [Indexed: 12/22/2022]
Abstract
One of the major missions of the Taiwan Society of Cardiology is to publish practice guidelines that are suitable for local use in Taiwan. The ultimate purpose is to continuously improve cardiovascular health care from the implementation of the recommendations in the guidelines. Despite recent improvement of medical care, patients with ST-segment elevation myocardial infarction (STEMI) still carry a high morbidity and mortality. There have been many changes in the concepts of STEMI diagnosis and treatment in recent years. The 2020 focused update of the 2012 guidelines of the Taiwan Society of Cardiology for the management of STEMI is an amendment of the 2012 guidelines based on the newest published scientific data. The recommendations in this focused update provide the diagnosis and treatment strategy for STEMI that should be generally implemented in Taiwan. Nevertheless, guidelines never completely replace clinical judgment and medical decision still should be determined individually.
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Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
| | - Cheng-Han Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- School of Medicine, National Yang Ming University, Taipei
- Department of Physical Therapy, Fooyin University, Kaohsiung
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital
- Department of Biotechnology, Asia University
- Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital
| | - Chun-Hung Su
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital
- Institute of Medicine, School of Medicine, Chung Shan Medical University, Taichung
| | - Pei-Hsun Sung
- Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, College of Medicine
| | - Shih-Chieh Chien
- Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
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Zhang N, Xu W, Li O, Zhang B. The risk of dyspnea in patients treated with third-generation P2Y 12 inhibitors compared with clopidogrel: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2020; 20:140. [PMID: 32183711 PMCID: PMC7079377 DOI: 10.1186/s12872-020-01419-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 12/15/2022] Open
Abstract
Background Ticagrelor and prasugrel are two third-generation oral P2Y12 inhibitors which are more commonly used in clinical practice. However, dyspnea has been consecutively reported in patients using third-generation oral P2Y12 inhibitors. This study aims to compare the risk of dyspnea in patients treated with third-generation P2Y12 inhibitors compared with clopidogrel. Methods We systematically searched the PubMed, Cochrane Central Register of Controlled Trials databases, ClinicalTrials.gov and Web of Science for randomized control trials (RCTs) comparing ticagrelor or prasugrel with clopidogrel until July 2019. The primary outcome was the incidence of dyspnea. The risk ratios (RR) and 95% confidence intervals (CI) were estimated using meta-analysis. Results We included 25 RCTs involving 63,484 patients in this meta-analysis, including 21 studies on ticagrelor and 4 studies on prasugrel. Compared to the clopidogrel group, third-generation oral P2Y12 inhibitors were associated with an increased risk of dyspnea compared with clopidogrel (RR 2.15, 95% CI 1.59–2.92), which was consistent in the analysis of ticagrelor (RR 2.65, 95% CI 1.87–3.76). However, the adverse effect was not found among patients receiving prasugrel therapy (RR 1.03, 95% CI 0.86–1.22). The increased dyspnea risk of ticagrelor was consistent in subgroups with different follow-up durations (≤ 1 month RR 1.87, 95% CI 1.56–2.24; 1–6 months RR 4.19, 95% CI 1.99–8.86; > 6 months 2.45, 95% CI 1.13–5.34). Conclusions Ticagrelor has a higher risk of dyspnea than clopidogrel, which was not observed in patients using prasugrel.
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Affiliation(s)
- Na Zhang
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China.
