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Kim JT, Lee JS, Kim H, Kim BJ, Lee KJ, Park JM, Kang K, Lee SJ, Kim JG, Cha JK, Kim DH, Park TH, Lee K, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Choi JC, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Lee SH, Park MS, Ryu WS, Park KY, Lee J, Saver JL, Bae HJ. Trends in Dual Antiplatelet Therapy of Aspirin and Clopidogrel and Outcomes in Ischemic Stroke Patients Noneligible for POINT/CHANCE Trial Treatment. J Am Heart Assoc 2024; 13:e033611. [PMID: 38761083 PMCID: PMC11179811 DOI: 10.1161/jaha.123.033611] [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: 01/12/2024] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Recent clinical trials established the benefit of dual antiplatelet therapy with aspirin and clopidogrel (DAPT-AC) in early-presenting patients with minor ischemic stroke. However, the impact of these trials over time on the use and outcomes of DAPT-AC among the patients with nonminor or late-presenting stroke who do not meet the eligibility criteria of these trials has not been delineated. METHODS AND RESULTS In a multicenter stroke registry, this study examined yearly changes from April 2008 to August 2022 in DAPT-AC use for stroke patients ineligible for CHANCE/POINT (Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events/Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke) clinical trials due to National Institutes of Health Stroke Scale >4 or late arrival beyond 24 hours of onset. A total of 32 118 patients (age, 68.1±13.1 years; male, 58.5%) with National Institutes of Health Stroke Scale of 4 (interquartile range, 1-7) were analyzed. In 2008, DAPT-AC was used in 33.0%, other antiplatelets in 62.7%, and no antiplatelet in 4.3%. The frequency of DAPT-AC was relatively unchanged through 2013, when the CHANCE trial was published, and then increased steadily, reaching 78% in 2022, while other antiplatelets decreased to 17.8% in 2022 (Ptrend<0.001). From 2011 to 2022, clinical outcomes nonsignificantly improved, with an average relative risk reduction of 2%/y for the composite of stroke, myocardial infarction, and all-cause mortality, both among patients treated with DAPT-AC and patients treated with other antiplatelets. CONCLUSIONS Use of DAPT-AC in stroke patients with stroke ineligible for recent DAPT clinical trials increased markedly and steadily after CHANCE publication in 2013, reaching deployment in nearly 4 of every 5 patients by 2022. The secondary prevention in patients with ischemic stroke seems to be gradually improving, possibly due to the enhancement of risk factor control.
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Affiliation(s)
- Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital Chonnam National University Medical School Gwangju Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Institute for Life Sciences, Asan Medical Center University of Ulsan College of Medicine Seoul Korea
| | - Hyunsoo Kim
- Department of Neurology, Chonnam National University Hospital Chonnam National University Medical School Gwangju Korea
| | - Beom Joon Kim
- Department of Neurology, Cerebrovascular Center Seoul National University Bundang Hospital Seongnam Korea
| | - Keon-Joo Lee
- Department of Neurology Korea University Guro Hospital Seoul Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center Eulji University School of Medicine Uijeongbu-si Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center Eulji University School of Medicine Seoul Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital Eulji University Daejeon Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital Eulji University Daejeon Korea
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University Hospital Busan Korea
| | - Dae-Hyun Kim
- Department of Neurology Dong-A University Hospital Busan Korea
| | - Tai Hwan Park
- Department of Neurology Seoul Medical Center Seoul Korea
| | - Kyungbok Lee
- Department of Neurology, Soonchunhyang University Seoul Hospital Soonchunhyang University College of Medicine Seoul Korea
| | - Jun Lee
- Department of Neurology Yeungnam University Hospital Daegu Korea
| | - Keun-Sik Hong
- Department of Neurology, Ilsan Paik Hospital Inje University Goyang Korea
| | - Yong-Jin Cho
- Department of Neurology, Ilsan Paik Hospital Inje University Goyang Korea
| | - Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital Inje University Goyang Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
| | - Kyung-Ho Yu
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
| | - Mi Sun Oh
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
| | - Dong-Eog Kim
- Department of Neurology Dongguk University Ilsan Hospital Goyang Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital Jeju National University School of Medicine Jeju Korea
| | - Jee-Hyun Kwon
- Department of Neurology Ulsan University College of Medicine Ulsan Korea
| | - Wook-Joo Kim
- Department of Neurology Ulsan University College of Medicine Ulsan Korea
| | - Dong-Ick Shin
- Department of Neurology Chungbuk National University Hospital Cheongju Korea
| | - Kyu Sun Yum
- Department of Neurology Chungbuk National University Hospital Cheongju Korea
| | - Sung Il Sohn
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Korea
| | - Jeong-Ho Hong
- Department of Neurology Keimyung University Dongsan Medical Center Daegu Korea
| | - Sang-Hwa Lee
- Department of Neurology Hallym University Chuncheon Sacred Heart Hospital Chuncheon-si Gangwon-do Korea
| | - Man-Seok Park
- Department of Neurology, Chonnam National University Hospital Chonnam National University Medical School Gwangju Korea
| | - Wi-Sun Ryu
- Artificial Intelligence Research Center JLK Inc. Seoul Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University College of Medicine Chung-Ang University Hospital Seoul Korea
| | - Juneyoung Lee
- Department of Biostatistics Korea University College of Medicine Seoul Korea
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine University of California Los Angeles CA
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center Seoul National University Bundang Hospital Seongnam Korea
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van Voorst H, Pitkänen J, van Poppel L, de Vries L, Mojtahedi M, Martou L, Emmer BJ, Roos YBWEM, van Oostenbrugge R, Postma AA, Marquering HA, Majoie CBLM, Curtze S, Melkas S, Bentley P, Caan MWA. Deep learning-based white matter lesion volume on CT is associated with outcome after acute ischemic stroke. Eur Radiol 2024:10.1007/s00330-024-10584-z. [PMID: 38285103 DOI: 10.1007/s00330-024-10584-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) before endovascular treatment (EVT) for acute ischemic stroke might induce intracerebral hemorrhages which could negatively affect patient outcomes. Measuring white matter lesions size using deep learning (DL-WML) might help safely guide IVT administration. We aimed to develop, validate, and evaluate a DL-WML volume on CT compared to the Fazekas scale (WML-Faz) as a risk factor and IVT effect modifier in patients receiving EVT directly after IVT. METHODS We developed a deep-learning model for WML segmentation on CT and validated with internal and external test sets. In a post hoc analysis of the MR CLEAN No-IV trial, we associated DL-WML volume and WML-Faz with symptomatic-intracerebral hemorrhage (sICH) and 90-day functional outcome according to the modified Rankin Scale (mRS). We used multiplicative interaction terms between WML measures and IVT administration