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Sajid B, Tufail Z, Asim M, Riaz S, Imtiaz S, Khan H, Shabbir MA, Shah SMB, Ejaz F, Anis MW, Khan A, Ahmed A, Rana M, Sohail F, Anjum MU, Larik MO. Comparison of Clopidogrel Versus Ticagrelor for Percutaneous Coronary Intervention (PCI) Patients Managed with Therapeutic Hypothermia: A Systematic Review and Meta-Analysis. Ther Hypothermia Temp Manag 2023. [PMID: 37870599 DOI: 10.1089/ther.2023.0055] [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: 10/24/2023] Open
Abstract
Various antiplatelet drugs, such as clopidogrel and ticagrelor, are available on the market for use after percutaneous coronary intervention (PCI). However, the efficacy of such drugs in patients being managed with therapeutic hypothermia (TH) has always been debated. In light of this controversy, this systematic review and meta-analysis was performed to enhance existing literature. Various databases were searched for potentially relevant studies from inception to April 2023, including PubMed, Cochrane Library, and Scopus. The risk of bias was assessed using the Newcastle-Ottawa scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Outcomes of interest included risk of bleeding, stent thrombosis, and all-cause mortality. Five studies were shortlisted for inclusion into the meta-analysis, featuring a total of 245 patients receiving either clopidogrel or ticagrelor. Overall, no significant differences were noted when the use of clopidogrel and ticagrelor was compared in PCI patients being managed with TH. To the best of our knowledge, this is the most comprehensive meta-analysis comparing the outcomes of clopidogrel and ticagrelor in PCI patients being managed with TH. Despite existing studies claiming an altered efficacy of clopidogrel in such conditions, our meta-analytic findings could not prove this relationship. Due to the limited sample size, further comprehensive and randomized studies are encouraged to arrive at a robust conclusion.
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Affiliation(s)
| | | | - Maria Asim
- Fazaia Ruth Pfau Medical College, Karachi, Pakistan
| | - Sania Riaz
- Allama Iqbal Medical College, Lahore, Pakistan
| | | | | | | | | | - Fariha Ejaz
- Karachi Medical and Dental College, Karachi, Pakistan
| | | | - Arais Khan
- Islamabad Medical and Dental College, Islamabad, Pakistan
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2
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Gall E, Lafont A, Varenne O, Dumas F, Cariou A, Picard F. Balancing thrombosis and bleeding after out-of-hospital cardiac arrest related to acute coronary syndrome: A literature review. Arch Cardiovasc Dis 2021; 114:667-679. [PMID: 34565694 DOI: 10.1016/j.acvd.2021.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/29/2021] [Accepted: 07/31/2021] [Indexed: 12/29/2022]
Abstract
Balance between thrombosis and bleeding is now well recognized in patients treated for acute coronary syndrome, with impact on short- and long-term prognosis, including survival. Recent data suggest that patients who are resuscitated after out-of-hospital cardiac arrest related to myocardial infarction are at an even higher risk of bleeding and thrombosis than those with uncomplicated acute coronary syndrome. Delayed enteral absorption of medication due to induced hypothermia and systemic inflammation increases thrombosis risk, whereas transfemoral access site, cardiopulmonary resuscitation manoeuvres and mechanical circulatory support devices increase bleeding risk. In addition, post-resuscitation syndrome and renal or hepatic impairment are potential risk factors for both bleeding and thrombotic complications. There are currently no randomized controlled trials comparing various P2Y12 inhibitor and/or anticoagulation strategies in the setting of out-of-hospital cardiac arrest, and current practice is largely derived from management of patients with uncomplicated acute coronary syndrome. The aim of this review is therefore to describe the bleeding and thrombosis risk factors in this specific population, and to review recent data on antithrombotic drugs in this patient subset.
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Affiliation(s)
- Emmanuel Gall
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alexandre Lafont
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Olivier Varenne
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France
| | - Florence Dumas
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Emergency Department, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Alain Cariou
- Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France; Medical Intensive Care Unit, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France
| | - Fabien Picard
- Department of Cardiology, Cochin Hospital, Hôpitaux Universitaire Paris Centre, AP-HP, 75014 Paris, France; Université de Paris, 75006 Paris, France; INSERM U970, Paris Cardiovascular Research Centre (PARCC), Georges-Pompidou European Hospital, 75015 Paris, France.
