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Zou Y, Wang Y, Yao Y, Wu Y, Lv C, Yin T. Platelet-derived circFAM13B associated with anti-platelet responsiveness of ticagrelor in patients with acute coronary syndrome. Thromb J 2024; 22:53. [PMID: 38907258 PMCID: PMC11191304 DOI: 10.1186/s12959-024-00620-9] [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: 04/09/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Platelet is enriched with Circular RNAs (circRNAs), with circFAM13B rank among the 10 most abundant circRNAs in platelets. The aim of the present study was to evaluate the predictive value of platelet-derived circFAM13B for the antiplatelet responsiveness and efficacy of ticagrelor in patients with acute coronary syndrome (ACS). METHODS Consecutive ACS patients treated with ticagrelor were enrolled, and the antiplatelet responsiveness of 3 days of ticagrelor maintenance treatment was assessed by measuring the adenosine diphosphate (ADP)-induced platelet inhibition rate (ADP%) using thromboelastography. The expression of circFAM13B in the patients' platelets was analyzed by quantitative real-time polymerase chain reaction. The correlation between circFAM13B expression and ticagrelor antiplatelet responsiveness, as well as the independent contribution of circFAM13B to the composite of adverse ischemic events during a follow-up period of at least 12 months was evaluated. RESULTS A total of 129 eligible ACS patients treated with ticagrelor were enrolled in the study. A negative correlation was found between the expression of circFAM13B and the ADP% value (r = -0.41, P < 0.001). Patients with ADP% ≥ 76% had a significantly lower level of circFAM13B compared to those with ADP% < 76% (adjusted P = 0.009). Receiver operating characteristic curve analysis demonstrated that combining circFAM13B expression > 1.05 with clinical risk factors could effectively predict the risk of adverse ischemic events (AUC = 0.81, 95% CI: 0.69 to 0.92, P < 0.001). Kaplan-Meier survival analysis showed that patients with circFAM13B > 1.05 had a significantly higher risk of adverse ischemic events compared to those with circFAM13B ≤ 1.05 (P = 0.003). Multivariate logistic hazard analysis identified circFAM13B > 1.05 as an independent risk factor for adverse ischemic events in in ticagrelor-treated ACS patients (adjusted OR: 5.60, 95% CI: 1.69-18.50; P = 0.005). CONCLUSIONS Platelet-derived circFAM13B could be utilized for predicting the antiplatelet responsiveness and efficacy of ticagrelor in patients with ACS.
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Affiliation(s)
- Yuting Zou
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China
- Senior Department of Cardiology, The 6th Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuyan Wang
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yanzhu Yao
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yangxun Wu
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Chao Lv
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tong Yin
- Institute of Geriatrics, National Clinical Research Center for Geriatric Diseases, 2nd Medical Center, Chinese PLA General Hospital, Beijing, China.
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Austin CA, Seligman B, Shan-Bala S, Kuchel GA, Loh KP, Kistler CE, Batsis JA. Aging precisely: Precision medicine through the lens of an older adult. J Am Geriatr Soc 2024. [PMID: 38888213 DOI: 10.1111/jgs.19036] [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: 03/22/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024]
Abstract
Precision medicine presents an opportunity to use novel, data-driven strategies to improve patient care. The field of precision medicine has undergone many advancements over the past few years. It has moved beyond incorporation of individualized genetic risk into medical decision-making to include multiple other factors such as unique social, demographic, behavioral, and clinical characteristics. Geriatric medicine stands to benefit heavily from the integration of precision medicine into its standard practices. Older adults, compared with other populations, have high clinical and biological heterogeneity that can alter the risks and benefits of different approaches to patient care. These factors have not been routinely considered previously by geriatricians. Yet, geriatricians' ability to address older adults' baseline heterogeneity is increasingly recognized as a cornerstone of delivering quality care in a geriatric medical practice. Given the shared focus of individualized decision-making, precision medicine is a natural fit for geriatric medicine. This manuscript provides, via cases and discussion, examples that illustrate how precision medicine can improve the care of our older patients today. We will share specific and existing tools and evidence, and review the existing multilevel barriers to further incorporate and implement these tools into clinical practice. We propose methods to address these barriers and to help realize the full potential of precision medicine for the care of older adults. We conclude with a brief discussion of potential future directions of research of precision medicine in the care of older adults.
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Affiliation(s)
- C Adrian Austin
- Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Benjamin Seligman
- Geriatric Research, Education and Clinical Center, VA Greater Los Angeles Health Care System, Los Angeles, California, USA
- Division of Geriatric Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Sangeetha Shan-Bala
- Division of Geriatric Medicine, Department of Medicine, Inova Health System, Fairfax Medical Campus, Falls Church, Virginia, USA
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Kah Poh Loh
- Division of Hematology/Oncology, Department of Medicine, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Chrissy E Kistler
- Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John A Batsis
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina, Chapel Hill, North Carolina, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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Herron GC, Bates ER. Review of the Ticagrelor Trials Evidence Base. J Am Heart Assoc 2024; 13:e031606. [PMID: 38804216 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 Medicine University of Michigan Ann Arbor MI USA
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Sachdev D, Khalil L, Gendi K, Brand J, Cominos N, Xie V, Mehran N. Perioperative Management of Traditional and Direct Oral Anticoagulants in Hip Fracture Patients. Orthop Rev (Pavia) 2024; 16:115605. [PMID: 38751452 PMCID: PMC11093752 DOI: 10.52965/001c.115605] [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] [Received: 08/15/2023] [Accepted: 02/05/2024] [Indexed: 05/18/2024] Open
Abstract
Hip fractures are an increasingly common injury in the senior population and almost always require surgical fixation or prosthetic replacement. These surgeries, according to the American Academy of Orthopaedic Surgeons, are considered high-risk for bleeding, especially in a population fraught with comorbidities and often presenting on anticoagulation medications. Direct oral anticoagulants represent a class of drugs that have been becoming more popular in use in this population, with many benefits over the historically used Warfarin. There are recommendations for preoperative discontinuation and postoperative resumption of these medications, which can be more readily managed for elective surgeries. However, there is a paucity of literature detailing best practice guidelines for the perioperative management of direct oral anticoagulants when a patient presents with a hip fracture. This review article summary of the periprocedural management of DOACs for hip surgery was developed by examining the American College of Chest Physicians evidence-based clinical practice guidelines, Perioperative Guidelines on Antiplatelet and Anticoagulant Agents written by anesthesiologists, various retrospective studies, and drug labels for pharmacokinetic data. These recommendations should be used as a guideline, along with the collaboration of multidisciplinary hospital teams during inpatient admission, to manage these complex patients.
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Affiliation(s)
| | - Lafi Khalil
- Department of Orthopaedic SurgeryMcLaren Flint
| | - Kirollos Gendi
- Department of Orthopaedic SurgeryMount Sinai Hospital (florida)
| | - Jordan Brand
- Department of Orthopaedic Surgery, Division of Traumatologyuniversity of maryland
| | | | | | - Nima Mehran
- Department of Orthopaedic SurgeryKaiser Permanente
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Comparing Measures of Adherence and Persistence to P2Y12 Inhibitors in Acute Coronary Syndromes. Am J Cardiol 2024:S0002-9149(24)00329-1. [PMID: 38697453 DOI: 10.1016/j.amjcard.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/12/2024] [Accepted: 04/26/2024] [Indexed: 05/05/2024]
Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California
| | | | - Maneesh Sud
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California; ICES, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California.
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Hong B, Bea S, You SC, Chang Y, Kim W, Shin JY. Comparative Effectiveness and Safety of Ticagrelor and Clopidogrel in Patients with or Without Chronic Liver Disease: A Nationwide Cohort study. Am J Med 2024:S0002-9343(24)00220-1. [PMID: 38641192 DOI: 10.1016/j.amjmed.2024.03.042] [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] [Received: 10/05/2023] [Revised: 01/28/2024] [Accepted: 03/31/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Although the effectiveness and safety of ticagrelor versus clopidogrel may differ in patients with chronic liver disease, there is a scarcity of evidence comparing ticagrelor and clopidogrel in patients with chronic liver disease. We aimed to evaluate the risk of major adverse cardiovascular events (MACE) and major bleeding associated with ticagrelor versus clopidogrel in patients undergoing percutaneous coronary intervention (PCI) due to acute coronary syndrome by chronic liver disease status. METHODS Using the Korean healthcare claim database, we included adult patients who underwent PCI and initiated ticagrelor or clopidogrel treatment within 7 days of an acute coronary syndrome diagnosis. Patients were classified into 2 mutually exclusive groups: patients with chronic liver disease and patients without chronic liver disease. Within each group, the hazard ratios (HRs) with 95% confidence intervals (CIs) of MACE and major bleeding associated with ticagrelor versus clopidogrel were calculated using a Cox proportional hazards model within a 1:1 propensity score (PS) matched cohort. RESULTS The final cohort included 14,261 and 148,535 patients with and without chronic liver disease, respectively. After PS matching, the risk of MACE (with chronic liver disease, HR: 1.01, 95% CI: 0.91-1.13; without chronic liver disease, HR: 1.02, 95% CI: 0.98-1.05; P for homogeneity: 0.865) and major bleeding (with chronic liver disease, HR: 1.07, 95% CI: 0.71-1.61; without chronic liver disease, HR: 1.32, 95% CI: 1.15-1.53; P for homogeneity: 0.342) for ticagrelor versus clopidogrel do not vary with chronic liver disease status. CONCLUSIONS Among acute coronary syndrome patients undergoing PCI, the use of ticagrelor versus clopidogrel was associated with a similar risk of MACE and an increased risk of major bleeding, but these risks did not vary with chronic liver disease status.
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Affiliation(s)
- Bin Hong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Sungho Bea
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seng Chan You
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, South Korea
| | - Yoosoo Chang
- Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea; Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea; Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea.
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Chakraborty S, Sarkar D, Samajdar SS, Biswas P, Mohapatra D, Halder S, Yunus M. Efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI): a systematic review and meta-analysis. Egypt Heart J 2024; 76:48. [PMID: 38625596 PMCID: PMC11021388 DOI: 10.1186/s43044-024-00480-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/08/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND This systematic review and meta-analysis aimed to compare the efficacy and safety of cangrelor as compared to ticagrelor in patients with ST-elevated myocardial infarction (STEMI) who underwent percutaneous intervention. METHODS PubMed, Embase, Scopus, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov databases were searched for relevant head-on-comparison or swapping studies. The primary outcome was the rate of high platelet reactivity (HPR) at specific time intervals after stopping cangrelor infusion during the first 24 h. Secondary outcomes were the risks of thrombosis, all-cause mortality and bleeding. Pooled odds ratios (ORs) were calculated using random-effects models. RESULTS A total of 1018 studies were screened and eight were included in the analysis. There were four head-on-comparison studies and four swapping studies. There was no significant difference in the proportion of patients achieving a high platelet reactivity in swapping studies [OR, 0.71 (95% CI 0.04, 13.87), p = 0.82, i2 = 88%]. In head-on-comparison studies, PRU from Fig. 2B shows there was no significant reduction in high platelet reactivity [mean difference - 77.83 (95% CI - 238.84, 83.18), p < 0.001, i2 = 100%]. PRU results from (Fig. 2C) show a mean difference of 7.38 (95% CI - 29.74, 44.51), p < 0.001, i2 = 97%. There was no significant difference in the risks of thrombosis [OR, 0.91 (95% CI 0.20, 4.13), p = 0.81, i2 = 0%], all-cause mortality [OR, 3.52 (95% CI 0.44, 27.91), p = 0.24, i2 = 26%] and bleeding [OR, 0.89 (95% CI 0.37, 2.17), p = 0.93, i2 = 0%] between the two groups as revealed in the head-on-comparison studies. CONCLUSION The efficacy and safety profiles of cangrelor and ticagrelor were similar in patients with STEMI.
