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Chen S, Li J, Qiu M, Ma S, Jiang Z, Na K, Qi Z, Li Y, Li Y, Han Y. Predictors and long-term outcomes of in-hospital switching from clopidogrel to ticagrelor among patients with acute coronary syndrome undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2022; 99 Suppl 1:1424-1431. [PMID: 35077608 DOI: 10.1002/ccd.30089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 11/11/2022]
Abstract
This study evaluated clinical outcomes of switching from clopidogrel to ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). The clinical benefit of in-hospital switching from clopidogrel to ticagrelor in these patients remains unclear. Among patients with ACS initially receiving clopidogrel, logistic regression was used to identify independent predictors of switching to ticagrelor. Multivariable Cox regression was used to compare efficacy and safety between switching to ticagrelor and continuing clopidogrel. The primary endpoint was net adverse clinical events (NACEs) at 12 months, a composite of major adverse cardiovascular events (MACE) and Bleeding Academic Research Consortium (BARC) type 2/3/5 bleeding. Among 10,519 patients initially receiving clopidogrel, 1405 (13.4%) were switched to ticagrelor at discharge. Stent number, left main artery lesions, diabetes, male sex, age, estimated glomerular filtration rate of <45 ml/min/1.73 m2 , and history of PCI or stroke were identified as independent predictors of switching to ticagrelor. The rate of NACE (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.18-1.91) or BARC type 2/3/5 bleeding (HR: 2.01; 95% CI: 1.52-2.66) was significantly higher in patients switching to ticagrelor than in those continuing clopidogrel. The risk of MACE was comparable between both the groups (HR: 0.71; 95% CI: 0.41-1.22). In real-world practice, in-hospital switching from clopidogrel to ticagrelor was independently associated with several clinical factors. Patients switching to ticagrelor had a higher rate of NACE or BARC type 2/3/5 bleeding than those continuing clopidogrel, without any reduction in the MACE rate.
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Affiliation(s)
- Sanbao Chen
- General Hospital of Northern Theater Command of China Medical University, Shenyang, China.,Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.,The Graduate School of Harbin Medical University, Harbin, China
| | - Miaohan Qiu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sicong Ma
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zaixin Jiang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Kun Na
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zizhao Qi
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yuzhuo Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
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Peyracchia M, Saglietto A, Biolè C, Raposeiras-Roubin S, Abu-Assi E, Kinnaird T, Ariza-Solé A, Liebetrau C, Manzano-Fernández S, Boccuzzi G, Henriques JPS, Wilton SB, Velicki L, Xanthopoulou I, Correia L, Rognoni A, Fabrizio U, Nuñez-Gil I, Montabone A, Taha S, Fujii T, Durante A, Gili S, Magnani G, Autelli M, Grosso A, Kawaji T, Blanco PF, Garay A, Quadri G, Queija BC, Huczek Z, Paz RC, González-Juanatey JR, Fernández MC, Nie SP, D’Amico M, Pousa IM, Kawashiri MA, Gallo D, Morbiducci U, Dominguez-Rodriguez A, Lopez-Cuenca A, Cequier A, Alexopoulos D, Iñiguez-Romo A, Grossomarra W, Usmiani T, Rinaldi M, D’Ascenzo F. Efficacy and Safety of Clopidogrel, Prasugrel and Ticagrelor in ACS Patients Treated with PCI: A Propensity Score Analysis of the RENAMI and BleeMACS Registries. Am J Cardiovasc Drugs 2020; 20:259-269. [PMID: 31586336 DOI: 10.1007/s40256-019-00373-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Real-life data comparing clopidogrel, prasugrel, and ticagrelor for unselected patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) are lacking, as are data for the temporal distribution of ischemic and bleeding risks. METHODS A total of 19,825 patients were enrolled from the RENAMI and BleeMACS registries. Both were multicenter, retrospective, observational registries including the data and outcomes of consecutive patients with ACS who underwent primary PCI and were discharged with dual antiplatelet therapy (DAPT). We evaluated the long-term outcome stratified by the different antiplatelet agents. RESULTS A total of 14,105 patients (71.2%) were treated with clopidogrel, 2364 patients (11.9%) with prasugrel and 3356 patients (16.9%) with ticagrelor. After propensity score matching, at 1 year, prasugrel reduced the incidence of net adverse clinical events (NACE; a composite endpoint of all-cause death, myocardial infarction [MI] and Bleeding Academic Research Consortium [BARC] 3-5 bleeding) (4.2% vs.7.6%, p = 0.002) and of major adverse cardiovascular events (MACE; a composite endpoint of death and MI) compared with clopidogrel (2.6% vs. 5.2%, p = 0.007). Ticagrelor decreased rates of MACE compared with clopidogrel (2.7% vs. 6.2%, p < 0.001), but not of NACE (6.6% vs. 8.7%, p = 0.07). Ticagrelor presented similar performance in terms of MACE compared with prasugrel (2.8% vs. 2.4%, p = 0.56), with a trend towards a reduction in MI (0.2% vs. 0.4%, p = 0.56), but with higher risk of BARC 3-5 bleedings (3.8% vs. 1.7%, p = 0.04). In the daily risk analysis, clopidogrel presented a binomial distribution with a peak of ischemic risk at 3 months, which decreased towards bleedings; prasugrel had a constant equivalence between opposite risks; and ticagrelor constantly reduced recurrent MIs despite higher risk of BARC 3-5 events. CONCLUSION In real life, ticagrelor is more effective in reducing ischemic events during the first year after ACS, despite an increased risk of major bleedings, while prasugrel assures a better balance between ischemic and bleeding recurrent events.
