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Kim JA, Kim SE, El Hachem K, Virk HUH, Alam M, Virani SS, Sharma S, House A, Krittanawong C. Medical Management of Coronary Artery Disease in Patients with Chronic Kidney Disease. Am J Med 2023; 136:1147-1159. [PMID: 37380060 DOI: 10.1016/j.amjmed.2023.06.013] [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: 06/09/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease patients are at increased risk of cardiovascular disease, which is the leading cause of mortality among this population. In addition, chronic kidney disease is a major risk factor for the development of coronary artery disease and is widely regarded as a coronary artery disease risk equivalent. Medical therapy is the cornerstone of coronary artery disease management in the general population. However, there are few trials to guide medical therapy of coronary artery disease in chronic kidney disease, with most data extrapolated from clinical trials of mainly non-chronic kidney disease patients, which were not adequately powered to evaluate this subgroup. There is some evidence to suggest that the efficacy of certain therapies such as aspirin and statins is attenuated with declining estimated glomerular filtration rate, with questionable benefit among end-stage renal disease (ESRD) patients. Furthermore, chronic kidney disease and ESRD patients are at higher risk of potential side effects with therapy, which may limit their use. In this review, we summarize the available evidence supporting the safety and efficacy of medical therapy of coronary artery disease in chronic kidney disease and ESRD patients. We also discuss the data on new emerging therapies, including PCSK9i, SGLT2i, GLP1 receptor agonists, and nonsteroidal mineralocorticoid receptor antagonists, which show promise at reducing risk of cardiovascular events in the chronic kidney disease population and may offer additional treatment options. Overall, dedicated studies directly evaluating chronic kidney disease patients, particularly those with advanced chronic kidney disease and ESRD, are greatly needed to establish the optimal medical therapy for coronary artery disease and improve outcomes in this vulnerable population.
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Affiliation(s)
- Jitae A Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Seulgi E Kim
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Karim El Hachem
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Ohio
| | - Mahboob Alam
- Texas Heart Institute and Baylor College of Medicine, Houston
| | - Salim S Virani
- Section of Cardiology, Baylor College of Medicine, Houston, Texas; Office of the Vice Provost (Research), The Aga Khan University, Karachi, Pakistan
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
| | - Andrew House
- Division of Nephrology, Department of Medicine, Western University and London Health Sciences Centre, Ont, Canada
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Festa MC, Rasasingam S, Sharma A, Mavrakanas TA. Early Discontinuation of Aspirin Among Patients with Chronic Kidney Disease Undergoing Percutaneous Coronary Intervention with a Drug-Eluting Stent: A Meta-Analysis. KIDNEY360 2023; 4:e1245-e1256. [PMID: 37768893 PMCID: PMC10547225 DOI: 10.34067/kid.0000000000000223] [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: 04/19/2023] [Revised: 06/20/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023]
Abstract
Key Points P2Y12 inhibitor monotherapy after 1–3 months of dual antiplatelet therapy (DAPT) decreases the risk of clinically significant bleeding when compared with 12 months of DAPT in patients with CKD treated with a drug-eluting stent. There is no significant difference in the risk of cardiovascular events with early aspirin discontinuation when compared with 12 months of DAPT post-PCI in patients with CKD. Background Conflicting evidence exists to support whether short duration of dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor monotherapy reduces bleeding complications after coronary artery drug-eluting stent (DES) insertion, compared with standard 12-month DAPT, particularly among patients with CKD who are at increased risk of bleeding. Methods A MEDLINE search identified randomized trials comparing up to 3 months of DAPT followed by P2Y12 inhibitor monotherapy versus twelve months of DAPT after insertion of a DES for any indication. Trials were included if they reported ischemic or bleeding outcomes among patients with CKD. The primary outcome was a composite of all-cause mortality, cardiac or cerebrovascular events, stent thrombosis (MACE), and major or minor bleeding events. Secondary outcomes were the individual components of the primary outcome and clinically significant bleeding. The relative risk (RR) was estimated using a random-effects model. Results Seven randomized trials were included for a total of 4996 patients with CKD (14% of the trial population). Early discontinuation of aspirin was associated with a similar incidence of the primary outcome among patients with CKD compared with 12-month DAPT (RR 0.97; 95% confidence interval [95% CI] 0.73 to 1.30). The RR of MACE was also similar between the two arms (RR 1.02; 95% CI 0.85 to 1.23). The risk of clinically significant bleeding was significantly lower with early discontinuation of aspirin (RR 0.60; 95% CI 0.46 to 0.78). Conclusion P2Y12 inhibitor monotherapy after a shortened course of DAPT seems to be associated with a similar risk of ischemic events and a lower risk of bleeding events after DES insertion among patients with CKD compared with 12-month DAPT.
