1
|
Bhatt DL, Pollack CV. The Future of Aspirin Therapy in Cardiovascular Disease. Am J Cardiol 2021; 144 Suppl 1:S40-S47. [PMID: 33706989 DOI: 10.1016/j.amjcard.2020.12.019] [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: 11/21/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
Much has been written about the demise of aspirin (ASA) but reports of its death are premature. The drug remains one of the most widely prescribed by physicians worldwide. It is cheap, familiar, and effective for a variety of uses, including in patients with acute or prior myocardial infarction, ischemic stroke, peripheral artery disease, and percutaneous or surgical revascularization procedures, as well as for use for pain and fever relief. Beyond physician prescription or recommendation, over the counter use of ASA is common, including for primary cardiovascular prevention, though this decision really should involve a discussion of risks and benefits with a physician. ASA is an essential member of the duo that makes up dual antiplatelet therapy (a P2Y12 inhibitor plus ASA) and also dual pathway inhibition (vascular dose rivaroxaban plus ASA), and data for both approaches are growing. Furthermore, research is ongoing as to the optimal dosing frequency (once vs twice daily), potentially safer gastrointestinal delivery, and possibly more effective formulations in terms of platelet inhibition. One goal of ASA research is to try to reduce bleeding complications that are a risk with all anti-thrombotic therapies. Although its exact roles will continue to evolve, the future for ASA remains bright.
Collapse
|
2
|
Masuyama T, Sakuma M, Waku R, Hirose S, Kitahara K, Naganuma J, Yazawa H, Toyoda S, Abe S, Nakajima T, Inoue T. Effects of switching from clopidogrel to prasugrel at the chronic phase after coronary stenting on antiplatelet action and vascular endothelial function: Switch-Pras study. Heart Vessels 2020; 36:442-451. [PMID: 33113567 PMCID: PMC7940291 DOI: 10.1007/s00380-020-01714-w] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/09/2020] [Indexed: 01/12/2023]
Abstract
Compared to clopidogrel, prasugrel has a lower incidence of ischemic events following percutaneous coronary intervention (PCI) because of an early reduction during the acute phase in P2Y12 reaction units (PRU). The objective of this study was to compare the antiplatelet effect and vascular endothelial function of both drugs during the chronic phase after PCI. Patients who had undergone PCI and were confirmed to have no restenosis by follow-up coronary angiography under dual anti-platelet therapy with clopidogrel (75 mg/day) and aspirin (100 mg/day) were randomized to either continue clopidogrel or switch to prasugrel (3.75 mg/day). At baseline, prior to randomization we determined the CYP2C19 genotype. At the baseline and 24 weeks after randomization, the P2Y12 reactivity unit (PRU) was measured using the VerifyNow™ P2Y12 assay. Endothelial function was evaluated by flow-mediated vasodilation (FMD) and reactive hyperemia peripheral arterial tonometry (RH-PAT), while and circulating CD34+/CD133+/CD45low progenitor cells were measured by flow cytometric analysis. Serum high-sensitivity C-reactive protein (hsCRP) level was also measured. The PRU was reduced significantly in the prasugrel group (P = 0.0008), especially in patients who were intermediate or poor metabolizers based on the CYP2C19 genotype (P < 0.0001). This reduction was not observed in the clopidogrel group. The number of CD34+/CD133+/CD45low cells increased in the clopidogrel group (P = 0.008), but not in the prasugrel group. The hsCRP, FMD and reactive hyperemia index measured by RH-PAT did not change in either group. Prasugrel is potentially better than clopidogrel for preventing thrombotic events, although clopidogrel may have an advantage over prasugrel in terms of preventing atherosclerotic events. Proper use of thienopyridine drugs based on the CYP2C19 genotype has promising clinical potential.