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Frequency and clinical outcomes of CYP2C19 genotype-guided escalation and de-escalation of antiplatelet therapy in a real-world clinical setting. Genet Med 2019; 22:160-169. [PMID: 31316169 PMCID: PMC6946839 DOI: 10.1038/s41436-019-0611-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose To evaluate the frequency and clinical impact of switches in antiplatelet therapy following implementation of CYP2C19 genotyping after percutaneous coronary intervention (PCI). Methods The frequency of escalation (clopidogrel switched to prasugrel/ticagrelor) and de-escalation (prasugrel/ticagrelor switched to clopidogrel) was evaluated in 1063 PCI patients who underwent CYP2C19 genotyping. Risk of major adverse cardiovascular or cerebrovascular (MACCE) and bleeding events over one-year was evaluated. Results Antiplatelet therapy switches were common (19%), with escalation (101/115: 88%) and de-escalation (77/84: 92%) occurring predominantly in patients with and without a CYP2C19 nonfunctional allele, respectively. Nonfunctional allele carriers initiated and continued on clopidogrel had a significantly higher risk of experiencing either a MACCE or bleeding event compared to those escalated to prasugrel/ticagrelor (52 vs. 19 events/100 patient-years; adjusted hazard ratio [HR] 2.89 [1.44–6.13], p=0.003). Patients without a nonfunctional allele de-escalated to clopidogrel had no difference in risk compared to those initiated and continued on prasugrel/ticagrelor (21 vs. 19 events/100 patient-years; adjusted HR 1.13 [0.51–2.34], p=0.751). Conclusions CYP2C19-guided escalation and de-escalation is common in a real-world setting. Continuation of clopidogrel in nonfunctional allele carriers is associated with adverse outcomes. De-escalation to clopidogrel in patients without a nonfunctional allele appears safe and warrants prospective study.
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Carrillo-Aleman L, Marín F, Rivera-Caravaca JM, Vicente-Ibarra N, Candela-Sanchez E, Esteve-Pastor MA, Lozano T, Sandín-Rollan M, Pernias-Escrig V, Macías M, Quintana-Giner M, Veliz A, Orenes-Piñero E, Martínez-Martínez JG, Ruiz-Nodar JM. Switching of Oral P2Y 12 Inhibitor Treatment in Patients with Acute Coronary Syndrome: Prevalence, Predictors, and Prognosis. Clin Drug Investig 2019; 39:275-283. [PMID: 30623372 DOI: 10.1007/s40261-018-0736-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Dual antiplatelet therapy is one of the main treatments in acute coronary syndrome (ACS). Switching antiplatelet agents may be necessary in some patients to improve efficacy or safety. The objective of this study was to determine the prevalence, predictors, and implications of clinical switching in patients during hospital admission and 1-year follow-up at discharge. METHODS Observational, prospective, multicenter registry study in patients discharged following an admission for ACS and followed up for 1 year. We analyzed ischemic and bleeding events as well as treatment changes. RESULTS We recruited 1717 patients; in-hospital switching occurred in 425 (24.8%): 15.1% to clopidogrel and 84.9% to newer antiplatelet drugs (prasugrel or ticagrelor). Those switched to newer antiplatelets were younger, with lower scores on the GRACE and CRUSADE scales, admitted more frequently for ST-elevation myocardial infarction and underwent more invasive management and percutaneous revascularization. The clinical cardiologist was responsible for most in-hospital switching to newer antiplatelets (79.6%). The loading dose of the second antiplatelet did not affect incidence of bleeding events. Post-discharge switching was infrequent (2%) and depended mainly on clinical indications; only 30% was related to a new ACS. CONCLUSIONS In a contemporary registry with ACS, in-hospital switching of antiplatelet drugs was frequent. Those switched to newer antiplatelets were younger and admitted more frequently for ST-elevation myocardial infarction. Post-discharge switching was infrequent.