| | - Weisen Xu
- Department of Stomatology, Beijing University of Chinese Medicine Third Affiliated Hospital, Beijing, 100029, China
| | - Ou Li
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China
| | - Bing Zhang
- Intensive Care Unit, China Emergency General Hospital, 29 Xibahenanli, Beijing, 100028, China
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Tsarouchas A, Mouselimis D, Bakogiannis C, Gkasdaris G, Dimitriadis G, Zioutas D, Papadopoulos CE. Spontaneous Epidural Hematoma of the Cervical Spine Following Thrombolysis in a Patient with STEMI-Two Medical Specialties Facing a Rare Dilemma. J Neurosci Rural Pract 2020; 11:191-195. [PMID: 32140027 PMCID: PMC7055631 DOI: 10.1055/s-0039-3400182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Spontaneous spinal epidural hematoma (SSEH) is a rare, albeit well-documented complication following thrombolysis treatment in ST elevation myocardial infarction (STEMI). A SSEH usually manifests with cervical pain and neurologic deficits and may require surgical intervention. In this case report, we present the first reported SSEH to occur following thrombolysis with reteplase. In this case, the SSEH manifested with cervical pain shortly after the patient emerged from his rescue percutaneous coronary intervention (PCI). Although magnetic resonance imaging reported spinal cord compression, the lack of neurologic symptoms prompted the treating clinicians to delay surgery. A dangerous dilemma emerged, as the usual antithrombotic regimen that was necessary to avoid stent thrombosis post-PCI, was also likely to exacerbate the bleeding. As a compromise, the patient only received aspirin as a single antiplatelet therapy. Ultimately, the patient responded well to conservative treatment, with the hematoma stabilizing a week later, without residual neurologic deficits. In conclusion, the conservative treatment of SSEH appears to be an acceptable option for carefully selected patients, but the risks of permanent neurologic deficits and stent thrombosis have to be weighted for each patient.
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Affiliation(s)
- Anastasios Tsarouchas
- 3rd Cardiology Department, Hippokrateio University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Mouselimis
- 3rd Cardiology Department, Hippokrateio University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Constantinos Bakogiannis
- 3rd Cardiology Department, Hippokrateio University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | | | | | - Christodoulos E Papadopoulos
- 3rd Cardiology Department, Hippokrateio University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Cassese S, Ndrepepa G, Byrne RA, Laugwitz KL, Schunkert H, Fusaro M, Alfonso F, Kastrati A. Ticagrelor-based antiplatelet regimens in patients with atherosclerotic artery disease-A meta-analysis of randomized clinical trials. Am Heart J 2020; 219:109-116. [PMID: 31756624 DOI: 10.1016/j.ahj.2019.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/27/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Randomized trials did not consistently support superiority of ticagrelor, as monotherapy or in combination with aspirin, in terms of efficacy or safety, in patients with atherosclerotic artery disease. METHODS Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and scientific session abstracts were searched for trials of patients with coronary or peripheral artery disease (with >1,000 participants and a follow-up ≥3 months) randomly assigned to ticagrelor-based or conventional antiplatelet therapies. Trial-level hazard ratios (HRs) were pooled using a fixed- or random-effect model (in case of significant heterogeneity) with the inverse variance weighting. The primary outcome was all-cause mortality. Other outcomes were myocardial infarction (MI), stroke, and major bleeding. RESULTS Overall 77,489 patients received either ticagrelor-based (n = 38,721) or conventional antiplatelet regimens (n = 38,768) in 6 trials. The primary outcome occurred in 4.5% of patients treated with experimental therapy and 4.9% of patients treated with control therapy (HR = 0.91, 95% CI 0.81-1.01; P = .07). Overall, patients treated with ticagrelor-based versus conventional antiplatelet regimens showed no significant difference in terms of all-cause death, MI, stroke, or major bleeding after 20 months. However, in trials of patients with coronary artery disease as primary diagnosis, the risk for all-cause death (HR = 0.84 [0.77-0.91], P < .001) and MI (HR = 0.87 [0.80-0.94], P = .007) was significantly reduced by experimental therapy. CONCLUSIONS In patients with atherosclerotic artery disease, the benefit of ticagrelor-based therapies was confined to patients treated for coronary artery disease. The drug significantly reduced the risk for all-cause death and MI without excess risk of bleeding in these patients. In consideration of limitations of subgroup analyses, these results need further validation.
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Affiliation(s)
- Salvatore Cassese
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany.