Collapse
Affiliation(s)
- Taiki Masuyama
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Masashi Sakuma
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan.
| | - Ryutaro Waku
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Suguru Hirose
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Keijiro Kitahara
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Jin Naganuma
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Hiroko Yazawa
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Shichiro Abe
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Toshiaki Nakajima
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| | - Teruo Inoue
- Department of Cardiovascular Medicine, School of Medicine, Dokkyo Medical University, 880 Kitakobayashi, Mibu, Tochigi, 321-0293, Japan
| |
Collapse
|
3
|
Doly JS, Lorian E, Desormais I, Constans J, Bura Rivière A, Lacroix P. [Prevalence and prognosis of aspirin resistance in critical limb ischemia patients]. ACTA ACUST UNITED AC 2016; 41:358-364. [PMID: 27745943 DOI: 10.1016/j.jmv.2016.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 07/29/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To assess the prevalence and the association between aspirin resistance in critical limb ischemia patients using the VerifyNow® bed-side platelet test, and occurrence of cardiovascular morbidity and/or death at one year. MATERIALS AND METHODS National multicenter prospective observational study related to COPART II centers. From 2010 through 2014, 64 subjects hospitalized for critical limb ischemia and already treated by aspirin before the VerifyNow® test were included. A VerifyNow® test>550 ARU was defined as aspirin resistance. Critical limb ischemia was defined according to the TASC I criteria. The primary outcome was a composite including death, acute coronary syndrome, stroke and major amputation during the one-year follow-up period. RESULTS In all, 9/64 patients were aspirin resistant, the status was confirmed in one case. The prevalence of aspirin resistance was 14.06%. There was no significant difference between aspirin resistant and aspirin non-resistant groups in terms of cardiovascular history and glycemia status. Neither was there significant difference between the two groups in terms of survival. CONCLUSION Aspirin resistance was not predictive of poorer survival in critical limb ischemia patients. However, our population was limited. Considering that a clear definition of aspirin resistance and standardized diagnostic tests are lacking, complementary studies might be useful.
Collapse
Affiliation(s)
- J-S Doly
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France.
| | - E Lorian
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - I Desormais
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - J Constans
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - A Bura Rivière
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - P Lacroix
- Service chirurgie thoracique et cardiovasculaire et angiologie, unité de médecine vasculaire, CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| |
Collapse
|
4
|
Abstract
Ischemic heart disease and stroke are major causes of death and morbidity worldwide. Coronary and cerebrovascular events are a consequence of thrombus formation caused by atherosclerotic plaque rupture or embolism, both of which result from platelet activation and aggregation and thrombin-mediated fibrin generation via the coagulation cascade. Current and emerging antiplatelet and anticoagulant agents are evolving rapidly. The use of aspirin for primary prevention continues to be controversial, as are the doses appropriate for secondary prevention. Development of new oral and intravenous adenosine diphosphate P2Y12 inhibitors and novel antiplatelet agents continues to transform the landscape of antiplatelet therapy. Oral anticoagulation has advanced with the use of direct thrombin and factor Xa inhibitors that do not require therapeutic monitoring. In this review, we discuss the pharmacology and growing clinical evidence for traditional and new antiplatelet and anticoagulant therapies.
Collapse
Affiliation(s)
- Jeremiah P Depta
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts 02115;
| | | |
Collapse
|
5
|