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Affiliation(s)
- Subhro Chakraborty
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India.
| | - Debalina Sarkar
- Department of Endocrinology, RGKar Medical College, Kolkata, India
| | - Shambo Samrat Samajdar
- School of Tropical Medicine Kolkata, Diabetes and Allergy-Asthma Therapeutics Speciality Clinic, Kolkata, India
| | - Pallab Biswas
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Debasish Mohapatra
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Saptarshi Halder
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
| | - Mohammad Yunus
- Department of Cardiology, RGKar Medical College, HA 35, Sector 3, Saltlake CityKolkata, 700097, India
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Huang CL, Tsao TP, Yin WH, Huang WB, Jen HL, Lin CC, Chang CY, Hsu CH. Comprehensive comparative efficacy and safety of potent P2Y 12 inhibitors in patients undergoing coronary intervention: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 51:101359. [PMID: 38371311 PMCID: PMC10869917 DOI: 10.1016/j.ijcha.2024.101359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/05/2024] [Indexed: 02/20/2024]
Abstract
Potent P2Y12 receptor antagonists have been used widely for patients undergoing percutaneous coronary intervention with different results. Benefits from different regimens various between trials. Randomized controlled trials (RCTs) have restrictive inclusion and exclusion criteria; thus, they may limit the generalizability of the findings to a broader population. This study was aimed to comprehensively investigate the outcomes of potent P2Y12 inhibitors in patients undergoing PCI, including RCTs and real-world evidence (RWE) studies. Multiple electronic databases were systemically reviewed and searched on compared potent P2Y12 inhibitors with clopidogrel. The primary efficacy end point was composite ischemic cardiovascular event and primary safety endpoint was major bleeding. Overall estimates of proportions and incidence rates with 95 % confidence intervals (CI) were calculated using fixed-effects models. Total 24 studies (140,986 patients) underwent coronary intervention were included in this meta-analysis, including 18 RCTs and 6 large cohort studies with propensity score matching. The potent P2Y12 inhibitors including cangrelor, prasugrel, and ticagrelor, significantly decreased the risk of composite adverse cardiovascular ischemic events (95 % CI 0.89-0.96, p < 0.001), but increased major bleeding (95 % CI 1.15-1.33, p < 0.001) or any bleeding (95 % CI 1.21-1.33, p < 0.001) compared with Clopidogrel. This meta-analysis merges RCTs and RWE studies and comprehensively evidences newer potent P2Y12 inhibitors are significantly more effective than clopidogrel in reduction of composite adverse thrombotic events, but the incidence of major or any bleeding was higher compared with clopidogrel.
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Affiliation(s)
- Chien-Lung Huang
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Tien-Ping Tsao
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
- National Defense Medical Centre, Taipei, Taiwan, ROC
| | - Wei-Hsian Yin
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
- Deputy Dean, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Wen-Bin Huang
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Hsu-Lung Jen
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chang-Chyi Lin
- Division of Cardiology, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chung-Yi Chang
- Cardiovascular surgeon, Division of Cardiovascular Surgery, Heart Center, Chen Hsin General Hospital, Taipei, Taiwan, ROC
| | - Ching-Hwa Hsu
- School of Nursing, College of Medicine, Chang Gung University, Taiwan, ROC
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Yang J, Zhang R, Liu Q, Bai Y, Zhang L, He T, Zhao Z, Huang M, Cao Y, Wang X, Zhang M. Comparison of clopidogrel and ticagrelor in treating acute coronary syndrome undergoing PCI: A systematic review and meta-analysis. Heliyon 2024; 10:e26553. [PMID: 38455558 PMCID: PMC10918014 DOI: 10.1016/j.heliyon.2024.e26553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/09/2024] Open
Abstract
Objective The study aims to evaluate and compare the efficacy and safety between ticagrelor and clopidogrel in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Methods We searched MEDLINE (via PubMed), Cochrane, Embase, and the Cochrane library databases for eligible citations (the last search was up to December 2021). Subgroup analyses were performed based on region, study design, dose, and single-center/multicenter. Meta regressions were conducted to explore the source of heterogeneity. A sensitivity analysis was conducted to assess the robustness of the results. Funnel plots and Egger's test were preformed to test publication bias of the meta-analysis. Results A total of 29 studies were included, totaling 165,981 patients. Ticagrelor reduced the overall incidence rate of major adverse cardiovascular events (MACEs) (HR 0.74; 95% CI, 0.62, 0.89; P = 0.001; I2 = 88.3%, P < 0.001) and all-cause mortality (HR 0.85; 95% CI, 0.75, 0.97; P = 0.019; I2 = 39.7%, P = 0.052) compared with clopidogrel. However, there was a higher risk of major bleeding (HR 1.21; 95% CI, 1.02,1.44; P = 0.026, I2 = 59.3%, P = 0.012) and all bleeding (HR 1.42; 95% CI, 1.24, 1.62; P < 0.001, I2 = 76.4%, P < 0.001) with ticagrelor compared to clopidogrel. The stability of the results was demonstrated by sensitivity analysis. Furthermore, subgroup analyses and meta-regression revealed that the heterogeneity in the study may stem from factors such as whether it was conducted in a single-center or multicenter setting, as well as the geographical region. Conclusion Ticagrelor has demonstrated superior efficacy compared to clopidogrel in ACS patients undergoing PCI, particularly in Asia and Europe. Nevertheless, it is crucial to acknowledge that the utilization of ticagrelor is linked to a heightened risk of bleeding. To provide guidance for clinical decision-making regarding the use of ticagrelor, future multicenter randomized trials that are relevant and encompass longer follow-up periods are necessary. The category of the manuscript a meta-analysis PROSPERO registration number CRD42021274198.
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Affiliation(s)
- Jing Yang
- Department of Pathology, Chengdu First People's Hospital, Chengdu, Sichuan, China
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Rui Zhang
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
- Gansu Key Laboratory of Stem Cell and Gene Medicine, Gansu, China
| | - Qianqian Liu
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Yuping Bai
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- The Department of Pathology, Hainan Provincial Hospital, Haikou, Hainan, China
| | - Liyan Zhang
- Integrated Traditional Chinese and Western Medicine Hospital, Cangzhou, Hebei, China
| | - Tingting He
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Ziru Zhao
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
| | - Min Huang
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
- Department of Pathology, The 940th Hospital of Joint Logistics Support Force of Chinese People's Liberation Army, Lanzhou, China
- Gansu Key Laboratory of Stem Cell and Gene Medicine, Gansu, China
| | - Yunshan Cao
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
| | | | - Min Zhang
- First School of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou 730000, Gansu, China
- Gansu Provincial Hospital, Lanzhou, Gansu, China
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Li Y, Li Y, Qiu M, Xue Y, Xu K, Han Y. Ticagrelor vs clopidogrel when coadministered with bivalirudin in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Res Pract Thromb Haemost 2024; 8:102375. [PMID: 38623472 PMCID: PMC11017352 DOI: 10.1016/j.rpth.2024.102375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/11/2023] [Accepted: 01/05/2024] [Indexed: 04/17/2024] Open
Abstract
Background The optimal perioperative antithrombotic strategy for patients with acute coronary syndrome (ACS) during percutaneous coronary intervention (PCI) remains controversial. Objectives To determine the safety and effectiveness of bivalirudin plus ticagrelor vs bivalirudin plus clopidogrel in patients with ACS undergoing PCI in the real world. Methods Between March 2016 and March 2019, 7234 patients with ACS who had undergone PCI, received bivalirudin periprocedurally, and were prescribed ticagrelor or clopidogrel were enrolled in a single-center, all-comer, modern, retrospective cohort study. Incidence rates of 12-month ischemia (cardiac death, myocardial infarction, or stroke), all-cause death, Bleeding Academic Research Consortium (BARC) type 2,3,5 bleeding, and BARC type 3,5 bleeding were compared between different groups. Results In total, 4960 patients received bivalirudin plus clopidogrel and 2274 patients received bivalirudin plus ticagrelor. Compared with bivalirudin plus clopidogrel, bivalirudin plus ticagrelor was associated with lower ischemic events (1.74% vs 2.84%; relative risk, 0.61; 95% CI, 0.41-0.91; P = .02) and stroke (0.05% vs 1.01%, P < .001) within 12 months after PCI without excessive risk of bleeding (BARC type 2,3,5 bleeding: 4.49% vs 3.76%, P = .22; BARC type 3,5 bleeding: 2.84% vs 2.02%, P = .08). The beneficial effects of bivalirudin plus ticagrelor were consistent among subgroups. Conclusion As an initial treatment strategy, bivalirudin plus ticagrelor could reduce the 12-month risk of ischemic events compared with bivalirudin plus clopidogrel significantly without increasing the bleeding risk in ACS patients undergoing PCI.
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Affiliation(s)
- Yang Li
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Miaohan Qiu
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Xue
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kai Xu
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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11
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Khalid AR, Ahmad F, Naeem MAB, Ahmed S, Umar M, Mehmood H, Kashif M, Ali S. Safety of Clopidogrel vs. Ticagrelor in Dual Antiplatelet Therapy Regimens for High-Bleeding Risk Acute Coronary Syndrome Patients: A Comprehensive Meta-analysis of Adverse Outcomes. High Blood Press Cardiovasc Prev 2024; 31:141-155. [PMID: 38557855 DOI: 10.1007/s40292-024-00635-3] [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: 12/07/2023] [Accepted: 03/09/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Patients of acute coronary syndrome (ACS) at a high-bleeding risk (HBR) often require dual antiplatelet therapy (DAPT) to reduce the risk of recurrent cardiovascular events. Clopidogrel and ticagrelor are the most commonly used antiplatelet agents in DAPT regimens. However, the safety profiles of these drugs in ACS patients at HBR remain a subject of ongoing debate. AIM To investigate any difference between the safety of clopidogrel and ticagrelor used as a part of DAPT regimen in ACS patients at HBR. METHODS A systematic search on PubMed, Cochrane Library, and Google Scholar was conducted to identify experimental and observational studies published up to the knowledge cutoff date in September 2023. Studies comparing the safety of clopidogrel and ticagrelor in ACS patients at HBR were included for analysis. The primary outcomes assessed were major bleeding events, stroke, and myocardial infarction (MI), while secondary outcomes included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and net adverse clinical and cerebral events (NACCE). RESULTS We included a total of 8 observational studies in our meta-analysis. The pooled analysis revealed a statistically significant increase in the risk of MI (pooled RR = 1.43; 95% CI 1.12-1.83; P = 0.005) in the patients using clopidogrel. There were no statistically significant differences in major bleeding events (pooled RR = 0.94; 95% CI 0.82-1.09; P = 0.44), stroke (pooled RR = 1.36; 95% CI 0.86-2.14; P = 0.18), all-cause mortality (pooled RR = 1.17; 95% CI 0.97-1.41; P = 0.10), MACCE (pooled RR = 1.07; 95% CI 0.76-1.50; P = 0.69) and NACCE (pooled RR = 0.95; 95% CI 0.66-1.37; P = 0.78) between the two groups. Subgroup analyses based on region were performed. CONCLUSION Both drugs are generally safe for treating ACS patients with HBR at baseline, although a higher risk of MI was observed with the use of clopidogrel. Nevertheless, drug choice should factor in regional variations, patient-specific characteristics, cost, accessibility, and potential drug interactions.