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Affiliation(s)
- Luna Carrillo-Aleman
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain.
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - José M Rivera-Caravaca
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Nuria Vicente-Ibarra
- Department of Cardiology, Hospital General Universitario de Elche, Alicante, Spain
| | - Elena Candela-Sanchez
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | | | - Teresa Lozano
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Miriam Sandín-Rollan
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Vicente Pernias-Escrig
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Manuel Macías
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Miriam Quintana-Giner
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Andrea Veliz
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Esteban Orenes-Piñero
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación (IMIB-Arrixaca), CIBER-CV, Murcia, Spain
| | - Juan G Martínez-Martínez
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
| | - Juan M Ruiz-Nodar
- Department of Cardiology, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), C/ Maestro Alonso s/n, 03010, Alicante, Spain
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Cerrato E, Bianco M, Bagai A, De Luca L, Biscaglia S, Luciano A, Destefanis P, Quadri G, Meynet I, Gravinese C, Chinaglia A, Goodman SG, Pozzi R, Campo G, Varbella F. Short term outcome following acute phase switch among P2Y 12 inhibitors in patients presenting with acute coronary syndrome treated with PCI: A systematic review and meta-analysis including 22,500 patients from 14 studies. IJC HEART & VASCULATURE 2019; 22:39-45. [PMID: 30560202 PMCID: PMC6288462 DOI: 10.1016/j.ijcha.2018.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/17/2018] [Accepted: 11/19/2018] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The efficacy and safety of switching P2Y12 receptor antagonists in patients admitted for acute coronary syndrome (ACS) remain unclear. We assessed the short-term clinical outcomes (in-hospital and within 30 days) of switching P2Y12 inhibitor (P2Y12I) drugs versus maintaining the same regimen by performing a comprehensive review and meta-analysis of available data. METHODS MEDLINE/PubMed/SCOPUS/Cochrane databases were screened for studies regarding switching of P2Y12I in patients with ACS that reported 30 days follow-up. Major cardiac events (MACE) and bleeding were compared between patients who were switched/not switched. RESULTS 22,500 patients from 14 studies were included. Unstable angina/non-ST elevation myocardial infarction (62.0%, interquartile range, 52.8%-68.0%) was the most common clinical presentation. The total number switched was 4294 (19.1%); escalation in 3416 (79.5%) patients (from clopidogrel to prasugrel, 62.9%) and de-escalation in 18.5%. Pooled analysis revealed no significant differences in MACE for any comparison; risk of bleeding was significantly increased among switched patients overall (odds ratio [OR], 1.60; 95% confidence interval [CI] 1.22-2.10) and increased in the escalation group (OR, 1.51; 95% CI, 1.06-2.16). CONCLUSIONS Among patients presenting with ACS, switching from one P2Y12I agent to another in the acute phase seems associated with a short-term increased risk of bleeding. Accurate upfront selection and prescription of a P2Y12I based on ischemic and bleeding risks is paramount to avoid adverse events switching-related during hospitalization and in the first 30 days.
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Affiliation(s)
- Enrico Cerrato
- Interventional Cardiology, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli, Turin, Italy
| | - Matteo Bianco
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Akshay Bagai
- St. Michael's Hospital, Division of Cardiology, Toronto, Canada
| | - Leonardo De Luca
- S. Giovanni Evangelista Hospital-Tivoli, Division of Cardiology, Rome, Italy
| | | | - Alessia Luciano
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Paola Destefanis
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Giorgio Quadri
- Interventional Cardiology, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli, Turin, Italy
| | - Ilaria Meynet
- Division of Cardiology, Infermi Hospital, Rivoli,Turin, Italy
| | - Carol Gravinese
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | | | | | - Roberto Pozzi
- Division of Cardiology, San Luigi Gonzaga University Hospital, Orbassano, Italy
| | - Gianluca Campo
- University of Ferrara, Division of Cardiology, Ferrara, Italy
| | - Ferdinando Varbella
- Interventional Cardiology, San Luigi Gonzaga University Hospital, Orbassano and Infermi Hospital, Rivoli, Turin, Italy
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Abstract
Antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment of patients with atherothrombotic disease manifestations. Switching between P2Y12 inhibitors occurs commonly in clinical practice for a variety of reasons, including safety, efficacy, adherence, and economic considerations. There are concerns about the optimal approach for switching because of potential drug interactions, which may lead to ineffective platelet inhibition and thrombotic complications, or potential overdosing due to overlap in drug therapy, which might cause excessive platelet inhibition and increased bleeding. This review provides practical considerations of switching based on pharmacodynamic and clinical data available from the literature.