Depta JP, Cresci S. CYP450 pharmacogenomics: a cardiology perspective. Per Med 2015; 12:59-62. [PMID: 29754539 DOI: 10.2217/pme.14.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Jeremiah P Depta
- Brigham & Women's Hospital, Heart & Vascular Center & Harvard Medical School, Boston, MA, USA
| | - Sharon Cresci
- Department of Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8086, St. Louis, MO 63110, USA.,Department of Genetics, Washington University School of Medicine, Saint Louis, MO, USA
| |
Collapse
|
6
|
Depta JP, Lenzini PA, Lanfear DE, Wang TY, Spertus JA, Bach RG, Cresci S. Clinical outcomes associated with proton pump inhibitor use among clopidogrel-treated patients within CYP2C19 genotype groups following acute myocardial infarction. THE PHARMACOGENOMICS JOURNAL 2015; 15:20-5. [PMID: 25001880 PMCID: PMC4287459 DOI: 10.1038/tpj.2014.28] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 04/09/2014] [Accepted: 05/22/2014] [Indexed: 12/13/2022]
Abstract
We examined clinical outcomes with proton pump inhibitors (PPI) use within CYP2C19 genotype groups during clopidogrel treatment following acute myocardial infarction (AMI). 2062 patients were genotyped for CYP2C19*2 and *17 variants in TRIUMPH. 12 month clinical outcomes were analyzed among patients discharged on clopidogrel within CYP2C19*2 carrier, CYP2C19*17 carrier, and CYP2C19*1 homozygote genotype groups. PPI use was not associated with a difference in mortality. Among clopidogrel-treated Caucasians following AMI, PPI use was associated with a significantly higher rate of cardiac rehospitalization (HR 1.62, 95% CI 1.19-2.19; P=0.002) compared with no PPI use. PPI users who were carriers of the CYP2C19*17 variant experienced significantly higher rates of cardiac rehospitalization (HR 2.05, 95% CI 1.26-3.33; P=0.003), carriers of the CYP2C19*2 variant had a trend toward increased 1-year cardiac rehospitalization (HR 1.69, 95% CI 0.95-2.99; P=0.07), while no significant differences were observed among CYP2C19*1 homozygotes. These results indicate that the risks associated with PPI use among clopidogrel-treated Caucasian post-MI patients are impacted by CYP2C19 genotype, and suggest knowledge of genotype may be useful for personalizing PPI use among patients following AMI to reduce rehospitalization.
Collapse
Affiliation(s)
- Jeremiah P. Depta
- Washington University School of Medicine, Department of Medicine, Saint Louis, Missouri
| | - Petra A. Lenzini
- Washington University School of Medicine, Department of Genetics, Saint Louis, Missouri
| | - David E. Lanfear
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke, Durham, North Carolina
| | - John A. Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Richard G. Bach
- Washington University School of Medicine, Department of Medicine, Saint Louis, Missouri
| | - Sharon Cresci
- Washington University School of Medicine, Department of Medicine, Saint Louis, Missouri
- Washington University School of Medicine, Department of Genetics, Saint Louis, Missouri
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW To review the current evidence on the clinical significance of the drug-drug interactions between the available antiplatelet agents and proton pump inhibitors (PPIs). RECENT FINDINGS Gastrointestinal bleeding is associated with higher rates of morbidity and mortality following a myocardial infarction. PPIs are commonly used to prevent gastrointestinal bleeding. PPIs can attenuate metabolism of clopidogrel to its active metabolite by inhibiting various hepatic CYP450 enzymes, mainly CYP2C19. Concomitant use of a PPI with clopidogrel reduces clopidogrel active metabolite generation and subsequent platelet inhibition. In observational studies, the clinical significance of this drug-drug interaction is mixed. Evidence from the only randomized trial studying the clinical implications of the PPI-clopidogrel interaction did not demonstrate any difference in cardiovascular outcomes but did show a reduction in gastrointestinal bleeding with use of a PPI. SUMMARY The drug-drug interaction between antiplatelet agents and PPIs at the enzymatic level does not seem to result in worse clinical outcomes. The risk of gastrointestinal bleeding with antiplatelet therapy is substantial. Clinicians should use PPIs in selected high-risk patients to prevent gastrointestinal bleeding.