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Affiliation(s)
- Maria Carolina Festa
- McGill University Health Centre, Department of Medicine, Division of General Internal Medicine, Montreal, Quebec, Canada
| | - Sathiepan Rasasingam
- McGill University Health Centre, Department of Medicine, Division of Nephrology, Montreal, Quebec, Canada
| | - Abhinav Sharma
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Thomas A. Mavrakanas
- McGill University Health Centre, Department of Medicine, Division of Nephrology, Montreal, Quebec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Kaneda K, Shiomi H, Abe M, Morimoto T, Yamamoto K, Obayashi Y, Nishikawa R, Tamura A, Kadota K, Domei T, Nakatsuma K, Yokomatsu T, Imai M, Taniguchi T, Nawada R, Toyofuku M, Tamura T, Inada T, Matsuda M, Sato Y, Furukawa Y, Ando K, Nakagawa Y, Kimura T. Post-contrast Acute Kidney Injury After Emergent and Elective Percutaneous Coronary Intervention (from the CREDO-Kyoto PCI/CABG Registry Cohort 3). Am J Cardiol 2023; 202:58-66. [PMID: 37421731 DOI: 10.1016/j.amjcard.2023.06.031] [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] [Received: 02/14/2023] [Revised: 04/28/2023] [Accepted: 06/06/2023] [Indexed: 07/10/2023]
Abstract
Post-contrast acute kidney injury (PC-AKI) is a common complication after percutaneous coronary intervention (PCI). However, it is unclear whether or not the effects of PC-AKI on long-term clinical outcomes were different between emergent and elective procedures. Among patients enrolled in the CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Grafting) registry cohort 3, we identified 10,822 patients treated using PCI (emergent PCI stratum: n = 5,022 [46%] and elective PCI stratum: n = 5,860 [54%]). PC-AKI was defined as ≥0.3 mg/100 ml absolute or 1.5-fold relative increase of serum creatinine within 72 hours after PCI. The incidence of PC-AKI was significantly higher after emergent PCI than after elective PCI (10.5% vs 3.7%, p <0.001). In the multivariable logistic regression model, emergent PCI was the strongest independent risk factor for PC-AKI in the entire study population. The excess adjusted risk of patients with PC-AKI relative to those without remained significant for all-cause death in both the emergent and elective PCI strata (hazard ratio 1.87, 95% confidence interval 1.59 to 2.21, p <0.001 and hazard ratio 1.31, 95% confidence interval 1.03 to 1.68, p = 0.03, respectively). There was a significant interaction between the PCI setting (emergent and elective) and the effect of PC-AKI on all-cause death, with a greater magnitude of effect in the emergent PCI stratum than in the elective PCI stratum (p for interaction = 0.01). In conclusion, the incidence of PC-AKI was 2.8 times higher after emergent PCI than after elective PCI. The excess mortality risk of PC-AKI relative to no PC-AKI was greater after emergent PCI than after elective PCI.