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Affiliation(s)
- Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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Mehta SR, Bainey KR, Cantor WJ, Lordkipanidzé M, Marquis-Gravel G, Robinson SD, Sibbald M, So DY, Wong GC, Abunassar JG, Ackman ML, Bell AD, Cartier R, Douketis JD, Lawler PR, McMurtry MS, Udell JA, van Diepen S, Verma S, Mancini GBJ, Cairns JA, Tanguay JF. 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2017; 34:214-233. [PMID: 29475527 DOI: 10.1016/j.cjca.2017.12.012] [Citation(s) in RCA: 163] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/09/2017] [Accepted: 12/10/2017] [Indexed: 12/20/2022] Open
Abstract
Antiplatelet therapy (APT) has become an important tool in the treatment and prevention of atherosclerotic events, particularly those associated with coronary artery disease. A large evidence base has evolved regarding the relationship between APT prescription in various clinical contexts and risk/benefit relationships. The Guidelines Committee of the Canadian Cardiovascular Society and Canadian Association of Interventional Cardiology publishes regular updates of its recommendations, taking into consideration the most recent clinical evidence. The present update to the 2011 and 2013 Canadian Cardiovascular Society APT guidelines incorporates new evidence on how to optimize APT use, particularly in situations in which few to no data were previously available. The recommendations update focuses on the following primary topics: (1) the duration of dual APT (DAPT) in patients who undergo percutaneous coronary intervention (PCI) for acute coronary syndrome and non-acute coronary syndrome indications; (2) management of DAPT in patients who undergo noncardiac surgery; (3) management of DAPT in patients who undergo elective and semiurgent coronary artery bypass graft surgery; (4) when and how to switch between different oral antiplatelet therapies; and (5) management of antiplatelet and anticoagulant therapy in patients who undergo PCI. For PCI patients, we specifically analyze the particular considerations in patients with atrial fibrillation, mechanical or bioprosthetic valves (including transcatheter aortic valve replacement), venous thromboembolic disease, and established left ventricular thrombus or possible left ventricular thrombus with reduced ejection fraction after ST-segment elevation myocardial infarction. In addition to specific recommendations, we provide values and preferences and practical tips to aid the practicing clinician in the day to day use of these important agents.
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Affiliation(s)
- Shamir R Mehta
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Kevin R Bainey
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Warren J Cantor
- University of Toronto and Southlake Regional Health Centre, Toronto, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | | | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Matthew Sibbald
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Graham C Wong
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Margaret L Ackman
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Alan D Bell
- University of Toronto, Toronto, Ontario, Canada
| | - Raymond Cartier
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada
| | - James D Douketis
- McMaster University and St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Patrick R Lawler
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael S McMurtry
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jacob A Udell
- University of Toronto and Women's College Hospital and Peter Munk Cardiac Centre of Toronto General Hospital, Toronto, Ontario, Canada
| | - Sean van Diepen
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Subodh Verma
- University of Toronto and St Michael's Hospital, Toronto, Ontario, Canada
| | - G B John Mancini
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John A Cairns
- University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Jean-François Tanguay
- Université de Montréal and Institut de Cardiologie de Montréal, Montréal, Quebec, Canada.
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Angiolillo DJ, Rollini F, Storey RF, Bhatt DL, James S, Schneider DJ, Sibbing D, So DY, Trenk D, Alexopoulos D, Gurbel PA, Hochholzer W, De Luca L, Bonello L, Aradi D, Cuisset T, Tantry US, Wang TY, Valgimigli M, Waksman R, Mehran R, Montalescot G, Franchi F, Price MJ. International Expert Consensus on Switching Platelet P2Y
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Receptor–Inhibiting Therapies. Circulation 2017; 136:1955-1975. [DOI: 10.1161/circulationaha.117.031164] [Citation(s) in RCA: 231] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.)
| | - Stefan James
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Sweden (S.J.)
| | - David J. Schneider
- Department of Medicine, Cardiology Unit, Cardiovascular Research Institute, University of Vermont, Burlington (D.J.S.)
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Germany (D.S.)