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Affiliation(s)
| | - Farooq Ahmad
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | - Smak Ahmed
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | - Muhammad Umar
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
| | | | | | - Shazib Ali
- Allama Iqbal Medical College, Lahore, Punjab, Pakistan
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12
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Liu J, Li C, Mei W, Qin H. The research progress and research trends in acute coronary syndrome nursing: A review of visual analysis based on the Web of Science database. Medicine (Baltimore) 2024; 103:e35849. [PMID: 38363951 PMCID: PMC10869036 DOI: 10.1097/md.0000000000035849] [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: 07/19/2023] [Accepted: 10/03/2023] [Indexed: 02/18/2024] Open
Abstract
Acute coronary syndrome (ACS) is one of the most common and severe forms of cardiovascular disease and has attracted worldwide attention with increased morbidity and mortality in recent years. There are few review studies in the field of its care in the form of bibliometric studies. We searched the Web of Science Core Collection database for articles and reviews in the area of ACS nursing for visual mapping analysis. Our objectives are to explore the hot topics and frontiers of research in the field of ACS nursing and to identify collaborative relationships between countries, institutions, and authors. This study will provide researchers with intuitive reference data for future in-depth studies of ACSs.
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Affiliation(s)
- Jialong Liu
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Chaojun Li
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Wanping Mei
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Hanzhi Qin
- Department of Nursing, the First Affiliated Hospital of University of Science and Technology of China, Hefei, China
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13
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Almendro-Delia M, Padilla-Rodríguez G, Hernández-Meneses B, Blanco-Ponce E, Arboleda-Sánchez JA, Rodríguez-Yáñez JC, Soto-Blanco JM, Fernández-García I, Castillo-Caballero JM, García-Rubira JC, Hidalgo-Urbano R. Nonadherence to ticagrelor versus clopidogrel and clinical outcomes in patients with ACS. Results from the CREA-ARIAM registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:113-124. [PMID: 37573968 DOI: 10.1016/j.rec.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/16/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Prior studies have not determined whether the effect of dual antiplatelet therapy (DAPT) cessation on the subsequent risk of major adverse cardiac events (MACE) varies by the choice of P2Y12-inhibitor after acute coronary syndrome (ACS). METHODS We performed a prespecified subanalysis of a multicenter, prospective registry of ACS patients discharged on ticagrelor or clopidogrel between 2015 and2019. Nonadherence to DAPT was categorized as physician-guided discontinuation and disruption due to adverse effects, nonadherence, or bleeding. The association between DAPT cessation and 1-year MACE was analyzed using multivariate time-updated Cox models with inverse probability of censoring weighted estimators. RESULTS Out of 2180 patients, 174 (8.3%) prematurely discontinued DAPT (physician-guided, n=126; disruption, n=48). Nonadherent patients were older and had more comorbidities than those on DAPT. Compared with physician-guided discontinuation, disruption occurred earlier after discharge and was more frequent with ticagrelor than with clopidogrel. In time-varying analysis, DAPT cessation was associated with an increased risk of MACE (adjusted HR, 1.32, 95%CI, 1.10-1.76), largely driven by disruption (adjusted HR, 1.47, 95%CI, 1.22-1.73). There was an exponential increase in MACE risk after DAPT cessation within 90 days after ACS, especially after disruption of ticagrelor compared with clopidogrel (Pinteraction<.001). After adjustment for DAPT duration, this interaction was not statistically significant on the additive scale (relative excess risk due to interaction 0.12, 95%CI,-0.99-1.24). CONCLUSIONS In this all-comers registry, 1 in 12 patients prematurely discontinued DAPT within 1 year after ACS. Compared with physician-recommended discontinuation, disruption resulted in a significantly higher risk of MACE. After adjustment for DAPT duration, this association was not moderated by the choice of P2Y12-inhibitor. Clinical trial registered at ClinicalTrials.gov (Identifier: NCT02500290).
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Affiliation(s)
- Manuel Almendro-Delia
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain.
| | | | | | - Emilia Blanco-Ponce
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | | | | | | | | | - Juan C García-Rubira
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rafael Hidalgo-Urbano
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
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14
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Ortega-Paz L, Mehran R, Angiolillo DJ. Nonadherence to dual antiplatelet therapy: old problems without new solutions. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:125-128. [PMID: 37659651 DOI: 10.1016/j.rec.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States.
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15
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Andò G, Gragnano F, Pelliccia F, Calabrò P. Choice of P2Y12 Inhibitors After Acute Coronary Syndrome. Am J Cardiol 2024; 211:377. [PMID: 37944777 DOI: 10.1016/j.amjcard.2023.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "G. Martino", Messina, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
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16
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Klein LW. Ticagrelor Versus Clopidogrel for Acute Coronary Syndrome: Have Things Changed? Am J Cardiol 2024; 210:315-316. [PMID: 37918476 DOI: 10.1016/j.amjcard.2023.10.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/04/2023]
Affiliation(s)
- Lloyd W Klein
- Cardiology Division, University of California, San Francisco, California.
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17
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes. Pharmacoepidemiol Drug Saf 2024; 33:e5704. [PMID: 37771242 DOI: 10.1002/pds.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.
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Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California, USA
| | | | - Maneesh Sud
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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18
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Mehdizadeh Parizi M, Golchin Vafa R, Ahmadi A, Heydarzade R, Sadeghi M, Khademolhossseini A, Amiri F, Khoshnood Mansorkhani S, Tavan A, Hosseini N, Montaseri M, Hosseini SA, Kojuri J. Comparison of Ticagrelor and Clopidogrel in Elective Coronary Stenting: A Double Blind Randomized Clinical Trial. J Interv Cardiol 2023; 2023:5544440. [PMID: 38170033 PMCID: PMC10761231 DOI: 10.1155/2023/5544440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/24/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
Background Dual antiplatelet therapy with a P2Y12 inhibitor (e.g., clopidogrel and ticagrelor) and aspirin is recommended for at least one year after percutaneous coronary intervention (PCI) to prevent further myocardial infarction and stent thrombosis as the major adverse effects of PCI. Methods This randomized clinical trial was conducted from October 2022 to March 2023. Patients who had undergone elective PCI were included in the study. Patients were randomized into two different groups. One group took ASA 80 mg and clopidogrel 75 mg once daily, while the other took ASA 80 mg once daily and ticagrelor 90 mg twice daily. After six months of close follow-up, patients were asked to score their dyspnea on a 10-point Likert scale. They were also asked about dyspnea on exertion, paroxysmal nocturnal dyspnea (PND), bleeding, and the occurrence of major adverse cardiovascular events (MACEs). Results 223 patients were allocated to the clopidogrel group and 214 to the ticagrelor group. In the ticagrelor group, 95 patients (44.3%) reported dyspnea at rest, compared with only 44 patients (19.7%) in the clopidogrel group (P < 0.001). MACEs occurred in 7 patients (2.8%) in the ticagrelor group, compared with 16 (7.6%) in the clopidogrel group (P = 0.031). Eight patients (3.8%) reported bleeding with ticagrelor, as did seven (3.2%) with clopidogrel (P = 0.799). Conclusions New-onset dyspnea was recorded more frequently with ticagrelor than clopidogrel, yet fewer MACEs occurred with ticagrelor (ClinicalTrials.gov number: NCT05858918).
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Affiliation(s)
| | | | - Amin Ahmadi
- Professor Kojuri Cardiology Clinic, Shiraz, Iran
| | | | | | | | | | | | - Ali Tavan
- Professor Kojuri Cardiology Clinic, Shiraz, Iran
| | | | | | | | - Javad Kojuri
- Professor Kojuri Cardiology Clinic, Shiraz, Iran
- Cardiology Department, Shiraz University of Medical Sciences, Shiraz, Iran
- Clinical Education Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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19
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Tang KS, Banerjee S, Tang G, Patel PM, Frangieh AH. Shortened Duration of Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention: A Contemporary Clinical Review. Interv Cardiol 2023; 18:e31. [PMID: 38213748 PMCID: PMC10782423 DOI: 10.15420/icr.2023.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/08/2023] [Indexed: 01/13/2024] Open
Abstract
Percutaneous coronary intervention with stent implantation is an integral aspect of minimally interventional cardiac procedures. The technology and techniques behind stent design and implantation have evolved rapidly over several decades. However, continued discourse remains around optimal peri- and post-interventional management with dual antiplatelet therapy to minimise both major cardiovascular or cerebrovascular events and iatrogenic bleeding risk. Standard guidelines around dual antiplatelet therapy historically recommended long-term dual antiplatelet therapy for 12 months (with consideration for >12 months in certain patients); however, emerging data and generational improvements in the safety of drug-eluting stents have ushered in a new era of short-term therapy to reduce the incidence of major bleeding events. This case review will provide an overview of the current state of guidelines around duration of dual antiplatelet therapy and examine recent updates and continued gaps in existing research.
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Affiliation(s)
- Kevin S Tang
- Division of Internal Medicine, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Shoujit Banerjee
- Division of Internal Medicine, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - George Tang
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Pranav M Patel
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
| | - Antonio H Frangieh
- Division of Cardiology, Department of Medicine, University of California Irvine HealthOrange, CA, US
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20
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Tunströmer K, Faxälv L, Larsson P, Lindahl TL, Boknäs N. Thrombus remodelling by reversible and irreversible P2Y 12 inhibitors. Platelets 2023; 34:2157805. [PMID: 36631918 DOI: 10.1080/09537104.2022.2157805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pharmacological inhibition of the platelet ADP-receptor P2Y12 is a cornerstone in the prevention of atherothrombotic events in adult patients with acute coronary syndrome (ACS). Thienopyridines such as clopidogrel and prasugrel exert their antithrombotic effect by means of active metabolites that irreversibly inhibit P2Y12. Due to the short half-life of these metabolites, a subpopulation of ADP-responsive platelets will form in between dosing. With increased platelet turnover rate or poor patient compliance, the fraction of ADP-responsive platelets will increase, potentially increasing the risk for new thrombotic events. In contrast, the reversible P2Y12 inhibition produced by direct-acting ADP blockers such as ticagrelor and cangrelor inhibit the entire platelet population. In this study, we evaluated the impact of these pharmacological differences on thrombus formation in an ex vivo flow chamber model. A customized image analysis pipeline was used for automatized, large-scale identification and tracking of single platelets incorporated into the thrombus, enabling quantitative analysis of the relative contribution of inhibited and uninhibited platelets to thrombus growth and consolidation. Comparative experiments were conducted using the irreversible and reversible P2Y12 inhibitors prasugrel active metabolite (PAM) and ticagrelor, respectively. Our results show that PAM inhibited thrombus platelet recruitment more gradually than ticagrelor, with a slower onset of inhibition. Further, we show that the presence of a small fraction (<10%) of uninhibited platelets did not abrogate the antithrombotic effect of PAM to any significant extent. Finally, we demonstrate a gradual enrichment of inhibited platelets in the thrombus shell due to selective recruitment of inhibited platelets to the thrombus periphery.
