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Numao Y, Takahashi S, Nakao YM, Tajima E, Noma S, Endo A, Honye J, Tsukada Y. Sex Differences in Bleeding Risk Associated With Antithrombotic Therapy Following Percutaneous Coronary Intervention. Circ Rep 2024; 6:99-109. [PMID: 38606417 PMCID: PMC11004037 DOI: 10.1253/circrep.cr-24-0015] [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: 02/21/2024] [Accepted: 02/21/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Antithrombotic therapy is crucial for secondary prevention of cardiovascular disease (CVD), but women with CVD may face increased bleeding complications post-percutaneous coronary intervention (PCI) under antithrombotic therapy. However, women are often underrepresented in clinical trials in this field, so evidence for sex-specific recommendations is lacking. Methods and Results: A search on PubMed was conducted for English-language articles addressing bleeding complications and antithrombotic therapy in women. Despite women potentially showing higher baseline platelet responsiveness than men, the clinical implications remain unclear. Concerning antiplatelet therapy post-PCI, although women have an elevated bleeding risk in the acute phase, no sex differences were observed in the chronic phase. However, women require specific considerations for factors such as age, renal function, and weight when determining the dose and duration of antiplatelet therapy. Regarding anticoagulation post-PCI, direct oral anticoagulants may pose a lower bleeding risk in women compared with warfarin. Concerning triple antithrombotic therapy (TAT) post-PCI for patients with atrial fibrillation, there is a lack of evidence on whether sex differences should be considered in the duration and regimen of TAT. Conclusions: Recent findings on sex differences in post-PCI bleeding complications did not provide enough evidence to recommend specific therapies for women. Further studies are needed to address this gap and recommend optimal antithrombotic therapy post-PCI for women.
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Affiliation(s)
- Yoshimi Numao
- Department of Cardiology, Itabashi Chuo Medical Center Tokyo Japan
| | - Saeko Takahashi
- Department of Cardiology, Shonan Oiso Hospital Kanagawa Japan
| | - Yoko M Nakao
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University Kyoto Japan
| | - Emi Tajima
- Department of Cardiology, Tokyo General Hospital Tokyo Japan
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School Tokyo Japan
| | - Ayaka Endo
- Department of Cardiology, Tokyo Saiseikai Central Hospital Tokyo Japan
| | - Junko Honye
- Cardiovascular Center, Kikuna Memorial Hospital Kanagawa Japan
| | - Yayoi Tsukada
- Department of General Medicine and Health Science, Nippon Medical School Tokyo Japan
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Galli M, Angiolillo DJ. De-escalation of antiplatelet therapy in acute coronary syndromes: Why, how and when? Front Cardiovasc Med 2022; 9:975969. [PMID: 36093167 PMCID: PMC9452742 DOI: 10.3389/fcvm.2022.975969] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/01/2022] [Indexed: 12/29/2022] Open
Abstract
The synergistic blockade of the key platelet signaling pathways of cyclooxygenase-1 blockade and P2Y12 signaling by combining aspirin plus a potent P2Y12 inhibitor (prasugrel or ticagrelor), the so called dual antiplatelet treatment (DAPT), has represented the antithrombotic regimen of choice in patients with acute coronary syndrome (ACS) for nearly a decade. Nevertheless, the use of such antiplatelet treatment regimen, while reduced the risk of thrombotic complications, it is inevitably associated with increased bleeding and this risk may outweigh the benefit of a reduction of ischemic events in specific subgroup of patients. In light of the adverse prognostic implications of a bleeding complication, there has been a great interest in the development of antiplatelet regimens aimed at reducing bleeding without any trade-off in ischemic events. The fact that the ischemic risk is highest in the early phase after an ACS while the risk of bleeding remains relatively stable over time has represented the rationale for the implementation of a more intense antithrombotic regimen early after an ACS, followed by a less intense antithrombotic regimen thereafter. This practice, known as a "de-escalation" strategy, represents one of the more promising approaches for personalization of antithrombotic therapy in ACS. In this review we discuss the rationale, appraise the evidence and provide practical recommendations on the use of a de-escalation strategy of antiplatelet therapy in patients with an ACS.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care and Research, Cotignola, Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
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3
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Galli M, Ortega-Paz L, Franchi F, Rollini F, Angiolillo DJ. Precision medicine in interventional cardiology: implications for antiplatelet therapy in patients undergoing percutaneous coronary intervention. Pharmacogenomics 2022; 23:723-737. [PMID: 35938534 DOI: 10.2217/pgs-2022-0057] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Precision medicine is a medical model that proposes the customization of medical treatments to the individual patient, as opposed to a one-drug-fits-all model. Such a "personalized medicine" approach has been widely adopted in several medical fields, such as cancer medicine, but the implementation of precision medicine in cardiovascular medicine has not been similarly straightforward. Because pharmacogenomics plays an important role in the safety and efficacy of cardiovascular drug therapy, there has been a great interest in the use of tools aiming at personalizing antiplatelet therapy. Moreover, antiplatelet therapy is essential for the treatment of cardiovascular patients to reduce the risk of thrombotic complications, particularly those undergoing percutaneous coronary intervention, but it is inevitably associated with increased bleeding risk. In this review, the authors discuss the rationale, summarize the evidence and discuss the current and future directions for the personalization of antiplatelet treatment regimens in patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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4
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Elevated AST/ALT ratio is associated with all-cause mortality in patients with stable coronary artery disease: a secondary analysis based on a retrospective cohort study. Sci Rep 2022; 12:9231. [PMID: 35654995 PMCID: PMC9163143 DOI: 10.1038/s41598-022-13355-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of this study is to explore the association between the aspartate amino transferase (AST)/alanine aminotransferase (ALT) ratio and all-cause mortality (ACM) in stable coronary artery disease (CAD) patients treated by percutaneous coronary intervention (PCI). The study is a secondary analysis of a retrospective cohort study involving 203 stable CAD patients. Patients were divided into two groups, based on the optimal AST/ALT ratio threshold calculated by the ROC curve (low group: AST/ALT ratio < 1.40; high group: AST/ALT ratio ≥ 1.40). Results were compared using hazard ratio (HR) and a 95% confidence interval (CI). ACM occurred in 18 patients after an average follow-up time of 749 (435–1122) days. Among them, ACM occurred in 6 patients in the low group and 12 patients in the high group, with significant differences between the groups (4.65% versus 16.22%, P value = 0.005). In the Kaplan–Meier analysis, an elevated AST/ALT ratio was associated with increased ACM in stable ACD patients (HR 3.78, 95% CI 1.44–9.93, P value < 0.001). An elevated AST/ALT ratio was still found to be an independent prognostic factor for ACM (HR 2.93, 95% CI 1.08–7.91, P value = 0.034) after adjusting for potential confounders. Therefore, an elevated AST/ALT ratio is an independent prognostic factor for ACM in stable ACD patients.