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3
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Milluzzo RP, Franchina GA, Capodanno D, Angiolillo DJ. Selatogrel, a novel P2Y12 inhibitor: a review of the pharmacology and clinical development. Expert Opin Investig Drugs 2020; 29:537-546. [DOI: 10.1080/13543784.2020.1764533] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rocco P. Milluzzo
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Gabriele A. Franchina
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, A.O.U. “Policlinico-vittorio Emanuele”, University of Catania, Catania, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine, University of Florida College of Medicine, Jacksonville, FL, USA
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Abstract
It must be remembered that clinically important haemostasis occurs in vivo and not in a tube, and that variables such as the number of bleeding events and bleeding volume are more robust measures of bleeding risk than the results of analyses. In this narrative review, we highlight trauma, surgery, and mild induced hypothermia as three clinically important situations in which the effects of hypothermia on haemostasis are important. In observational studies of trauma, hypothermia (body temperature <35°C) has demonstrated an association with mortality and morbidity, perhaps owing to its effect on haemostatic functions. Randomised trials have shown that hypothermia causes increased bleeding during surgery. Although causality between hypothermia and bleeding risk has not been well established, there is a clear association between hypothermia and negative outcomes in connection with trauma, surgery, and accidental hypothermia; thus, it is crucial to rewarm patients in these clinical situations without delay. Mild induced hypothermia to ≥33°C for 24 hours does not seem to be associated with either decreased total haemostasis or increased bleeding risk.
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Affiliation(s)
- Thomas Kander
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
| | - Ulf Schött
- Lund University, Skåne University Hospital, Department of Clinical Sciences Lund, Intensive and Perioperative Care, Lund, Sweden
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5
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Sullivan AE, Nanna MG, Rao SV, Cantrell S, Gibson CM, Verheugt FWA, Peterson ED, Lopes RD, Alexander JH, Granger CB, Yee MK, Kong DF. A systematic review of randomized trials comparing double versus triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2019; 96:E102-E109. [PMID: 31713326 DOI: 10.1002/ccd.28535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Prior randomized controlled trials (RCT) evaluating the optimal antithrombotic therapies for patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) have not been powered to evaluate ischemic outcomes. We compared double therapy with oral anticoagulation (OAC) and a P2Y12 inhibitor to triple therapy with an OAC + dual antiplatelet therapy in patients with AF requiring PCI. METHODS Using PRISMA guidelines, we searched for RCTs including patients with AF as an indication for OAC and undergoing PCI or medical management of acute coronary syndrome. The results were pooled using fixed-effects and random-effects models to estimate the overall effect of double therapy versus triple therapy on ischemic and bleeding outcomes. RESULTS We identified four RCTs, comprising 10,238 patients (5,498 double therapy, 4,740 triple therapy). Trial-reported major adverse cardiovascular events were similar between double therapy and triple therapy (fixed effect model OR 1.09, 95% CI 0.94-1.26). However, stent thrombosis (61/5,496 double therapy vs. 33/4738 triple therapy; fixed effect model OR 1.57, 95% CI 1.02-2.40; number needed to treat with triple therapy = 242) favored triple therapy. Bleeding outcomes were less frequent with double therapy (746/5470 vs. 950/4710; fixed effect model OR 0.59, 95% CI 0.53-0.65; number needed to harm with triple therapy = 16), but with significant heterogeneity (Q = 8.33, p = .04; I2 = 64%), as were intracranial hemorrhages (19/5470 vs. 30/4710; fixed effect model OR 0.54, 95% CI 0.31-0.96). CONCLUSIONS Double therapy in patients with AF requiring OAC following PCI or Acute coronary syndrome has a significantly better safety profile than triple therapy but may be associated with a modest increased risk of stent thrombosis.