to evaluate IVT treatment effect modification. Regression models were used to report unadjusted and adjusted common odds ratios (cOR/acOR). RESULTS In total, 516 patients from the MR CLEAN No-IV trial (male/female, 291/225; age median, 71 [IQR, 62-79]) were analyzed. Both DL-WML volume and WML-Faz are associated with sICH (DL-WML volume acOR, 1.78 [95%CI, 1.17; 2.70]; WML-Faz acOR, 1.53 95%CI [1.02; 2.31]) and mRS (DL-WML volume acOR, 0.70 [95%CI, 0.55; 0.87], WML-Faz acOR, 0.73 [95%CI 0.60; 0.88]). Only in the unadjusted IVT effect modification analysis WML-Faz was associated with more sICH if IVT was given (p = 0.046). Neither WML measure was associated with worse mRS if IVT was given. CONCLUSION DL-WML volume and WML-Faz had a similar relationship with functional outcome and sICH. Although more sICH might occur in patients with more severe WML-Faz receiving IVT, no worse functional outcome was observed. CLINICAL RELEVANCE STATEMENT White matter lesion severity on baseline CT in acute ischemic stroke patients has a similar predictive value if measured with deep learning or the Fazekas scale. Safe administration of intravenous thrombolysis using white matter lesion severity should be further studied. KEY POINTS White matter damage is a predisposing risk factor for intracranial hemorrhage in patients with acute ischemic stroke but remains difficult to measure on CT. White matter lesion volume on CT measured with deep learning had a similar association with symptomatic intracerebral hemorrhages and worse functional outcome as the Fazekas scale. A patient-level meta-analysis is required to study the benefit of white matter lesion severity-based selection for intravenous thrombolysis before endovascular treatment.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands.
| | - Johanna Pitkänen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura van Poppel
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Lucas de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Mahsa Mojtahedi
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Laura Martou
- Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, England
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, School for Mental health and sciences (Mhens), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Melkas
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul Bentley
- Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, England
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
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Liu X, Jiang J, Li D, Horrow J, Tamada H, Kahl A, Hariharan V, Avinav A, Li X. Antiplatelet Treatment Patterns and Outcomes for Secondary Stroke Prevention in the United Kingdom. Cardiol Ther 2023; 12:675-687. [PMID: 37789237 DOI: 10.1007/s40119-023-00332-7] [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: 06/20/2023] [Accepted: 09/08/2023] [Indexed: 10/05/2023] Open
Abstract
INTRODUCTION Stroke is a leading cause of death and disability worldwide. Antiplatelet therapies are recommended to reduce the risk of recurrent stroke in patients with ischemic stroke/transient ischemic attack (IS/TIA). This study evaluated outpatient antiplatelet treatment patterns and outcomes for secondary stroke prevention (SSP) among UK adults without atrial fibrillation who were hospitalized for IS/TIA. METHODS This retrospective observational study utilized data from the UK Clinical Practice Research Datalink linked with Hospital Episode Statistics data (01/01/2011-30/06/2019). Treatment patterns included type and duration of treatments. Treatment outcomes included IS, myocardial infarction, major bleeding, and cardiovascular-related and all-cause mortality. Descriptive statistics were reported. RESULTS Of 9270 patients, 13.9% (1292) might not receive antithrombotic therapy within 90 days of hospital discharge. Of 7978 patients who received antiplatelet therapies, most used clopidogrel (74.8%) or aspirin (16.7%) single antiplatelet therapy and clopidogrel + aspirin dual antiplatelet therapy (DAPT, 5.9%). At 1-year post-hospitalization, 36.9, 43.3, and 35.1% of those receiving these treatments discontinued them, respectively, and of the patients initiating DAPT, 62.3% switched to single antiplatelet therapy. At 1-year post-discharge, the incidence rate (per 100 person-years) of IS, myocardial infarction, major bleeding, cardiovascular-related mortality, and all-cause mortality among the treated were 6.5, 0.7, 4.1, 5.0, and 7.3, respectively, and among the untreated were 14.9, 0.7, 8.6, 28.1, and 39.8, respectively. CONCLUSIONS In the United Kingdom, 13.9% of patients hospitalized for stroke might not have any antiplatelet treatment to prevent secondary stroke; among the treated, clopidogrel, aspirin, and DAPT were commonly used. These study findings suggest that improved anti-thrombotic therapies for long-term SSP treatment are needed, which may lead to higher treatment and persistence rates and, therefore, improved outcomes in this population.
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Affiliation(s)
- Xuejun Liu
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jenny Jiang
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Danshi Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Jay Horrow
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Hiroshi Tamada
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | - Anja Kahl
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA
| | | | | | - Xiaoyan Li
- Bristol Myers Squibb, 3401 Princeton Pike, Lawrenceville, NJ, 08640, USA.
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Luo Y, Xia Y, Zhang H, Lin Y, He L, Gong T, Zhang Z, Deng L. Human Serum Albumin-enriched Clopidogrel Bisulfate Nanoparticle Alleviates Cerebral Ischemia-Reperfusion Injury in Rats. Pharm Res 2023; 40:1821-1833. [PMID: 37291463 DOI: 10.1007/s11095-023-03543-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
PURPOSE Cerebral ischemia-reperfusion (I/R) injury remains a leading cause of mobility and mortality among patients with ischemic stroke. This study aims to develop a human serum albumin (HSA)-enriched nanoparticle platform for solubilizing clopidogrel bisulfate (CLP) for intravenous administration, and to explore the protective effect of HSA-enriched nanoparticles loaded with CLP (CLP-ANPs) against cerebral I/R injury in transient middle cerebral artery occlusion (MCAO) rat model. METHODS CLP-ANPs were synthesized via a modified nanoparticle albumin-bound technology, lyophilized, and then characterized by morphology, particle size, zeta potential, drug loading capacity, encapsulation efficiency, stability and in vitro release kinetics. In vivo pharmacokinetic studies were conducted using Sprague-Dawley (SD) rats. Also, an MCAO rat model was established to explore the therapeutic effect of CLP-ANPs on cerebral I/R injury. RESULTS CLP-ANPs remained spherical particles with a layer of proteins forming protein corona. Lyophilized CLP-ANPs after dispersion displayed an average size of about 235.6 ± 6.6 nm (PDI = 0.16 ± 0.08) with a zeta potential of about - 13.5 ± 1.8 mV. CLP-ANPs achieved sustained release for up to 168 h in vitro. Next, a single injection of CLP-ANPs dose-dependently reversed the histopathological changes induced by cerebral I/R injury possibly via attenuating apoptosis and reducing oxidative damages in the brain tissues. CONCLUSIONS CLP-ANPs represent a promising and translatable platform system for the management of cerebral I/R injury during ischemic stroke.