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Germany (D.S.)
| | - Derek Y.F. So
- Division of Cardiology, University of Ottawa Heart Institute, Ontario, Canada (D.Y.S.F.)
| | - Dietmar Trenk
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, National and Capodistrian University of Athens, Attikon University Hospital, Greece (D. Alexopoulos)
| | - Paul A. Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Willibald Hochholzer
- Department of Cardiology & Angiology II, University Heart Center Freiburg-Bad Krozingen, Germany (D.T., W.H.)
| | - Leonardo De Luca
- Division of Cardiology, Laboratory of Interventional Cardiology, San Giovanni Evangelista Hospital, Tivoli-Rome, Italy (L.D.L.)
- Mediterranean Academic Association for Research and Studies in Cardiology, Marseille, France (L.D.L.)
- Aix-Marseille University, INSERM UMRS 1076, Marseille, France (L.D.L.)
| | - Laurent Bonello
- Assistance Publique-Hôpitaux de Marseille, Department of Cardiology, Hôpital Nord, Marseille, France (L.B.)
| | - Daniel Aradi
- Heart Center Balatonfüred and Semmelweis University Budapest, Hungary (D. Aradi)
| | - Thomas Cuisset
- Department of Cardiology, CHU Timone, and Aix-Marseille Université, Faculté de Médecine, Marseille, France (T.C.)
| | - Udaya S. Tantry
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G., U.S.T.)
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W.)
| | - Marco Valgimigli
- Swiss Cardiovascular Center Bern, Bern University Hospital, Switzerland (M.V.)
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, DC (R.W.)
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York City, NY (R.M.)
| | - Gilles Montalescot
- Sorbonne Université Paris 6, ACTION Study Group, Hôpital Pitié-Salpêtrière, France (G.M.)
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A., F.R., F.F.)
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
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Seguridad y eficacia clínica con prasugrel y ticagrelor en síndrome coronario agudo. Resultados de un registro multicéntrico en el mundo real. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2017.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Role of P2Y 12 Receptor in Thrombosis. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 906:307-324. [PMID: 27628007 DOI: 10.1007/5584_2016_123] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
P2Y12 receptor is a 342 amino acid Gi-coupled receptor predominantly expressed on platelets. P2Y12 receptor is physiologically activated by ADP and inhibits adenyl cyclase (AC) to decrease cyclic AMP (cAMP) level, resulting in platelet aggregation. It also activates PI3 kinase (PI3K) pathway leading to fibrinogen receptor activation, and may protect platelets from apoptosis. Abnormalities of P2Y12 receptor include congenital deficiencies or high activity in diseases like diabetes mellitus (DM) and chronic kidney disease (CKD), exposing such patients to a prothrombotic condition. A series of clinical antiplatelet drugs, such as clopidogrel and ticagrelor, are designed as indirect or direct antagonists of P2Y12 receptor to reduce incidence of thrombosis mainly for patients of acute coronary syndrome (ACS) who are at high risk of thrombotic events. Studies on novel dual-/multi-target antiplatelet agents consider P2Y12 receptor as a promising part in combined targets. However, the clinical practical phenomena, such as "clopidogrel resistance" due to gene variations of cytochrome P450 or P2Y12 receptor constitutive activation, call for better antiplatelet agents. Researches also showed inverse agonist of P2Y12 receptor could play a better role over neutral antagonists. Personalized antiplatelet therapy is the most ideal destination for antiplatelet therapy in ACS patients with or without other underlying diseases like DM or CKD, however, there is still a long way to go.
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Scherillo M, Cirillo P, Formigli D, Bonzani G, Calabrò P, Capogrosso P, Farina R, Lanzillo T, Mascia F, Mauro C, Tuccillo B, Bellis A, Bianchi R, Cimmino G, Piro O, Ravera A, Scotto di Uccio F, Tammaro P, Vetrano A, Trimarco B. Antiplatelet Therapy for Non-ST-Segment Elevation Myocardial Infarction in Complex "Real" Clinical Scenarios: A Consensus Document of the "Campania NSTEMI Study Group". Angiology 2017; 68:598-607. [PMID: 28660806 DOI: 10.1177/0003319716676721] [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] [Indexed: 12/22/2022]
Abstract
The incidence of ST-segment elevation myocardial infarction (STEMI) has significantly decreased. Conversely, the rate of non-STEMI (NSTEMI) has increased. Patients with NSTEMI have lower short-term mortality compared to patients with STEMI, whereas at long-term follow-up, the mortality becomes comparable. This might be due to the differences in baseline characteristics, including older age and a greater prevalence of comorbidities in the NSTEMI population. Although antithrombotic strategies used in patients with NSTEMI have been well studied in clinical trials and updated guidelines are available, patterns of use and outcomes in clinical practice are less well described. Thus, a panel of Italian cardiology experts assembled under the auspices of the "Campania NSTEMI Study Group" for comprehensive discussion and consensus development to provide practical recommendations, for both clinical and interventional cardiologists, regarding optimal management of antithrombotic therapy in patients with NSTEMI. This position article presents and discusses various clinical scenarios in patients with NSTEMI or unstable angina, including special subsets (eg, patients aged ≥85 years, patients with chronic renal disease or previous cerebrovascular events, and patients requiring triple therapy or long-term antithrombotic therapy), with the panel recommendations being provided for each scenario.