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5
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van Leeuwen MAH, van der Hoeven NW, Janssens GN, Everaars H, Nap A, Lemkes JS, de Waard GA, van de Ven PM, van Rossum AC, Ten Cate TJF, Piek JJ, von Birgelen C, Escaned J, Valgimigli M, Diletti R, Riksen NP, van Mieghem NM, Nijveldt R, van Royen N. Evaluation of Microvascular Injury in Revascularized Patients With ST-Segment-Elevation Myocardial Infarction Treated With Ticagrelor Versus Prasugrel. Circulation 2019; 139:636-646. [PMID: 30586720 DOI: 10.1161/circulationaha.118.035931] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite successful restoration of epicardial vessel patency with primary percutaneous coronary intervention, coronary microvascular injury occurs in a large proportion of patients with ST-segment-elevation myocardial infarction, adversely affecting clinical and functional outcome. Ticagrelor has been reported to increase plasma adenosine levels, which might have a protective effect on the microcirculation. We investigated whether ticagrelor maintenance therapy after revascularized ST-segment-elevation myocardial infarction is associated with less coronary microvascular injury compared to prasugrel maintenance therapy. METHODS A total of 110 patients with ST-segment-elevation myocardial infarction received a loading dose of ticagrelor and were randomized to maintenance therapy of ticagrelor (n=56) or prasugrel (n=54) after primary percutaneous coronary intervention. The primary outcome was coronary microvascular injury at 1 month, as determined with the index of microcirculatory resistance in the infarct-related artery. Cardiovascular magnetic resonance imaging was performed during the acute phase and at 1 month. RESULTS The primary outcome of index of microcirculatory resistance was not superior in ticagrelor- or prasugrel-treated patients (ticagrelor, 21 [interquartile range, 15-39] U; prasugrel, 18 [interquartile range, 11-29] U; P=0.08). Recovery of microcirculatory resistance over time was not better in patients with ticagrelor versus prasugrel (ticagrelor, -13.9 U; prasugrel, -13.5 U; P=0.96). Intramyocardial hemorrhage was observed less frequently in patients receiving ticagrelor (23% versus 43%; P=0.04). At 1 month, no difference in infarct size was observed (ticagrelor, 7.6 [interquartile range, 3.7-14.4] g, prasugrel 9.9 [interquartile range, 5.7-16.6] g; P=0.17). The occurrence of microvascular obstruction was not different in patients on ticagrelor (28%) or prasugrel (41%; P=0.35). Plasma adenosine concentrations were not different during the index procedure and during maintenance therapy with ticagrelor or prasugrel. CONCLUSIONS In patients with ST-segment-elevation myocardial infarction, ticagrelor maintenance therapy was not superior to prasugrel in preventing coronary microvascular injury in the infarct-related territory as assessed by the index of microcirculatory resistance, and this resulted in a comparable infarct size at 1 month. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT02422888.
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Affiliation(s)
- Maarten A H van Leeuwen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.).,Department of Cardiology, Isala Heart Centre, Zwolle, The Netherlands (M.A.H.v.L.)
| | - Nina W van der Hoeven
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Gladys N Janssens
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Henk Everaars
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Alexander Nap
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Jorrit S Lemkes
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Guus A de Waard
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Peter M van de Ven
- Department of Epidemiology and Biostatistics, VU University, Amsterdam, The Netherlands (P.M.v.d.V.)
| | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.)
| | - Tim J F Ten Cate
- Department of Cardiology (T.J.F.t.C., R.N., N.v.R.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands (J.J.P.)
| | - Clemens von Birgelen
- Department of Cardiology, Medisch Spectrum Twente, Enschede, The Netherlands (C.v.B.)
| | - Javier Escaned
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (J.E.)
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, Switzerland (M.V.)
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands (R.D., N.M.v.M.)
| | - Niels P Riksen
- Department of Internal Medicine (N.P.R.), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.).,Department of Cardiology (T.J.F.t.C., R.N., N.v.R.), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Niels van Royen
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands (M.A.H.v.L., N.W.v.d.H., G.N.J., H.E., A.N., J.S.L., G.A.d.W., A.C.v.R., R.N., N.v.R.).,Department of Cardiology (T.J.F.t.C., R.N., N.v.R.), Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Nishikawa M, Takeda Y, Isomura N, Tanigawa T, Nanasato M, Tsukahara K, Kimura K, Takayama T, Hirayama A, Kato M, Nishikawa H, Nishimura Y, Isshiki T, Yokoi H. Association between High Platelet Reactivity Following Dual Antiplatelet Therapy and Ischemic Events in Japanese Patients with Coronary Artery Disease Undergoing Stent Implantation. J Atheroscler Thromb 2019; 27:13-24. [PMID: 31092743 PMCID: PMC6976717 DOI: 10.5551/jat.48934] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Although high on-treatment platelet reactivity (HTPR) with dual antiplatelet therapy (DAPT) correlates with long-term adverse outcomes in patients undergoing percutaneous coronary intervention, the correlation in Japanese patients remains unclear. Therefore, we examined the relationship between platelet reactivity during DAPT with aspirin and clopidogrel and 1-year clinical outcomes following successful coronary stent implantation. METHODS A prospective, multicenter registry study (j-CHIPS) was conducted in patients undergoing coronary stenting and receiving aspirin and clopidogrel at 16 hospitals in Japan. A VerifyNow point-of-care assay was used to assess platelet reactivity, and a cutoff value to define HTPR was established. RESULTS Between February 2011 and May 2013, 1047 patients were prospectively enrolled, of which 854 patients with platelet function evaluation at 12-24 h after PCI were included in the final analysis. After 1 year of follow-up, the incidence of the primary endpoint (a composite of all-cause mortality, myocardial infarction, stent thrombosis, and ischemic stroke) was significantly higher in patients with HTPR than in those without (5.9% vs. 1.5%, p=0.008), and HTPR showed a modest ability to discriminate between patients who did and did not experience major adverse cardiac and cerebrovascular events (area under the curve, 0.60; 95% confidence interval, 0.511-0.688, p=0.039). HTPR status did not identify patients at risk for major or minor bleeding events. CONCLUSION HTPR was significantly associated with adverse ischemic outcomes at 1 year after PCI in Japanese patients receiving maintenance DAPT, indicating its potential as a prognostic indicator of clinical outcomes in this high-risk patient population.