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Affiliation(s)
- Kjersti Tunströmer
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lars Faxälv
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Pia Larsson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Tomas L Lindahl
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Clinical Chemistry and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Niklas Boknäs
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.,Department of Hematology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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21
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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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22
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Magavern EF, Jacobs B, Warren H, Finocchiaro G, Finer S, van Heel DA, Smedley D, Caulfield MJ. CYP2C19 Genotype Prevalence and Association With Recurrent Myocardial Infarction in British-South Asians Treated With Clopidogrel. JACC. ADVANCES 2023; 2:None. [PMID: 37808344 PMCID: PMC10550831 DOI: 10.1016/j.jacadv.2023.100573] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/04/2023] [Accepted: 07/17/2023] [Indexed: 10/10/2023]
Abstract
Background Cytochrome P450 family 2 subfamily C member 19 (CYP2C19) is a hepatic enzyme involved in the metabolism of clopidogrel from a prodrug to its active metabolite. Prior studies of genetic polymorphisms in CYP2C19 and their relationship with clinical efficacy have not included South Asian populations. Objectives The objective of this study was to assess prevalence of common CYP2C19 genotype polymorphisms in a British-South Asian population and correlate these with recurrent myocardial infarction risk in participants prescribed clopidogrel. Methods The Genes & Health cohort of British Bangladeshi and Pakistani ancestry participants were studied. CYP2C19 diplotypes were assessed using array data. Multivariable logistic regression was used to test for association between genetically inferred CYP2C19 metabolizer status and recurrent myocardial infarction, controlling for known cardiovascular disease risk factors, percutaneous coronary intervention, age, sex, and population stratification. Results Genes & Health cohort participants (N = 44,396) have a high prevalence (57%) of intermediate or poor CYP2C19 metabolizers, with at least 1 loss-of-function CYP2C19 allele. The prevalence of poor metabolizers carrying 2 CYP2C19 loss-of-function alleles is 13%, which is higher than that in previously studied European (2.4%) and Central/South Asian populations (8.2%). Sixty-nine percent of the cohort who were diagnosed with an acute myocardial infarction were prescribed clopidogrel. Poor metabolizers were significantly more likely to have a recurrent myocardial infarction (OR: 3.1; P = 0.019). Conclusions A pharmacogenomic-driven approach to clopidogrel prescribing has the potential to impact significantly on clinical management and outcomes in individuals of Bangladeshi and Pakistani ancestry.
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Affiliation(s)
- Emma F. Magavern
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Benjamin Jacobs
- The Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Helen Warren
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gherardo Finocchiaro
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
| | - Sarah Finer
- The Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - David A. van Heel
- The Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Genes & Health Research Team
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- The Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom
- Cardiovascular Sciences Research Centre, St George's, University of London, London, United Kingdom
- The Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Damian Smedley
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Mark J. Caulfield
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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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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24
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Wu H, Jia S. A Comparative Study on Ticagrelor and Clopidogrel in Patients With Acute Coronary Syndrome Treated With Primary Percutaneous Coronary Intervention. J Clin Pharmacol 2023; 63:776-783. [PMID: 37017131 DOI: 10.1002/jcph.2239] [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: 01/17/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Abstract
This study was conducted to compare the efficacy and safety of ticagrelor and clopidogrel in patients with acute coronary syndrome (ACS) treated with primary percutaneous coronary intervention (PPCI). A total of 3528 consecutive patients with ACS treated with PPCI were divided into the ticagrelor and clopidogrel groups based on their dual antiplatelet therapy regimen at hospital discharge. Patient follow-up visits were completed 1, 6, and 12 months after PPCI treatment. Major adverse cardiac events (MACEs) and Bleeding Academic Research Consortium (BARC) bleeding events were assessed in both groups. In total, 2501 cases were included in the ticagrelor group, and 817 cases were included in the clopidogrel group. The incidence of MACEs was lower in the ticagrelor group than in the clopidogrel group (P < .05). The ticagrelor group had lower incidence of all-cause death and cardiac death compared with the clopidogrel group, and the difference was significant (P < .05). The incidences of study end points, including recurrent myocardial infarction and repeat revascularization, were not significantly different between the groups (P > .05). The incidences of BARC total and major bleeding events were not significantly different between the groups (P > .05). However, the incidences of BARC type 1 and 2 bleeding events were lower in the ticagrelor group than in the clopidogrel group (P < .05). The multivariate Cox regression analysis suggested that ticagrelor could decrease all-cause death compared with clopidogrel (P = .021). In patients with ACS treated with PPCI, ticagrelor could significantly reduce the risk of MACEs compared with clopidogrel, without increasing the risk of bleeding.
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Affiliation(s)
- Hui Wu
- Heart Centre & Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical Medical College, Ningxia Medical University, Yinchuan, Ningxia, China
| | - Shaobin Jia
- Heart Centre & Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, Ningxia, China
- Clinical Medical College, Ningxia Medical University, Yinchuan, Ningxia, China
- Ningxia Key Laboratory of Vascular Injury and Repair Research, Ningxia Medical University, Yinchuan, China
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25
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Sachdeva A, Mutyala R, Mantri N, Zhu S, McNulty E, Solomon M. P2Y12 Inhibitors in Acute Coronary Syndromes: A Real-World, Community-Based Comparison of Ischemic and Bleeding Outcomes. J Interv Cardiol 2023; 2023:1147352. [PMID: 37251366 PMCID: PMC10224789 DOI: 10.1155/2023/1147352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 02/09/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background Randomized trials have shown superiority of the novel P2Y12 inhibitors over clopidogrel in patients with acute coronary syndrome (ACS), but clinical benefit in the community remains controversial. Our objective was to compare the safety and efficacy of clopidogrel to ticagrelor and prasugrel in patients with ACS undergoing percutaneous coronary intervention (PCI) in a real-world population. Methods We conducted a retrospective cohort study of patients with ACS who underwent PCI and were discharged with clopidogrel, ticagrelor, or prasugrel from 2012 to 2018 within Kaiser Permanente Northern California. We used Cox proportional hazard models with propensity-score matching to evaluate the association of the P2Y12 agent with the primary outcomes of all-cause mortality, myocardial infarction (MI), stroke, and bleeding events. Results The study included 15,476 patients (93.1% on clopidogrel, 3.6% on ticagrelor and 3.2% on prasugrel). Compared to the clopidogrel group, ticagrelorand prasugrel patients were younger with less comorbidities. In multivariable models with propensity-score matching, we found a lower risk of all-cause mortality in the ticagrelor vs the clopidogrel group (HR (95% CI) 0.43 (0.20-0.92)), but no differences in the other endpoints, and no difference between prasugrel and clopidogrel among any endpoints. A larger proportion of patients on ticagrelor or prasugrel switched to an alternative P2Y12 agent vs. clopidogrel (p < 0.01), and a higher level of persistence was seen among patients on clopidogrel vs. ticagrelor (p = 0.03) or prasugrel (p < 0.01). Conclusion Among patients with ACS who underwent PCI, we observed a lower risk of all-cause mortality in patients treated with ticagrelor vs clopidogrel, but no difference in other clinical endpoints nor any differences in endpoints between prasugrel vs. clopidogrel users. These results suggest that further study is needed to identify an optimal P2Y12 inhibitor in a real-world population.
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Affiliation(s)
- Amit Sachdeva
- Division of Cardiology, Kaiser Permanente Northern California, Walnut Creek, California, USA
| | | | - Neha Mantri
- Division of Cardiology, Kaiser Permanente Northern California, San Francisco, California, USA
| | - Shiyun Zhu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Edward McNulty
- Division of Cardiology, Kaiser Permanente Northern California, San Francisco, California, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Matthew Solomon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Division of Cardiology, Kaiser Permanente Northern California, Oakland, California, USA
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26
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Wiens EJ, Leon SJ, Whitlock R, Tangri N, Shah AH. Ticagrelor as Compared to Clopidogrel Following Percutaneous Coronary Intervention for Acute Coronary Syndrome. Am J Cardiol 2023; 198:26-32. [PMID: 37196530 DOI: 10.1016/j.amjcard.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/02/2023] [Accepted: 03/16/2023] [Indexed: 05/19/2023]
Abstract
Dual antiplatelet therapy with acetylsalicylic acid and a P2Y12 inhibitor has become a mainstay of therapy after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Although higher-potency P2Y12 inhibitors are preferred over clopidogrel in major society guidelines, recent evidence has questioned the extent of the benefit. It is important to evaluate the relative efficacy and safety of P2Y12 inhibitors in a real-world setting. This is a retrospective cohort study of all patients who underwent PCI for ACS in a Canadian province from January 1, 2015 to March 31, 2020. Baseline characteristics, including co-morbidities, medications, and bleeding risk, were obtained. Propensity matching was used to compare patients who received ticagrelor versus clopidogrel. The primary outcome was occurrence of major adverse cardiovascular events (MACEs) at 12 months, defined as death, nonfatal myocardial infarction, or unplanned revascularization. Secondary outcomes included all-cause mortality, major bleeding, stroke, and all-cause hospitalization. A total of 6,665 patients were included; 2,108 received clopidogrel and 4,214 received ticagrelor. Patients who received clopidogrel were older, had more co-morbidities, including cardiovascular risk factors, and had a higher bleeding risk. In 1.925 propensity score-matched pairs, ticagrelor was associated with a significantly lower risk of MACE (hazard ratio 0.79, 0.67 to 0.93, p <0.01) and hospitalization (hazard ratio 0.85, 0.77 to 0.95, p <0.01). No difference was observed in the risk of major bleeding. A statistically nonsignificant trend toward reduced risk of all-cause mortality was noted. In conclusion, in a real-world high-risk cohort, ticagrelor was associated with decreased risk of MACE and all-cause hospitalization compared with clopidogrel after PCI for ACS.
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Affiliation(s)
- Evan J Wiens
- Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Silvia J Leon
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Reid Whitlock
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada
| | - Navdeep Tangri
- Chronic Disease Innovation Center, Seven Oaks General Hospital, Winnipeg, Manitoba, Canada; Section of Nephology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ashish H Shah
- Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, Canada; Institute of Cardiovascular Sciences, Albretchsen Research Center, Winnipeg, Manitoba, Canada.
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27
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Moser N, Omar MA, Koshman SL, Lin M, Youngson E, Kent W, Harten C. Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00198-8. [PMID: 37061910 DOI: 10.1016/j.jtcvs.2023.03.004] [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] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 03/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.
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Affiliation(s)
- Nils Moser
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - William Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Cheryl Harten
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
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28
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Akdogan RE, Chen J, Varon A, Muradova E, Fusco J. Generalized Drug Eruption Secondary to Ticagrelor: A Case Report and Review of the Literature. Cureus 2023; 15:e34800. [PMID: 36915853 PMCID: PMC10007906 DOI: 10.7759/cureus.34800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2023] [Indexed: 02/11/2023] Open
Abstract
Currently, guidelines recommend ticagrelor over clopidogrel as part of dual antiplatelet therapy with aspirin in treating individuals with acute coronary syndrome. As there is an increased usage of ticagrelor, it is important to keep in mind uncommon adverse events, including hypersensitivity skin reactions. To date, only a few studies have been published regarding ticagrelor-induced skin eruptions. Additionally, there is no consensus on antiplatelet therapy management after a hypersensitivity reaction to antiplatelet agents. Hereinafter, we describe a case of an 81-year-old female who presents with a diffuse erythematous hypersensitivity eruption, including palms and soles, secondary to ticagrelor use. Ticagrelor transitioned to clopidogrel, and the patient was started on steroid taper with an antihistamine. The patient's rash progressively improved after the treatment. Our case demonstrates a rare adverse effect of ticagrelor, which needs prompt diagnosis and switching to one of the thienopyridines to prevent thrombosis.