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Affiliation(s)
- Marino Scherillo
- 1 U.O.C. Cardiologia Interventistica ed UTIC. Azienda Ospedaliera "G.Rummo" di Benevento
| | - Plinio Cirillo
- 2 Division of Cardiology, Department of Advanced Biomedical Sciences, Universitaà di Napoli "Federico II," Napoli, Italy
| | - Dario Formigli
- 1 U.O.C. Cardiologia Interventistica ed UTIC. Azienda Ospedaliera "G.Rummo" di Benevento
| | - Giulio Bonzani
- 3 U.O.C. Cardiologia Interventistica. Azienda Ospedaliera Specialistica dei Colli, Napoli
| | - Paolo Calabrò
- 4 U.O.C. Cardiologia Interventistica ed UTIC. Seconda Università di Napoli, Napoli
| | - Paolo Capogrosso
- 5 U.O.C. Cardiologia ed UTIC, Ospedale San Giovanni Bosco, Napoli
| | - Rosario Farina
- 6 Cardiologia ed UTIC, Ospedale San Giovanni di Dio ed Ruggi d' Aragona, Salerno
| | - Tonino Lanzillo
- 7 Unità operativa di Cardiologia ed UTIC, Ospedale Moscati, Avellino
| | - Franco Mascia
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Ciro Mauro
- 9 U.O.C. Cardiologia Interventistica ed UTIC. Ospedale Cardarelli, Napoli
| | | | - Alessandro Bellis
- 9 U.O.C. Cardiologia Interventistica ed UTIC. Ospedale Cardarelli, Napoli
| | - Renato Bianchi
- 4 U.O.C. Cardiologia Interventistica ed UTIC. Seconda Università di Napoli, Napoli
| | - Giovanni Cimmino
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Orlando Piro
- 3 U.O.C. Cardiologia Interventistica. Azienda Ospedaliera Specialistica dei Colli, Napoli
| | - Amelia Ravera
- 6 Cardiologia ed UTIC, Ospedale San Giovanni di Dio ed Ruggi d' Aragona, Salerno
| | | | - Paolo Tammaro
- 5 U.O.C. Cardiologia ed UTIC, Ospedale San Giovanni Bosco, Napoli
| | - Alfredo Vetrano
- 8 U.O.C. Cardiologia-UTIC. Ospedale S. Anna e S. Sebastiano, Caserta
| | - Bruno Trimarco
- 2 Division of Cardiology, Department of Advanced Biomedical Sciences, Universitaà di Napoli "Federico II," Napoli, Italy
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De Luca L, D’Ascenzo F, Musumeci G, Saia F, Parodi G, Varbella F, Marchese A, De Servi S, Berti S, Bolognese L. Incidence and outcome of switching of oral platelet P2Y12 receptor inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention: the SCOPE registry. EUROINTERVENTION 2017; 13:459-466. [DOI: 10.4244/eij-d-17-00092] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Khayata M, Gabra JN, Nasser MF, Litman GI, Bhakta S, Raina R. Comparison of Clopidogrel With Prasugrel and Ticagrelor in Patients With Acute Coronary Syndrome: Clinical Outcomes From the National Cardiovascular Database ACTION Registry. Cardiol Res 2017; 8:105-110. [PMID: 28725326 PMCID: PMC5505293 DOI: 10.14740/cr560w] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/22/2022] Open
Abstract
Background We aimed to compare the clinical outcomes of clopidogrel, prasugrel, and ticagrelor in clinical practice using the National Cardiovascular Database ACTION Registry®. Treatment guidelines for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention recommend dual antiplatelet therapy (DAPT) for 12 months. Few clinical trials have compared the safety and efficacy of clopidogrel with that of newer antiplatelet therapies. Methods A retrospective study of patients hospitalized for ACS at Cleveland Clinic Akron General was conducted. Data elements included detailed medical history and clinical outcomes during hospital stay. The primary outcome was a composite of major clinical events (cardiogenic shock, atrial fibrillation, ventricular fibrillation, ventricular tachycardia, heart failure, bleeding, and mechanical ventilation). The independent variable was the type of DAPT. Statistical analyses were performed using Chi-square and Mann-Whitney U tests. A post-hoc analysis was performed to compare between the antiplatelet drugs head-to-head. Results Subjects (n = 1,388) admitted between January 2011 and March 2016 with ACS and treated with clopidogrel, prasugrel, or ticagrelor were included in the study. Mean age was 65 ± 14 years and 46% had ST-segment elevation myocardial infarction. Prasugrel administration within 24 h was associated with a lower incidence of the composite outcome (P = 0.049), bleeding (P = 0.028), and heart failure (P = 0.002). Conclusion There was a significant difference between the type of antiplatelet drug and clinical outcomes in ACS patients who were treated with DAPT. Observations from current study may provide important information for prescribers in clinical decision-making.