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Affiliation(s)
| | | | - Naoei Isomura
- Department of Cardiology, Showa University Northern Yokohama Hospital
| | | | - Mamoru Nanasato
- Cardiovascular Center, Japanese Red Cross Nagoya Daini Hospital
| | | | | | - Tadateru Takayama
- Department of Cardiovascular Medicine, Nihon University Itabashi Hospital
| | - Atsushi Hirayama
- Department of Cardiovascular Medicine, Nihon University Itabashi Hospital
| | | | | | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital
| | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital.,Division of Cardiology, Kokura Memorial Hospital
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Laboratory Monitoring of Antiplatelet Therapy. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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8
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Kwon TJ, Tantry US, Park Y, Choi YM, Ahn JH, Kim KH, Koh JS, Park JR, Hwang SJ, Kwak CH, Hwang JY, Gurbel PA, Smith SC, Jeong YH. Influence of platelet reactivity on BARC classification in East Asian patients undergoing percutaneous coronary intervention. Thromb Haemost 2017; 115:979-92. [DOI: 10.1160/th15-05-0366] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 12/28/2015] [Indexed: 11/05/2022]
Abstract
SummaryAn increasing body of data suggests that East Asian patients have differing risk profiles for both thrombophilia and bleeding compared with Western population. This study was designed to evaluate the relationship of bleeding to platelet function in East Asians undergoing percutaneous coronary intervention (PCI). Patients who had undergone uneventful PCI (n= 301) were prospectively enrolled and bleeding events were evaluated during dual antiplatelet therapy (DAPT) with aspirin and clopidogrel. Platelet function was measured during hospitalisation and at 30-day follow-up by light transmittance aggregometry (LTA) and vasodilator-stimulated phosphoprotein phosphorylation (VASP-P) assay. During 30-day follow-up, 29.2 % of patients (n=88) experienced post-discharge Bleeding Academic Research Consortium (BARC) complications (24.6 % and 7.0 % of BARC type 1 and 2, respectively). Patients presenting with acute myocardial infarction had fewer episodes of type 1 BARC bleeding (odds ratio: 0.41; 95 % confidence interval: 0.22 to 0.76; p= 0.005). The cut-off of low platelet reactivity (LPR) (20 μM ADP-induced platelet aggregation ≤ 46.1 %; platelet reactivity index ≤ 45.1 %) was the independent determinant of type 2 BARC bleeding (odds ratio: 3.55 and 4.44; p= 0.009 and 0.002, respectively). The first 30-day BARC bleeding episodes were associated with an increased rate of subsequent premature DAPT discontinuation during one-year follow-up (4.7 % vs 11.4 %; odds ratio: 2.60; 95 % confidence interval: 1.04 to 6.50; p= 0.035). In conclusion, among East Asians, mild bleeding episodes are common early after PCI and are associated with premature DAPT discontinuation. Type 2 BARC bleeding episodes are associated with LPR cut-offs measured at 30 days post-discharge.
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9
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Saucedo JF, Cardillo TE, Jakubowski JA, Henneges C, Effron MB, Lipkin FR, Walker JR, Duvvuru S, Sundseth SS, Fisher HN, Angiolillo DJ, Diodati JG. Transferring from clopidogrel loading dose to prasugrel loading dose in acute coronary syndrome patients. Thromb Haemost 2017; 112:311-22. [DOI: 10.1160/th13-09-0747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 02/27/2014] [Indexed: 11/05/2022]
Abstract
SummaryHigh on-treatment platelet reactivity (HPR) has been identified as an independent risk factor for ischaemic events. The randomised, doubleblind, TRIPLET trial included a pre-defined comparison of HPR in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) following a placebo/600-mg clopidogrel loading dose (LD) immediately before a subsequent prasugrel 60-mg or 30-mg LD. Platelet reactivity was assessed using the VerifyNow® P2Y12 assay (P2Y12 Reaction Units, PRU) within 24 hours (h) following the placebo/clopidogrel LD (immediately prior to prasugrel LD), and at 2, 6, 24, 72 h following prasugrel LDs. The impact of CYP2C19 predicted metaboliser phenotype (extensive metaboliser [EM] and reduced metabolisers [RM]) on HPR status was also assessed. HPR (PRU ≥240) following the clopidogrel LD (prior to the prasugrel LD) was 58.5% in the combined clopidogrel LD groups. No significant difference was noted when stratified by time between the clopidogrel and prasugrel LDs (≤6 hs vs >6 h). At 6 h following the 2nd loading dose in the combined prasugrel LD groups, HPR was 7.1%, with 0% HPR by 72 h. There was no significant effect of CYP2C19 genotype on pharmacodynamic (PD) response following either prasugrel LD treatments at any time point, regardless of whether it was preceded by a clopidogrel 600-mg LD. In conclusion, in this study, patients with ACS intended for PCI showed a high prevalence of HPR after clopidogrel 600-mg LD regardless of metaboliser status. When prasugrel LD was added, HPR decreased substantially by 6 h, and was not seen by 72 h.
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10
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Jeong YH, Bliden K, Shuldiner A, Tantry U, Gurbel P. Thrombin-induced platelet-fibrin clot strength: Relation to high on-clopidogrel platelet reactivity, genotype, and post-percutaneous coronary intervention outcomes. Thromb Haemost 2017; 111:713-24. [DOI: 10.1160/th13-08-0643] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/03/2013] [Indexed: 01/01/2023]
Abstract
SummaryThe relationship between thrombin-induced platelet-fibrin clot strength (MATHROMBIN), genotype and high on-treatment platelet reactivity (HPR) is unknown. The aim of this study is to assess the influence of MATHROMBIN measured by thrombelastography on HPR and long-term major adverse cardiovascular events (MACE) in percutaneous coronary intervention (PCI)-treated patients during aspirin and clopidogrel therapy. MATHROMBIN, platelet aggregation, genotype, and two-year MACE were assessed in 197 PCI-treated patients. HPR was defined as 5 µM ADP-induced PR46% measured by conventional aggregometry. Both high MATHROMBIN ( 68 mm) and CYP2C19*2 allele carriage were independently associated with ADP-induced platelet aggregation ([uni03B2] coefficient: 8.3% and 12.0%, respectively). The combination of CYP2C19*2 allele carriage and high MATHROMBIN increased the predictive value for the risk of HPR (odds ratio: 13.89; 95% confidence interval: 3.41 to 55.56; p < 0.001). MACE occurred in 25 patients (12.7%). HPR and high MATHROMBIN were both associated with MACE (hazard ratio: 3.09 and 2.24, respectively), and patients with both HPR and high MATHROMBIN showed an increased risk for MACE (adjusted hazard ratio: 5.56; 95% confidence interval: 1.85 to 16.67; p = 0.002). In conclusion, this is the first study to demonstrate that high platelet-fibrin clot strength is an independent determinant of HPR in PCI-treated patients. Combining the measurements of platelet aggregation and platelet-fibrin clot strength may enhance post-PCI risk stratification and deserves further study.