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Affiliation(s)
- Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.
| | - Mitsuru Abe
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ko Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuki Obayashi
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akinori Tamura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takenori Domei
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Kenji Nakatsuma
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan
| | | | - Masao Imai
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ryuzo Nawada
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | | | - Tsukasa Inada
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mitsuo Matsuda
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kosai Hospital, Hirakata, Japan
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Zhou X, Angiolillo DJ, Ortega-Paz L. P2Y 12 Inhibitor Monotherapy after Percutaneous Coronary Intervention. J Cardiovasc Dev Dis 2022; 9:jcdd9100340. [PMID: 36286292 PMCID: PMC9604207 DOI: 10.3390/jcdd9100340] [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: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y12 inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y12 inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y12 inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y12 inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y12 inhibitor monotherapy compared to aspirin for long-term prevention.
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Affiliation(s)
- Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Department of Internal Medicine, University of Alabama at Birmingham Montgomery, Montgomery, AL 36116, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Correspondence: ; Tel.: +1-904-244-3378; Fax: +1-904-244-3102
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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Natale P, Palmer SC, Saglimbene VM, Ruospo M, Razavian M, Craig JC, Jardine MJ, Webster AC, Strippoli GF. Antiplatelet agents for chronic kidney disease. Cochrane Database Syst Rev 2022; 2:CD008834. [PMID: 35224730 PMCID: PMC8883339 DOI: 10.1002/14651858.cd008834.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013. OBJECTIVES To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated. DATA COLLECTION AND ANALYSIS Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost. AUTHORS' CONCLUSIONS Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.
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Affiliation(s)
- Patrizia Natale
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Valeria M Saglimbene
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Marinella Ruospo
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Mona Razavian
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, Australia
| | - Jonathan C Craig
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Angela C Webster
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead, Australia
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Use and outcomes of dual antiplatelet therapy for acute coronary syndrome in patients with chronic kidney disease: insights from the Canadian Observational Antiplatelet Study (COAPT). Heart Vessels 2022; 37:1291-1298. [PMID: 35089380 DOI: 10.1007/s00380-022-02029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 01/14/2022] [Indexed: 11/27/2022]
Abstract
Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post-percutaneous coronary intervention (PCI) in CKD poses a challenge due to the increased bleeding and clotting tendencies, particularly since patients with CKD were underrepresented in randomized controlled trials. We examined the practice patterns of DAPT prescription stratified by the presence of CKD. The multicentre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with ACS between December 2011 and May 2013. The present study is a subgroup analysis comparing type and duration of DAPT and associated outcomes among patients with and without CKD (eGFR < 60 ml/min/1.73 m2, calculated by CKD-EPI). Patients with CKD (275/1921, 14.3%) were prescribed prasugrel/ticagrelor less (18.5% vs 25.8%, p = 0.01) and had a shorter duration of DAPT therapy versus patients without CKD (median 382 vs 402 days, p = 0.003). CKD was associated with major adverse cardiovascular events (MACE) at 12 months (p < 0.001) but not bleeding when compared to patients without CKD. CKD was associated with MACE in both patients on prasugrel/ticagrelor (p = 0.017) and those on clopidogrel (p < 0.001) (p for heterogeneity = 0.70). CKD was associated with increased bleeding only among patients receiving prasugrel/ticagrelor (p = 0.007), but not among those receiving clopidogrel (p = 0.64) (p for heterogeneity = 0.036). Patients with CKD had a shorter DAPT duration and were less frequently prescribed potent P2Y12 inhibitors than patients without CKD. Overall, compared with patients without CKD, patients with CKD had higher rates of MACE and similar bleeding rates. However, among those prescribed more potent P2Y12 inhibitors, CKD was associated with more bleeding than those without CKD. Further studies are needed to better define the benefit/risk evaluation, and establish a more tailored and evidence-based DAPT regimen for this high-risk patient group.