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Affiliation(s)
- Alexander E Sullivan
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sunil V Rao
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Sarah Cantrell
- Duke University School of Medicine, Durham, North Carolina
| | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Eric D Peterson
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - John H Alexander
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christopher B Granger
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Megan K Yee
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - David F Kong
- Section of Cardiovascular Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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6
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Eyileten C, Soplinska A, Pordzik J, Siller‐Matula JM, Postuła M. Effectiveness of Antiplatelet Drugs Under Therapeutic Hypothermia: A Comprehensive Review. Clin Pharmacol Ther 2019; 106:993-1005. [DOI: 10.1002/cpt.1492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/12/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Ceren Eyileten
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Aleksandra Soplinska
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | - Justyna Pordzik
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
| | | | - Marek Postuła
- Department of Experimental and Clinical PharmacologyCenter for Preclinical Research and Technology CEPTMedical University of Warsaw Warsaw Poland
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7
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Umińska JM, Ratajczak J, Buszko K, Sobczak P, Sroka W, Marszałł MP, Adamski P, Steblovnik K, Noč M, Kubica J. Impact of mild therapeutic hypothermia on bioavailability of ticagrelor in patients with acute myocardial infarction after out-of-hospital cardiac arrest. Cardiol J 2019; 27:780-788. [PMID: 30799546 DOI: 10.5603/cj.a2019.0024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/20/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) frequently occurs in the early phase of acute myocardial infarction (MI). Survivors require percutaneous coronary intervention (PCI) with concomitant dual antiplatelet therapy. Target temperature management, including mild therapeutic hypothermia (MTH), should be applied in comatose patients after resuscitation. However, an increased risk of stent thrombosis in patients undergoing hypothermia is observed. The aim of this study was to assess the impact of MTH on pharmacokinetics of ticagrelor in cardiac arrest survivors with MI treated with MTH and PCI. METHODS In a prospective, observational, single-center study pharmacokinetics of ticagrelor were evaluated in 41 MI patients, including 11 patients after OHCA undergoing MTH (MTH group) and 30 MI patients without OHCA and MTH (no-MTH group). Blood samples were drawn before administration of a 180 mg ticagrelor loading dose, and 30 min, 1, 2, 4, 6, 12, and 24 h after the loading dose. RESULTS In patients treated with MTH total exposure to ticagrelor during the first 12 h after the loading dose and maximal plasma concentration of ticagrelor were significantly lower than in the no-MTH group (AUC(0-12): 3403 ± 2879 vs. 8746 ± 5596 ng·h/mL, difference: 61%, p = 0.01; Cmax: 475 ± 353 vs. 1568 ± 784 ng/mL, p = 0.0002). Time to achieve maximal ticagrelor plasma concentration was also delayed in the MTH group (tmax for ticagrelor: 12 [6-24] vs. 4 [2-12] h, p = 0.01). CONCLUSIONS Bioavailability of ticagrelor was substantially decreased and delayed in MI patients treated with MTH after OHCA. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02611934.
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Affiliation(s)
- Julia M Umińska
- Department of Geriatric, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland.