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Affiliation(s)
- Raziye E Akdogan
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Jennifer Chen
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Alberto Varon
- Internal Medicine, University of Connecticut School of Medicine, Farmington, USA
| | - Elnara Muradova
- Dermatology, University of Connecticut School of Medicine, Farmington, USA
| | - Joseph Fusco
- Internal Medicine, St. Francis Hospital, Hartford, USA
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29
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Kumar A, Lutsey PL, St Peter WL, Schommer JC, Van't Hof JR, Rajpurohit A, Farley JF. Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study. Clin Pharmacol Ther 2023; 113:401-411. [PMID: 36399019 PMCID: PMC9877194 DOI: 10.1002/cpt.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022]
Abstract
Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.
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Affiliation(s)
- Arun Kumar
- Department of Pharmacy Practice & Administrative SciencesJames L. Winkle College of Pharmacy, University of CincinnatiCincinnatiOhioUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthSchool of Public Health, University of MinnesotaMinneapolisMinnesotaUSA
| | - Wendy L. St Peter
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jon C. Schommer
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Jeremy R. Van't Hof
- Cardiovascular Division and Lillehei Heart InstituteUniversity of Minnesota Medical SchoolMinneapolisMinnesotaUSA
| | - Abhijeet Rajpurohit
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
| | - Joel F. Farley
- Department of Pharmaceutical Care and Health SystemsCollege of Pharmacy, University of MinnesotaMinneapolisMinnesotaUSA
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30
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Yeh CH, Chung WJ, Chen TY, Wu PJ, Tseng CH, Lee CH, Cheng CI. The Impact of FEV1/FVC Ratio on the Clinical Outcomes in Acute Coronary Syndrome Patients Treated with Dual Anti-Platelet Agents. ACTA CARDIOLOGICA SINICA 2023; 39:116-126. [PMID: 36685154 PMCID: PMC9829852 DOI: 10.6515/acs.202301_39(1).20220601a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 06/01/2022] [Indexed: 01/24/2023]
Abstract
Background Few studies have investigated the clinical efficacy and pulmonary side effects of different P2Y12 inhibitors in acute coronary syndrome (ACS) patients. The aim of this study was to explore the impact of forced expiratory volume in 1 second over forced vital capacity (FEV1/FVC) ratio on the clinical outcomes in ACS patients treated with dual antiplatelet therapy after percutaneous coronary intervention (PCI). Methods ACS patients who underwent PCI, had documented pre-existing spirometry tests, and received aspirin with either ticagrelor or clopidogrel were enrolled for retrospective analysis. Results Of the enrolled ACS patients, 275 and 247 received ticagrelor and clopidogrel, respectively. The incidence of wheeze was significantly higher in the ticagrelor group compared to the clopidogrel group within 360 days (14.91% vs. 8.09%, p = 0.016). Multivariable analysis revealed that ticagrelor treatment, as compared to clopidogrel treatment, independently predicted 1-year hospitalization for acute exacerbation (AE) of obstructive airway disease (hazard ratio: 3.44; 95% confidence interval: 1.92 to 6.15; p < 0.01). The receiver operating characteristic curve indicated that an FEV1/FVC ratio of 63.85% had the highest sensitivity and specificity for predicting the incidence of AE of obstructive airway disease within 1 year (p < 0.001). The 1-year hospitalization rate for AE of obstructive airway disease was significantly higher in the ticagrelor group when the FEV1/FVC ratio was < 63%. Conclusions This study demonstrated higher incidence of wheeze and hospitalization for AE of obstructive airway disease in ACS patients treated with ticagrelor compared to clopidogrel. Furthermore, the FEV1/FVC ratio ≤ 63% in the ACS patients predicted hospitalization for AE of obstructive airway disease in 1 year.
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Affiliation(s)
- Chia-Hung Yeh
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Wen-Jung Chung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Tien-Yu Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Chien-Hao Tseng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Chien-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Cheng-I Cheng
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital
- Chang Gung University School of Medicine, Kaohsiung, Taiwan
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31
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Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, Christensen MK, Butt JH, Gislason G, Køber L, Fosbøl EL, Sessa M, Bhatt DL, Torp-Pedersen C, Pareek M. Effectiveness and safety of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a nationwide registry-based study. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:697-705. [PMID: 35950769 DOI: 10.1093/ehjacc/zuac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 07/10/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
AIMS To compare the effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS Nationwide, registry-based study of STEMI patients treated with primary PCI (2011-17) and subsequently with aspirin and a P2Y12 inhibitor. The effectiveness outcome was major adverse cardiovascular events (MACE) defined as a composite of recurrent myocardial infarction, repeat revascularization, stroke, or cardiovascular death at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate absolute and relative risks for outcomes standardized to the distributions of demographic characteristics of all included subjects. We included 10 832 patients; 1 697 were treated with clopidogrel, 7 508 with ticagrelor, and 1,627 with prasugrel. Median ages were 66, 63, and 59 years (P < 0.001). Standardized relative risks of MACE were 0.75 for ticagrelor vs. clopidogrel (95% confidence interval [CI], 0.64-0.83), 0.84 for prasugrel vs. clopidogrel (95% CI, 0.73-0.94), and 1.12 for prasugrel vs. ticagrelor (95% CI, 1.00-1.24). Standardized relative risks of bleeding were 0.77 for ticagrelor vs. clopidogrel (95% CI, 0.59-0.93), 0.89 for prasugrel vs. clopidogrel (95% CI, 0.64-1.15), and 1.17 for prasugrel vs. ticagrelor (95% CI, 0.89-1.45). CONCLUSION Ticagrelor and prasugrel were associated with lower risks of MACE after STEMI than clopidogrel, and ticagrelor was associated with a marginal reduction compared with prasugrel. The risk of bleeding was lower with ticagrelor compared with clopidogrel, but did not significantly differ between ticagrelor and prasugrel.
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Affiliation(s)
- Sissel J Godtfredsen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
| | - Peter Leutscher
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Steen Hylgaard Jørgensen
- Centre for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
- Department of Cardiology, North Denmark Regional Hospital, Bispensgade 37, 9800 Hjørring, Denmark
| | - Martin Kirk Christensen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Maurizio Sessa
- Department of Drug Design and Pharmacology, University of Copenhagen, Jagtvej 160 Building 22, 2100 Copenhagen, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
| | - Christian Torp-Pedersen
- Department of Clinical Medicine, Aalborg University, Søndre Skovvej 15, 9000 Aalborg, Denmark
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Manan Pareek
- Department of Cardiology, Copenhagen University Hospital, Gentofte Hospitalsvej 1, 2900 Hellerup, Denmark
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, 70 Francis St., Boston, MA 02115, USA
- Department of Cardiology and Clinical Epidemiology, North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
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Abrahams T, Brown A, Pol D. Prescribing Trends and Health Care Expenditure of P2Y12 Prescriptions in Australia Over the Last Decade. Heart Lung Circ 2022; 31:1369-1375. [DOI: 10.1016/j.hlc.2022.06.667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/02/2022] [Accepted: 06/06/2022] [Indexed: 10/16/2022]
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Ozaki AF, Jackevicius CA, Chong A, Sud M, Fang J, Austin PC, Ko DT. Hospital-Level Variation in Ticagrelor Use in Patients With Acute Coronary Syndrome. J Am Heart Assoc 2022; 11:e024835. [PMID: 35766263 PMCID: PMC9333376 DOI: 10.1161/jaha.121.024835] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Despite improved outcomes associated with ticagrelor compared with clopidogrel in acute coronary syndrome (ACS), many studies have demonstrated slow adoption of ticagrelor in the United States because of its increased cost. Less is known about how ticagrelor is adopted when there is no added cost consideration. Our objectives were to determine patterns of use of ticagrelor, hospital‐level adoption of ticagrelor use, and factors associated with its use after ACS in a publicly funded health care system. Methods and Results We conducted a population‐based cohort study including patients (≥65 years) hospitalized with their first ACS from April 2014 to March 2018 in Ontario, Canada. We determined temporal trends in ticagrelor use and hospital‐level adoption of its use post‐ACS discharge. Using hierarchical regression models, we identified significant predictors of ticagrelor use. There were 23 962 patients with ACS (mean age 76.3 years, 59.7% men) hospitalized in 156 hospitals. Overall ticagrelor use increased from 32.6% in 2014/2015 to 51.8% in 2017/2018. There was substantial variation in ticagrelor use post‐ACS across hospitals, with hospital‐specific prescribing rates ranging from 0% to 83.6%. Lower odds of ticagrelor use was associated with advanced age and the presence of comorbidities. Besides patient factors, being admitted to a rurally located hospital more than halved the odds of being prescribed ticagrelor (odds ratio [OR], 0.49; 95% CI, 0.32–0.77). Being managed by a cardiologist during the index ACS hospitalization was associated with higher odds of having a ticagrelor prescription after ACS (OR, 2.80; 95% CI, 2.36–3.33). Conclusions Ticagrelor use rates varied substantially across hospitals and were strongly associated with physician and hospital factors independent of patient characteristics.
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Affiliation(s)
- Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine CA United States
| | - Cynthia A Jackevicius
- School of Pharmacy & Pharmaceutical Sciences University of California Irvine CA United States.,College of Pharmacy Western University of Health Sciences Pomona CA United States.,Veterans Affairs Greater Los Angeles Healthcare System Los Angeles CA United States.,ICES Toronto Canada.,University of Toronto Ontario Canada
| | | | - Maneesh Sud
- University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Ontario Canada
| | | | - Peter C Austin
- ICES Toronto Canada.,University of Toronto Ontario Canada
| | - Dennis T Ko
- ICES Toronto Canada.,University of Toronto Ontario Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Ontario Canada
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34
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Almendro-Delia M, Blanco-Ponce E, Carmona-Carmona J, Arboleda Sánchez JA, Rodríguez Yáñez JC, Soto Blanco JM, Fernández García I, Castillo Caballero JM, García-Rubira JC, Hidalgo-Urbano RJ. Comparative Safety and Effectiveness of Ticagrelor versus Clopidogrel in Patients With Acute Coronary Syndrome: An On-Treatment Analysis From a Multicenter Registry. Front Cardiovasc Med 2022; 9:887748. [PMID: 35711382 PMCID: PMC9197128 DOI: 10.3389/fcvm.2022.887748] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The net clinical benefit of ticagrelor over clopidogrel in acute coronary syndrome (ACS) has recently been questioned by observational studies which did not account for time-dependent confounders. We aimed to assess the comparative safety and effectiveness of ticagrelor vs. clopidogrel accounting for non-adherence in a real-life setting. Methods This is a prospective, multicenter cohort study of patients with ACS discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, and the use of prasugrel or oral anticoagulation. Association of P2Y12 inhibitor therapy with 1-year risk of Bleeding Academic Research Consortium Type 3 or 5 bleeding; major adverse cardiac events (MACEs), a composite endpoint of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or urgent target lesion revascularization; definite/probable stent thrombosis; vascular death; and net adverse clinical event (a composite endpoint of major bleeding and MACE) were analyzed according to the “on-treatment” principle, using fully adjusted Cox and Fine-Gray regression models with doubly robust inverse probability of censoring weighted estimators. Results Among 2,070 patients (mean age 63 years, 27% women, 62.5% ST-elevation MI), 1,035 were discharged on ticagrelor and clopidogrel, respectively. Ticagrelor-treated patients were younger and had few comorbidities, but high rates of medication non-compliance, compared with clopidogrel users. After comprehensive multivariate adjustments, ticagrelor did not increase the risk of major bleeding compared with clopidogrel [subhazard ratio, 1.40; 95% confidence interval (CI), 0.96–2.05], while proved superior in reducing MACE (hazard ratio 0.62; 95% CI, 0.43–0.90), vascular death (subhazard ratio, 0.71; 95% CI, 0.52–0.97) and definite/probable stent thrombosis (subhazard ratio, 0.54; 95% CI, 0.30-0.79); thereby resulting in a favorable net clinical benefit (hazard ratio 0.78; 95% CI, 0.60–0.98) compared with clopidogrel. Results from sensitivity analyses were consistent with those from the primary analysis, whereas those from the intention-to-treat (ITT) analysis went in the opposite direction. Conclusion Among all-comers with ACS, ticagrelor did not significantly increase the risk of major bleeding, while resulting in a net clinical benefit compared with clopidogrel. Further research is warranted to confirm these findings in high bleeding risk populations. CREA-ARIAM Andalucía (ClinicalTrials.gov Identifier: NCT02500290); Current pre-specified analysis (ClinicalTrials.gov Identifier: NCT04630288).