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7
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Tan JWC, Chew DP, Tsui KL, Tan D, Duplyakov D, Hammoudeh A, Zhang B, Li Y, Xu K, Ong PJ, Firman D, Gamra H, Almahmeed W, Dalal J, Tam LW, Steg G, Nguyen QN, Ako J, Al Suwaidi J, Chan M, Sobhy M, Shehab A, Buddhari W, Wang Z, Fong AYY, Karadag B, Kim BK, Baber U, Chin CT, Han YL. 2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y1 2 Receptor Antagonists in the Asia-Pacific Region: Special Populations. Eur Cardiol 2021; 16:e43. [PMID: 34815751 PMCID: PMC8591619 DOI: 10.15420/ecr.2021.35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/17/2022] Open
Abstract
Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.
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Affiliation(s)
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University Adelaide, Australia
| | - Kin Lam Tsui
- Pamela Youde Nethersole Eastern Hospital Hong Kong, China
| | - Doreen Tan
- Department of Pharmacy, Faculty of Science, National University of Singapore Singapore
| | | | | | - Bo Zhang
- Department of Cardiology, First Affiliated Hospital, Dalian Medical University Dalian, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
| | - Kai Xu
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | - Paul J Ong
- Heart Specialist International, Mount Elizabeth Novena Hospital Singapore.,Tan Tock Seng Hospital Singapore
| | - Doni Firman
- Harapan Kita National Cardiovascular Center/Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia Harapan Kita Jakarta, Indonesia
| | - Habib Gamra
- Cardiology Department, Fattouma Bourguiba University Hospital and University of Monastir Monastir, Tunisia
| | | | - Jamshed Dalal
- Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital Mumbai, India
| | | | - Gabriel Steg
- Department of Cardiology, Hôpital Bichat Paris, France
| | - Quang N Nguyen
- Department of Cardiology, Hanoi Medical University Hanoi, Vietnam
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine Sagamihara, Kanagawa, Japan
| | | | - Mark Chan
- National University Heart Centre Singapore
| | | | - Abdulla Shehab
- College of Medicine and Health Sciences, UAE University, Al Ain United Arab Emirates
| | | | - Zulu Wang
- Department of Cardiology, General Hospital of Shenyang Military Shenyang, China
| | | | - Bilgehan Karadag
- Istanbul University-Cerrahpasa School of Medicine Istanbul, Turkey
| | - Byeong-Keuk Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine Seoul, South Korea
| | - Usman Baber
- University of Oklahoma Health Sciences Center Oklahoma City, OK, US
| | | | - Ya Ling Han
- Department of Cardiology, General Hospital of Northern Theatre Command Shenyang, China
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8
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Stefanini GG, Briguori C, Cao D, Baber U, Sartori S, Zhang Z, Dangas G, Angiolillo DJ, Mehta S, Cohen DJ, Collier T, Dudek D, Escaned J, Gibson CM, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Oldroyd KG, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Ticagrelor monotherapy in patients with chronic kidney disease undergoing percutaneous coronary intervention: TWILIGHT-CKD. Eur Heart J 2021; 42:4683-4693. [PMID: 34423374 DOI: 10.1093/eurheartj/ehab533] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/07/2021] [Accepted: 07/26/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this study was to assess the impact of chronic kidney disease (CKD) on the safety and efficacy of ticagrelor monotherapy among patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS In this prespecified subanalysis of the TWILIGHT trial, we evaluated the treatment effects of ticagrelor with or without aspirin according to renal function. The trial enrolled patients undergoing drug-eluting stent implantation who fulfilled at least one clinical and one angiographic high-risk criterion. Chronic kidney disease, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, was a clinical study entry criterion. Following a 3-month period of ticagrelor plus aspirin, event-free patients were randomly assigned to aspirin or placebo on top of ticagrelor for an additional 12 months. Of the 6835 patients randomized and with available eGFR at baseline, 1111 (16.3%) had CKD. Ticagrelor plus placebo reduced the primary endpoint of Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding as compared with ticagrelor plus aspirin in both patients with [4.6% vs. 9.0%; hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.31-0.80] and without (4.0% vs. 6.7%; HR 0.59, 95% CI 0.47-0.75; Pinteraction = 0.508) CKD, but the absolute risk reduction was greater in the former group. Rates of death, myocardial infarction, or stroke were not significantly different between the two randomized groups irrespective of the presence (7.9% vs. 5.7%; HR 1.40, 95% CI 0.88-2.22) or absence of (3.2% vs. 3.6%; HR 0.90, 95% CI 0.68-1.20; Pinteraction = 0.111) CKD. CONCLUSION Among CKD patients undergoing PCI, ticagrelor monotherapy reduced the risk of bleeding without a significant increase in ischaemic events as compared with ticagrelor plus aspirin.