| | - Jakub Ratajczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Katarzyna Buszko
- Department of Theoretical Foundations of Biomedical Science and Medical Informatics, Collegium Medicum, Nicolaus Copernicus University, ul. Jagiellońska 13-15,, 85-067 Bydgoszcz, Poland
| | - Przemysław Sobczak
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Wiktor Sroka
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Michał P Marszałł
- Department of Medicinal Chemistry, Collegium Medicum, Nicolaus Copernicus University, Ul. M.Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Klemen Steblovnik
- Ljubljana University Medical Centre, University of Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Marko Noč
- Ljubljana University Medical Centre, University of Ljubljana, Zaloška cesta 7, 1000 Ljubljana, Slovenia
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Ul. M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
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Ferreiro JL, Vivas D, De La Hera JM, Marcano AL, Lugo LM, Gómez-Polo JC, Silva I, Tello-Montoliu A, Marín F, Roldán I. High and low on-treatment platelet reactivity to P2Y 12 inhibitors in a contemporary cohort of acute coronary syndrome patients undergoing percutaneous coronary intervention. Thromb Res 2019; 175:95-101. [PMID: 30738371 DOI: 10.1016/j.thromres.2019.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 01/05/2019] [Accepted: 01/30/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION There is compelling evidence supporting the association between high on-treatment platelet reactivity (HPR) and low on-treatment platelet reactivity (LPR) to clopidogrel with atherothrombotic and bleeding events, respectively. However, it is uncertain if current cutoff values should be used in prasugrel- or ticagrelor-treated subjects. The objective of this analysis was to evaluate the pharmacodynamic (PD) efficacy of P2Y12 antagonists in a contemporary real-world population. MATERIALS AND METHODS This PD study included 988 patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) and receiving dual therapy with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor). Platelet function was assessed at day 1 and day 30 post-PCI by VerifyNow P2Y12 assay, multiple electrode aggregometry and vasodilator-stimulated phosphoprotein (VASP) assay. RESULTS Clopidogrel-treated patients (n = 324) had greater platelet reactivity than those receiving ticagrelor (n = 469) or prasugrel (n = 195) at both time points (p < 0.001 for all comparisons). No difference between ticagrelor and prasugrel was observed at day 1 with the VerifyNow P2Y12 assay (51.5 ± 2.8 vs. 42.7 ± 3.5 PRUs; p = 0.298), whereas ticagrelor achieved greater platelet inhibition at day 30 (48.1 ± 2.5 vs. 89.2 ± 4.2 PRUs; p < 0.001). Similar results were obtained with the VASP assay. Both prasugrel and ticagrelor had markedly lower HPR rates than clopidogrel and very high rates of LPR at both time points. CONCLUSIONS Prasugrel and ticagrelor displayed more potent and consistent PD effects than clopidogrel in ACS patients undergoing PCI, with a trend towards greater platelet inhibition with ticagrelor during the maintenance phase of therapy compared to prasugrel.
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Affiliation(s)
- José Luis Ferreiro
- Heart Diseases Institute, Hospital Universitario de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
| | - David Vivas
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Jesús María De La Hera
- Department of Cardiology, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Ana Lucrecia Marcano
- Heart Diseases Institute, Hospital Universitario de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Leslie Marisol Lugo
- Heart Diseases Institute, Hospital Universitario de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Iria Silva
- Department of Cardiology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Antonio Tello-Montoliu
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBER-CV, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBER-CV, Murcia, Spain
| | - Inmaculada Roldán
- Department of Cardiology, Hospital Universitario La Paz, IDIPAZ, CIBER-CV, Madrid, Spain
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Prüller F, Milke OL, Bis L, Fruhwald F, Scherr D, Eller P, Pätzold S, Altmanninger-Sock S, Rainer P, Siller-Matula J, von Lewinski D. Impaired aspirin-mediated platelet function inhibition in resuscitated patients with acute myocardial infarction treated with therapeutic hypothermia: a prospective, observational, non-randomized single-centre study. Ann Intensive Care 2018; 8:28. [PMID: 29468430 PMCID: PMC5821616 DOI: 10.1186/s13613-018-0366-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 02/01/2018] [Indexed: 12/20/2022] Open
Abstract
The majority of resuscitated patients present with underlying cardiac disease, and out of these myocardial infarction is most common. Immediate interventional treatment is recommended and routinely requires dual antiplatelet therapy including aspirin and a P2Y12-inhibitor. Therapeutic hypothermia or target temperature management is also recommended in these patients. Cardiogenic shock as well as reduced body temperature impacts platelet reactivity and its medical inhibition. The study aims to quantify aspirin- and P2Y12-mediated platelet inhibition in patients presenting with myocardial infarction and cardiopulmonary resuscitation. Twenty-five resuscitated patients were enrolled in this prospective, observational, non-randomized single-centre study. These patients were compared to 77 matched controls from the ATLANTIS-ACS database of non-resuscitated patients with myocardial infarction. Platelet function testing was performed by light transmittance aggregometry. Aspirin reactivity was monitored by inducing platelet aggregation with collagen and arachidonic acid, respectively. P2Y12 inhibition was recorded by stimulation of platelet aggregation with adenosine diphosphate. To quantify the overall platelet response, thrombin receptor-activated peptide was used. Aspirin-mediated platelet reactivity decreased significantly in resuscitated patients during the first days and was significantly weaker on day 3 (collagen AUC 253.8 (122.7–352.2) vs. 109.0 (73.0–182.0); p = 0.022). P2Y12-mediated platelet inhibition was also impaired in resuscitated patients on day 3 (mean ADP AUC (IQR): CPR 172.1 (46.7−346.5) vs. control 43.9 (18.9–115.2); p < 0.05). Aspirin- and P2Y12-mediated platelet inhibition is impaired in resuscitated patients treated with therapeutic hypothermia. On day 3, we recorded lowest inhibitory effects of both drug types and patients might be at particular risk at that time. Potentially, intravenous aspirin and P2Y12 inhibitors might still supply a more predictable and stable platelet inhibition.