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany; 1. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Heribert Schunkert
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Fernando Alfonso
- Cardiac Department, Hospital Universitario de La Princesa Madrid, Madrid, Spain
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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Leung JT, Barnes SL, Lo ST, Leung DY. Non-inferiority trials in cardiology: what clinicians need to know. Heart 2019; 106:99-104. [PMID: 31672779 PMCID: PMC6993027 DOI: 10.1136/heartjnl-2019-315772] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 09/13/2019] [Accepted: 09/19/2019] [Indexed: 01/21/2023] Open
Abstract
Clinical trials traditionally aim to show a new treatment is superior to placebo or standard treatment, that is, superiority trials. There is an increasing number of trials demonstrating a new treatment is non-inferior to standard treatment. The hypotheses, design and interpretation of non-inferiority trials are different to superiority trials. Non-inferiority trials are designed with the notion that the new treatment offers advantages over standard treatment in certain important aspects. The non-inferior margin is a predetermined margin of difference between the new and standard treatment that is considered acceptable or tolerable for the new treatment to be considered ‘similar’ or ‘not worse’. Both relative difference and absolute difference methods can be used to define the non-inferior margin. Sequential testing for non-inferiority and superiority is often performed. Non-inferiority trials may be necessary in situations where it is no longer ethical to test any new treatment against placebo. There are inherent assumptions in non-inferiority trials which may not be correct and which are not being tested. Successive non-inferiority trials may introduce less and less effective treatments even though these treatments may have been shown to be non-inferior. Furthermore, poor quality trials favour non-inferior results. Intention-to-treat analysis, the preferred way to analyse randomised trials, may favour non-inferiority. Both intention-to-treat and per-protocol analyses should be recommended in non-inferiority trials. Clinicians should be aware of the pitfalls of non-inferiority trials and not accept non-inferiority on face value. The focus should not be on the p values but on the effect size and confidence limits.
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Affiliation(s)
- James T Leung
- Cardiology, Royal North Shore Hospital, Saint Leonards, New South Wales, Australia
| | - Stephanie L Barnes
- Neurology, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sidney T Lo
- Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Dominic Y Leung
- Cardiology, University of New South Wales, Liverpool Hospital, Liverpool, New South Wales, Australia
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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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Hee L, Gibbs OJ, Assad JG, Sharma LD, Hopkins A, Juergens CP, Lo S, Mussap CJ. Real-world use of ticagrelor versus clopidogrel in percutaneous coronary intervention-treated ST-elevation myocardial infarction patients: A single-center registry study. J Saudi Heart Assoc 2019; 31:151-160. [PMID: 31296977 PMCID: PMC6599087 DOI: 10.1016/j.jsha.2019.05.005] [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] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 05/25/2019] [Accepted: 05/26/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES The primary aim was to investigate the efficacy and safety of dual antiplatelet therapy (DAPT) using ticagrelor (T-DAPT) versus clopidogrel (C-DAPT) in a real-world ST-elevation myocardial infarction (STEMI) population. METHODS We retrospectively analyzed 655 consecutive patients having primary percutaneous coronary intervention (PCI) for STEMI at Liverpool Hospital, Sydney, Australia (from January 2013 to April 2016). Medical and procedural therapies were at clinician discretion. Patient data were retrieved from hospital records and primary clinicians. RESULTS T-DAPT (65%) was used more frequently, and in patients with lower mean CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) score, than C-DAPT (24.6 vs. 32.2; p < 0.0001, respectively). All-cause mortality was 9.0% at 2.7 years follow-up, with fewer deaths for T-DAPT (4.5% vs. 17.2%; p < 0.0001). T-DAPT incurred less BARC (Bleeding Academic Research Consortium) 3-5 major bleeding (5.0% vs. 12.4%; p < 0.0001). Multivariate regression showed that C-DAPT, GRACE (Global Registry of Acute Cardiac Events) score, and renal insufficiency were independently associated with mortality. Intra-aortic balloon pump (IABP) and GRACE score independently predicted BARC 3-5 bleeding. Early DAPT discontinuation (1.7%) and ticagrelor intolerance (7.6%) was rare. Switching DAPT regimen was infrequent (21.7%) and mostly attributed to clinician preference (73.2%). Independent determinants of C-DAPT selection were older age, diabetes, prior PCI, IABP, and higher CRUSADE score. CONCLUSION Ticagrelor was preferred in low bleeding risk patients, which may have contributed to less BARC 3-5 bleeding and lower mortality for T-DAPT. Thus, bleeding mitigation is a clinical priority when selecting DAPT for PCI-treated STEMI patients. Continuation of initial DAPT regimen was typical, but early switching from clopidogrel to ticagrelor shows willingness to optimize DAPT. Patients with very low CRUSADE scores (<21.5) may be appropriate for switching to a potent P2Y12 inhibitor.