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11
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Larsen SB, Grove EL, Neergaard-Petersen S, Würtz M, Hvas AM, Kristensen SD. Reduced Antiplatelet Effect of Aspirin Does Not Predict Cardiovascular Events in Patients With Stable Coronary Artery Disease. J Am Heart Assoc 2017; 6:JAHA.117.006050. [PMID: 28780510 PMCID: PMC5586446 DOI: 10.1161/jaha.117.006050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Increased platelet aggregation during antiplatelet therapy may predict cardiovascular events in patients with coronary artery disease. The majority of these patients receive aspirin monotherapy. We aimed to investigate whether high platelet‐aggregation levels predict cardiovascular events in stable coronary artery disease patients treated with aspirin. Methods and Results We included 900 stable coronary artery disease patients with either previous myocardial infarction, type 2 diabetes mellitus, or both. All patients received single antithrombotic therapy with 75 mg aspirin daily. Platelet aggregation was evaluated 1 hour after aspirin intake using the VerifyNow Aspirin Assay (Accriva Diagnostics) and Multiplate Analyzer (Roche; agonists: arachidonic acid and collagen). Adherence to aspirin was confirmed by serum thromboxane B2. The primary end point was the composite of nonfatal myocardial infarction, ischemic stroke, and cardiovascular death. At 3‐year follow‐up, 78 primary end points were registered. The primary end point did not occur more frequently in patients with high platelet‐aggregation levels (first versus fourth quartile) assessed by VerifyNow (hazard ratio: 0.5 [95% CI, 0.3–1.1], P=0.08) or Multiplate using arachidonic acid (hazard ratio: 1.0 [95% CI, 0.5–2.1], P=0.92) or collagen (hazard ratio: 1.4 [95% CI, 0.7–2.8], P=0.38). Similar results were found for the composite secondary end point (nonfatal myocardial infarction, ischemic stroke, stent thrombosis, and all‐cause death) and the single end points. Thromboxane B2 levels did not predict any end points. Renal insufficiency was the only clinical risk factor predicting the primary and secondary end points. Conclusions This study is the largest to investigate platelet aggregation in stable coronary artery disease patients receiving aspirin as single antithrombotic therapy. We found that high platelet‐aggregation levels did not predict cardiovascular events.
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Affiliation(s)
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
| | | | - Morten Würtz
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
| | - Steen Dalby Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark .,Faculty of Health, Institute of Clinical Medicine Aarhus University, Aarhus, Denmark
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Choi KN, Jin HY, Shin HC, Park YA, Seo JS, Jang JS, Yang TH, Kim DK, Kim DS. Comparison of the Antiplatelet Effects of Once and Twice Daily Low-Dose Ticagrelor and Clopidogrel After Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:201-206. [PMID: 28554486 DOI: 10.1016/j.amjcard.2017.04.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/29/2023]
Abstract
Although Asian people are believed to be more susceptible to bleeding on currently recommended dose of ticagrelor, there is limited evidence supporting low-dose ticagrelor. We prospectively randomized patients receiving dual antiplatelet therapy with aspirin and clopidogrel into 3 groups; aspirin plus clopidogrel 75 mg versus aspirin plus ticagrelor 90 mg once daily versus aspirin plus ticagrelor 45 mg twice daily. Platelet function assessments were conducted using VerifyNow P2Y12 assay at baseline and 28 days after randomization. No differences in baseline P2Y12 reaction unit (PRU) values were observed among the 3 groups. PRU values at the end of the treatment periods were significantly lower in low-dose ticagrelor (90 mg QD group, 98.6 ± 73.4 and 45 mg BID group, 65.5 ± 58.8) compared with clopidogrel (221.2 ± 50.1, both p <0.001). There was no significant difference in PRU values between 2 groups of low-dose ticagrelor (p = 0.208). The rates of high on-treatment platelet reactivity were significantly lower in low-dose ticagrelor compared with clopidogrel, whereas clopidogrel showed higher rate of optimal on-treatment platelet reactivity than ticagrelor 45 mg BID. However, similar rate of optimal on-treatment platelet reactivity was observed in clopidogrel and ticagrelor 90 mg QD. In conclusion, low-dose ticagrelor treatment, either with 90 mg QD or 45 mg BID, was associated with a more potent antiplatelet effect compared with clopidogrel treatment and once daily dose provided similar antiplatelet effect but favorable effect on optimal platelet inhibition compared with twice daily dose.
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Olędzki S, Kornacewicz-Jach Z, Safranow K, Kiedrowicz R, Gawrońska-Szklarz B, Jastrzębska M, Gorący J. Variability of platelet response to clopidogrel is not related to adverse cardiovascular events in patients with stable coronary artery disease undergoing percutaneous coronary intervention. Eur J Clin Pharmacol 2017; 73:1085-1094. [PMID: 28589365 DOI: 10.1007/s00228-017-2271-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antiplatelet response to clopidogrel and its influence upon the risk of cardiovascular adverse events among patients with stable coronary artery disease undergoing percutaneous coronary intervention (PCI) has not been investigated fully. METHODS Two hundred eleven patients treated with aspirin and clopidogrel were included in the study. Immediately before PCI, residual platelet reactivity testing with impedance aggregometry assay and a single-nucleotide polymorphism genotyping analysis targeting variants of CYP2C19, ABCB1, and PON1 genes was performed. After the index PCI, the patients were screened for cardiovascular events 6 months following bare-metal stent implantation or 12 months following drug-eluting stent implantation. RESULTS High on-treatment platelet reactivity (HTPR) was observed in 19.43% individuals and low-TPR (LTPR) in 26.54%. In multivariate analysis, HTPR was significantly (p < 0.05) associated with a history of diabetes, higher systolic blood pressure, and platelet count comparing to that of other patients. LTPR was significantly associated with no history of hypertension, younger age, lower platelet count, absence of the CYP2C19*2 variant, and lower CRP plasma level. Overall, cardiac adverse events were noted in 14.23% patients. Survival analysis with the Cox proportional hazard model showed no influence of residual platelet reactivity during clopidogrel therapy upon both ischemic and hemorrhagic events. However, significant predictors for composite of major adverse cardiac events and hospitalization for cardiovascular causes were identified (the higher CCS class prior to coronary intervention and the higher creatinine serum concentration). CONCLUSIONS The platelet response to clopidogrel has no impact upon post-procedural adverse events at mid-term follow-up in patients with stable CAD undergoing PCI. This finding suggests that routine platelet reactivity testing is not beneficial in this group of patients.