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Affiliation(s)
- Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, Graz, Austria
| | | | - Lukasz Bis
- Medical University of Graz, Graz, Austria
| | - Friedrich Fruhwald
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Daniel Scherr
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Philipp Eller
- Department of Internal Medicine, Intensive Care Unit, University Hospital Graz, Graz, Austria
| | - Sascha Pätzold
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Siegfried Altmanninger-Sock
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Peter Rainer
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | | | - Dirk von Lewinski
- Department of Cardiology, Intensive Care Unit, University Hospital Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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Role of New Antiplatelet Drugs on Cardiovascular Disease: Update on Cangrelor. Curr Atheroscler Rep 2017; 18:66. [PMID: 27714642 DOI: 10.1007/s11883-016-0617-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Dual therapy with a P2Y12 receptor antagonist in addition to aspirin is the antiplatelet treatment of choice in patients with acute coronary syndromes or undergoing percutaneous coronary intervention (PCI). However, available oral P2Y12 antagonists have several limitations, mostly due to their pharmacological profile, which can affect outcomes in certain clinical settings. Cangrelor is an intravenous, direct-acting, potent P2Y12 inhibitor with rapid onset and offset of action, which has been recently approved for clinical use in patients undergoing PCI. In clinical trials, cangrelor has demonstrated greater efficacy than clopidogrel with a favorable safety profile among PCI patients not receiving pretreatment with oral P2Y12 antagonists. However, its definitive role in contemporary practice is yet to be determined. This review aims to provide a comprehensive overview of the current status of knowledge on cangrelor, focusing on its pharmacological properties, clinical development, and the potential applications of this newly available agent.
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11
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Rollini F, Franchi F, Angiolillo DJ. Crushed ticagrelor in comatose patients treated with primary percutaneous coronary intervention. EUROINTERVENTION 2017; 12:1681-1683. [PMID: 28216470 DOI: 10.4244/eijv12i14a276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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12
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Luchessi AD, Concheiro M, Germano JDF, Silbiger VN, Bortolin RH, Cruz A, Quintela O, Brion M, Carracedo A, Iñiguez A, Bravo M, López-Rivadulla M, Hirata RDC, Sousa AGMR, Hirata MH. ABCC3 Polymorphisms and mRNA Expression Influence the Concentration of a Carboxylic Acid Metabolite in Patients on Clopidogrel and Aspirin Therapy. Basic Clin Pharmacol Toxicol 2017; 120:466-474. [PMID: 27862978 DOI: 10.1111/bcpt.12703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/06/2016] [Indexed: 12/13/2022]
Abstract
Acetylsalicylic acid (ASA) and clopidogrel combined therapy has been reported to be beneficial in patients with acute coronary syndrome (ACS). Antiplatelet drug resistance, especially to clopidogrel, is a multifactorial phenomenon that affects a large number of ACS patients. The genetic contribution to this drug response is not fully elucidated. We investigated the relationship of ABC-type efflux subfamily C member 3 (ABCC3) polymorphisms and mRNA expression with plasma concentrations of clopidogrel, salicylic acid (SA) and a carboxylic acid metabolite (CAM). Clopidogrel, CAM and SA plasma concentrations were measured simultaneously by liquid chromatography-tandem mass spectrometry (LCMS/MS) from 83 ACS patients undergoing percutaneous coronary intervention. ABCC3 (rs757421, rs733392 and rs739923) and CYP2C19*2 (rs4244285) polymorphisms as well as mRNA expression were evaluated. A positive correlation was found between CAM concentrations and ABCC3 mRNA expression (r = 0.494, p < 0.0001). Patients carrying genotype AA (rs757421 variant) had higher CAM concentrations and ABCC3 mRNA expression as compared to those of GG + GA carriers (p = 0.017). A multiple linear regression analysis revealed that ABCC3 mRNA expression (p = 0.017), rs757421 AA genotype (p = 0.001), blood collection time (p = 0.018) and clopidogrel dose (p = 0.001) contributed to the concentration of CAM. No associations were observed for the CYP2C19*2 polymorphism. These results suggest that up-regulation of ABCC3 mRNA expression leads to increased plasma CAM levels through MRP3-mediated cell efflux. The ABCC3 rs757421 polymorphism may contribute to gene expression. Therefore, ABCC3 may be a potential biomarker for the response to clopidogrel.