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Affiliation(s)
- Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan 20090, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan 20089, Italy
| | | | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | | | | | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Timothy Collier
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid 28040, Spain
| | | | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw 02-507, Poland
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith G Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - Giora Weisz
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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9
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Moisi MI, Bungau SG, Vesa CM, Diaconu CC, Behl T, Stoicescu M, Toma MM, Bustea C, Sava C, Popescu MI. Framing Cause-Effect Relationship of Acute Coronary Syndrome in Patients with Chronic Kidney Disease. Diagnostics (Basel) 2021; 11:diagnostics11081518. [PMID: 34441451 PMCID: PMC8391570 DOI: 10.3390/diagnostics11081518] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/15/2021] [Accepted: 08/16/2021] [Indexed: 02/06/2023] Open
Abstract
The main causes of death in patients with chronic kidney disease (CKD) are of cardiovascular nature. The interaction between traditional cardiovascular risk factors (CVRF) and non-traditional risk factors (RF) triggers various complex pathophysiological mechanisms that will lead to accelerated atherosclerosis in the context of decreased renal function. In terms of mortality, CKD should be considered equivalent to ischemic coronary artery disease (CAD) and properly monitored. Vascular calcification, endothelial dysfunction, oxidative stress, anemia, and inflammatory syndrome represents the main uremic RF triggered by accumulation of the uremic toxins in CKD subjects. Proteinuria that appears due to kidney function decline may initiate an inflammatory status and alteration of the coagulation—fibrinolysis systems, favorizing acute coronary syndromes (ACS) occurrence. All these factors represent potential targets for future therapy that may improve CKD patient’s survival and prevention of CV events. Once installed, the CAD in CKD population is associated with negative outcome and increased mortality rate, that is the reason why discovering the complex pathophysiological connections between the two conditions and a proper control of the uremic RF are crucial and may represent the solutions for influencing the prognostic. Exclusion of CKD subjects from the important trials dealing with ACS and improper use of the therapeutical options because of the declined kidney functioned are issues that need to be surpassed. New ongoing trials with CKD subjects and platelets reactivity studies offers new perspectives for a better clinical approach and the expected results will clarify many aspects.
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Affiliation(s)
- Mădălina Ioana Moisi
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
| | - Simona Gabriela Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
- Correspondence: (S.B.); (C.M.V)
| | - Cosmin Mihai Vesa
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
- Correspondence: (S.B.); (C.M.V)
| | - Camelia Cristina Diaconu
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Tapan Behl
- Department of Pharmacology, Chitkara College of Pharmacy, Chitkara University, Punjab 140401, India;
| | - Manuela Stoicescu
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
| | - Mirela Mărioara Toma
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.I.M.); (C.B.)
| | - Cristian Sava
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
| | - Mircea Ioachim Popescu
- Doctoral School of Biological and Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania; (M.S.); (C.S.); (M.I.P.)