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Affiliation(s)
- Yiting Luo
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
- College of Pharmacy, Southwest Minzu University, Chengdu, 610041, China
| | - Yunli Xia
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Haonan Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Yunzhu Lin
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
- Department of Pharmacy, Evidence-Based Pharmacy Center, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, 610041, China
| | - Lili He
- College of Pharmacy, Southwest Minzu University, Chengdu, 610041, China
| | - Tao Gong
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Zhirong Zhang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Li Deng
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry and Sichuan Province, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China.
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Huang J, Liao F, Tang J, Shu X. Risk factors for gastrointestinal bleeding in patients with cerebral infarction after dual antiplatelet therapy. Clin Neurol Neurosurg 2023; 231:107802. [PMID: 37295199 DOI: 10.1016/j.clineuro.2023.107802] [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: 03/27/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND To investigate the risk factors for gastrointestinal bleeding in patients with cerebral infarction after dual antiplatelet therapy. METHODS Cerebral infarction patients who received dual antiplatelet therapy during January 2019 and December 2021 in Nanchang University Affiliated Ganzhou Hospital were included. Patients were divided into a bleeding group and a nonbleeding group. Propensity score matching was used to match the data between the two groups. The risk factors for cerebral infarction with gastrointestinal bleeding after receiving dual antiplatelet therapy were analyzed by conditional logistic regression. RESULTS There were 2370 cerebral infarction patients who received dual antiplatelet therapy included in the study. There were significant differences between the bleeding group and the nonbleeding group in terms of sex, age, smoking, drinking, hypertension, coronary heart disease, diabetes and peptic ulcer before matching. After matching, 85 patients were included in the bleeding group and nonbleeding group, and there was no significant difference between the two groups in terms of sex, age, smoking, drinking, previous cerebral infarction, hypertension, coronary heart disease, diabetes, gout or peptic ulcer. Conditional logistic regression analysis showed that long-term use of aspirin and severity of cerebral infarction were risk factors for gastrointestinal bleeding in cerebral infarction patients receiving dual antiplatelet therapy, whereas the use of PPI was a protective factor against gastrointestinal bleeding. CONCLUSIONS Long-term use of aspirin and severity of cerebral infarction are risk factors for gastrointestinal bleeding in cerebral infarction patients receiving dual antiplatelet therapy. The use of PPIs could reduce the risk of gastrointestinal bleeding.
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Affiliation(s)
- Jiaming Huang
- Department of Gastroenterology, Nanchang University Affiliated Ganzhou Hospital, Ganzhou, Jiangxi 341000, China.
| | - Foqiang Liao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.
| | - Jianhua Tang
- Department of Gastroenterology, Nanchang University Affiliated Ganzhou Hospital, Ganzhou, Jiangxi 341000, China.
| | - Xu Shu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China.
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Pomero F, Galli E, Bellesini M, Maroni L, Squizzato A. P2Y12 inhibitors plus aspirin for acute treatment and secondary prevention in minor stroke and high-risk transient ischemic attack: A systematic review and meta-analysis. Eur J Intern Med 2022; 100:46-55. [PMID: 35331593 DOI: 10.1016/j.ejim.2022.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Aspirin is a cornerstone of preventive treatment for stroke recurrence, but during the last few years the role of dual antiplatelet therapy (DAPT) is much more emerging. OBJECTIVE This systematic review aimed to compare early use of P2Y12 inhibitors (clopidogrel/ticagrelor) plus aspirin to aspirin alone for acute treatment and secondary prevention in acute non-cardioembolic minor ischemic stroke or TIA. METHODS A systematic search on MEDLINE and EMBASE was performed. Treatment effects were estimated with RRs and 95% CI. We used RevMan 5.4 for data analyses. We assessed methodological quality of selected studies according to Rob2 tools and quality of evidence with GRADE approach. RESULTS Four RCTs were included, enrolling 21,459 patients. Compared to aspirin alone, DAPT was superior in reducing stroke recurrence (RR 0.74, 95% CI 0.67-0.82, P <0.00001, absolute risk difference by 2%, NNT 50) and disabling stroke defined as mRS>2 (RR 0.84, 95% CI 0.75-0.95, P = 0.004), with no impact on all causes of mortality (RR 1.30, 95% CI 0.90-1.89, P = 0.16). An increased risk of major bleeding was emerged (RR 2.54, 95% CI 1.65-3.92, P <0.0001, absolute risk difference by 0,4%, NNH 250), in particular with ticagrelor, but there was no correlation between therapy duration and bleeding risk, as appeared from one-month (RR 3.06, 95% CI 1.64 to 5.69) and three-month (RR 2.09, 95% CI 1.18 to 3.69) follow-up analysis. CONCLUSIONS Early administration of P2Y12 inhibitors plus aspirin in patients with acute non-cardioembolic minor ischemic stroke or TIA reduced the incidence of ischemic stroke recurrence, impacting more significantly than the increased bleeding risk and influencing patients' quality of life by reducing disabling stroke.