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Affiliation(s)
- Mohamed Khayata
- Department of Internal Medicine, Akron General Health System, Akron, OH, USA
| | - Joseph N Gabra
- Department of Research, Akron General Health System, Akron, OH, USA
| | - M Farhan Nasser
- Department of Internal Medicine, Akron General Health System, Akron, OH, USA
| | - George I Litman
- Department of Internal Medicine, Akron General Health System, Akron, OH, USA.,Section of Cardiology, Department of Internal Medicine, Northeast Ohio University College of Medicine, Rootstown, OH, USA
| | - Shyam Bhakta
- Department of Internal Medicine, Akron General Health System, Akron, OH, USA.,Section of Cardiology, Department of Internal Medicine, Northeast Ohio University College of Medicine, Rootstown, OH, USA
| | - Rupesh Raina
- Department of Internal Medicine, Akron General Health System, Akron, OH, USA
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Safety and Efficacy of Prasugrel and Ticagrelor in Acute Coronary Syndrome. Results of a "Real World" Multicenter Registry. ACTA ACUST UNITED AC 2017; 70:952-959. [PMID: 28576388 DOI: 10.1016/j.rec.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/07/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES The incorporation of the new antiplatelet agents (NAA) prasugrel and ticagrelor into routine clinical practice is irregular and data from the "real world" remain scarce. We aimed to assess the time trend of NAA use and the clinical safety and efficacy of these drugs compared with those of clopidogrel in a contemporary cohort of patients with acute coronary syndromes (ACS). METHODS A multicenter retrospective observational study was conducted in patients with ACS admitted to coronary care units and prospectively included in the ARIAM-Andalusia registry between 2013 and 2015. In-hospital rates of major cardiovascular events and bleeding with NAA vs clopidogrel were analyzed using propensity score matching and multivariate regression models. RESULTS The study included 2906 patients: 55% received clopidogrel and 45% NAA. A total of 60% had ST-segment elevation ACS. Use of NAA significantly increased throughout the study. Patients receiving clopidogrel were older and were more likely to have comorbidities. Total mortality, ischemic stroke, and stent thrombosis were lower with NAA (2% vs 9%, P < .0001; 0.1% vs 0.5%, P = .025; 0.07% vs 0.5%, P = .025, respectively). There were no differences in the rate of total bleeding (3% vs 4%; P = NS). After propensity score matching, the mortality reduction with NAA persisted (OR, 0.37; 95%CI, 0.13 to 0.60; P < .0001) with no increase in total bleeding (OR, 1.07; 95%CI, 0.18 to 2.37; P = .094). CONCLUSIONS In a "real world" setting, NAA are selectively used in younger patients with less comorbidity and are associated with a reduction in major cardiac events, including mortality, without increasing bleeding compared with clopidogrel.
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Switching of platelet P2Y12 receptor inhibitors in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Review of the literature and practical considerations. Am Heart J 2016; 176:44-52. [PMID: 27264219 DOI: 10.1016/j.ahj.2016.03.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 03/03/2016] [Indexed: 11/22/2022]
Abstract
The combination of aspirin and a P2Y12 receptor inhibitor is the cornerstone of treatment in patients with acute coronary syndromes (ACSs) and in those undergoing percutaneous coronary intervention (PCI). At the present time, 3 different oral P2Y12 receptor inhibitors are available on the market; 2 have obtained the indication for ACS (clopidogrel and ticagrelor) and 1 for ACS with planned PCI (prasugrel). An intravenous direct acting P2Y12 inhibitor, cangrelor, has also been recently approved by US and European regulatory agencies for patients undergoing PCI. Although the correct timing and modality of transition from intravenous cangrelor to oral P2Y12 inhibitors is still controversial and needs further evidence, switching between oral P2Y12 receptor inhibitors frequently occurs in clinical practice for several reasons. This practice raises the question of the relative safety of this strategy and of which switching approaches are preferable. In this article, we review the data on switching antiplatelet treatment strategies with P2Y12 receptor inhibitors and discuss practical considerations for switching therapies in patients with ACS undergoing PCI.