Collapse
|
8
|
Depta JP, Fowler J, Novak E, Katzan I, Bakdash S, Kottke-Marchant K, Bhatt DL. Clinical outcomes using a platelet function-guided approach for secondary prevention in patients with ischemic stroke or transient ischemic attack. Stroke 2012; 43:2376-81. [PMID: 22713488 DOI: 10.1161/strokeaha.112.655084] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Antiplatelet therapy nonresponse is associated with worse clinical outcomes. We studied the clinical outcomes associated with platelet function-guided modifications in antiplatelet therapy in patients with ischemic stroke or transient ischemic attack. METHODS From January 2005 to August 2007, 324 patients with ischemic stroke underwent platelet function testing using platelet aggregometry. Aspirin nonresponse was defined as a mean platelet aggregation ≥20% with 0.5 mg/mL arachidonic acid and/or ≥70% with 5 μmol/L adenosine diphosphate. Clopidogrel nonresponse was defined as a mean platelet aggregation ≥40% with 5 μmol/L adenosine diphosphate. A modification was any increase in antiplatelet therapy occurring after testing. Clinical outcomes were compared between patients with and without platelet function-guided antiplatelet therapy modifications using univariate and propensity score-adjusted analyses. RESULTS In patients with ischemic stroke or transient ischemic attack, 43% (n=128) and 35% (n=54) were nonresponders to aspirin and clopidogrel, respectively. After platelet function testing, antiplatelet therapy was increased in 23% of patients (n=73). After propensity score matching (n=61 in each group), antiplatelet therapy modification was associated with significantly increased rates of death, ischemic events, or bleeding (hazard ratio, 2.24; 95% CI, 1.12-4.47; P=0.02) compared with no modification in antiplatelet therapy and a trend toward increased bleeding (hazard ratio, 3.56; 95% CI, 0.98-12.95; P=0.05). No differences in ischemic events were observed. CONCLUSIONS Platelet function-guided modification in antiplatelet therapy after an ischemic stroke or transient ischemic attack was associated with significantly higher rates of adverse clinical outcomes.
Collapse
Affiliation(s)
- Jeremiah P Depta
- VA Boston Healthcare System, 1400 VFW Parkway, Boston, MA 02132, USA
| | | | | | | | | | | | | |
Collapse
|
9
|
Spath B, Hansen A, Bokemeyer C, Langer F. Succinate reverses in-vitro platelet inhibition by acetylsalicylic acid and P2Y receptor antagonists. Platelets 2011; 23:60-8. [PMID: 21736422 DOI: 10.3109/09537104.2011.590255] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
High on-treatment platelet reactivity has been associated with adverse cardiovascular events in patients receiving anti-platelet agents, but the molecular mechanisms underlying this phenomenon remain incompletely understood. Succinate, a citric acid cycle intermediate, is released into the circulation under conditions of mitochondrial dysfunction due to hypoxic organ damage, including sepsis, stroke, and myocardial infarction. Because the G protein-coupled receptor (GPCR) for succinate, SUCNR1 (GPR91), is present on human platelets, we hypothesized that succinate-mediated platelet stimulation may counteract the pharmacological effects of cyclooxygenase-1 and ADP receptor antagonists. To test this hypothesis in a controlled in-vitro study, washed platelets from healthy donors were treated with acetylsalicylic acid (ASA) or small-molecule P2Y(1) or P2Y(12) inhibitors and subsequently analyzed by light transmittance aggregometry using arachidonic acid (AA), ADP and succinate as platelet agonists. Aggregation in response to succinate alone was highly variable with only 29% of donors showing a (mostly delayed) platelet response. In contrast, succinate reproducibly and concentration-dependently (10-1000 µM) enhanced platelet aggregation in response to low concentrations of exogenous ADP. Furthermore, while succinate alone had no effect in the presence of platelet inhibitors, responsiveness of platelets to ADP after pretreatment with P2Y(1) or P2Y(12) antagonists was fully restored, when platelets were co-stimulated with 100 µM succinate. Similarly, succinate completely (at 1000 µM) or partially (at 100 µM) reversed the inhibitory effect of ASA on AA-induced platelet aggregation. In contrast, succinate failed to restore platelet responsiveness in the presence of both ASA and the P2Y(12) antagonist, suggesting that concomitant signaling via different GPCRs was required. Essentially identical results were obtained, when flow cytometric analysis of surface CD62P expression was used as a different readout for platelet activation. In summary, extracellular succinate may have a co-stimulatory role in platelet aggregation and, by (partially) antagonizing the effects of platelet inhibitors, may contribute to the inter-individual variability frequently observed in platelet function testing.