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Affiliation(s)
- Leia Hee
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Oliver J. Gibbs
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Joseph G. Assad
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Lokesh D. Sharma
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Andrew Hopkins
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Craig P. Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Sidney Lo
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christian J. Mussap
- Department of Cardiology, Liverpool Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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Volney C, Collins A, Adams S. Ticagrelor versus clopidogrel in the management of acute myocardial infarction. J Community Hosp Intern Med Perspect 2019; 9:314-318. [PMID: 31531213 PMCID: PMC6737723 DOI: 10.1080/20009666.2019.1644915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 07/11/2019] [Indexed: 10/29/2022] Open
Abstract
Hypothesis: In the care of acute myocardial infarction, ticagrelor attenuates post-ischemic myocardial damage and inhibits platelet activity to a greater extent than clopidogrel. Methods: Scholarly articles published in the last 10 years were compiled from a PubMed MeSH search focusing on acute coronary infarction and the antiplatelet therapies clopidogrel and ticagrelor. The databases used were PubMed, Google Scholar, Dynamed, and EBSCOhost. Eight articles were chosen based on subject matter related to the hypothesis, including cardioprotective effects, mortality benefits, platelet reactivity, angiographic effects, and electrocardiography changes. Results: Evidence from randomized clinical trials demonstrates that ticagrelor reduces infarct size, prevents remodeling, and reduces mortality rate after acute myocardial infarction to a greater extent than clopidogrel. However, some angiography studies show no difference between the two treatment regimes. Two articles show that ticagrelor is more effective in treating individuals with high platelet reactivity (HPR). In addition, there is some evidence of increased dyspnea and significant bleeding with ticagrelor. Discussion: Although there is growing evidence that ticagrelor is the better antiplatelet drug post-acute coronary infarction, more research needs to be done to determine the situations in which ticagrelor provides the optimal treatment regime in regards to cardioprotective effects, antiplatelet effects and an overall decrease in mortality. Conclusion: Ticagrelor was found to be superior to clopidogrel in relation to cardioprotective effects, mortality, and antiplatelet activity.