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Affiliation(s)
- Fulvio Pomero
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy
| | - Eleonora Galli
- Department of Internal Medicine, Michele and Pietro Ferrero Hospital, Via Tanaro 7, 12060 Verduno, CN, Italy; Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Torino, Italy.
| | - Marta Bellesini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
| | - Lorenzo Maroni
- Department of General Medicine, Hypertension Dyslipidemia and Cardiovascular Risk Clinic, ASST Valle Olona, Sant'Antonio Abate Hospital, Via Eusebio Pastori, 21013 Gallarate, VA, Italy; Ospedale di Circolo, Via Arnaldo da Brescia 1, 21052 Busto Arsizio, VA, Italy
| | - Alessandro Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Viale Luigi Borri 57, 21100 Varese, Italy
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Shah J, Liu S, Yu W. Contemporary antiplatelet therapy for secondary stroke prevention: a narrative review of current literature and guidelines. Stroke Vasc Neurol 2022; 7:406-414. [PMID: 35393359 DOI: 10.1136/svn-2021-001166] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/16/2022] [Indexed: 11/04/2022] Open
Abstract
Antiplatelet therapy is one of the mainstays for secondary stroke prevention. This narrative review aimed to highlight the current evidence and recommendations of antiplatelet therapy for stroke prevention.We conducted advanced literature search for antiplatelet therapy. Landmark studies and randomised controlled trials evaluating antiplatelet therapy for secondary stroke prevention are reviewed. Results from Cochrane systematic review, pooled data analysis and meta-analysis are discussed.Single-antiplatelet therapy (SAPT) with aspirin, aspirin/extended-release dipyridamole or clopidogrel reduces the risk of recurrent ischaemic stroke in patients with non-cardioembolic ischaemic stroke or transient ischaemic attack (TIA). Dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or ticagrelor for 21-30 days is more effective than SAPT in patients with minor acute noncardioembolic ischaemic stroke or high-risk TIA. Prolonged use of DAPT is associated with higher risk of haemorrhage without reduction in stroke recurrence than SAPT. Compared with placebo, aspirin reduces the relative risk of recurrent stroke by approximately 22%. Aspirin/dipyridamole and cilostazol are superior to aspirin but associated with significant side effects. Cilostazol or ticagrelor might be more effective than aspirin or clopidogrel in patients with intracranial stenosis.SAPT is indicated for secondary stroke prevention in patients with non-cardioembolic ischaemic stroke or TIA. DAPT with aspirin and clopidogrel or ticagrelor for 21-30 days followed by SAPT is recommended for patients with minor acute noncardioembolic stroke or high-risk TIA. Selection of appropriate antiplatelet therapy should also be based on compliance, drug tolerance or resistance.
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Affiliation(s)
- Jay Shah
- Neurology, University of California, Irvine, California, USA
| | - Shimeng Liu
- Neurology, University of California, Irvine, California, USA.,Neurology, Tiantan Hospital, Beijing, China
| | - Wengui Yu
- Neurology, University of California, Irvine, California, USA
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Chai E, Chen J, Li C, Zhang X, Fan Z, Yang S, Zhao K, Li W, Xiao Z, Zhang Y, Tang F. The Efficacy and Safety of Cilostazol vs. Aspirin for Secondary Stroke Prevention: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:814654. [PMID: 35242099 PMCID: PMC8885726 DOI: 10.3389/fneur.2022.814654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/05/2022] [Indexed: 11/16/2022] Open
Abstract
Background Cilostazol is often used in Asia-Pacific countries for stroke prevention. The current systematic review and meta-analysis aimed to evaluate the effectiveness, safety, and adverse outcomes of cilostazol monotherapy compared to aspirin monotherapy for secondary stroke prevention. Methods The researchers conducted a comprehensive research in multiple databases (PubMed, Embase, and Cochrane library) of randomized controlled trials from conception to December 2020. The primary efficacy outcome was the occurrence of any stroke, the primary safety outcome was the bleeding risk, and the primary adverse outcome was the rate of headache and dizziness. The Mantel-Haenszel method was used to calculate a random-effects prediction. Cilostazol and aspirin were compared using a pooled risk assessment with 95% CIs. Results Six studies involving 5,617 patients were included in this review. Compared with aspirin monotherapy, cilostazol was associated with significantly lower rates of any strokes (RR: 0.67; 95% CI: 0.55–0.82) and significantly lower bleeding rates [risk ratio (RR): 0.53; 95% CI: 0.37–0.74]. However, compared with aspirin monotherapy, cilostazol was associated with significantly higher rates of headache (RR: 1.77; 95% CI: 1.41–2.20) and dizziness (RR: 1.28; 95% CI: 1.08–1.52). Conclusions Consistent with previous studies, cilostazol monotherapy is superior to aspirin monotherapy in reducing the rate of any strokes and the bleeding risk after having a stroke. However, the use of cilostazol monotherapy is associated with several adverse life outcomes such as headaches and dizziness.
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Affiliation(s)
- Erqing Chai
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China.,Emergency General Hospital, Beijing, China
| | - Jinhua Chen
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, China
| | - Changqing Li
- Cerebrovascular Disease Center, Gansu Provincial Hospital, Lanzhou, China
| | - Xue Zhang
- Intensive Care Unit 1, Gansu Provincial Hospital, Lanzhou, China
| | - Zhiqiang Fan
- First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Shijie Yang
- First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Kaixuan Zhao
- School of Clinical Medicine, Ningxia Medical University, Ningxia, China
| | - Wei Li
- First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Zaixing Xiao
- First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Yichuan Zhang
- School of Clinical Medicine, Ningxia Medical University, Ningxia, China
| | - Futian Tang
- Key Laboratory of Gansu Digestive System Tumor, Lanzhou University Second Hospital, Lanzhou, China
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9
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Yang Y, Huang Z, Zhang X. Efficacy and safety of clopidogrel and/or aspirin for ischemic stroke/transient ischemic attack: An overview of systematic reviews and meta-analysis. Medicine (Baltimore) 2021; 100:e27804. [PMID: 34918630 PMCID: PMC8677993 DOI: 10.1097/md.0000000000027804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/28/2021] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Patients experiencing acute ischemic stroke or transient ischemic attack are commonly treated with clopidogrel and/or aspirin (mono- and dual-antiplatelet therapy) to minimize the risk for recurrent stroke. Updated data from systematic studies can be used to guide practice. The present study aimed to compare findings from systematic reviews and meta-analyses addressing the efficacy and safety of clopidogrel or aspirin - alone or in combination - in patients experiencing acute ischemic stroke or transient ischemic attack. METHODS The Cochrane Library, PubMed, Ovid, Scopus, EBSCO, and CINAHL databases were searched for relevant studies published from inception to 2020. Data from each study were extracted independently using a predefined data abstraction form. The Risk of Bias in Systematic Reviews tool and A Measurement Tool to Assess Systematic Reviews 2 were used to evaluate risk of bias and the quality of the included studies. RESULTS Seven studies, published between 2010 and 2020, were eligible for analysis. The included studies evaluated a wide range of outcomes, including recurrent stroke, myocardial infarction, recurrent ischemic stroke, vascular mortality and vascular events, bleeding events, all-cause mortality, functional disability, and quality of life. The risk of bias and methodological validity of the included studies ranged from low to high according to ROBIS and AMSTAR 2 parameters. Results revealed that clopidogrel plus aspirin was more effective than aspirin alone in reducing the risk for recurrent stroke (ischemic or hemorrhagic), with high-quality evidence. However, compared with aspirin, dual treatment increased major bleeding events (intracranial bleeding and extracranial bleeding), supported by high-quality evidence. CONCLUSIONS High-quality evidence suggested that clopidogrel plus aspirin was more efficient than monotherapy, although the risk for hemorrhagic stroke was relatively higher in combined therapy regimens lasting >1 month.