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Affiliation(s)
- André Ducati Luchessi
- School of Pharmaceutical Science, University of Sao Paulo, Sao Paulo, Brazil.,Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Marta Concheiro
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | | | - Vivian Nogueira Silbiger
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Raul Hernandes Bortolin
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Angelines Cruz
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Oscar Quintela
- Department of Madrid, National Institute of Toxicology and Forensic Science, Madrid, Spain
| | - Maria Brion
- Genetics of Cardiovascular and Ophthalmological Diseases, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.,Genomic Medicine, University of Santiago de Compostela, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Angel Carracedo
- Genomic Medicine, University of Santiago de Compostela, IDIS, CIBERER, Santiago de Compostela, Spain
| | - Andres Iñiguez
- Cardiology Service, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Marisol Bravo
- Cardiology Service, Alvaro Cunqueiro Hospital, Vigo, Spain
| | - Manuel López-Rivadulla
- Luis Concheiro Institute of Forensic Sciences, University of Santiago de Compostela, Santiago de Compostela, Spain
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13
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Braune S, Fröhlich GM, Lendlein A, Jung F. Effect of temperature on platelet adherence. Clin Hemorheol Microcirc 2017; 61:681-8. [PMID: 26639771 DOI: 10.3233/ch-152028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thrombogenicity is one of the main parameters tested in vitro to evaluate the hemocompatibility of artificial surfaces. While the influence of the temperature on platelet aggregation has been addressed by several studies, the temperature influence on the adherence of platelets to body foreign surfaces as an important aspect of biomedical device handling has not yet been explored. Therefore, we analyzed the influence of two typically applied incubation-temperatures (22°C and 37°C) on the adhesion of platelets to biomaterials. MATERIAL AND METHODS Thrombogenicity of three different polymers - medical grade poly(dimethyl siloxane) (PDMS), polytetrafluoroethylene (PTFE) and polyethylene terephthalate (PET) - were studied in an in vitro static test. Platelet adhesion was studied with stringently characterized blood from apparently healthy subjects. Collection of whole blood and preparation of platelet rich plasma (PRP) was carried out at room temperature (22°C). PRP was incubated with the polymers either at 22°C or 37°C. Surface adherent platelets were fixed, fluorescently labelled and assessed by an image-based approach. RESULTS AND DISCUSSION Differences in the density of adherent platelets after incubation at 22°C and 37°C occurred on PDMS and PET. Similar levels of adherent platelets were observed on the very thrombogenic PTFE. The covered surface areas per single platelet were analyzed to measure the state of platelet activation and revealed no differences between the two incubation temperatures for any of the analyzed polymers. Irrespective of the observed differences between the low and medium thrombogenic PDMS and PET and the higher variability at 22°C, the thrombogenicity of the three investigated polymers was evaluated being comparable at both incubation temperatures.
