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Gao H, Yang N, Yang L, Wang H, Zhang G, Ma X, Deng N. Advances and Perspectives in methods for identifying high platelet reactivity. Heliyon 2023; 9:e22214. [PMID: 38107326 PMCID: PMC10724541 DOI: 10.1016/j.heliyon.2023.e22214] [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: 05/08/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy is the foundational treatment for the prevention and treatment of coronary and cerebrovascular ischemic events in patients with coronary heart disease, ischemic stroke, and transient ischemic attack (TIA). However, with more and more studies reporting an increased risk of thrombosis in some patients due to poor response to therapeutic agents, the selection of appropriate P2Y12 inhibitors has become a major challenge that needs to be addressed urgently. Currently, commonly used oral P2Y12 inhibitors include clopidogrel, ticagrelor, and prasugrel. Assessing patients' risk factors before the development of treatment regimens by effectively predicting the risk of high platelet reactivity with specific P2Y12 inhibitors in advance to avert the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) is the key point to the problem. Up to now, methods available for predicting platelet reactivity include genetic testing, platelet function testing, and risk scores. This review provides a summarization of the existent available identification methods and analyzes the advantages and drawbacks of different methods in specific clinical settings, intending to guide the rational clinical application of P2Y12 receptor inhibitors.
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Affiliation(s)
- Hua Gao
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Nan Yang
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Libo Yang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Hui Wang
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Guoshan Zhang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xueping Ma
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Ning Deng
- Office of Drug Clinical Trial Organization, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
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Qureshi K, Farooq MU, Gorelick PB. Genotype-guided dual antiplatelet therapy in cerebrovascular disease: assessing the risk and benefits for ethnic populations. Expert Rev Cardiovasc Ther 2023; 21:621-630. [PMID: 37551687 DOI: 10.1080/14779072.2023.2245754] [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: 04/12/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/09/2023]
Abstract
INTRODUCTION Cerebrovascular disease is a leading cause of morbidity and mortality in the world and antiplatelet therapy is a main pharmacologic means of secondary prevention. Clinical information has accumulated about benefit of dual antiplatelet therapy in certain clinical scenarios, genetic causes of antiplatelet resistance and its effect on clinical outcomes, and ethnic and geographic distributions of genetic polymorphisms. AREAS COVERED This review covers literature related to the pharmacogenomics of antiplatelet agents with a focus on ethnic variability, antiplatelet resistance, and dual antiplatelet therapy in cerebrovascular disease. EXPERT OPINION Selecting patients for dual antiplatelet therapy and specific agents require consideration of multiple factors. Ethnic factors should be considered in certain circumstances, but additional research is needed to determine the generalizability of the findings.
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Affiliation(s)
- Kasim Qureshi
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Department of Neurology, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Muhammad U Farooq
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Department of Neurology, Michigan State University College of Human Medicine, Grand Rapids, MI, United States
| | - Philip B Gorelick
- Department of Neurology, Trinity Health, Saint Mary's, Grand Rapids, MI, United States
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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van der Sangen NM, Küçük IT, Ten Berg JM, Beijk MA, Delewi R, den Hartog AW, Appelman Y, Verouden NJ, Kikkert WJ, Henriques JP, Claessen BE. P2Y 12-inhibitor monotherapy after coronary stenting: are all P2Y 12-inhibitors equal? Expert Rev Cardiovasc Ther 2022; 20:637-645. [PMID: 35916833 DOI: 10.1080/14779072.2022.2104248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION P2Y12-inhibitor monotherapy following 1-3 months of dual antiplatelet therapy (DAPT) reduces (major) bleeding without an apparent increase in ischemic events and has therefore emerged as an alternative to 6-12 months of DAPT following percutaneous coronary intervention (PCI). However, there are important differences between the available P2Y12-inhibitors (clopidogrel, prasugrel, and ticagrelor) as agents of choice for P2Y12-inhibitor monotherapy. AREAS COVERED This review critically appraises the evidence for P2Y12-inhibitor monotherapy after PCI using either clopidogrel, prasugrel, or ticagrelor. Furthermore, we discuss ongoing trials and future directions for research. EXPERT OPINION P2Y12-inhibitor monotherapy following 1-3 months of DAPT is an alternative to 6-12 months of DAPT following PCI. Ticagrelor may be considered the current preferred option due to its reliable effect on platelet reactivity and its predominant use in clinical trials. Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but more research into prasugrel monotherapy is warranted. Alternatively, clopidogrel can be used, although there are concerns of high platelet reactivity, especially when genotyping and/or platelet function testing are not used. Future research will need to address the minimal duration of DAPT before switching to P2Y12-inhibitor monotherapy and what the optimal antithrombotic therapy beyond 12 months is.
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Affiliation(s)
- Niels Mr van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Marcel Am Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Jw Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - José Ps Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bimmer Epm Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Verheugt FWA, Damman P, Damen SAJ, Wykrzykowska JJ, Woelders ECI, van Geuns RJM. P2Y12 blocker monotherapy after percutaneous coronary intervention. Neth Heart J 2021; 29:566-576. [PMID: 34101134 PMCID: PMC8556441 DOI: 10.1007/s12471-021-01582-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
For secondary prevention of coronary artery disease (CAD) antiplatelet therapy is essential. For patients undergoing a percutaneous coronary intervention (PCI) temporary dual antiplatelet platelet therapy (DAPT: aspirin combined with a P2Y12 blocker) is mandatory, but leads to more bleeding than single antiplatelet therapy with aspirin. Therefore, to reduce bleeding after a PCI the duration of DAPT is usually kept as short as clinically acceptable; thereafter aspirin monotherapy is administered. Another option to reduce bleeding is to discontinue aspirin at the time of DAPT cessation and thereafter to administer P2Y12 blocker monotherapy. To date, five randomised trials have been published comparing DAPT with P2Y12 blocker monotherapy in 32,181 stented patients. Also two meta-analyses addressing this novel therapy have been presented. P2Y12 blocker monotherapy showed a 50-60% reduction in major bleeding when compared to DAPT without a significant increase in ischaemic outcomes, including stent thrombosis. This survey reviews the findings in the current literature concerning P2Y12 blocker monotherapy after PCI.