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10
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Pilling LC, Türkmen D, Fullalove H, Atkins JL, Delgado J, Kuo CL, Kuchel GA, Ferrucci L, Bowden J, Masoli JAH, Melzer D. Analysis of CYP2C19 genetic variants with ischaemic events in UK patients prescribed clopidogrel in primary care: a retrospective cohort study. BMJ Open 2021; 11:e053905. [PMID: 34903548 PMCID: PMC8671970 DOI: 10.1136/bmjopen-2021-053905] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 11/18/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To determine whether CYP2C19 loss-of-function (LoF) alleles increase risk of ischaemic stroke and myocardial infarction (MI) in UK primary care patients prescribed clopidogrel. DESIGN Retrospective cohort analysis. SETTING Primary care practices in the UK from January 1999 to September 2017. PARTICIPANTS 7483 European-ancestry adults from the UK Biobank study with genetic and linked primary care data, aged 36-79 years at time of first clopidogrel prescription. INTERVENTIONS Clopidogrel prescription in primary care, mean duration 2.6 years (range 2 months to 18 years). MAIN OUTCOME MEASURE Hospital inpatient-diagnosed ischaemic stroke, MI or angina while treated with clopidogrel. RESULTS 28.7% of participants carried at least one CYP2C19 LoF variant. LoF carriers had higher rates of incident ischaemic stroke while treated with clopidogrel compared with those without the variants (8 per 1000 person-years vs 5.2 per 1000 person-years; HR 1.53, 95% CIs 1.04 to 2.26, p=0.031). LoF carriers also had increased risk of MI (HR 1.14, 95% CI 1.04 to 1.26, p=0.008). In combined analysis LoF carriers had increased risk of any ischaemic event (stroke or MI) (HR 1.17, 95% CI 1.06 to 1.29, p=0.002). Adjustment for aspirin coprescription produced similar estimates. In lifetables using observed incidence rates, 22.5% (95% CI 14.4% to 34.0%) of CYP2C19 LoF carriers on clopidogrel were projected to develop an ischaemic stroke by age 79 (oldest age in the study), compared with 15.4% (95% CI 11.4% to 20.5%) in non-carriers, that is, 7.1% excess stroke incidence in LoF carriers by age 79. CONCLUSIONS A substantial proportion of the UK population carry genetic variants that reduce metabolism of clopidogrel to its active form. In family practice patients on clopidogrel, CYP2C19 LoF variants are associated with substantially higher incidence of ischaemic events. Genotype-guided selection of antiplatelet medications may improve outcomes in patients carrying CYP2C19 genetic variants.
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Affiliation(s)
- Luke C Pilling
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Deniz Türkmen
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Hannah Fullalove
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Janice L Atkins
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Joao Delgado
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - Chia-Ling Kuo
- Connecticut Convergence Institute for Translation in Regenerative Engineering, University of Connecticut Health, Farmington, Connecticut, USA
- University of Connecticut Center on Aging, University of Connecticut Health, Farmington, Connecticut, USA
| | - George A Kuchel
- University of Connecticut Center on Aging, University of Connecticut Health, Farmington, Connecticut, USA
| | - Luigi Ferrucci
- National Institute on Aging NIA-ASTRA Unit, Harbor Hospital, Baltimore, Maryland, USA
| | - Jack Bowden
- Exeter Diabetes Group (ExCEED), College of Medicine and Health, University of Exeter, Exeter, UK
| | - Jane A H Masoli
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health group, College of Medicine and Health, University of Exeter, Exeter, UK
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11
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Abstract
Structurally, aquaporins (AQPs) are small channel proteins with monomers of ~ 30 kDa that are assembled as tetramers to form pores on cell membranes. Aquaporins mediate the conduction of water but at times also small solutes including glycerol across cell membranes and along osmotic gradients. Thirteen isoforms of AQPs have been reported in mammalian cells, and several of these are likely expressed in platelets. Osmotic swelling mediated by AQP1 sustains the calcium entry required for platelet phosphatidylserine exposure and microvesiculation, through calcium permeable stretch-activated or mechanosensitive cation channels. Notably, deletion of AQP1 diminishes platelet procoagulant membrane dynamics in vitro and arterial thrombosis in vivo, independent of platelet granule secretion and without affecting hemostasis. Water entry into platelets promotes procoagulant activity, and AQPs may also be critical for the initiation and progression of venous thrombosis. Platelet AQPs may therefore represent valuable targets for future development of a new class of antithrombotics, namely, anti-procoagulant antithrombotics, that are mechanistically distinct from current antithrombotics. However, the structure of AQPs does not make for easy targeting of these channels, hence they remain elusive drug targets. Nevertheless, thrombosis data in animal models provide compelling reasons to continue the pursuit of AQP-targeted antithrombotics. In this review, we discuss the role of aquaporins in platelet secretion, aggregation and procoagulation, the challenge of drugging AQPs, and the prospects of targeting AQPs for arterial and venous antithrombosis.