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Affiliation(s)
- Manuel Almendro-Delia
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
- *Correspondence: Manuel Almendro-Delia
| | - Emilia Blanco-Ponce
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jesús Carmona-Carmona
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | | | | | | | | | - Juan C. García-Rubira
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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35
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In-hospital outcomes of Ticagrelor versus Clopidogrel in high bleeding risk patients with acute coronary syndrome: Findings from the CCC-ACS project. Thromb Res 2022; 216:43-51. [DOI: 10.1016/j.thromres.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022]
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36
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Zou Y, Wang Y, Wu Y, Zhang S, Liu H, Yin T. Prediction of residual ischemic risk in ticagrelor-treated patients with acute coronary syndrome. Thromb J 2022; 20:21. [PMID: 35448998 PMCID: PMC9022318 DOI: 10.1186/s12959-022-00380-4] [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] [Received: 03/08/2022] [Accepted: 04/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite strong antiplatelet therapy with ticagrelor, serious ischemic events still occur in patients with acute coronary syndrome (ACS). The predictability of platelet reactivity to the residual risk of ischemic events during ticagrelor treatment remains uncertain. OBJECTIVES We aimed to investigate the predictability of the thromboelastography (TEG)-measured adenosine disphosphate (ADP)-induced platelet inhibition rate (ADP%) to the ischemic events in ticagrelor-treated patients with ACS. METHODS A cohort of ticagrelor-treated patients with ACS were consecutively recruited. ADP% was measured by TEG after 3 days of ticagrelor maintenance treatment. The primary ischemic event was defined as rehospitalization for unstable angina (UA) within 1 year, and the secondary ischemic event was a composite of the primary ischemic event plus all-cause death, nonfatal myocardial infarction (MI), stent thrombosis, stroke, and unplanned revascularization within 1 year. RESULTS A total of 751 eligible patients with ACS were included in the analysis, with 336 patients randomly assigned to the derivation group and 415 to the validation group. The overall rates of primary and secondary ischemic events were 14.51% (n = 109) and 16.91% (n = 127), respectively. Compared to the patients without ischemic events, those with ischemic events had a significantly lower ADP% both in the derivation group (for primary ischemic events: 66.05% vs. 92.80%, p < 0.001; for secondary ischemic events: 66.05% vs. 93.20%, p < 0.001) and in the validation group (for primary ischemic events: 66.40% vs. 89.20%, p < 0.001; for secondary ischemic events: 66.90% vs. 89.20%, p < 0.001). Receiver operating characteristic curve (ROC) analysis showed that an ADP% < 76% was the optimal cut-off value for predicting 1-year primary ischemic events, with an area under the curve (AUC) of 0.80 (95% CI: 0.72-0.86, p < 0.001) in the derivation group and 0.77 (95% CI: 0.69-0.85, p < 0.001) in the validation group. The multivariate Cox regression hazard analysis consistently identified an ADP% < 76% as an independent predictor of primary ischemic events in the derivation group (HR: 8.21, 95% CI: 4.82-13.99, p < 0.001) and in the validation group (HR: 6.34 95% CI: 3.32-12.11, p < 0.001). There was also a strong association between an ADP% < 76 and the occurrence of secondary ischemic events in the derivation group (HR: 7.33, 95% CI: 4.47-12.00, p < 0.001) and in the validation group (HR: 4.76, 95% CI: 2.73-8.32, p < 0.001). CONCLUSION The ADP-induced platelet inhibition rate measured by TEG could predict ischemic events in ticagrelor-treated patients with ACS.
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Affiliation(s)
- Yuting Zou
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China.,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China.,Department of Cardiology, the 6th Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yuyan Wang
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China.,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China
| | - Yangxun Wu
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China.,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China
| | - Shizhao Zhang
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China.,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China
| | - Haiping Liu
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China.,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China
| | - Tong Yin
- Institute of Geriatrics, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, 100853, Beijing, China. .,Medical School of Chinese PLA, Chinese PLA General Hospital, 100853, Beijing, China.
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Stehli J, Dinh D, Dagan M, Dick R, Oxley S, Brennan A, Lefkovits J, Duffy SJ, Zaman S. Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction. Clin Cardiol 2022; 45:427-434. [PMID: 35253228 PMCID: PMC9019891 DOI: 10.1002/clc.23797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients. METHODS Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models. RESULTS A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13). CONCLUSIONS In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.
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Affiliation(s)
- Julia Stehli
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Epworth HealthCareRichmondVictoriaAustralia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Misha Dagan
- Department of General MedicineThe Alfred HospitalMelbourneVictoriaAustralia
| | - Ron Dick
- Epworth HealthCareRichmondVictoriaAustralia
| | | | - Angela Brennan
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Jeffrey Lefkovits
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Stephen J. Duffy
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Sarah Zaman
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
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Ennezat PV, Guerbaai RA, LeJemtel TH, Hansen MR. Full transparency of ticagrelor trials in coronary artery disease should be warranted. Hosp Pract (1995) 2022; 50:89-92. [PMID: 35236204 DOI: 10.1080/21548331.2022.2049099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Pierre-Vladimir Ennezat
- Cardiology department, Service de cardiologie, Centre Hospitalier Universitaire Henri Mondor, Créteil, France
| | | | | | - Morten Rix Hansen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Clinical Pharmacology, Pharmacy and Enviromental Medicine, Deparment of Public Health, University of Southern Denmark, Denmark
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Thrane PG, Olesen KKW, Würtz M, Gyldenkerne C, Madsen M, Jensen LO, Raungaard B, Sørensen HT, Thim T, Kristensen SD, Maeng M. Effectiveness and Safety of Ticagrelor Implementation in Patients with Acute Coronary Syndrome undergoing Percutaneous Coronary Intervention: A Cohort Study in Western Denmark. THE LANCET REGIONAL HEALTH. EUROPE 2022; 14:100301. [PMID: 35146473 PMCID: PMC8802857 DOI: 10.1016/j.lanepe.2021.100301] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Methods Findings Interpretation
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Affiliation(s)
- Pernille Gro Thrane
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Address for correspondence: Pernille Gro Thrane, Department of Cardiology, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark, Phone: +45 26140993.
| | | | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Morten Madsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Bent Raungaard
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Thim
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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40
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González-Juanatey C, Anguita-Sá́nchez M, Barrios V, Núñez-Gil I, Gómez-Doblas JJ, García-Moll X, Lafuente-Gormaz C, Rollán-Gómez MJ, Peral-Disdie V, Martínez-Dolz L, Rodríguez-Santamarta M, Viñolas-Prat X, Soriano-Colomé T, Muñoz-Aguilera R, Plaza I, Curcio-Ruigómez A, Orts-Soler E, Segovia J, Maté C, Cequier Á. Assessment of medical management in Coronary Type 2 Diabetic patients with previous percutaneous coronary intervention in Spain: A retrospective analysis of electronic health records using Natural Language Processing. PLoS One 2022; 17:e0263277. [PMID: 35143527 PMCID: PMC8830700 DOI: 10.1371/journal.pone.0263277] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 01/15/2022] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Patients with type 2 diabetes (T2D) and stable coronary artery disease (CAD) previously revascularized with percutaneous coronary intervention (PCI) are at high risk of recurrent ischemic events. We aimed to provide real-world insights into the clinical characteristics and management of this clinical population, excluding patients with a history of myocardial infarction (MI) or stroke, using Natural Language Processing (NLP) technology. METHODS This is a multicenter, retrospective study based on the secondary use of 2014-2018 real-world data captured in the Electronic Health Records (EHRs) of 1,579 patients (0.72% of the T2D population analyzed; n = 217,632 patients) from 12 representative hospitals in Spain. To access the unstructured clinical information in EHRs, we used the EHRead® technology, based on NLP and machine learning. Major adverse cardiovascular events (MACE) were considered: MI, ischemic stroke, urgent coronary revascularization, and hospitalization due to unstable angina. The association between MACE rates and the variables included in this study was evaluated following univariate and multivariate approaches. RESULTS Most patients were male (72.13%), with a mean age of 70.5±10 years. Regarding T2D, most patients were non-insulin-dependent T2D (61.75%) with high prevalence of comorbidities. The median (Q1-Q3) duration of follow-up was 1.2 (0.3-4.5) years. Overall, 35.66% of patients suffered from at least one MACE during follow up. Using a Cox Proportional Hazards regression model analysis, several independent factors were associated with MACE during follow up: CAD duration (p < 0.001), COPD/Asthma (p = 0.021), heart valve disease (p = 0.031), multivessel disease (p = 0.005), insulin treatment (p < 0.001), statins treatment (p < 0.001), and clopidogrel treatment (p = 0.039). CONCLUSIONS Our results showed high rates of MACE in a large real-world series of PCI-revascularized patients with T2D and CAD with no history of MI or stroke. These data represent a potential opportunity to improve the clinical management of these patients.
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Affiliation(s)
| | | | | | - Iván Núñez-Gil
- Hospital Clínico Universitario San Carlos, Madrid, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ángel Cequier
- Hospital Universitario de Bellvitge and Universidad de Barcelona, IDIBELL, Barcelona, Spain
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Tatarunas V, Aldujeli A, Kurnickaite Z, Maciulevicius L, Burkanas M, Venius J, Ciapiene I, Skipskis V, Norvilaite R, Giedraitiene A, Unikas R, Baksyte G, Gustiene O, Sakalyte G, Lesauskaite V. Blood direct PCR: impact of CYP2C19 and CYP4F2 variants for bleeding prediction in ST-elevation myocardial infarction patients with ticagrelor. Per Med 2022; 19:207-217. [PMID: 35172619 DOI: 10.2217/pme-2021-0152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aims: The goals of this study were to develop a new technique that could pave the way for a quicker determination of CYP4F2 rs3093135 and CYP2C19 rs4244285 variants directly from a patient's blood and to attempt to apply this technique in clinical practice. Patients & methods: The study included 144 consecutive patients admitted with ST elevation myocardial infarction. A blood-direct PCR and real-time PCR were used to detect variants of interest. Results & conclusion: Patients with bleeding events had the CYP2C19 GG (*1*1) variant more frequently than patients without bleeding events. The CYP4F2 TT variant was more frequently detected in patients with bleeding events 3 months after hospitalization.