Collapse
Affiliation(s)
- Brigitte Spath
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | | | | | | |
Collapse
|
10
|
Lambrinoudaki I, Karaflou M, Kaparos G, Grigoriou O, Alexandrou A, Panoulis C, Logothetis E, Creatsa M, Christodoulakos G, Kouskouni E. The effect of hormone therapy and tibolone on serum CD40L and ADAM-8 in healthy post-menopausal women. J Endocrinol Invest 2010; 33:720-4. [PMID: 20436265 DOI: 10.1007/bf03346677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND/AIM The role of neutrophils and platelets in atherothrombotic disease is well established. The aim of our study was to investigate the effect of HT and tibolone on the soluble markers of neutrophil and platelet activation, "a disentigrin and metalloproteinase domain" (ADAM-8) and CD40 ligand (CD40L) respectively, in healthy post-menopausal women. SUBJECTS AND METHODS One hundred and six healthy post-menopausal women were randomly allocated to: estradiol plus drospirenone (E₂/DSP), E₂ hemihydrate 1 mg plus norethisterone acetate (E₂/NETA) 0.5 mg, and tibolone 2.5 mg. Serum ADAM-8 and CD40L were measured at baseline and at 6 months. RESULTS Baseline values of ADAM-8 and CD40L were similar between groups. No significant correlation was revealed between ADAM-8 or CD40L and parameters related to cardiovascular risk factors in each group. No significant changes were observed between baseline values and values at 6 months (E₂/DSP group: ADAM-8: 267.4±71.3 pg/ml vs 270.7±42.8 pg/ml, p=0.86, CD40L: 6.43±3.13 vs 6.79±2.70 ng/ml, p=0.67), (E₂/NETA group: ADAM-8: 308.3±64.3 vs 294.7±57.7 pg/ml, p=0.40, CD40L: 9.68±2.81 vs 8.59±5.13 ng/ml, p=0.51), (tibolone group: ADAM-8: 307.5±87.5 vs 289±48.1 pg/ml, p=0.48, CD40L: 9.46±4.30 vs 9.26±4.60 ng/ml, p=0.99). CONCLUSIONS Our study has not revealed an association between estrogen plus progestin treatment or tibolone on serum ADAM-8 and CD40L levels in healthy post-menopausal women. Larger prospective studies are needed to further investigate the effect of low-dose HT or tibolone on serum markers of neutrophil and platelet activation.
Collapse
Affiliation(s)
- I Lambrinoudaki
- 2nd Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Preventing serious sequelae after an acute coronary syndrome: the consequences of thrombosis versus bleeding with antiplatelet therapy. J Cardiovasc Pharmacol 2010; 55:585-94. [PMID: 20224426 DOI: 10.1097/fjc.0b013e3181d9f81f] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute coronary syndrome (ACS) is associated with a persistent prothrombotic state, placing patients at high risk of subsequent ischemic events. Guidelines recommend the use of dual antiplatelet therapy with aspirin + a thienopyridine (clopidogrel) for at least a year after ACS in most patients, except those who undergo coronary artery bypass grafting. Clinical studies demonstrate that this strategy significantly reduces the risk of ischemic events at the expense of a small increase in the risk of bleeding. Physicians must balance the risk of bleeding against the benefit of ischemia prevention, bearing in mind that ischemic events are generally more common than major bleeding and often associated with more catastrophic consequences or ongoing morbidity. The relationship between bleeding and mortality is complicated by the fact that many risk factors for bleeding are also those for mortality and that bleeding may lead to discontinuation of antiplatelet therapy, thereby increasing the risk for an ischemic event. Data suggest that physicians tend to overestimate the risk of bleeding and underestimate the risk of ischemia. Careful patient selection and thorough patient education are the keys to managing antiplatelet therapy after ACS, especially as newer more potent antiplatelet agents, such as prasugrel, become available.