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Affiliation(s)
- Ejaife O Agbani
- Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Alastair W Poole
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, England, UK
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12
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1057] [Impact Index Per Article: 352.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Brown DL, Levine DA, Albright K, Kapral MK, Leung LY, Reeves MJ, Sico J, Strong B, Whiteley WN. Benefits and Risks of Dual Versus Single Antiplatelet Therapy for Secondary Stroke Prevention: A Systematic Review for the 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Stroke 2021; 52:e468-e479. [PMID: 34024115 DOI: 10.1161/str.0000000000000377] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) after ischemic stroke or transient ischemic attack may reduce recurrent stroke but also increase severe bleeding compared with single antiplatelet therapy (SAPT). The American Heart Association/American Stroke Association convened an evidence review committee to perform a systematic review and meta-analysis of the benefits and risks of DAPT compared with SAPT for secondary ischemic stroke prevention. METHODS The Medline, Embase, and Cochrane databases were searched on December 5, 2019, to identify phase III or IV randomized controlled trials (n≥100) from December 1999 to December 2019. We calculated unadjusted relative risks (RRs) and performed meta-analyses of studies based on the duration of treatment (short [≤90 days] versus long [>90 days]). RESULTS Three short-duration randomized controlled trials were identified that enrolled mostly patients with minor stroke or high risk transient ischemic attack. In these trials, DAPT, compared with SAPT, was associated with a lower 90-day risk of recurrent ischemic stroke (pooled RR, 0.68 [95% CI, 0.55-0.83], I 2=37.1%). There was no significant increase in major bleeding with DAPT in short-duration trials (pooled RR, 1.88 [95% CI, 0.93-3.83], I 2=8.9%). In 2 long-duration treatment randomized controlled trials (mean treatment duration, 18-40 months), DAPT was not associated with a significant reduction in recurrent ischemic stroke (pooled RR, 0.89 [95% CI, 0.79-1.02], I 2=1.4%), but was associated with a higher risk of major bleeding (pooled RR, 2.42 [95% CI, 1.37-4.30], I 2=75.5%). CONCLUSIONS DAPT was more effective than SAPT for prevention of secondary ischemic stroke when initiated early after the onset of minor stroke/high-risk transient ischemic attack and treatment duration was <90 days. However, when the treatment duration was longer and initiated later after stroke or transient ischemic attack onset, DAPT was not more effective than SAPT for ischemic stroke prevention and it increased the risk of bleeding.
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14
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Alkattan A, Alsalameen E. Polymorphisms of genes related to phase-I metabolic enzymes affecting the clinical efficacy and safety of clopidogrel treatment. Expert Opin Drug Metab Toxicol 2021; 17:685-695. [PMID: 33931001 DOI: 10.1080/17425255.2021.1925249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Clopidogrel is an antiplatelet medication described as a prodrug, which cannot exert the antiplatelet effect until being biotransformed to the active metabolite. It is commonly used to reduce the risk of blood coagulation in patients diagnosed with acute coronary syndrome, or ischemic stroke.Area covered: We reviewed published articles in PubMed and Google Scholar that focused on the mutations of CYP2C19, CYP3A4, CYP2C9, CYP2B6, and CYP1A2 genes related to clopidogrel clinical efficacy and safety.Expert opinion: Based on current pharmacogenetic studies, patients carrying CYP2C19*2, CYP2C19*3, CYP2C9*3, and CYP2B6*5 alleles may not respond to clopidogrel due to poor platelet inhibition efficacy revealed among them. In contrast, carriers of CYP2C19*17, CYP3A4*1G, and CYP1A2*1C alleles showed a more significant antiplatelet effect in clopidogrel users and expected to have a protective role as a genetic factor against cardiovascular events. Genotyping for either CYP2C19, CYP3A4, CYP2C9, CYP2B6, or CYP1A2 variants is not recommended when considering clopidogrel treatment for patients, as some trials showed specific non-genetic factors (e.g. age and diabetes) that could affect clopidogrel responsiveness. Instead, platelets inhibition tests could be used as predictors of the clinical efficacy of clopidogrel treatment. Other P2Y12 receptor inhibitors should be considered as alternative medications.
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Affiliation(s)
- Abdullah Alkattan
- Department of Research and Development, General Directorate of Medical Consultations, Assisting Deputyship for Primary Health Care, Ministry of Health, Riyadh, Saudi Arabia.,Department of Biomedical Sciences, College of Veterinary Medicine, King Faisal University, Al-Hofuf, Al-Ahsa, Saudi Arabia
| | - Eman Alsalameen
- Department of Pharmacy, King Khaled University Hospital, Medical City King Saud University, Riyadh, Saudi Arabia
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15
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Kargiotis O, Tsivgoulis G. The 2020 breakthroughs in early secondary prevention: dual antiplatelet therapy versus single antiplatelet therapy. Curr Opin Neurol 2021; 34:45-54. [PMID: 33196579 DOI: 10.1097/wco.0000000000000878] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Single antiplatelet therapy represents an established treatment in secondary prevention of ischemic strokes and transient ischemic attacks (TIAs). In contrast with coronary artery disease, the use of dual antiplatelet therapy (DAPT) for secondary prevention in patients with acute cerebral ischemia (ACI) remains under debate. In this narrative review, we present and analyse the most recent findings concerning the potential efficacy and safety of DAPT therapy after ischemic strokes or TIA. RECENT FINDINGS Following the publication of the three (CHANCE, POINT and THALES) large, randomized-controlled, clinical trials (RCTs) that showed efficacy of early DAPT for the secondary prevention after minor AIS or TIA, short-term DAPT use is becoming the most prevalent choice of treatment. Notably, DAPT is even more popular after AIS attributed to large artery atherosclerosis given randomized data from small RCTs supporting the use of DAPT in patients with extracranial or intracranial atherosclerosis and microembolization detected by transcranial Doppler. Recent subanalysis of data from the randomized trials aim to identify specific patient subgroups, which are determined by genetic, imaging or clinical characteristics, and for whom DAPT appears to be more beneficial. The potential role of different antiplatelet agents (aspirin, clopidogrel, ticagrelor) is also discussed. SUMMARY DAPT has recently proven its efficacy for the early secondary prevention of AIS patients with minor stroke severity and high-risk TIA patients. However, the length of DAPT is still controversial, as well as the individualized selection of AIS or TIA patients with the lower risk of bleeding and with the greater benefit in prevention of ischemic cerebrovascular and cardiovascular events.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, 'Attikon' University Hospital, Athens, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
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16
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Sakai T, Aokage K, Katsumata S, Tane K, Miyoshi T, Tsuboi M. Continuation of aspirin perioperatively for lung resection: a propensity matched analysis. Surg Today 2021; 51:1054-1060. [PMID: 33389188 DOI: 10.1007/s00595-020-02202-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To clarify the safety and effectiveness of continuing aspirin during the perioperative period of lung resection. METHODS We analyzed, retrospectively, consecutive patients who underwent lung resection between 2008 and 2017. To investigate the safety of aspirin continuation, patients who continued taking aspirin perioperatively (Group C) were matched to other patients (Group O), using a propensity score, and bleeding outcomes were compared. To assess the effect of aspirin interruption, Group C was matched to a group of patients whose aspirin regimen was interrupted (Group I), and the postoperative complications related to thromboembolism were compared. RESULTS Among 3393 patients, 52 continued on aspirin (Group C) perioperatively, whereas 184 had their aspirin discontinued (Group I). Comparing the matched cohorts extracted from Group C and Group O (n = 45), there were no significant differences in bleeding outcomes. Comparing the matched cohorts extracted from Group C and Group I (n = 40), group C had fewer postoperative complications related to thromboembolism (0% vs. 7.5%, p = 0.039). CONCLUSION Bleeding complications did not increase by continuing aspirin, but thromboembolic complications increased when the aspirin regimen was interrupted during the perioperative period of lung resection. Thus, in the absence of a prohibitive bleeding risk, the continuation of aspirin during the perioperative period of lung resection appears to be desirable.
