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Gamal AS, Hara H, Tomaniak M, Lunardi M, Gao C, Ono M, Kawashima H, Jüni P, Vranckx P, Windecker S, Hamm C, Steg PG, Onuma Y, Serruys PW. 'Ticagrelor alone vs. dual antiplatelet therapy from 1 month after drug-eluting coronary stenting among patients with STEMI': a post hoc analysis of the randomized GLOBAL LEADERS trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:756-773. [PMID: 34212187 PMCID: PMC8483765 DOI: 10.1093/ehjacc/zuab033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/17/2021] [Accepted: 05/06/2021] [Indexed: 11/12/2022]
Abstract
AIM To evaluate the efficacy and safety of ticagrelor monotherapy beyond 1 month and up to 24 months vs. standard 12-month dual antiplatelet therapy (DAPT) with aspirin and ticagrelor followed by aspirin monotherapy among ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) in the GLOBAL LEADERS trial. METHODS AND RESULTS We performed a post hoc analysis of STEMI patients in the GLOBAL LEADERS trial comparing experimental ticagrelor monotherapy (1062 patients) with standard 12-month DAPT (1030 patients). We evaluated predefined primary and secondary endpoints in both treatment arms. Rates of net adverse clinical events (NACE), patient-oriented composite endpoints (POCE), and bleeding academic research consortium (BARC)-defined bleeding Type 3 or 5 were also evaluated. At 2 years, there were no significant differences in rates of primary endpoints in patients who had STEMI [0.89 (0.61-1.31)]. There were similar rates of NACE and POCE in both experimental and reference treatment groups at 2 years post-PCI [hazard ratio (HR) 0.96 (0.77-1.20) and 0.96 (0.77-1.21), respectively]. BARC 3 or 5 bleeding events were numerically less in experimental compared to reference treatment groups at 1 year [HR 0.55 (0.27-1.13)] and 2 years [0.61 (0.32-1.16)]. CONCLUSION Presentation with STEMI has not influenced the incidence of GLOBAL LEADERS defined primary endpoints. There were no significant differences in rates of NACE, POCE, and BARC bleeding between the two treatment groups up to 2 years of follow-up. Although these findings should be viewed as exploratory, they expand the evidence on potential safety of aspirin-free antiplatelet strategies after PCI in STEMI.
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Affiliation(s)
- Amr S Gamal
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, North Cumbria University Hospital NHS Trust, Newtown Road, Cumbria CA2 7HY, England, UK.,Department of Cardiology, Zagazig University, Zagazig, Sharkia, 44519, Egypt
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Mariusz Tomaniak
- Department of Cardiology, Erasmus University MC, Dr. Molewaterplein 40 Street, 3015 GD Rotterdam, The Netherlands.,First Department of Cardiology, Medical University of Warsaw, Banacha 1a Street, 02-097 Warsaw, Poland
| | - Mattia Lunardi
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Division of Cardiology, University of Verona, Piazzale Stefani 1, Verona 37100, Italy
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street Toronto, Ontario M5B 1W8, Canada
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Stadsomvaart 11, 3500 Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Christian Hamm
- Department of Cardiology, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Benekestrasse 2-8, 61231, Bad Nauheim, Germany
| | - Philippe Gabriel Steg
- Université de Paris, FACT, Assistance Publique-Hôpitaux de Paris Hôpital Bichat, AP-HP, 46 rue Henri Huchard, 75018 Paris, France
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), University Road, Galway H91 TK33, Ireland.,Department of Cardiology, Imperial College London, Exhibition Road, London SW7 2BX, UK
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Ono M, Kawashima H, Hara H, Gamal A, Wang R, Gao C, O'Leary N, Soliman O, Piek JJ, van Geuns RJ, Jüni P, Hamm CW, Valgimigli M, Vranckx P, Windecker S, Steg PG, Fox KA, Onuma Y, Serruys PW. External validation of the GRACE risk score 2.0 in the contemporary all-comers GLOBAL LEADERS trial. Catheter Cardiovasc Interv 2021; 98:E513-E522. [PMID: 34000088 DOI: 10.1002/ccd.29772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 12/22/2022]
Abstract
OBJECTIVES This study aimed to assess the predictive ability of the Global Registry of Acute Coronary Events (GRACE) risk score 2.0 in contemporary acute coronary syndrome (ACS) patients, and its relation to antiplatelet strategies. BACKGROUND The predictive value of the GRACE risk score in the contemporary ACS cohort and the appropriate antiplatelet regimen according to the risk remain unclear. METHODS This is a subgroup analysis of the all-comers, randomized GLOBAL LEADERS trial, comparing ticagrelor monotherapy versus conventional dual-antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). The GRACE risk score 2.0 with 1-year mortality prediction was implemented. The randomized antiplatelet effect was assessed in predefined three GRACE risk-groups; low-risk (GRACE <109), moderate-risk (GRACE 109-140), and high-risk (GRACE >140). RESULTS The GRACE risk score was available in 6,594 out of 7,487 ACS patients among whom 1,743, 2,823, and 2,028 patients were classified as low-risk, moderate-risk, and high-risk, respectively. At 1 year, all-cause mortality occurred in 120 patients (1.8%). The discrimination ability of the GRACE model was moderate (C-statistic = 0.742), whereas 1-year mortality risk was overestimated (mean predicted mortality rate: 3.9%; the Hosmer-Lemeshow chi-square: 21.47; p = 0.006). There were no significant interactions between the GRACE risk strata and effects of the ticagrelor monotherapy on ischemic or bleeding outcomes at 1 year compared to the reference strategy. CONCLUSION The GRACE risk score 2.0 is valuable in discriminating high risk ACS patients, however, the recalibration of the score is recommended for better risk stratification. There is no significant differences in efficacy and safety of ticagrelor monotherapy across the three GRACE risk strata.
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Affiliation(s)
- Masafumi Ono
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Hideyuki Kawashima
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Hironori Hara
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.,Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Amr Gamal
- Department of Cardiology, National University of Ireland, Galway, Ireland.,Department of Cardiology, North Cumbria University Hospitals NHS Trust, Carlisle, UK
| | - Rutao Wang
- Department of Cardiology, National University of Ireland, Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Chao Gao
- Department of Cardiology, National University of Ireland, Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Neil O'Leary
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Osama Soliman
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Jan J Piek
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Robert-Jan van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Christian W Hamm
- Kerckhoff Heart Center, Campus University of Giessen, Bad Nauheim, Germany
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt; and Faculty of Medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Philippe Gabriel Steg
- Université de Paris, FACT, French Alliance for Cardiovascular Trials; Hôpital Bichat, AP-HP and INSERM U-1148, Paris, France
| | - Keith Aa Fox
- Centre For cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland.,NHLI, National Heart and Lung Institute, Imperial College, London, UK
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