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Safety and Efficacy of Switching From Clopidogrel to Prasugrel in Patients Undergoing Percutaneous Coronary Intervention: A Study-level Meta-analysis From 15 Studies. J Cardiovasc Pharmacol 2016; 67:336-43. [PMID: 26771153 DOI: 10.1097/fjc.0000000000000359] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is poor evidence on clinical outcome of switching from clopidogrel to prasugrel in patients undergoing percutaneous coronary intervention. OBJECTIVES Data on the topic are limited and we performed a study-level meta-analysis to assess safety and efficacy of such strategy. METHODS A total of 15 studies and 3974 patients were included. The following comparisons were performed: prasugrel switching versus prasugrel only therapy; and prasugrel switching versus clopidogrel only therapy. Outcome measures were overall bleeding, major bleeding, and major adverse cardiac events (MACE). RESULTS There was no statistically significant increased bleeding risk in the prasugrel switching versus prasugrel only group [overall bleeding: OR 1.07, 95% confidence interval (CI), 0.69-1.66; P = 0.77; major bleeding: OR 0.69, 95% CI, 0.32-1.49; P = 0.34]; MACE rates were also comparable. Incidence of safety end points was similar in the prasugrel switching and clopidogrel only groups (overall bleeding: OR 1.27, 95% CI, 0.75-2.15; P = 0.37; major bleeding: OR 0.70, 95% CI, 0.29-1.68; P = 0.42); occurrence of MACE was 3.8% in the prasugrel switching versus 8.3% in the clopidogrel only group (P = 0.23). No statistically significant difference in the safety outcomes was present stratifying by clinical presentation. CONCLUSIONS Switching from clopidogrel to prasugrel does not increase bleeding complications during follow-up of patients undergoing percutaneous coronary intervention; however, the strength of the data is not sufficient to make definitive clinical recommendations.
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Chandrasekhar J, Hibbert B, Froeschl M, So D, Mehran R, May ML. The impact of switching P2Y12 receptor inhibitor therapy during index hospitalization: a systematic review. Eur J Clin Pharmacol 2015; 72:83-91. [PMID: 26453463 DOI: 10.1007/s00228-015-1949-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 09/14/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE With the availability of novel P2Y12 receptor inhibitors, patients presenting with acute coronary syndrome (ACS) may receive more than one type of this drug during index hospitalization. We sought to determine the effect of switching from clopidogrel to a novel P2Y12 receptor inhibitor on the occurrence of major adverse cardiovascular events (MACE) and bleeding. METHODS We conducted a literature search on SCOPUS for English language entries until 7 March 2015. Out of 188 citations, seven studies encompassing 16,431 patients were selected for analysis of (i) switching to a novel P2Y12 agent (switching group) versus continued clopidogrel or (ii) switching to a novel P2Y12 agent (switching group) versus upfront novel agent initiation during index hospitalization RESULTS MACE was significantly lower in the switching group (odds ratio (OR) 0.77, 95 % confidence interval (CI) 0.63-0.96, p = 0.02), whereas bleeding was higher (OR 1.55, 1.29-1.85, p < 0.01) compared with continued clopidogrel. Conversely, MACE was similar with switching to a novel agent and upfront novel therapy initiation (OR 1.01, 95 % CI 0.8-1.29, p = 0.90), but bleeding was higher in the switching group (OR 1.24, 95 % CI 1.03-1.48, p = 0.02). CONCLUSIONS The current study suggests that switching to a novel P2Y12 agent in patients with ACS and/or patients undergoing coronary stenting is more efficacious than continuing clopidogrel. In this cohort, switching to a novel agent did not result in worse ischemic outcomes than upfront initiation of novel therapies. However, switching was associated with greater bleeding compared with both continued clopidogrel as well as upfront use of novel P2Y12 agents.
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Affiliation(s)
- Jaya Chandrasekhar
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada. .,Icahn School of Medicine at Mount Sinai, PO Box 1030, 1 Gustave L Levy place, New York, NY, 10029, USA.
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada
| | - Michael Froeschl
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada
| | - Derek So
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada
| | - Roxana Mehran
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada
| | - Michel Le May
- Division of Cardiology, University of Ottawa Heart Institute, CAPITAL Research Group, Ottawa, Ontario, Canada
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