Intensified P2Y12 inhibition for high-on treatment platelet reactivity

Current Strategies to Guide the Antiplatelet Therapy in Acute Coronary Syndromes

The role of antiplatelet therapy in patients with acute coronary syndromes is a moving target with considerable novelty in the last few years. The pathophysiological basis of the treatment depends on platelet biology and physiology, and the interplay between these aspects and clinical practice must guide the physician in determining the best therapeutic options for patients with acute coronary syndromes. In the present narrative review, we discuss the latest novelties in the antiplatelet therapy of patients with acute coronary syndromes. We start with a description of platelet biology and the role of the main platelet signal pathways involved in platelet aggregation during an acute coronary syndrome. Then, we present the latest evidence on the evaluation of platelet function, focusing on the strengths and weaknesses of each platelet's function test. We continue our review by describing the role of aspirin and P2Y12 inhibitors in the treatment of acute coronary syndromes, critically appraising the available evidence from clinical trials, and providing current international guidelines and recommendations. Finally, we describe alternative therapeutic regimens to standard dual antiplatelet therapy, in particular for patients at high bleeding risk. The aim of our review is to give a comprehensive representation of current data on antiplatelet therapy in patients with acute coronary syndromes that could be useful both for clinicians and basic science researchers to be up-to-date on this complex topic.

G protein-coupled P2Y12 receptor is involved in the progression of neuropathic pain

The pathological mechanism of neuropathic pain is complex, which seriously affects the physical and mental health of patients, and its treatment is also difficult. The role of G protein-coupled P2Y12 receptor in pain has been widely recognized and affirmed. After nerve injury, stimulated cells can release large amounts of nucleotides into the extracellular matrix, act on P2Y12 receptor. Activated P2Y12 receptor activates intracellular signal transduction and is involved in the development of pain. P2Y12 receptor activation can sensitize primary sensory neurons and receive sensory information. By transmitting the integrated information through the dorsal root of the spinal cord to the secondary neurons of the posterior horn of the spinal cord. The integrated information is then transmitted to the higher center through the ascending conduction tract to produce pain. Moreover, activation of P2Y12 receptor can mediate immune cells to release pro-inflammatory factors, increase damage to nerve cells, and aggravate pain. While inhibits the activation of P2Y12 receptor can effectively relieve pain. Therefore, in this article, we described P2Y12 receptor antagonists and their pharmacological properties. In addition, we explored the potential link between P2Y12 receptor and the nervous system, discussed the intrinsic link of P2Y12 receptor and neuropathic pain and as a potential pharmacological target for pain suppression.

Clinical Outcomes of Individualized Antiplatelet Therapy Based on Platelet Function Test in Patients After Percutaneous Coronary Intervention: A Systematic Review and Meta-analysis

ABSTRACT

Platelet function test (PFT) is universally used to assess platelet reactivity to antiplatelet drugs in patients after percutaneous coronary intervention (PCI). However, it remains controversial whether individualized antiplatelet therapy guided by PFT can improve the prognosis in patients after PCI. This meta-analysis was conducted to explore the efficacy and safety of individualized antiplatelet therapy guided by PFT in patients after PCI. Studies that compared PFT-guided antiplatelet therapy with standard antiplatelet therapy were researched. The risks of major adverse cardiovascular and cerebrovascular events (MACCE) and major bleeding events were assessed. Pooled odds ratios (ORs) with 95% CIs were obtained. Finally, a total of 16,835 patients from 22 studies met the criteria and were included in the meta-analysis. Compared with standard antiplatelet therapy, individualized antiplatelet therapy guided by PFT significantly decreased the risk of MACCE (OR: 0.58, 95% CI: 0.43-0.77) in patients after PCI. There was no significant difference in major bleeding events (OR: 0.85, 95% CI: 0.70-1.05, P = 0.13). This study identified that PFT-guided individualized antiplatelet therapy could reduce the incidence of MACCE without increasing the risk of hemorrhage in patients after PCI.

Role of platelet function testing in acute coronary syndromes: a meta-analysis

OBJECTIVE

This meta-analysis aimed to evaluate whether using platelet function testing (PFT) in acute coronary syndromes (ACS) to personalise antiplatelet therapy including a P2Y₁₂ antagonist offers any clinical benefits to indicate incorporation into routine practice.

METHODS

A search was conducted on five databases for randomised controlled trials (RCTs) conducted between 1 January 2000 and 17 July 2022, which included an ADP-specific platelet function assays and P2Y₁₂ antagonists as part of dual antiplatelet therapy (DAPT) and have reported the efficacy and/or safety outcomes. The reported event frequencies were used to calculate the risk ratios (RRs) with a 95% CI. The χ² heterogeneity statistical test and sensitivity analysis were used for heterogeneity assessment.

RESULTS

Five RCTs with 7691 patients were included in the analysis. No significant risk reduction was seen in major adverse cardiovascular events (RR=0.95, p=0.42), individual cardiac events (cardiovascular death: RR=0.76, p=0.26; myocardial infarction: RR=0.96, p=0.74; stent thrombosis: RR=0.92, p=0.83; stroke: RR=0.91, p=0.72; target vessel revascularisation: RR=1.06, p=0.47) and overall clinical outcome (RR=0.90, p=0.22). There was also no difference in the rate of bleeding between PFT-guided and standard therapies (major bleeding: RR=0.97, p=0.78, minor bleeding: RR=0.89, p=0.19 and any bleeding: RR=1.04, p=0.33).

CONCLUSION

Compared with standard DAPT with P2Y₁₂ antagonists, using PFT to adjust antiplatelet therapy does not improve clinical outcomes. Therefore, the positions of key guidelines on routine testing in ACS should remain unchanged. In addition, the study highlights the need for well-designed and powered RCTs and standardised testing methodologies to provide reliable findings and definitive conclusions.

Mean platelet volume/platelet count ratio as a predictor of stent thrombosis in patients with ST-segment-elevation myocardial infarction

BACKGROUND

Despite the important role of some haematological parameters in tendency to thrombosis is known, their relationship with long-term stent thrombosis (ST) remains unclear.

AIMS

This study aimed to investigate the association between the mean platelet volume (MPV) to platelet count (PC) ratio and long-term ST and mortality in patients with ST-segment-elevation myocardial infarction (STEMI) treated successfully by primary percutaneous coronary intervention (pPCI).

METHODS

In a retrospective cohort study, according to their baseline MPV/PC ratios, 3667 consecutive STEMI patients undergoing pPCI were divided into three groups: tertile 1 (T1) (n = 1222, 0.357 ≥ MPV/PC ≥ 0.043), tertile 2 (T2) (n = 1222, 0.033 < MPV/PC < 0.043) and tertile 3 (T3) (n = 1223, 0.009 ≤ MPV/PC ≤ 0.032). Patients were followed up with for 5 years, focusing on ST and all-cause mortality outcomes.

RESULTS

Patients with T1 displayed a greater 5-year ST rate, including a 2.76-fold greater (95% confidence interval 1.68-10.33) rate than that of patients with T3, who had the lowest rates and were used as the reference group. Meanwhile, the 5-year mortality rate was similarly higher among patients with T1 by 1.72 times (95% confidence interval 1.33-2.22) relative to that among patients with T3. These significant relationships persisted even after adjustment for all confounders.

CONCLUSION

We found that higher MPV/PC ratios were associated with long-term ST and mortality. The MPV/PC ratio may constitute both a rapid and an easily obtainable parameter for identifying reliably high-risk patients who have undergone pPCI.