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10
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Lee SJ, Lee YJ, Kim BK, Hong SJ, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Ticagrelor Monotherapy Versus Ticagrelor With Aspirin in Acute Coronary Syndrome Patients With a High Risk of Ischemic Events. Circ Cardiovasc Interv 2021; 14:e010812. [PMID: 34281363 DOI: 10.1161/circinterventions.121.010812] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Seung-Jun Lee
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yong-Joon Lee
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chul-Min Ahn
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young-Guk Ko
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
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11
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Wang R, Wu S, Gamal A, Gao C, Hara H, Kawashima H, Ono M, van Geuns RJ, Vranckx P, Windecker S, Onuma Y, Serruys PW, Garg S. Aspirin-free antiplatelet regimens after PCI: insights from the GLOBAL LEADERS trial and beyond. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 7:547-556. [PMID: 33930107 PMCID: PMC8566303 DOI: 10.1093/ehjcvp/pvab035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/21/2021] [Accepted: 04/28/2021] [Indexed: 01/16/2023]
Abstract
Historically, aspirin has been the primary treatment for the prevention of ischaemic events in patients with coronary artery disease. For patients undergoing percutaneous coronary intervention (PCI) standard treatment has been 12 months of dual antiplatelet therapy (DAPT) with aspirin and clopidogrel, followed by aspirin monotherapy; however, DAPT is undeniably associated with an increased risk of bleeding. For over a decade novel P2Y12 inhibitors, which have increased specificity, potency, and efficacy have been available, prompting studies which have tested whether these newer agents can be used in aspirin-free antiplatelet regimens to augment clinical benefits in patients post-PCI. Among these studies, the GLOBAL LEADERS trial is the largest by cohort size, and so far has provided a wealth of evidence in a variety of clinical settings and patient groups. This article summarizes the state-of-the-art evidence obtained from the GLOBAL LEADERS and other trials of aspirin-free strategies.
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Affiliation(s)
- Rutao Wang
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sijing Wu
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of cardiology, Beijing Anzhen hospital, Beijing, China.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Amr Gamal
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, North Cumbria University Hospitals NHS Trust, England, United Kingdom.,Department of Cardiology, Zagazig University, Egypt
| | - Chao Gao
- Department of Cardiology, Xijing hospital, Xi'an, China.,Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Hironori Hara
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hideyuki Kawashima
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Masafumi Ono
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert-Jan van Geuns
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium.,Faculty of medicine and Life Sciences, University of Hasselt, Hasselt, Belgium
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland.,Imperial College London, London, United Kingdom
| | - Scot Garg
- East Lancashire Hospitals NHS Trust, Blackburn, Lancashire, United Kingdom
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12
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Sandner SE, Schunkert H, Kastrati A, Milojevic M, Böning A, Zimpfer D, Zellmer S, Wiedemann D, Laufer G, von Scheidt M. Ticagrelor or aspirin after coronary artery bypass in patients with chronic kidney disease. Ann Thorac Surg 2021; 113:554-562. [PMID: 33819474 DOI: 10.1016/j.athoracsur.2021.03.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/19/2021] [Accepted: 03/22/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The optimal antiplatelet therapy for patients with chronic kidney disease (CKD) undergoing coronary artery bypass grafting (CABG) remains unknown. METHODS This post hoc analysis of the Ticagrelor in Coronary Artery Bypass (TiCAB) trial examined the efficacy and safety of ticagrelor versus aspirin in patients with or without CKD. Primary endpoint was the composite of cardiovascular death, stroke, myocardial infarction or revascularization (MACCE) at 1 year after CABG. Secondary endpoints included individual components of the primary endpoint, all-cause death, and major bleeding. RESULTS CKD was present in 276 of 1,843 randomized patients (15.0%). Patients with CKD versus those without CKD had higher 1-year rates of MACCE (13.0% vs. 8.3%, HR 1.63, 95% CI 1.12-2.39, P=0.01) and major bleeding (5.6% vs. 3.1%, HR 1.84, 95% CI 1.03-3.28, P=0.04). The 1-year rate of MACCE was increased with ticagrelor versus aspirin in patients with CKD (18.2% vs. 8.9%, HR 2.15, 95% CI 1.08-4.30, P=0.03), but not in patients without CKD (8.5% vs. 8.1%, HR 1.05, 95% CI 0.74-1.49, P=0.79) (Pinteraction=0.067). There was no difference in the 1-year rate of major bleeding with ticagrelor versus aspirin in patients with CKD (6.6% vs. 4.7%, HR 1.44, 95% CI 0.52-3.97, P=0.48) and without CKD (3.3% vs. 2.9%, HR 1.14, 95% CI 0.64-2.01, P=0.65). CONCLUSIONS In patients with CKD and CABG, those who received ticagrelor had a higher incidence of MACCE but a similar incidence of major bleeding compared to those who received aspirin.