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Affiliation(s)
- Candice Volney
- Department of Physiology, Saba University School of Medicine, Edmonton, Alberta, Canada
| | - Anthony Collins
- Department of Physiology, Saba University School of Medicine, Caribbean Netherlands
| | - Sarah Adams
- Department of Physiology, Saint James School of Medicine, Chicago, IL, USA
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Kanorsky SG, Mamedov MN, Oganov RG. Congress of the American College of Cardiology (New Orleans, 2019): Clinical Findings. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2019. [DOI: 10.15829/1728-8800-2019-4-129-136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
| | - M. N. Mamedov
- National Medical Research Center for Preventive Medicine
| | - R. G. Oganov
- National Medical Research Center for Preventive Medicine
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Berwanger O, Lopes RD, Moia DD, Fonseca FA, Jiang L, Goodman SG, Nicholls SJ, Parkhomenko A, Averkov O, Tajer C, Malaga G, Saraiva JF, Guimaraes HP, de Barros e Silva PG, Damiani LP, Santos RH, Paisani DM, Miranda TA, Valeis N, Piegas LS, Granger CB, White HD, Nicolau JC. Ticagrelor Versus Clopidogrel in Patients With STEMI Treated With Fibrinolysis. J Am Coll Cardiol 2019; 73:2819-2828. [DOI: 10.1016/j.jacc.2019.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 11/25/2022]
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Verdoia M, Kedhi E, Suryapranata H, De Luca G. Ticagrelor in the prevention of coronary and non-coronary atherothrombotic events: A comprehensive meta-analysis of 10 randomized trials. Atherosclerosis 2019; 284:136-147. [PMID: 30884417 DOI: 10.1016/j.atherosclerosis.2019.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/17/2019] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND AND AIMS More potent antithrombotic strategies have significantly reduced the rate of recurrent ischemic events in cardiovascular disease. Ticagrelor, in particular, has significantly improved the outcome in patients with acute coronary syndromes, offering potential benefits also in terms of survival. In addition, more recent data have suggested that the advantages of ticagrelor could be extended also to non-coronary atherothrombotic disease, although with contrasting results, especially for mortality reduction. The aim of the present meta-analysis was to investigate the safety and effectiveness of a newer antiplatelet strategy with ticagrelor as compared to traditional antiplatelet regimens in patients with coronary or non-coronary atherothrombotic disease. METHODS Literature and main scientific session abstracts were searched for studies comparing a ticagrelor-based antiplatelet regimen vs. different antiplatelet agents in the secondary prevention of cardiac, cerebral or vascular atherothrombotic events. The primary efficacy endpoint was mortality, primary safety endpoint was the occurrence of major bleedings. Secondary endpoints were myocardial infarction and stroke. RESULTS We included 10 randomized clinical trials, for a total population of 73,121 patients, 54.9% randomized to ticagrelor. At a mean follow-up of 13.4 ± 12.6 months, a newer antiplatelet strategy based on ticagrelor was associated with a significant reduction in mortality as compared to a traditional therapy (OR[95%CI] = 0.92[0.86,0.99], p=0.02; phet = 0.14), however, such benefits were more evident in patients with coronary artery disease, while not in non-coronary trials, with a significant interaction between patients' setting and the prognostic impact of ticagrelor (p int = 0.03). A similar result was achieved for cardiovascular mortality, recurrent myocardial infarction, while for the risk of stroke, the largest advantages were observed in patients with a previous cerebrovascular accident. Major bleeding events were increased in ticagrelor treated patients (OR [95%CI] = 1.11 [1.02, 1.20], p=0.01; phet = 0.0003), although not affecting overall mortality, as confirmed by meta-regression analysis. CONCLUSIONS Based on the current meta-analysis, a newer antiplatelet strategy based on ticagrelor is associated with a significant reduction in mortality and recurrent cardiovascular events, as compared to a traditional treatment, among patients treated for coronary disease but not among those with non-coronary atherothrombotic disease. However, ticagrelor therapy was associated with a significant increase in major bleeding complications.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Elvin Kedhi
- Department of Cardiology, ISALA Hospital, Zwolle, the Netherlands
| | | | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