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Affiliation(s)
- Szymon Olędzki
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland.
| | - Zdzisława Kornacewicz-Jach
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Radosław Kiedrowicz
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Barbara Gawrońska-Szklarz
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Maria Jastrzębska
- Department of Laboratory Diagnostics and Molecular Medicine, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Jarosław Gorący
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
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Bagai A, Peterson ED, McCoy LA, Effron MB, Zettler ME, Stone GW, Henry TD, Cohen DJ, Schulte PJ, Anstrom KJ, Wang TY. Association of measured platelet reactivity with changes in P2Y 12 receptor inhibitor therapy and outcomes after myocardial infarction: Insights into routine clinical practice from the TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome (TRANSLATE-ACS) study. Am Heart J 2017; 187:19-28. [PMID: 28454802 DOI: 10.1016/j.ahj.2017.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 02/07/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Little is known about the use of platelet function testing to guide choice of P2Y12 receptor inhibitor therapy in routine clinical practice. METHODS We studied 671 myocardial infarction (MI) patients treated with percutaneous coronary intervention in the TRANSLATE-ACS Registry who had VerifyNow platelet function testing performed while on clopidogrel treatment during their index hospitalization (April 2010-October 2012). RESULTS High platelet reactivity (>208 platelet reactivity units [PRU]) was present in 261 (38.9%) patients. Clopidogrel was switched in-hospital to prasugrel in 80 (30.7%) patients with high platelet reactivity and 18 (4.4%) patients with therapeutic platelet reactivity (≤208 PRU). Among high platelet reactivity patients, switch to prasugrel was associated with lower major adverse cardiovascular events (death, MI, stroke, or unplanned revascularization) at 1year (10.0% vs 22.7%, P=.02; adjusted odds ratio [OR] 0.39, 95% CI 0.18-0.85, P=.02) and no significant difference in Bleeding Academic Research Consortium type 2 or higher bleeding (23.8% vs 22.1%, P=.77; adjusted OR 0.91, 95% CI 0.48-1.7, P=.77) compared with patients continued on clopidogrel. No significant differences in major adverse cardiovascular event (22.2% vs 12.8%, P=.25; adjusted OR 1.8, 95% CI 0.47-7.3, P=.38) or bleeding (22.2% vs 19.4%, P=.77; adjusted OR 1.3, 95% CI 0.27-6.8, P=.72) were observed among therapeutic platelet reactivity patients between switching and continuation on clopidogrel. CONCLUSIONS Only one-third of percutaneous coronary intervention-treated MI patients with high on-clopidogrel platelet reactivity were switched to a more potent P2Y12 receptor inhibitor. Intensification of antiplatelet therapy was associated with lower risk of ischemic events at 1year among HPR patients.
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Kukula K, Klopotowski M, Kunicki PK, Jamiolkowski J, Debski A, Bekta P, Polanska-Skrzypczyk M, Chmielak Z, Witkowski A. Platelet aggregation and risk of stent thrombosis or bleeding in interventionally treated diabetic patients with acute coronary syndrome. BMC Cardiovasc Disord 2016; 16:252. [PMID: 27931181 PMCID: PMC5146852 DOI: 10.1186/s12872-016-0433-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/03/2016] [Indexed: 12/13/2022] Open
Abstract
Background Platelet aggregation monitoring in diabetic patients treated with coronary interventions (PCI) for an acute coronary syndrome (ACS) is a promising way of optimizing treatment and outcomes in this high risk group. The aim of the study was to verify whether clopidogrel response measured by Multiplate analyzer (ADPtest) in diabetic ACS patients treated with PCI predicts the risk of stent thrombosis or cardiovascular mortality and bleeding. Methods Into this prospective, observational study 206 elective PCI patients were enrolled. Two cutoff points of ADPtest were used in analysis to divide patients into groups. One (345 AU x min) was calculated based on ROC curve analysis; this cutoff provided the best ROC curve fit, although it did not reach statistical significance. The other (468 AU x min) was accepted based on the consensus of the Working Group on On-Treatment Platelet Reactivity. The risk of stent thrombosis and mortality was assessed using Cox regression analysis and Kaplan-Meier curves. Results The risk of stent thrombosis was higher in the group of patients with impaired clopidogrel response for either cutoff value (for >354 AU x min - HR 12.33; 95% CI 2.49–61.1; P = 0.002). Cardiovascular mortality was also higher in the impaired clopidogrel response group (for >354 AU x min - HR 10.58; 95% CI 2.05–54.58; P = 0.005). We did not find a clear relation of increased clopidogrel response to the risk of bleeding. Conclusions The results of this study show that in diabetic ACS patient group treated with PCI an impaired platelet response to clopidogrel measured by the Multiplate analyzer results in increased risk of stent thrombosis and cardiac death.
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Affiliation(s)
- K Kukula
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland.
| | - M Klopotowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - P K Kunicki
- Clinical Pharmacology Unit, Department of Clinical Biochemistry, Institute of Cardiology, Warsaw, Poland
| | - J Jamiolkowski
- Department of Public Health, Medical University of Bialystok, Bialystok, Poland
| | - A Debski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - P Bekta
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - M Polanska-Skrzypczyk
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - Z Chmielak
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
| | - A Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Alpejska 42, 04-628, Warsaw, Poland
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Comparison of short-term clinical outcomes between ticagrelor versus clopidogrel in patients with acute myocardial infarction undergoing successful revascularization; from Korea Acute Myocardial Infarction Registry—National Institute of Health. Int J Cardiol 2016; 215:193-200. [DOI: 10.1016/j.ijcard.2016.04.044] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 04/08/2016] [Accepted: 04/10/2016] [Indexed: 02/06/2023]
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Wang TY, Henry TD, Effron MB, Honeycutt E, Hess CN, Zettler ME, Cohen DJ, Baker BA, Berger PB, Anstrom KJ, Angiolillo DJ, Peterson ED. Cluster-randomized clinical trial examining the impact of platelet function testing on practice: the treatment with adenosine diphosphate receptor inhibitors: longitudinal assessment of treatment patterns and events after acute coronary syndrome prospective open label antiplatelet therapy study. Circ Cardiovasc Interv 2016; 8:e001712. [PMID: 26025216 DOI: 10.1161/circinterventions.114.001712] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Little is known about how clinicians use platelet function testing to guide choice and dosing of adenosine diphosphate receptor inhibitor (ADPri) therapy in routine community practice. METHODS AND RESULTS The Treatment With Adenosine Diphosphate Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome (ACS)-Prospective, Open Label, Antiplatelet Therapy Study (TRANSLATE-POPS) was a cluster-randomized trial in which 100 hospitals were assigned access to no-cost platelet function testing versus usual care for acute myocardial infarction patients treated with percutaneous coronary intervention. In both arms, ADPri treatment decisions were left up to the care team. The primary end point was the frequency of ADPri therapy adjustment before discharge. Secondary end points included 30-day rates of major adverse cardiovascular events and Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-defined bleeding events. Platelet function testing was performed in 66.9% of patients treated in intervention sites versus 1.4% of patients in usual care sites. Intervention arm patients were more likely to have ADPri therapy adjustment than usual care patients (14.8% versus 10.5%, P=0.004; odds ratio 1.68, 95% confidence interval 1.18-2.40); however, there were no significant differences in 30-day major adverse cardiovascular events (4.8% versus 5.4%, P=0.73; odds ratio 0.94, 95% confidence interval 0.66-1.34) or bleeding (4.3% versus 4.2%, P=0.33; odds ratio 0.86, 95% confidence interval 0.55-1.34). One-year outcomes were also not significantly different between groups. An as-treated analysis showed higher incidence of ADPri therapy adjustment among intervention arm patients who received platelet function testing than untested usual care arm (16.4% versus 10.2%, P<0.0001), but no significant differences in major adverse cardiovascular events or bleeding. CONCLUSIONS TRANSLATE-POPS found that when clinicians routinely used platelet function testing, they were more likely to adjust their choice or dosing of ADPri therapy; yet with few changes in therapy overall, significant differences in clinical outcomes were not seen. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503.