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Affiliation(s)
- Sigrid E Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Austria.
| | - Heribert Schunkert
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Milan Milojevic
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, The Netherlands; Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Serbia
| | - Andreas Böning
- Department of Cardiovascular Surgery, University Hospital Giessen, Germany
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Stephan Zellmer
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
| | - Dominik Wiedemann
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Austria
| | - Moritz von Scheidt
- Deutsches Herzzentrum Mu¨nchen, Technische Universität Mu¨nchen, Germany; German Center for Cardiovascular Research (DZHK), Munich Heart Alliance, Germany
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13
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Mayer O, Seidlerová J, Bruthans J, Opatrný J, Hromádka M, Jirák J, Filipovský J. The prognostic impact of renal function decline during hospitalization for myocardial infarction. J Comp Eff Res 2021; 10:219-228. [PMID: 33541131 DOI: 10.2217/cer-2020-0085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: We analyzed the mortality risk of myocardial infarction (MI) patients according to renal function, observed during hospitalization. Materials & methods: Patients hospitalized for MI between 2006 and 2018 were followed (n = 5659). We divided the sample into four groups by estimated glomerular filtration (eGFR) [ml/min]: normal functions (lowest eGFR during hospitalization >60); transiently moderate insufficiency (lowest eGFR >30 and ≤60, highest >60); permanently moderate insufficiency (highest eGFR >30 and ≤60); severe insufficiency (highest and lowest eGFR ≤30). Results: Permanently moderate renal insufficiency indicates increased 5-years all-cause mortality (hazard risk ratio: 2.27 [95% CIs: 1.87-2.75], p < 0.0001), but a similar risk was found in patients with the only transient decline of renal functions (hazard risk ratio: 2.08 [95% CIs: 1.70-2.55], p < 0.0001). Both moderate insufficiency subgroups (transient/permanent) did not statistically differ regarding mortality risk. Conclusion: Even just fluctuation of eGFR toward moderate insufficiency during hospitalization represents an important prognostic indicator in MI patients.
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Affiliation(s)
- Otto Mayer
- 2nd Department of Internal Medicine, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic.,Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Jitka Seidlerová
- 2nd Department of Internal Medicine, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic.,Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic
| | - Jan Bruthans
- 2nd Department of Internal Medicine, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic.,Centre for Cardiovascular Prevention, First Faculty of Medicine, Charles, University & Thomayer's Hospital, Prague, Czech Republic
| | - Jan Opatrný
- Department of Cardiology, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic
| | - Milan Hromádka
- Department of Cardiology, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic
| | - Josef Jirák
- Department of Informatics, University Hospital, Pilsen, Czech Republic
| | - Jan Filipovský
- 2nd Department of Internal Medicine, Medical Faculty of Charles University & University Hospital, Pilsen, Czech Republic.,Biomedical Center, Medical Faculty of Charles University, Pilsen, Czech Republic
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14
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Galli M, Capodanno D, Andreotti F, Crea F, Angiolillo DJ. Safety and efficacy of P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions. Expert Opin Drug Saf 2020; 20:9-21. [PMID: 33180563 DOI: 10.1080/14740338.2021.1850691] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y12 inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y12 inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y12 monotherapy regimen warrant further investigation.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy.,Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico," Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
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