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Affiliation(s)
- Takashi Sakai
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Keiju Aokage
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Shinya Katsumata
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Kenta Tane
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Tomohiro Miyoshi
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masahiro Tsuboi
- Department of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
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Espinoza C, Mukherjee D. Dual Antiplatelet Therapy in Patients with High Cardiovascular Risk. Heart Int 2021; 15:26-36. [DOI: 10.17925/hi.2021.15.1.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/29/2021] [Indexed: 11/24/2022] Open
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18
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Landzberg DR, English S, Frankel M, Navalkele D. Stroke Thrombolysis in Patients Taking Ticagrelor -Two Successful Cases and a Review of the Literature. J Stroke Cerebrovasc Dis 2020; 30:105520. [PMID: 33310594 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Ticagrelor is a novel antiplatelet agent that is frequently used for secondary prevention in coronary artery disease and has emerging evidence in stroke after the recent results of SOCRATES and THALES trials. The use of intravenous thrombolysis with alteplase in acute ischemic stroke (AIS) patients on ticagrelor is a topic of debate as the safety profile of ticagrelor in this setting is not well established. METHODS We identified consecutive AIS patients taking ticagrelor who received intravenous alteplase at a comprehensive stroke center from January 2016 to December 2019. We then performed a literature search to capture all known published cases of intravenous thrombolysis in stroke patients on ticagrelor. RESULTS Of the 3896 patients who were treated for AIS at our local comprehensive stroke center during this time period, two patients received intravenous alteplase while on ticagrelor. Both patients had posterior circulation acute strokes and were successfully treated with intravenous alteplase without a systemic or intracranial bleeding event. Only five other cases of intravenous thrombolysis in AIS patients on ticagrelor have been reported in the literature. Among these cases, four of the five cases had a hemorrhagic complication. CONCLUSION Despite prior reports of hemorrhagic complications with use of IV alteplase in setting of pre-treatment with ticagrelor, we report the safe use of intravenous thrombolysis in two cases presenting with acute ischemic stroke. Until safety is established in large studies, decision for thrombolysis should be made on case-by-case basis.
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Affiliation(s)
- David R Landzberg
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Stephen English
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Michael Frankel
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA
| | - Digvijaya Navalkele
- Department of Neurology, Emory University School of Medicine/Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Atlanta, Georgia 30303, USA.
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19
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Lin SF, Lin PC, Chang CC, Chang WL, Chu FY. Investigation of the interaction between proton pump inhibitors and clopidogrel using VerifyNow P2Y12 assay. Medicine (Baltimore) 2020; 99:e23695. [PMID: 33327360 PMCID: PMC7738015 DOI: 10.1097/md.0000000000023695] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 09/11/2020] [Accepted: 11/13/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Randomized trials and observation studies have revealed conflicting results regarding the interaction between clopidogrel and proton pump inhibitors (PPIs). The aim of our study was to provide laboratory evidence regarding whether PPIs blunt the antiplatelet reactivity of clopidogrel. METHODS We included records of Asian patients who received clopidogrel treatment for cardiovascular or cerebrovascular events and the VerifyNow P2Y12 assay for platelet reactivity monitoring. The responsiveness of antiplatelet effect to clopidogrel was analyzed according to 3 criteria:Results: Patients treated without PPIs did not differ significantly from those concomitantly treated with PPIs in terms of levels of PI (25.7% ± 24.3% vs 23.0 ± 25.3%, P = .4315), PRU (187.3 ± 74.0 vs 197.4 ± 77.3, P = .3373), or responsiveness to antiplatelet (adjusted absolute risk, 3.5%; 95% confidence interval, - 10.7 to 17.7%; P = .6297). Patients treated with lansoprazole, esomeprazole, pantoprazole, and rabeprazole exhibited no significant differences in PRU or PI levels compared with those treated without PPIs. By contrast, patients treated with dexlansoprazole exhibited a significantly decreased level of PI (25.7% ± 24.3% vs 14.0% ± 21.6%, P = .0297) and responsiveness to clopidogrel under the criterion PI > 20% (adjusted absolute risk: 10.5%; 95% confidence interval: 2.6% to 43.6%; P = .0274). CONCLUSION No robust interaction between clopidogrel and PPIs was found, but caution should be exercised in the concomitant use of dexlansoprazole and clopidogrel in Asians.