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Affiliation(s)
- Tracy Y Wang
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.).
| | - Timothy D Henry
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Mark B Effron
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Emily Honeycutt
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Connie N Hess
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Marjorie E Zettler
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - David J Cohen
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Brian A Baker
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Peter B Berger
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Dominick J Angiolillo
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Department of Medicine, Duke University Medical Center, Durham, NC (T.Y.W., E.H., C.N.H., K.J.A., E.D.P.); Department of Medicine, Cedars-Sinai Heart Institute, Los Angeles, CA (T.D.H.); Lilly USA, LLC, Indianapolis, IN (M.B.E., M.E.Z.); Department of Medicine, Saint Luke's Mid America Heart Institute, Kansas City, MO (D.J.C.); Daiichi Sankyo, Inc, Parsippany, NJ (B.A.B.); Department of Medicine, Geisinger Medical Center, Danville, PA (P.B.B.); and Department of Medicine, University of Florida College of Medicine, Jacksonville, FL (D.J.A.)
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Li Q, Ren X, Yu X, He J, Gao Y, Zhang X, Wu C, Luo Y, Zhang Y, Chen F. The Importance of the Mean Platelet Aggregation Degree in Long-term Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation. Cardiovasc Ther 2016; 34:127-37. [PMID: 26826703 DOI: 10.1111/1755-5922.12177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION The dual antiplatelet therapy (DAPT) and the response of clopidogrel were two pivotal issues in drug-eluting stent (DES) era. AIMS To analyze the combined impacts of DAPT and the response to clopidogrel to evaluate their long-term effect on patients undergoing DES implantation. METHODS Platelet aggregation was serially measured by light transmission aggregometry in all eligible patients during the course of treatment with DAPT, and the mean platelet aggregation degree of each participant was calculated. Based on the duration of DAPT and the mean platelet aggregation degree, all the enrolled patients were then divided into four groups. The primary endpoint was a composite of major adverse cardiovascular events. RESULTS We analyzed 1245 suitable patients in this study. They were divided into four groups: Group A (12-month DAPT & low platelet aggregation degree) with 233 subjects, Group B (12-month DAPT & high platelet aggregation degree) with 260 subjects, Group C (>12-month DAPT & low platelet aggregation degree) with 374 subjects, and Group D (>12-month DAPT & high platelet aggregation degree) with 378 subjects. Group C was associated with a decreased incidence of primary endpoints [HR 0.512, 95%CI (0.27-0.97); P = 0.040]. The Cox proportional hazard model was further analyzed with Groups A and B combined as the reference category [HR for Group C vs. Group A, 0.84, 95%CI (0.33-2.15); P = 0.719; HR for Group C vs. Group B, 0.45, 95%CI (0.21-0.98); P = 0.043]. Their respective multivariate Cox proportional hazard regressions confirmed these trends. CONCLUSIONS The mean platelet aggregation degree is of importance in long-term use of DAPT; extension of DAPT beyond 1 year should be implemented cautiously in patients implanted with DESs.
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Affiliation(s)
- Quan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xuejun Ren
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xianpeng Yu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Jiqiang He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yuechun Gao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Xiaoling Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Changyan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yawei Luo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Yuchen Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
| | - Fang Chen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing, China
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Bonello L, Dignat-George F, Laine M. Personalized Antiplatelet Therapy: The Odyssey Continues. JACC Cardiovasc Interv 2016; 9:105-106. [PMID: 26762919 DOI: 10.1016/j.jcin.2015.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/07/2015] [Indexed: 11/28/2022]
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Ou W, He Y, Li A, Liu B, Jin L. Genotype Frequencies of CYP2C19, P2Y 12 and GPIIIa Polymorphisms in Coronary Heart Disease Patients of Han Ethnicity, and Their Impact on Clopidogrel Responsiveness. Int Heart J 2016; 57:586-92. [DOI: 10.1536/ihj.16-006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Wenchao Ou
- Department of Cardiology, Guang-zhou Institute of Cardiovascular Diseases, The Second Affiliated Hospital of Guangzhou Medical University
| | - Yongcong He
- Department of Cardiology, Guangdong No. 2 Provincial People’s Hospital
| | - Aiqun Li
- Department of Cardiology, Guang-zhou Institute of Cardiovascular Diseases, The Second Affiliated Hospital of Guangzhou Medical University
| | - Benrong Liu
- Department of Cardiology, Guang-zhou Institute of Cardiovascular Diseases, The Second Affiliated Hospital of Guangzhou Medical University
| | - Lijun Jin
- Department of Cardiology, Guang-zhou Institute of Cardiovascular Diseases, The Second Affiliated Hospital of Guangzhou Medical University
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Platelet reactivity following high loading doses of clopidogrel in patients undergoing primary percutaneous coronary angioplasty: A pilot study. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ctrsc.2015.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lee JH, Ahn SG, Park B, Park SW, Kang YS, Lee JW, Youn YJ, Ahn MS, Kim JY, Yoo BS, Lee SH, Yoon J. A pharmacodynamic study of the optimal P2Y12 inhibitor regimen for East Asian patients with acute coronary syndrome. Korean J Intern Med 2015; 30:620-8. [PMID: 26354056 PMCID: PMC4578016 DOI: 10.3904/kjim.2015.30.5.620] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 09/11/2014] [Accepted: 11/03/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND/AIMS Newer P2Y12 inhibitors, such as prasugrel and ticagrelor, have greater antiplatelet efficacy but may increase the risk of bleeding. In this study, we compared the pharmacodynamic efficacy of prasugrel and ticagrelor in East Asian patients with acute coronary syndrome (ACS). METHODS We selected 83 ACS patients undergoing percutaneous coronary intervention who were discharged with 90 mg ticagrelor twice daily (n = 24), 10 mg prasugrel daily (n = 39) or 5 mg prasugrel daily (n = 20). After 2 to 4 weeks, on-treatment platelet reactivity (OPR) was assessed in terms of P2Y12 reaction units (PRUs) using the VerifyNow P2Y12 assay (Accumetrics). We compared East Asian (85 < PRU ≤ 275) and Caucasian (85 < PRU ≤ 208) criteria for assessing the therapeutic window of OPR. RESULTS OPR was lowest in the ticagrelor group, followed by the 10 mg prasugrel and 5 mg prasugrel groups (49.1 ± 29.9 vs. 83.7 ± 57.1 vs. 168.5 ± 60.8, respectively; p < 0.001). The 5 mg prasugrel group had the highest proportion of patients with OPR values within the therapeutic window, followed by the 10 mg prasugrel and ticagrelor groups (90.0% vs. 46.2% vs. 12.5%, respectively; p < 0.001 for East Asian criteria; 60.0% vs. 43.6% vs. 12.5%, respectively; p < 0.001 for Caucasian criteria). CONCLUSIONS Short-term administration of 5 mg prasugrel facilitated maintenance within the therapeutic window of OPR compared with the 10 mg prasugrel and ticagrelor groups. Thus, 5 mg prasugrel daily may be the optimal antiplatelet regimen for stabilized East Asian ACS patients.