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Guo CG, Chen L, Chan EW, Cheung KS, Isshiki T, Wong ICK, Leung WK. Systematic review with meta-analysis: the risk of gastrointestinal bleeding in patients taking third-generation P2Y 12 inhibitors compared with clopidogrel. Aliment Pharmacol Ther 2019; 49:7-19. [PMID: 30506985 DOI: 10.1111/apt.15059] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 09/26/2018] [Accepted: 10/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ticagrelor and prasugrel are third-generation oral P2Y12 receptor antagonists with rapid onset and pronounced platelet inhibition. However, higher overall bleeding rates have been reported for these agents when compared with clopidogrel. AIM To compare the risk of gastrointestinal bleeding (GIB) among users of third-generation P2Y12 inhibitors with clopidogrel. METHODS We systematically searched for published randomised controlled trials of ticagrelor or prasugrel versus clopidogrel until September 2018. The primary outcome was the risk of GIB among users of third-generation P2Y12 inhibitors when compared to clopidogrel, expressed as risk ratio (RR) and 95% confidence interval (CI). The rates of non-coronary artery bypass graft (CABG) major bleeding, life-threatening bleeding, fatal bleeding, and intracranial bleeding were analysed as secondary outcomes. RESULTS Forty-one studies were included in the analysis of non-CABG major bleeding, of which 12 were included in the analysis of GIB including 58 678 patients. Third-generation P2Y12 inhibitors were associated with higher risk of GIB as compared with clopidogrel (RR 1.28, 95% CI 1.13-1.46). The findings were consistent for upper (RR 1.32, 95% CI 1.05-1.67) and unspecified GIB (RR 1.25, 95% CI 1.01-1.53), but not lower GIB (RR 1.25, 95% CI 0.95-1.65). Subgroup analysis showed higher GIB risk in prasugrel studies (RR 1.40, 95% CI 1.10-1.77) than in ticagrelor studies (RR 1.15, 95% CI 0.94-1.39). Third-generation P2Y12 inhibitors also increased the risk of non-CABG major bleeding (RR 1.18, 95% CI 1.08-1.28). CONCLUSION Third-generation P2Y12 inhibitors were associated with increased risk of GIB and non-CABG major bleeding when compared with clopidogrel.
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Affiliation(s)
- Chuan-Guo Guo
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Lijia Chen
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Ka Shing Cheung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Takaaki Isshiki
- Cardiovascular Center, Ageo Central General Hospital, Ageo, Saitama, Japan
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
| | - Wai K Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China
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Graipe A, Söderström L, Mooe T. Increased Use of Ticagrelor After Myocardial Infarction Is Not Associated With Intracranial Hemorrhage. Stroke 2018; 49:2877-2882. [PMID: 30571411 DOI: 10.1161/strokeaha.118.022970] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- Guidelines recommend dual antiplatelet treatment with ticagrelor instead of clopidogrel after acute myocardial infarction. Ticagrelor increases major and minor noncoronary artery bypass graft bleeding compared with clopidogrel, but whether the risk of intracranial hemorrhage (ICH) increases is unknown. We aimed to examine any association between ticagrelor and ICH and to identify predictors of ICH among unselected patients after acute myocardial infarction. Methods- Patients with acute myocardial infarction were identified using the Register of Information and Knowledge About Swedish Heart Intensive Care Admissions, and the data were combined with the Swedish National Patient Registry to identify ICH occurrence. To avoid obvious selection bias related to the choice of dual antiplatelet treatment, we divided the study cohorts into 2 time periods of similar length using the first prescription of ticagrelor as a cutoff point (December 20, 2011). The risk of ICH during the first period (100% clopidogrel treatment) versus the second period (52.1% ticagrelor and 47.8% clopidogrel treatment) was assessed using Kaplan-Meier analysis. Cox proportional-hazards regression analyses, with assessment of interactions between all significant variables, were used to identify predictors of ICH. Results- The analysis included 47 674 patients with acute myocardial infarction. The cumulative incidence of ICH during the first period was 0.59% (91 cases [95% CI, 0.49-0.69]) versus 0.52% (97 cases [95% CI, 0.43-0.61]) during the second period ( P=0.83). In multivariable Cox analysis, study period (second versus first period) was not predictive of ICH. Interaction analyses showed that age and prior cardiovascular morbidities were of importance in predicting the risk of ICH. Conclusions- The increased use of ticagrelor was not associated with ICH, whereas age and prior cardiovascular morbidities were related to the risk of ICH and interacted significantly.