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Affiliation(s)
- Vacis Tatarunas
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Ali Aldujeli
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania.,Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Zemyna Kurnickaite
- Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, LT, 44307, Lithuania
| | - Laurynas Maciulevicius
- Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, LT, 44307, Lithuania
| | | | - Jonas Venius
- National Cancer Institute, Vilnius, LT, 08660, Lithuania
| | - Ieva Ciapiene
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Vilius Skipskis
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Rita Norvilaite
- Faculty of Medicine, Lithuanian University of Health Sciences, Kaunas, LT, 44307, Lithuania
| | - Agne Giedraitiene
- Institute of Microbiology & Virology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Ramunas Unikas
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Giedre Baksyte
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Olivija Gustiene
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Gintare Sakalyte
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania.,Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
| | - Vaiva Lesauskaite
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, LT, 50009, Lithuania
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Sun M, Cui W, Li L. Comparison of Clinical Outcomes Between Ticagrelor and Clopidogrel in Acute Coronary Syndrome: A Comprehensive Meta-Analysis. Front Cardiovasc Med 2022; 8:818215. [PMID: 35155618 PMCID: PMC8829718 DOI: 10.3389/fcvm.2021.818215] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/24/2021] [Indexed: 01/10/2023] Open
Abstract
BackgroundTicagrelor is currently recommended for patients with the acute coronary syndrome (ACS). However, recent studies have yielded controversial results.ObjectiveTo compare the clinical outcomes between ticagrelor and clopidogrel in patients with ACS.MethodsThree electronic databases were queried until April 25, 2021. We defined major adverse cardiovascular events (MACEs) as the primary efficacy endpoint. The secondary efficacy endpoints included stroke, stent thrombosis, cardiovascular death, all-cause death, and myocardial infarction. The safety endpoints were (major and minor) bleeding. Odds ratios (ORs) and 95% CIs were calculated to represent the estimated effect sizes.ResultsA total of 270,937 patients with ACS from 10 clinical trials and 18 observational studies were included. No significant difference was detected in MACE (OR 0.81, 95% CI 0.60–1.08, p = 0.15, I2 = 64.83%). However, ticagrelor introduced a higher risk of bleeding (1.46, 1.17–1.83, 0.00, 61.66%) and minor bleeding (1.71, 1.33–2.21, 0.00, 4.65%) in clinical trials. The results of secondary efficacy endpoints differed in the clinical trials and observational studies. Subgroup analysis demonstrated that ticagrelor showed better therapeutic effects in patients who underwent the percutaneous coronary intervention (PCI) (0.38, 0.23–0.63, 0.00, 0) than those intended for PCI (1.03, 0.76–1.38, 0.87, 64.26%). Meanwhile, ticagrelor showed different therapeutic effects on patients with ACS of different ethnicities and different countries.ConclusionThis meta-analysis demonstrated that ticagrelor is not superior to clopidogrel in MACE but is associated with a higher risk of bleeding in patients with ACS. Different PCI strategies, ethnicities, and countries may be the factors that contribute to different therapeutic effects of ticagrelor.Systematic Review RegistrationThis study is registered with PROSPERO (CRD42021251212).
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Affiliation(s)
- Mengyi Sun
- Department of Clinical Laboratory, Jining Academy of Medical Sciences, Jining, China
| | - Weichen Cui
- Department of Clinical Laboratory, Jiaxiang Women and Children's Hospital, Jining, China
| | - Linping Li
- Department of Cardiology, Jining Academy of Medical Sciences, Jining, China
- *Correspondence: Linping Li
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43
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Chen S, Li J, Qiu M, Ma S, Jiang Z, Na K, Qi Z, Li Y, Li Y, Han Y. Predictors and long-term outcomes of in-hospital switching from clopidogrel to ticagrelor among patients with acute coronary syndrome undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1424-1431. [PMID: 35077608 DOI: 10.1002/ccd.30089] [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] [Received: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/11/2022]
Abstract
This study evaluated clinical outcomes of switching from clopidogrel to ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). The clinical benefit of in-hospital switching from clopidogrel to ticagrelor in these patients remains unclear. Among patients with ACS initially receiving clopidogrel, logistic regression was used to identify independent predictors of switching to ticagrelor. Multivariable Cox regression was used to compare efficacy and safety between switching to ticagrelor and continuing clopidogrel. The primary endpoint was net adverse clinical events (NACEs) at 12 months, a composite of major adverse cardiovascular events (MACE) and Bleeding Academic Research Consortium (BARC) type 2/3/5 bleeding. Among 10,519 patients initially receiving clopidogrel, 1405 (13.4%) were switched to ticagrelor at discharge. Stent number, left main artery lesions, diabetes, male sex, age, estimated glomerular filtration rate of <45 ml/min/1.73 m2 , and history of PCI or stroke were identified as independent predictors of switching to ticagrelor. The rate of NACE (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.18-1.91) or BARC type 2/3/5 bleeding (HR: 2.01; 95% CI: 1.52-2.66) was significantly higher in patients switching to ticagrelor than in those continuing clopidogrel. The risk of MACE was comparable between both the groups (HR: 0.71; 95% CI: 0.41-1.22). In real-world practice, in-hospital switching from clopidogrel to ticagrelor was independently associated with several clinical factors. Patients switching to ticagrelor had a higher rate of NACE or BARC type 2/3/5 bleeding than those continuing clopidogrel, without any reduction in the MACE rate.
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Affiliation(s)
- Sanbao Chen
- General Hospital of Northern Theater Command of China Medical University, Shenyang, China.,Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,The Graduate School of Harbin Medical University, Harbin, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zaixin Jiang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yuzhuo Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Gao S, Xu H, Huang S, Yuan J, Yu M. Real-World Use of Clopidogrel and Ticagrelor in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries: Patient Characteristics and Long-Term Outcomes. Front Cardiovasc Med 2022; 8:807494. [PMID: 34993242 PMCID: PMC8724121 DOI: 10.3389/fcvm.2021.807494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/02/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Current guidelines recommend ticagrelor as the preferred P2Y12 inhibitor on top of aspirin in patients after an acute coronary syndrome. Yet, the efficacy and safety of ticagrelor vs. clopidogrel in patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) remain uncertain. Methods: A total of 1,091 patients with MINOCA who received dual antiplatelet therapy were enrolled and divided into the clopidogrel (n = 878) and ticagrelor (n = 213) groups. The primary efficacy endpoint was a composite of major adverse cardiovascular events (MACE), including all-cause death, nonfatal MI, stroke, revascularization, and hospitalization for unstable angina or heart failure. The safety endpoint referred to bleeding events. The Kaplan-Meier, propensity score matching (PSM), and Cox regression analyses were performed. Results: The incidence of MACE was similar for clopidogrel- and ticagrelor-treated patients over the median follow-up of 41.7 months (14.3 vs. 15.0%; p = 0.802). The use of ticagrelor was not associated with a reduced risk of MACE compared with clopidogrel after multivariable adjustment in overall (HR = 1.25, 95% CI: 0.84-1.86, p = 0.262) and in subgroups of MINOCA patients. Further, there was no significant difference in the risk of bleeding between two groups (HR = 1.67, 95% CI: 0.83-3.36, p = 0.149). After PSM, 206 matched pairs were identified, and the differences between clopidogrel and ticagrelor for ischemic endpoints and bleeding events remained nonsignificant (all p > 0.05). Conclusions: In this observational analysis of MINOCA patients, ticagrelor was not superior to clopidogrel in reducing ischemic events and did not cause a significant increase in bleeding, indicating a similar efficacy and safety between clopidogrel and ticagrelor. A randomized study of ticagrelor vs. clopidogrel in this specific population is needed.
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Affiliation(s)
- Side Gao
- National Center for Cardiovascular Diseases, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haobo Xu
- National Center for Cardiovascular Diseases, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sizhuang Huang
- National Center for Cardiovascular Diseases, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiansong Yuan
- National Center for Cardiovascular Diseases, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengyue Yu
- National Center for Cardiovascular Diseases, Department of Cardiology, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Hwang BO, Park SY, Cho ES, Zhang X, Lee SK, Ahn HJ, Chun KS, Chung WY, Song NY. Platelet CLEC2-Podoplanin Axis as a Promising Target for Oral Cancer Treatment. Front Immunol 2022; 12:807600. [PMID: 34987523 PMCID: PMC8721674 DOI: 10.3389/fimmu.2021.807600] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 11/26/2021] [Indexed: 12/21/2022] Open
Abstract
Cancer tissues are not just simple masses of malignant cells, but rather complex and heterogeneous collections of cellular and even non-cellular components, such as endothelial cells, stromal cells, immune cells, and collagens, referred to as tumor microenvironment (TME). These multiple players in the TME develop dynamic interactions with each other, which determines the characteristics of the tumor. Platelets are the smallest cells in the bloodstream and primarily regulate blood coagulation and hemostasis. Notably, cancer patients often show thrombocytosis, a status of an increased platelet number in the bloodstream, as well as the platelet infiltration into the tumor stroma, which contributes to cancer promotion and progression. Thus, platelets function as one of the important stromal components in the TME, emerging as a promising chemotherapeutic target. However, the use of traditional antiplatelet agents, such as aspirin, has limitations mainly due to increased bleeding complications. This requires to implement new strategies to target platelets for anti-cancer effects. In oral squamous cell carcinoma (OSCC) patients, both high platelet counts and low tumor-stromal ratio (high stroma) are strongly correlated with increased metastasis and poor prognosis. OSCC tends to invade adjacent tissues and bones and spread to the lymph nodes for distant metastasis, which is a huge hurdle for OSCC treatment in spite of relatively easy access for visual examination of precancerous lesions in the oral cavity. Therefore, locoregional control of the primary tumor is crucial for OSCC treatment. Similar to thrombocytosis, higher expression of podoplanin (PDPN) has been suggested as a predictive marker for higher frequency of lymph node metastasis of OSCC. Cumulative evidence supports that platelets can directly interact with PDPN-expressing cancer cells via C-type lectin-like receptor 2 (CLEC2), contributing to cancer cell invasion and metastasis. Thus, the platelet CLEC2-PDPN axis could be a pinpoint target to inhibit interaction between platelets and OSCC, avoiding undesirable side effects. Here, we will review the role of platelets in cancer, particularly focusing on CLEC2-PDPN interaction, and will assess their potentials as therapeutic targets for OSCC treatment.