Collapse
|
12
|
Börgermann J, Kanashnik A, Sossdorf M, Gummert J, Lösche W. Individual variability of response and non-response to acetyl salicylic acid after cardiac surgery. Platelets 2010; 21:610-5. [PMID: 20807171 DOI: 10.3109/09537104.2010.502981] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Insufficient inhibition of platelet function by acetyl salicylic acid (ASA) or other platelet inhibitors is a risk factor for arterial thrombosis in cardiovascular patients. We wanted to collect and analyse information on the frequency and probable causes of non-response to ASA in patients prior to and after cardiac surgery. One hundred and one patients (mean age 68 ± 9 years) undergoing cardiac surgery (98 patients with coronary bypass grafting, 18 cases had combined valve replacement, and three patients with only valve replacement) were enrolled. Post-operatively all patients received metamizole for analgesia. Platelet aggregation in platelet-rich plasma was induced by arachidonic acid (AA; 1.6 mM) or ADP (3 mM) in the absence and presence of exogenous ASA (100 µM). ASA non-response was defined as a maximum AA-induced aggregation of >30%. Eighty eight patients had pre-operative medication with ASA (100 mg/d), and ASA non-response was found in 24%. Irrespective of whether or not ASA medication was continued immediately after surgery, incidence of non-response increased to 55% at the first post-operative day. During continuous post-operative ASA medication (100 mg/d), 65% of patients were non-responder at fifth-7th post-operative day. When estimated on the basis of exogenously added ASA, non-response was observed pre-operative in 10%, at first post-operative day in 53% and at fifth-7th post-operative day in 39% of the patients. Twenty six of the 52 patients who did not adequately respond to exogenous ASA at the first post-operative day became responders when tested at the fifth-7th post-operative day, and 13 of the 46 responders became non-responders. The conversions were not due to small changes around the threshold of 30% aggregation but due to a highly significant decrease or increase in the extend of aggregation. Neither extracorporal circulation nor co-medication with clopidogrel had any significant influence on the platelet response to ASA medication or exogenously added ASA. Some non-steroidal analgesics, including metamizole, have been suggested to prevent inhibition of platelet cylcooxygenase by ASA. However, in 10 healthy volunteers we did not observe any interference of metamizole with the response to ASA. In conclusion, platelet response to ASA is markedly decreased after cardiac surgery. The underlying mechanisms and the clinical consequences of the post-operative instability of non-response to ASA need further evaluation.
Collapse
Affiliation(s)
- Jochen Börgermann
- Department for Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | | | | | | | | |
Collapse
|
13
|
Depta JP, Cannon CP, Fonarow GC, Zhao X, Peacock WF, Bhatt DL. Patient characteristics associated with the choice of triple antithrombotic therapy in acute coronary syndromes. Am J Cardiol 2009; 104:1171-8. [PMID: 19840557 DOI: 10.1016/j.amjcard.2009.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 06/05/2009] [Accepted: 06/05/2009] [Indexed: 10/20/2022]
Abstract
Evidence regarding the use of dual antiplatelet therapy and oral anticoagulation (i.e., triple therapy) in acute coronary syndromes (ACS) is limited. We evaluated the characteristics associated with the choice of triple therapy in ACS. Using the Get With The Guidelines (GWTG) Coronary Artery Disease national registry, we studied patients with ACS at 361 sites in the United States from 2004 to 2007. Both univariate analysis and multivariate logistic regression analysis were used to assess the factors associated using triple therapy on discharge. The Generalized Estimating Equation method was used to account for within-hospital clustering in modeling. A total of 86,304 patients presented with ACS during the study period. At discharge, 3,933 patients (4.6%) were prescribed triple therapy, 60,716 patients (70.4%) received dual antiplatelet therapy, 2,348 patients (2.7%) received single antiplatelet therapy plus oral anticoagulation, 19,065 patients (22.1%) received antiplatelet monotherapy, and 242 patients (0.3%) received oral anticoagulation alone. Patients with a history of atrial fibrillation (odds ratio 7.01, 95% confidence interval 6.06 to 8.12; p <0.001), documented new-onset atrial fibrillation (odds ratio 3.76, 95% confidence interval 2.87 to 4.93; p <0.001), or history of atrial flutter (odds ratio 3.38, 95% confidence interval 2.15 to 5.32; p <0.001) were more frequently discharged with triple therapy. In conclusion, for patients with ACS, atrial fibrillation and atrial flutter were most strongly associated with the use of triple therapy; however, this therapy was used less often than dual or single antiplatelet therapy.
Collapse
|
14
|
Depta JP, Bhatt DL, Kottke-Marchant K, Gupta R, Murugesan G, Jain A, Lincoff AM, Ellis SG. Management of patients with aspirin and clopidogrel impaired response. Interv Cardiol 2009. [DOI: 10.2217/ica.09.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|