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Affiliation(s)
- Anna Graipe
- From the Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden (A.G., T.M.)
| | - Lars Söderström
- Unit of Research, Development, and Education, Östersund Hospital, Sweden (L.S.)
| | - Thomas Mooe
- From the Department of Public Health and Clinical Medicine, Östersund, Umeå University, Sweden (A.G., T.M.)
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ACC/AHA Versus ESC Guidelines on Dual Antiplatelet Therapy. J Am Coll Cardiol 2018; 72:2915-2931. [DOI: 10.1016/j.jacc.2018.09.057] [Citation(s) in RCA: 204] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 09/05/2018] [Accepted: 09/08/2018] [Indexed: 01/25/2023]
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Berwanger O, Abdelhamid M, Alexander T, Alzubaidi A, Averkov O, Aylward P, Contreras Zúñiga E, Halvorsen S, Iglesias R, A Sk Abdul Kader M, Zubaid M, AlHabib KF. Use of ticagrelor alongside fibrinolytic therapy in patients with ST-segment elevation myocardial infarction: Practical perspectives based on data from the TREAT study. Clin Cardiol 2018; 41:1322-1327. [PMID: 30098028 DOI: 10.1002/clc.23043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/07/2018] [Accepted: 08/08/2018] [Indexed: 01/03/2023] Open
Abstract
Primary percutaneous coronary intervention (PCI) is the preferred reperfusion method in patients with ST-segment elevation myocardial infarction (STEMI). In patients with STEMI who cannot undergo timely primary PCI, pharmacoinvasive treatment is recommended, comprising immediate fibrinolytic therapy with subsequent coronary angiography and rescue PCI if needed. Improving clinical outcomes following fibrinolysis remains of great importance for the many patients globally for whom rapid treatment with primary PCI is not possible. For patients with acute coronary syndrome who underwent primary PCI, the PLATO trial demonstrated superior efficacy of ticagrelor relative to clopidogrel. Results in the predefined subgroup of patients with STEMI were consistent with the overall PLATO trial. Patients who received fibrinolytic therapy in the 24 hours before randomization were excluded from PLATO, and there is thus a lack of data on the safety of using ticagrelor in conjunction with fibrinolytic therapy in the first 24 hours after STEMI. The TREAT study addresses this knowledge gap; patients with STEMI who had symptom onset within the previous 24 hours and had received fibrinolytic therapy (of whom 89.4% had also received clopidogrel) were randomized to treatment with ticagrelor or clopidogrel (median time between fibrinolysis and randomization: 11.5 hours). At 30 days, ticagrelor was found to be non-inferior to clopidogrel for the primary safety outcome of Thrombolysis in Myocardial Infarction (TIMI)-defined first major bleeding. Considering together the results of the PLATO and TREAT studies, initiating or switching to treatment with ticagrelor within the first 24 hours after STEMI in patients receiving fibrinolysis is reasonable.