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Affiliation(s)
| | - Sung Gyun Ahn
- Correspondence to Sung Gyun Ahn, M.D. Division of Cardiology, Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea Tel: +82-33-741-0917 Fax: +82-33-741-1219 E-mail:
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D'Ascenzo F, Barbero U, Bisi M, Moretti C, Omedè P, Cerrato E, Quadri G, Conrotto F, Zoccai GB, DiNicolantonio JJ, Gasparini M, Bangalore S, Gaita F. The prognostic impact of high on-treatment platelet reactivity with aspirin or ADP receptor antagonists: systematic review and meta-analysis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:610296. [PMID: 25374889 PMCID: PMC4211328 DOI: 10.1155/2014/610296] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 06/26/2014] [Accepted: 06/26/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Negative results of recent randomized clinical trials testing the hypothesis of target therapy for patients with high on-treatment platelet reactivity (HOPR) have questioned its independent impact on clinical outcomes. 26 studies with 28.178 patients were included, with a median age of 66.8 (64-68) and 22.7% (22.4-27.8), of female gender. After a median follow-up of 1 year (0.1-1), cardiac adverse events occurred in 8.3% (3-11; all results are reported as median and interquartile range) of patients. Pooling all studies together, on-treatment platelet reactivity significantly increased the risk of adverse events (OR 1.33 [1.09, 1.64], I(2) = 0%). However, a sensitivity analysis showed that HOPR did not increase the risk of adverse events for patients with ACS, AMI, or stable angina as well as patients resistant to aspirin, ADP antagonists, or both. For all studies, publication bias was formally evident; after adjusting for this, HOPR did not significantly increase adverse cardiac events (OR 1.1 : 0.89-1.22, I(2) 0%). CONCLUSIONS After adjusting for clinical confounders (like risk factors and clinical presentation) and for relevant publication bias, HOPR was not an independent prognostic indicator in unselected patients with both stable and unstable coronary disease for an adverse cardiac event. The clinical importance of HOPR for high-risk populations remains to be assessed.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Umberto Barbero
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Marta Bisi
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Claudio Moretti
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Pierluigi Omedè
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Enrico Cerrato
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Giorgio Quadri
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Federico Conrotto
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | | | | | | | - Fiorenzo Gaita
- Department of Internal Medicine, Division of Cardiology, Città Della Salute e Della Scienza, Turin, Italy
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Paarup Dridi N, Johansson PI, Lønborg JT, Clemmensen P, Radu MD, Qayyum A, Pedersen F, Kollslid R, Helqvist S, Saunamäki K, Kelbæk H, Jørgensen E, Engstrøm T, Holmvang L. Tailored antiplatelet therapy to improve prognosis in patients exhibiting clopidogrel low-response prior to percutaneous coronary intervention for stable angina or non-ST elevation acute coronary syndrome. Platelets 2014; 26:521-9. [PMID: 25166751 DOI: 10.3109/09537104.2014.948837] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM To investigate whether an intensified antiplatelet regimen could improve prognosis in stable or non-ST elevation in acute coronary syndrome (ACS) patients exhibiting high on-treatment platelet reactivity (HTPR) on clopidogrel and treated with percutaneous coronary intervention (PCI). There is a wide variability in the platelet reactivity to clopidogrel and HTPR has been associated with a poor prognosis. METHODS In this observational study, 923 consecutive patients without ST-elevation myocardial infarction (STEMI) and adequately pre-treated with clopidogrel were screened for HTPR with multiple electrode aggregometry after assessment of the coronary anatomy. Patients were grouped based on their response to clopidogrel and the assigned antiplatelet strategy. The primary endpoint was a composite of cardiovascular death, myocardial infarction, stroke, or stent thrombosis. RESULTS HTPR was demonstrated in 237 patients (25.7%). Of these, 114 continued on conventional clopidogrel therapy, while the remaining 123 received intensified antiplatelet therapy with either double-dose clopidogrel (150 mg daily, n = 55) or the newer P2Y12-inhibitors, prasugrel or ticagrelor (n = 68) for at least 30 days after the index procedure. The median follow-up was 571 days (interquartile range, 373-746). Intensifying antiplatelet therapy reduced the rate of the composite endpoint (p < 0.001). After adjustment for potential confounders, HTPR in combination with conventional clopidogrel therapy remained independently associated with an increased risk of cardiovascular events (hazard ratio (HR), 2.92; 95% CI, 1.90-4.48), whereas intensified treatment reduced the risk to a level equivalent to that of patients exhibiting normal platelet reactivity (HR, 1.08; 95% CI, 0.59-1.99). CONCLUSION Tailored antiplatelet therapy significantly reduced the event rate in patients exhibiting HTPR prior to PCI.
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Cano P, Consuegra-Sánchez L, Conesa P, Torres-Moreno D, Jaulent L, Dau D, Picó F, Villegas M. Impacto de CYP2C19*2 en la reactividad plaquetar en pacientes con síndrome coronario agudo tratados con clopidogrel. Med Clin (Barc) 2014; 143:6-12. [DOI: 10.1016/j.medcli.2013.04.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 04/05/2013] [Accepted: 04/11/2013] [Indexed: 11/26/2022]
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Anselmi CV, Briguori C, Roncarati R, Papa L, Visconti G, Focaccio A, De Micco F, Latronico MVG, Pagnotta P, Condorelli G. Reply: Platelet reactivity is preferred over genotyping in monitoring efficacy of antiplatelet therapy. JACC Cardiovasc Interv 2014; 7:448-9. [PMID: 24742945 DOI: 10.1016/j.jcin.2014.01.154] [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] [Received: 01/27/2014] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
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“East Asian Paradox”: Challenge for the Current Antiplatelet Strategy of “One-Guideline-Fits-All Races” in Acute Coronary Syndrome. Curr Cardiol Rep 2014; 16:485. [DOI: 10.1007/s11886-014-0485-4] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Platelet function testing in contemporary clinical and interventional practice. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:300. [PMID: 24652579 DOI: 10.1007/s11936-014-0300-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OPINION STATEMENT Dual antiplatelet therapy with a combination of aspirin and an inhibitor of the ADP P2Y12 receptor is the recommended treatment for patients with acute coronary syndrome or who are undergoing percutaneous coronary intervention (PCI). However, patients may continue to have ischemic recurrences, including stent thrombosis, which have been linked with the well-known variability in individual response to antiplatelet therapy, and clopidogrel in particular. There are currently several assays available to measure platelet reactivity, and platelet function testing has been shown to be a valuable tool to assess the pharmacodynamic efficacy of antiplatelet drugs. Moreover, platelet reactivity has important prognostic implications, as several studies have shown an association with thrombotic and bleeding events in patients with high and low platelet reactivity, respectively. Consequently, over the past years there has been a plethora of studies investigating the optimal range of platelet reactivity associated with the highest protection against ischemic complications and the lowest risk of bleeding. Given the correlation between on-treatment platelet reactivity and outcomes, the use of platelet function testing has also been advocated to create personalized antiplatelet therapy. Several studies have been conducted in this field, but major clinical trials have failed to demonstrate a benefit of such a strategy in improving clinical outcomes. Indeed, inherent limitations of these trials may have contributed to their failure. The present manuscript provides an overview on the role of platelet function testing in contemporary clinical and interventional practice.