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Affiliation(s)
- Sheng-Feng Lin
- School of Public Health, College of Public Health, Taipei Medical University, Taipei
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Department of Neurology, Far Eastern Memorial Hospital
- Division of Hospitalist, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei
| | - Pei-Chin Lin
- Department of Clinical Pathology, Far Eastern Memorial Hospital
| | - Chih-Chun Chang
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Department of Nursing, Cardinal Tien Junior College of Healthcare and Management, Yilan
| | - Wei-Lun Chang
- Department of Pharmacy, Far Eastern Memorial Hospital, New Taipei
| | - Fang-Yeh Chu
- Department of Clinical Pathology, Far Eastern Memorial Hospital
- Graduate School of Biotechnology and Bioengineering, Yuan Ze University, Taoyuan City
- Department of Medical Laboratory Science and Biotechnology, Yuanpei University of Medical Technology, Hsinchu City
- School of Medical Laboratory Science and Biotechnology, Taipei Medical University, Taipei City, Taiwan
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Valeria C, Carmine S, Valentina M, Teresa I, Maria C, Martina T, Giancarlo A, Giovanna N, Graziamaria C, Amelia F. The need of a multicomponent guiding approach to personalize clopidogrel treatment. THE PHARMACOGENOMICS JOURNAL 2020; 21:116-127. [PMID: 33033370 DOI: 10.1038/s41397-020-00189-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/13/2020] [Accepted: 09/23/2020] [Indexed: 12/18/2022]
Abstract
Patients bearing polymorphisms termed CYP2C19 loss of function (LoF) alleles and ABCB1-C3435T may do not properly respond to standard dosage of clopidogrel and have an increased risk of thrombosis. Moreover, co-administration of proton pump inhibitors (PPIs) and clopidogrel may attenuate the antiplatelet effect. The role of pharmacogenetics and PPIs/clopidogrel drug-drug interaction has been extensively investigated in patients with acute coronary syndrome after stent implantation (ACS/PCI), while data in patients undergoing vascular surgery are scarce. Here we have performed a systematic review to evaluate the available literature in such a clinical setting and have discussed the controversies about the use of CYP2C19 pharmacogenetics and platelet function testing to personalize clopidogrel treatment. In addition, we have made a comparison of the literature data with our findings concerning patients eligible for vascular surgery and treated with clopidogrel, in whom we used a combined management based on the CYP2C19 and ABCB1 pharmacogenetic testing with monitoring of therapeutic adherence and PPIs-clopidogrel interaction. Both our data and those produced during both observational studies and randomized clinical trials confirm the validity of pharmacogenetics to personalize clopidogrel treatment and stress the importance to make a drug monitoring considering all the known variables, potentially responsible for treatment failure. However, the American Heart Association and the European Cardiovascular Society recommend against the routine use of clopidogrel pharmacogenetic testing. An update of the international guidelines on antiplatelet therapy, incorporating the evidence related to CYP2C19 pharmacogenetics and PPIs-clopidogrel drug-drug interactions is warranted both in ACS/PCI patients and subjects undergoing vascular surgery.
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Affiliation(s)
- Conti Valeria
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy. .,Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo 1, Salerno, Italy.
| | - Sellitto Carmine
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Manzo Valentina
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Iannaccone Teresa
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Costantino Maria
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy.,Association non-profit F.I.R.S.Thermae (Interdisciplinary Training, Researches and spa Sciences) in Italian National Register of Research of MIUR, Via Marziale, 21, 80070, Bacoli, Naples, Italy
| | - Torsiello Martina
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy
| | - Accarino Giancarlo
- Vascular surgery Unit, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno- via S. Leonardo 1, Salerno, Italy
| | - Nicolella Giovanna
- Vascular surgery Unit, University Hospital "San Giovanni di Dio e Ruggi D'Aragona", Salerno- via S. Leonardo 1, Salerno, Italy
| | - Corbi Graziamaria
- Department of Medicine and Health Sciences, University of Molise, Via Francesco De Sanctis, 1, 86100, Campobasso, Italy
| | - Filippelli Amelia
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno- S, Allende street, 84081, Baronissi, Salerno, Italy.,Clinical Pharmacology and Pharmacogenetics Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", via S. Leonardo 1, Salerno, Italy
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Should Aspirin Be Prescribed to Prevent Recurrence in Nonarteritic Anterior Ischemic Optic Neuropathy? J Neuroophthalmol 2020; 40:428-433. [DOI: 10.1097/wno.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bulwa Z, Saleh Velez FG, Brorson JR, Pinto CB. Ipsilateral Nonstenotic Carotid Disease in Minor Ischemic Stroke: an Exploratory Analysis of The POINT Randomized Clinical Trial. J Stroke Cerebrovasc Dis 2020; 29:105115. [PMID: 33066893 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105115] [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: 06/15/2020] [Revised: 06/25/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND AND AIM Ipsilateral nonstenotic carotid disease is increasingly recognized as an etiology of ischemic stroke, however tailored treatment strategies are lacking. We aimed to examine clinical characteristics and treatment effects in patients with minor ischemic stroke associated with ipsilateral nonstenotic carotid disease in the Platelet Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial. METHODS We performed an exploratory analysis of the interaction of the treatment effects of aspirin plus clopidogrel versus aspirin monotherapy, stratified by presence of ipsilateral nonstenotic carotid disease in patients with minor ischemic stroke in the POINT trial. RESULTS For this exploratory analysis, 167 patients presenting with ischemic stroke and ipsilateral nonstenotic carotid disease, defined as 1%-49% carotid stenosis ipsilateral to the corresponding territory of ischemic stroke, and 833 patients no carotid disease were included. Compared to patients with no carotid disease, patients with ipsilateral nonstenotic carotid disease were older (68.5 ± 11.3 years versus 61.3 ± 12.8 years; P < 0.001), and had a higher prevalence of hypertension (76.6% versus 59.2%, P < 0.001), ischemic heart disease (13.8% versus 5.4%, P < 0.001), and tobacco use (past: 34.1% versus 25.2%, P = 0.005; present: 27.5% versus 22.8%, P = 0.005). 5.4% of patients with ipsilateral nonstenotic carotid disease had recurrent ischemic stroke within 14 days. Patients receiving dual antiplatelet therapy had a numerical reduction in recurrent ischemic stroke compared to patients receiving aspirin monotherapy, however the exploratory analysis was underpowered to detect a statistically significant difference in treatment effect (HR 0.50, 95% CI 0.18-1.40, P = 0.19). CONCLUSION Patients with minor ischemic stroke and ipsilateral nonstenotic carotid disease had a high risk of early stroke recurrence in the POINT trial. Dual antiplatelet therapy provided a non-statistically significant reduction in recurrent ischemic stroke with no difference in safety outcomes compared to aspirin monotherapy. Further study is needed to determine if early and short duration dual antiplatelet therapy is beneficial for all patients with ipsilateral nonstenotic carotid disease.
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Affiliation(s)
- Zachary Bulwa
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - Faddi G Saleh Velez
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - James R Brorson
- Department of Neurology, University of Chicago Medical Center, 5841 South Maryland Avenue MC 2030, Chicago, IL 60637, USA.
| | - Camila B Pinto
- University of Sao Paulo, Institute of Psychology, Sao Paulo, Brazil.
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Parker WAE, Storey RF. Pharmacology and potential role of selatogrel, a subcutaneous platelet P2Y12 receptor antagonist. Expert Opin Emerg Drugs 2020; 25:1-6. [DOI: 10.1080/14728214.2020.1729121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- William A. E. Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Robert F. Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Abstract
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Arjun Majithia
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L Bhatt
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
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