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Affiliation(s)
| | | | | | | | - Oleg Averkov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Philip Aylward
- South Australian Health and Medical Research Institute, Flinders University and Medical Centre, Adelaide, Australia
| | | | | | | | | | | | - Khalid F AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Centre, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Romano S, Buccheri S, Mehran R, Angiolillo DJ, Capodanno D. Gender differences on benefits and risks associated with oral antithrombotic medications for coronary artery disease. Expert Opin Drug Saf 2018; 17:1041-1052. [DOI: 10.1080/14740338.2018.1524869] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Sara Romano
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Sergio Buccheri
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Davide Capodanno
- Division of Cardiology, CAST, P.O. “Rodolico”, Azienda Ospedaliero-Universitaria “Policlinico-Vittorio Emanuele”, University of Catania, Catania, Italy
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An update on the use of anticoagulant therapy in ST-segment elevation myocardial infarction. Expert Opin Pharmacother 2018; 19:1441-1450. [PMID: 30185087 DOI: 10.1080/14656566.2018.1512583] [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: 10/28/2022]
Abstract
INTRODUCTION Together with antiplatelet therapy, anticoagulants are vital to improve outcomes in patients presenting with ST-segment elevation myocardial infarction. Challenges lie in finding the optimal balance between the risk of bleeding and preventing thrombotic complications such as reinfarction or stent thrombosis. During the last decade, bivalirudin was introduced as a valid alternative to heparin for patients undergoing primary percutaneous coronary intervention. Several trials have been conducted to identify the agent with the best antithrombotic results at the lowest bleeding complication rate. In a rapidly evolving field with changes in vascular access, available P2Y12 inhibitors, and indications for glycoprotein IIb/IIIa inhibitor administration, conflicting evidence became available. AREAS COVERED This paper mainly focuses on the evidence above and gives brief discussion to the recent literature on anticoagulation in fibrinolytic therapy and advances in antiplatelet therapy. EXPERT OPINION To date, no robust evidence is available challenging unfractionated heparin as the primary choice for anticoagulation in patients presenting with ST-segment elevation myocardial infarction. Further research should include efforts to refine anticoagulation strategies on an individual patient level. For patients undergoing primary percutaneous coronary intervention, bivalirudin could be used as an alternative to unfractionated heparin, while enoxaparin or fondaparinux is an alternative agent for patients treated with fibrinolytic therapy.
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Adamski P, Adamska U, Ostrowska M, Navarese EP, Kubica J. Evaluating current and emerging antithrombotic therapy currently available for the treatment of acute coronary syndrome in geriatric populations. Expert Opin Pharmacother 2018; 19:1415-1425. [PMID: 30132731 DOI: 10.1080/14656566.2018.1510487] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute coronary syndromes (ACS) represent one of the most perilous presentations of ischemic heart disease. Temporal trends clearly demonstrate that ACS occur later and later in life. Elderly patients with ACS comprise a populous and growing group, with more than half of individuals presenting with myocardial infarction being 75 years or older. Nevertheless, geriatric patients are greatly underrepresented in the landmark ACS trials evaluating innovative pharmacological strategies. AREAS COVERED The authors critically summarize recently published research on contemporary and emerging antithrombotic therapy for the treatment of ACS in geriatric patients. EXPERT OPINION Elderly ACS patients are characterized by simultaneously increased risk of cardiovascular events and bleeding. Very few studies assessing the efficacy and safety of novel ACS pharmacotherapy in geriatric patients are currently available. Guidelines on the treatment of ACS are based on the overall results of major randomized clinical trials (RCTs), and data supporting the recommended therapy in elderly mainly derive from subanalyses of these RCTs. Properly designed and powered RCTs are necessary to properly evaluate the net effect of current and emerging pharmacotherapy in geriatric patients. Until such data are available, elderly ACS patients should receive treatment according to the general recommendations.
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Affiliation(s)
- Piotr Adamski
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | - Urszula Adamska
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
| | | | - Eliano Pio Navarese
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland.,b Interventional Cardiology and Cardiovascular Medicine Research, Inova Center for Thrombosis Research and Drug Development , Inova Heart and Vascular Institute , Falls Church , VA , USA.,c SIRIO MEDICINE Research Network, Inova Heart and Vascular Institute, Inova Center for Thrombosis Research and Drug Development , Fairfax , VA , USA
| | - Jacek Kubica
- a Collegium Medicum , Nicolaus Copernicus University , Bydgoszcz , Poland
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Ticagrelor versus clopidogrel after fibrinolytic therapy in patients with ST-elevation myocardial infarction: a systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis 2018; 46:299-303. [DOI: 10.1007/s11239-018-1706-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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50
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Pocock SJ, Collier TJ. Critical Appraisal of the 2018 ACC Scientific Sessions Late-Breaking Trials From a Statistician's Perspective. J Am Coll Cardiol 2018; 71:2957-2969. [DOI: 10.1016/j.jacc.2018.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022]
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