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Affiliation(s)
- Byeong-Oh Hwang
- Department of Applied Life Science, The Graduate School, Yonsei University, Seoul, South Korea.,BK21 Four Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Oral Biology, Yonsei University College of Dentistry, Seoul, South Korea
| | - Se-Young Park
- Department of Applied Life Science, The Graduate School, Yonsei University, Seoul, South Korea.,BK21 Four Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Oral Biology, Yonsei University College of Dentistry, Seoul, South Korea
| | - Eunae Sandra Cho
- BK21 Four Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Oral Pathology, Yonsei University College of Dentistry, Seoul, South Korea.,Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, South Korea
| | - Xianglan Zhang
- Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Pathology, Yanbian University Hospital, Yanji City, China
| | - Sun Kyoung Lee
- Department of Oral Biology, Yonsei University College of Dentistry, Seoul, South Korea
| | - Hyung-Joon Ahn
- Department of Orofacial Pain and Oral Medicine, Dental Hospital, Yonsei University College of Dentistry, Seoul, South Korea
| | - Kyung-Soo Chun
- College of Pharmacy, Keimyung University, Daegu, South Korea
| | - Won-Yoon Chung
- Department of Applied Life Science, The Graduate School, Yonsei University, Seoul, South Korea.,BK21 Four Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Oral Biology, Yonsei University College of Dentistry, Seoul, South Korea.,Oral Cancer Research Institute, Yonsei University College of Dentistry, Seoul, South Korea
| | - Na-Young Song
- Department of Applied Life Science, The Graduate School, Yonsei University, Seoul, South Korea.,BK21 Four Project, Yonsei University College of Dentistry, Seoul, South Korea.,Department of Oral Biology, Yonsei University College of Dentistry, Seoul, South Korea
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46
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D'Ascenzo F, Elia E, de Filippo O, Manai R, Breviario S, Bruno F, Iannaccone M, Wańha W, Bianco M, Patti G, Raposeiras-Roubin S, Abu-Assi E, Bo M, De Ferrari GM, Conrotto F. Net clinical benefit of different strategies of dual antiplatelet therapy in elderly patients: Data from the praise registry. Int J Cardiol 2022; 353:9-14. [DOI: 10.1016/j.ijcard.2022.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 11/22/2021] [Accepted: 01/07/2022] [Indexed: 11/24/2022]
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OUP accepted manuscript. Eur Heart J 2022; 43:2303-2313. [DOI: 10.1093/eurheartj/ehac116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 01/31/2022] [Accepted: 02/24/2022] [Indexed: 11/13/2022] Open
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48
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Galli M, Benenati S, Franchi F, Rollini F, Capodanno D, Biondi-Zoccai G, Vescovo GM, Cavallari LH, Bikdeli B, Ten Berg J, Mehran R, Gibson CM, Crea F, Pereira NL, Sibbing D, Angiolillo DJ. Comparative effects of guided vs. potent P2Y12 inhibitor therapy in acute coronary syndrome: a network meta-analysis of 61 898 patients from 15 randomized trials. Eur Heart J 2021; 43:959-967. [PMID: 34918066 DOI: 10.1093/eurheartj/ehab836] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/30/2021] [Accepted: 11/22/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS Guidelines recommend the use of potent P2Y12 inhibitors over clopidogrel for the reduction of ischaemic events in patients with acute coronary syndrome (ACS). However, this comes at the expense of increased bleeding. A guided selection of P2Y12 inhibiting therapy has the potential to overcome this limitation. We aimed at evaluating the comparative safety and efficacy of guided vs. routine selection of potent P2Y12 inhibiting therapy in patients with ACS. METHODS AND RESULTS We performed a network meta-analysis of randomized controlled trials (RCTs) comparing different oral P2Y12 inhibitors currently recommended for the treatment of patients with ACS (clopidogrel, prasugrel, and ticagrelor). RCTs including a guided approach (i.e. platelet function or genetic testing) vs. standard selection of P2Y12 inhibitors among patients with ACS were also included. Incidence rate ratios (IRR) and associated 95% confidence intervals (CIs) were estimated. P-scores were used to estimate hierarchies of efficacy and safety. The primary efficacy endpoint was major adverse cardiovascular events (MACE) and the primary safety endpoint was all bleeding. A total of 61 898 patients from 15 RCTs were included. Clopidogrel was used as reference treatment. A guided approach was the only strategy associated with reduced MACE (IRR: 0.80, 95% CI: 0.65-0.98) without any significant trade-off in all bleeding (IRR: 1.22, 95% CI: 0.96-1.55). A guided approach and prasugrel were associated with reduced myocardial infarction. A guided approach, prasugrel, and ticagrelor were associated with reduced stent thrombosis. Ticagrelor was also associated with reduced total and cardiovascular mortality. Prasugrel was associated with increased major bleeding. Prasugrel and ticagrelor were associated with increased minor bleeding. The incidence of stroke did not differ between treatments. CONCLUSION In patients with an ACS, compared with routine selection of potent P2Y12 inhibiting therapy (prasugrel or ticagrelor), a guided selection of P2Y12 inhibiting therapy is associated with the most favourable balance between safety and efficacy. These findings support a broader adoption of guided approach for the selection of P2Y12 inhibiting therapy in patients with ACS. STUDY REGISTRATION NUMBER This study is registered in PROSPERO (CRD42021258603). KEY QUESTION A guided selection of P2Y12 inhibiting therapy using platelet function or genetic testing improves outcomes among patients undergoing percutaneous coronary intervention. Nevertheless, the comparative safety and efficacy of a guided versus routine selection of potent P2Y12-inhibiting therapy in acute coronary syndrome has not been explored. KEY FINDING In a comprehensive network meta-analysis including the totality of available evidence and using clopidogrel as treatment reference, a guided approach was the only strategy associated with reduced major adverse cardiovascular events without any significant trade-off in bleeding. Prasugrel and ticagrelor increased bleeding and only ticagrelor reduced mortality. TAKE HOME MESSAGE A guided selection of P2Y12-inhibiting therapy represents the strategy associated with the most favourable balance between safety and efficacy. These findings support a broader adoption of guided P2Y12 inhibiting therapy in patients with acute coronary syndrome.
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Affiliation(s)
- Mattia Galli
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, Rome 00168, Italy
| | - Stefano Benenati
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), Policlinico San Martino IRCCS, University of Genoa, Largo Rosanna Benzi, 10, Genoa 16132, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via Santa Sofia, 78, Catania 95123, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Piazzale Aldo Moro, 5, Rome 00185, Italy.,Mediterranea Cardiocentro, Via Orazio, 2, Napoli 80122, Italy
| | - Giovanni Maria Vescovo
- Interventional Cardiology, Department of Cardiothoracic and Vascular Science, Ospedale dell'Angelo, Via Paccagnella, 11, Venice 30174, Italy
| | - Larisa H Cavallari
- Department of Pharmacotherapy & Translational Research, Center for Pharmacogenomics & Precision Medicine, University of Florida, Gainesville, FL 32611, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.,Center for Outcomes Research and Evaluation (CORE), Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.,Clinical Trials Center, Cardiovascular Research Foundation, 1700 Broadway, New York, NY 10019, USA
| | - Jurrien Ten Berg
- Department of Cardiology and Center for Platelet Function Research, St Antonius Hospital, The Cardiovascular Research Institute Maastricht (CARIM), Universiteitssingel 50, Maastricht 6229, the Netherlands
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, Cardiovascular Institute, 1 Gustave L. Levy Pl, New York, NY 10029, USA
| | - Charles Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, 169 Pilgrim Rd, Boston, MA 02215, USA
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Largo Francesco Vito, 1, Rome 00168, Italy
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Unterlauterbach 1, Seeshaupt 82402, Germany.,Department of Cardiology, Ludwig-Maximilians-Universität München (LMU Munich), Geschwister-Scholl-Platz 1, Munich 80539, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Greifswald 17475, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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Cabrera-Aguilera I, Ivern C, Badosa N, Marco E, Salas-Medina L, Mojón D, Vicente M, Llagostera M, Farré N, Ruiz-Bustillo S. Impact of and Reasons for Not Performing Exercise Training After an Acute Coronary Syndrome in the Setting of an Interdisciplinary Cardiac Rehabilitation Program: Results From a Risk-Op- Acute Coronary Syndrome Ambispective Registry. Front Physiol 2021; 12:768199. [PMID: 34899392 PMCID: PMC8654103 DOI: 10.3389/fphys.2021.768199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/31/2021] [Indexed: 12/24/2022] Open
Abstract
Background and Aims: Exercise training (ET) is a critical component of cardiac rehabilitation (CR), but it remains underused. The aim of this study was to compare clinical outcomes between patients who completed ET (A-T), those who accepted ET but did not complete it (A-NT), and those who did not accept to undergo it (R-NT), and to analyze reasons for rejecting or not completing ET. Methods and Results: A unicenter ambispective observational registry study of 497 patients with acute coronary syndrome (ACS) was carried out in Barcelona, Spain, from 2016 to 2019. The primary endpoint was a composite of all-cause mortality, hospitalization for ACS, or need for revascularization during follow-up. Multivariable analysis was carried out to identify variables independently associated with the primary outcome. Initially, 70% of patients accepted participating in the ET, but only 50.5% completed it. The A-T group were younger and had fewer comorbidities. Baseline characteristics in A-NT and R-NT groups were very similar. The main reason for not undergoing or completing ET was rejection (reason unknown) or work/schedule incompatibility. The median follow-up period was 31 months. Both the composite primary endpoint and mortality were significantly lower in the A-T group compared to the A-NT and R-NT (primary endpoint: 3.6% vs. 23.2% vs. 20.4%, p < 0.001, respectively; mortality: 0.8% vs. 9.1% vs. 8.2%, p < 0.001; respectively). During multivariable analysis, the only variables that remained statistically significant with the composite endpoint were ET completion, previous ACS, and anemia. Conclusion: Completion of ET after ACS was associated with improved prognosis. Only half of the patients completed the ET program, with the leading reasons for not completing it being refusal (reason unknown) and work/schedule incompatibility. These results highlight the need to focus on the needs of patients in order to guarantee that structural barriers to ET no longer exist.
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Affiliation(s)
- Ignacio Cabrera-Aguilera
- Facultat de Medicina i Ciències de la Salut, Unitat de Biofísica i Bioenginyeria, Universitat de Barcelona, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Human Movement Sciences, Faculty of Health Sciences, School of Kinesiology, Universidad de Talca, Talca, Chile
| | - Consolació Ivern
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Neus Badosa
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Ester Marco
- Cardiac Rehabilitation Unit, Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Spain.,Rehabilitation Research Group, Hospital del Mar Medical Research Institute, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luís Salas-Medina
- Cardiac Rehabilitation Unit, Physical Medicine and Rehabilitation Department, Parc de Salut Mar (Hospital del Mar - Hospital de l'Esperança), Barcelona, Spain
| | - Diana Mojón
- Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Miren Vicente
- Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Marc Llagostera
- Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain
| | - Nuria Farré
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sonia Ruiz-Bustillo
- Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Cardiac Rehabilitation Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain.,Department of Medicine, Universitat Pompeu Fabra, Barcelona, Spain
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Real-World Use and Outcomes of Oral Antiplatelets Among Patients with Acute Coronary Syndrome: A Retrospective Cohort Study. Drugs Real World Outcomes 2021; 9:121-127. [PMID: 34780040 PMCID: PMC8844330 DOI: 10.1007/s40801-021-00283-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Acute coronary syndrome (ACS)-related readmission is an important hospital quality measure. Medication management therapy, especially adherence to antiplatelet agents post discharge, could play an important role in reducing readmission rates. Newer agents such as ticagrelor and prasugrel have been shown, in randomized control trials, to have superior effectiveness to cardiovascular outcomes compared to clopidogrel, but they are more expensive and have more common adverse events such as bleeding and dyspnea. OBJECTIVE We compared real-world readmission rates and adherence to antiplatelet agents among patients who initiated these agents post discharge. METHODS This was a retrospective cohortstudy of patients with an index ACS-related hospitalization between 1 July 2017 and 31 December 2018. Using integrated pharmacy and medical claims data from a large national pharmacy benefits manager for commercially insured adults aged ≥ 18 years, we compared ACS-related readmission and medication adherence (as medication possession ratio (MPR)) among the three agents. ANOVA and logistic regression, controlling for demographics such as age, gender, and Charlson Comorbidity Index, were used to estimate any association between the agents and 365-day readmission rates. RESULTS Of the 948 eligible patients, 86, 342, and 520 were initiated on prasugrel, ticagrelor, and clopidogrel (PTC), respectively. There were 4.7%, 5.3%, and 8.5% readmissions rates in the PTC cohorts, respectively, but these were not statistically significant in either the ANOVA or the logistic regression analyses. MPR was highest in the ticagrelor (88.1%) cohort, followed by the prasugrel (79.1%) and clopidogrel (76.4%) cohorts. CONCLUSION Ticagrelor cohort had the highest medication adherence. Clopidogrel cohort had the highest readmission rate but the difference with the other cohorts was statistically insignificant.
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