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Affiliation(s)
- S Braune
- Institute of Biomaterial Science, Helmholtz-Zentrum Geesthacht, Teltow, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Teltow and Berlin, Germany
| | | | - A Lendlein
- Institute of Biomaterial Science, Helmholtz-Zentrum Geesthacht, Teltow, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Teltow and Berlin, Germany.,Institute of Chemistry, University of Potsdam, Potsdam, Germany
| | - F Jung
- Institute of Biomaterial Science, Helmholtz-Zentrum Geesthacht, Teltow, Germany.,Berlin-Brandenburg Center for Regenerative Therapies, Teltow and Berlin, Germany
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14
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Anderson KB, Poloyac SM, Kochanek PM, Empey PE. Effect of Hypothermia and Targeted Temperature Management on Drug Disposition and Response Following Cardiac Arrest: A Comprehensive Review of Preclinical and Clinical Investigations. Ther Hypothermia Temp Manag 2016; 6:169-179. [PMID: 27622966 DOI: 10.1089/ther.2016.0003] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Targeted temperature management (TTM) has been shown to reduce mortality and improve neurological outcomes in out-of-hospital cardiac arrest (CA) patients and in neonates with hypoxic-ischemic encephalopathy (HIE). TTM has also been associated with adverse drug events in the critically ill patient due to its effect on drug pharmacokinetics (PKs) and pharmacodynamics (PDs). We aim to evaluate the current literature on the effect of TTM on drug PKs and PDs following CA. MEDLINE/PubMed databases were searched for publications, which include the MeSH terms hypothermia, drug metabolism, drug transport, P450, critical care, cardiac arrest, hypoxic-ischemic encephalopathy, pharmacokinetics, and pharmacodynamics between July 2006 and October 2015. Twenty-three studies were included in this review. The studies demonstrate that hypothermia impacts PK parameters and increases concentrations of cytochrome-P450-metabolized drugs in the cooling and rewarming phase. Furthermore, the current data demonstrate a combined effect of CA and hypothermia on drug PK. Importantly, these effects can last greater than 4-5 days post-treatment. Limited evidence suggests hypothermia-mediated changes in the Phase II metabolism and the Phase III transport of drugs. Hypothermia also has been shown to potentially decrease the effect of specific drugs at the receptor level. Therapeutic hypothermia, as commonly deployed/applied during TTM, alters PK, and elevates concentrations of several commonly used medications. Hypothermia-mediated effects are an important factor when dosing and monitoring patients undergoing TTM treatment.
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Affiliation(s)
- Kacey B Anderson
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Samuel M Poloyac
- 1 Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Patrick M Kochanek
- 2 Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Philip E Empey
- 3 Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh , Pittsburgh, Pennsylvania
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15
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Kaufmann J, Wellnhofer E, Stockmann H, Graf K, Fleck E, Schroeder T, Stawowy P, Storm C. Clopidogrel pharmacokinetics and pharmacodynamics in out-of-hospital cardiac arrest patients with acute coronary syndrome undergoing target temperature management. Resuscitation 2016; 102:63-9. [DOI: 10.1016/j.resuscitation.2016.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
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16
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Flierl U, Röntgen P, Zauner F, Tongers J, Berliner D, Bauersachs J, Schäfer A. Platelet inhibition with prasugrel in patients with acute myocardial infarction undergoing therapeutic hypothermia after cardiopulmonary resuscitation. Thromb Haemost 2016; 115:960-8. [PMID: 26790884 DOI: 10.1160/th15-07-0599] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 12/22/2015] [Indexed: 11/05/2022]
Abstract