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Affiliation(s)
- F W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - P Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S A J Damen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J J Wykrzykowska
- Department of Cardiology, University Medical Centre, Groningen, The Netherlands
| | - E C I Woelders
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R -J M van Geuns
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Antithrombotics: From Aspirin to DOACs in Coronary Artery Disease and Atrial Fibrillation (Part 3/5). J Am Coll Cardiol 2019; 74:699-711. [PMID: 31277840 DOI: 10.1016/j.jacc.2019.02.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/22/2019] [Accepted: 02/04/2019] [Indexed: 01/09/2023]
Abstract
For secondary prevention of coronary artery disease (CAD), oral antiplatelet therapy is essential. In case of coronary intervention, temporary dual antiplatelet therapy is mandatory as well. Recently, low-dose oral anticoagulation has entered the CAD arena. Atrial fibrillation (AF) is often seen in CAD and vice versa. In most patients stroke prevention in AF consists of oral anticoagulation. In many cases of CAD in patients with AF, anticoagulation has to be combined with antiplatelet agents (so called, dual pathway antithrombotic therapy). Excess bleeding in these conditions is a rapidly rising problem. This review addresses the antithrombotic options in CAD alone, in AF alone, and in their combination, when either an invasive or a noninvasive approach has been chosen.
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Gwyn JCV, Thomas MR, Kirchhof P. Triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention: a viewpoint. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:157-162. [DOI: 10.1093/ehjcvp/pvx002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/11/2017] [Indexed: 12/31/2022]
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Thomas MR, Storey RF. Clinical significance of residual platelet reactivity in patients treated with platelet P2Y12 inhibitors. Vascul Pharmacol 2016; 84:25-7. [DOI: 10.1016/j.vph.2016.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 03/13/2016] [Accepted: 05/28/2016] [Indexed: 01/25/2023]
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Thomas MR, Storey RF. Effect of P2Y12 inhibitors on inflammation and immunity. Thromb Haemost 2015; 114:490-7. [PMID: 26156883 DOI: 10.1160/th14-12-1068] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Accepted: 05/04/2015] [Indexed: 02/04/2023]
Abstract
Platelet P2Y12 inhibitors form a major part of the treatment strategy for patients with acute coronary syndromes (ACS) due to the importance of the platelet P2Y12 receptor in mediating the pathophysiology of arterial thrombosis. It has been increasingly recognised that platelets also have a critical role in inflammation and immune responses. P2Y12 inhibitors reduce platelet release of pro-inflammatory α-granule contents and the formation of pro-inflammatory platelet-leukocyte aggregates. These are important mediators of inflammation in a variety of different contexts. Clinical evidence shows that P2Y12 inhibition by clopidogrel is associated with a reduction in platelet-related mediators of inflammation, such as soluble P-selectin and CD40L, following atherothrombosis. Clopidogrel in addition to aspirin, compared to aspirin alone, also reduces markers of systemic inflammation such as tumour necrosis factor (TNF) α and C-reactive protein (CRP) following ACS. The more potent thienopyridine P2Y12 inhibitor, prasugrel, has been shown to decrease platelet P-selectin expression and platelet-leukocyte aggregate formation compared to clopidogrel. The PLATO study suggested that the novel P2Y12 inhibitor ticagrelor might improve clinical outcomes from pulmonary infections and sepsis compared to clopidogrel in patients with ACS. Ticagrelor is a more potent P2Y12 inhibitor than clopidogrel and also inhibits cellular adenosine uptake via equilibrative nucleoside transporter (ENT) 1, whereas clopidogrel does not. Further examination of the involvement of these mechanisms in inflammation and immunity is therefore warranted.
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Affiliation(s)
- Mark R Thomas
- Dr. Mark R. Thomas, BMedSci BMBS MRCP, Department of Cardiovascular Science, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK, Tel.: +44 114 3052019, Fax: +44 114 2266159, E-mail
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Su Y, Cheng X, Dong Q. Dual Antiplatelet Therapy of Clopidogrel and Aspirin in Secondary Prevention of Ischemic Stroke: Evidence and Indications. CNS Neurosci Ther 2015; 21:870-6. [PMID: 26122554 DOI: 10.1111/cns.12419] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 01/16/2023] Open
Abstract
Nowadays the dual antiplatelet therapy (DAPT) becomes more widely used in patients with ischemic stroke. Nevertheless, controversies exist for indications of DAPT. In view of evidence-based medicine analysis, patients with high-risk transient ischemic attack and minor stroke, severe symptomatic intracranial artery stenosis, symptomatic intracranial and extracranial artery stenosis causing artery-to-artery embolism, ischemic stroke attributed to aortic arch plaques, high-risk atrial fibrillation not suitable for oral anticoagulants, intracranial and extracranial stent implantation, and ischemic stroke with acute coronary syndrome may gain great benefit from DAPT of clopidogrel and aspirin. In clinical practice, individualized antiplatelet therapy strategies should be taken by weighing risks of ischemia and hemorrhage.
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Affiliation(s)
- Ya Su
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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