Acute myocardial infarction (AMI) is the leading cause for out-of-hospital cardiac arrest. Therapeutic hypothermia improves neurological outcome in combination with early revascularisation, but seems to affect clopidogrel responsiveness. The more potent thienopyridine prasugrel has not yet been sufficiently evaluated during therapeutic hypothermia. We investigated 23 consecutive AMI patients (61 ± 11 years) following out-of-hospital resuscitation undergoing revascularisation and therapeutic hypothermia. Prasugrel efficacy was assessed by the platelet-reactivity-index (PRI) before and 2, 4, 6, 12, 24, 48, and 72 hours (h) following a loading dose of 60 mg via a gastric tube. Mean PRI (± SD) was 70 ± 12 % prior to loading and 60 ± 16 % (2 h, ns), 52 ± 21 % (4 h, p< 0.01), 42 ± 26 % (6 h, p< 0.01), 37 ± 21 % (12 h, p< 0.01), 27 ± 23 % (24 h, p< 0.01), 18 ± 14 % (48 h, p< 0.01), and 13 ± 10 % (72 h, p< 0.01) after loading. Sufficient platelet inhibition occurred later compared to stable AMI patients (6 h vs 2 h); however, high on-treatment platelet reactivity significantly decreased over time and was non-existent after 72 h (PRI> 50 %: 2 h: 72 %, 4 h: 52 %, 6 h: 43 %, 12 h: 29 %, 24 h: 17 %, 48 h: 5 %, 72 h: 0 %). There was no relation between 30-day mortality rate (26 %) and PRI values. Prasugrel significantly reduced platelet reactivity even during vasopressor use, analgosedation and therapeutic hypothermia. Despite a significant delay compared to stable AMI patients, sufficient platelet inhibition was reached in 83 % of patients within 24 h. Therefore, prasugrel administration via gastric tube might be a useful therapeutic strategy in these patients at high risk, providing potent and effective P2Y12 inhibition.
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Affiliation(s)
| | | | | | | | | | | | - Andreas Schäfer
- Prof. Dr. Andreas Schäfer, Medizinische Hochschule Hannover, Klinik für Kardiologie und Angiologie, Carl Neuberg Straße 1, 30625 Hannover, Germany, Tel: +49 511 532 5240; Fax: +49 511 532 8244, E-mail:
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17
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Barbato E, Barton PJ, Bartunek J, Huber S, Ibanez B, Judge DP, Lara-Pezzi E, Stolen CM, Taylor A, Hall JL. Review and Updates in Regenerative and Personalized Medicine, Preclinical Animal Models, and Clinical Care in Cardiovascular Medicine. J Cardiovasc Transl Res 2015; 8:466-74. [DOI: 10.1007/s12265-015-9657-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Accepted: 09/28/2015] [Indexed: 12/22/2022]
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18
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Kander T, Brokopp J, Erlinge D, Lood C, Schött U. Temperature effects on haemostasis in whole blood from ticagrelor- and aspirin-treated patients with acute coronary syndrome. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 75:27-35. [PMID: 25365333 DOI: 10.3109/00365513.2014.965735] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Comatose survivors after cardiac arrest are treated with mild induced hypothermia and potent platelet- inhibiting drugs after coronary stenting. Previous studies have shown an increased incidence of stent thrombosis during clopidogrel and aspirin treatment in conjunction with induced hypothermia. The aim of this study was to investigate the in vitro effect of induced hypo- and hyperthermia on blood from patients undergoing ticagrelor- and aspirin-mediated platelet inhibition. METHODS Whole blood from 15 patients with acute coronary syndrome who were treated with ticagrelor and aspirin and from eight healthy volunteers was incubated for 1 hour at 28, 33, 37, and 39°C. RESULTS In blood from patients with acute coronary syndrome, the activated clotting time (Sonoclot) was prolonged in mild hypothermic (33°C) compared to normothermic (37°C) samples. Sonoclot, clotting rate and platelet function were decreased in hypothermic compared to normothermic samples. Platelet-induced activation and aggregation (Multiplate) was unchanged in mild hypothermic compared to normothermic samples. In contrast, mild hypothermia supported increased platelet activation as measured with flow cytometry with up-regulation of PAC-1 and P-selectin on the platelet surface. CONCLUSION In acute coronary syndrome patients treated with ticagrelor and aspirin, in vitro hypothermia to 33°C markedly increased platelet activity measured with flow cytometry, whereas viscoelastic coagulation test (Sonoclot) revealed a hypocoagulative response. Prospective clinical trials studying platelet inhibition at different temperatures and correlating changes in platelet function to bleeding or stent occlusion are needed.
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Affiliation(s)
- Thomas Kander
- Department of Intensive and Perioperative Care, Skåne University Hospital , Lund , Sweden
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