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Routine Assessment of On-Clopidogrel Platelet Reactivity and Gene Polymorphisms in Predicting Clinical Outcome Following Drug-Eluting Stent Implantation in Patients With Stable Coronary Artery Disease. JACC Cardiovasc Interv 2013; 6:1166-75. [DOI: 10.1016/j.jcin.2013.06.010] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 06/07/2013] [Accepted: 06/20/2013] [Indexed: 11/23/2022]
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Patel PA, Lane B, Augoustides JGT. Progress in platelet blockers: the target is the P2Y12 receptor. J Cardiothorac Vasc Anesth 2013; 27:620-4. [PMID: 23672863 DOI: 10.1053/j.jvca.2013.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Indexed: 11/11/2022]
Abstract
The considerable progress in P2Y12-platelet blockers has important perioperative implications due to a family of novel agents beyond clopidogrel. Although prasugrel is more potent than clopidogrel due to more efficient hepatic metabolism, it is limited clinically by its irreversibility and bleeding risks. Ticagrelor, as the first approved direct and reversible oral P2Y12 blocker, still is limited clinically by its novel side-effect profile. Intravenous reversible P2Y12 blockade is possible now with both cangrelor and elinogrel, although both agents are still in clinical development. Furthermore, elinogrel offers the possibility of both oral and parenteral P2Y12 blockade with a single agent. Future trials likely will continue to evaluate and compare the safety and efficacy of these agents in multiple clinical settings, including the perioperative period.
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Affiliation(s)
- Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Tantry US, Bonello L, Aradi D, Price MJ, Jeong YH, Angiolillo DJ, Stone GW, Curzen N, Geisler T, Ten Berg J, Kirtane A, Siller-Matula J, Mahla E, Becker RC, Bhatt DL, Waksman R, Rao SV, Alexopoulos D, Marcucci R, Reny JL, Trenk D, Sibbing D, Gurbel PA. Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol 2013; 62:2261-73. [PMID: 24076493 DOI: 10.1016/j.jacc.2013.07.101] [Citation(s) in RCA: 715] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/29/2013] [Accepted: 07/31/2013] [Indexed: 12/28/2022]
Abstract
Dual antiplatelet therapy with aspirin and a P2Y12 receptor blocker is a key strategy to reduce platelet reactivity and to prevent thrombotic events in patients treated with percutaneous coronary intervention. In an earlier consensus document, we proposed cutoff values for high on-treatment platelet reactivity to adenosine diphosphate (ADP) associated with post-percutaneous coronary intervention ischemic events for various platelet function tests (PFTs). Updated American and European practice guidelines have issued a Class IIb recommendation for PFT to facilitate the choice of P2Y12 receptor inhibitor in selected high-risk patients treated with percutaneous coronary intervention, although routine testing is not recommended (Class III). Accumulated data from large studies underscore the importance of high on-treatment platelet reactivity to ADP as a prognostic risk factor. Recent prospective randomized trials of PFT did not demonstrate clinical benefit, thus questioning whether treatment modification based on the results of current PFT platforms can actually influence outcomes. However, there are major limitations associated with these randomized trials. In addition, recent data suggest that low on-treatment platelet reactivity to ADP is associated with a higher risk of bleeding. Therefore, a therapeutic window concept has been proposed for P2Y12 inhibitor therapy. In this updated consensus document, we review the available evidence addressing the relation of platelet reactivity to thrombotic and bleeding events. In addition, we propose cutoff values for high and low on-treatment platelet reactivity to ADP that might be used in future investigations of personalized antiplatelet therapy.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Laurent Bonello
- Département de Cardiologie, Hôpital Universitaire Nord, Aix-Marseille University, Marseille, France
| | - Daniel Aradi
- Department of Cardiology, Heart Center Balatonfüred, Balatonfüred, Hungary
| | - Matthew J Price
- Scripps Clinic and Scripps Translational Science Institute, La Jolla, California
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University, Jinju, South Korea
| | - Dominick J Angiolillo
- Cardiovascular Research Center, University of Florida College of Medicine, Jacksonville, Florida
| | - Gregg W Stone
- Cardiovascular Research and Education, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Nick Curzen
- Wessex Cardiothoracic Unit, University Hospital, Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Tobias Geisler
- Medizinische Klinik III, Kardiologie und Kreislauferkrankungen, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jurrien Ten Berg
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, the Netherlands
| | - Ajay Kirtane
- Cardiovascular Research and Education, Columbia University Medical Center/New York-Presbyterian Hospital, New York, New York
| | | | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Richard C Becker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Deepak L Bhatt
- Veterans Affairs Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ron Waksman
- Interventional Cardiology, Medstar Washington Hospital Center, Washington, DC
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, North Carolina
| | | | - Rossella Marcucci
- Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy
| | - Jean-Luc Reny
- Department of Internal Medicine, Rehabilitation, and Geriatrics, Geneva Platelet Group, Geneva University Hospitals and School of Medicine, Geneva, Switzerland
| | - Dietmar Trenk
- Universitaets-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians Universität München, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland.
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Steiner S, Moertl D. Platelet reactivity tests for assessing antiplatelet drug response: what the clinician needs to know. Expert Rev Cardiovasc Ther 2013; 11:975-84. [PMID: 23984925 DOI: 10.1586/14779072.2013.816120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Antiplatelet therapy is a cornerstone in the treatment of cardiovascular disease to prevent ischemic events. Various tests have become clinically available to measure platelet function after antiplatelet treatment. A wide interpatient variability in the magnitude of platelet inhibition has been demonstrated in numerous studies, especially in response to clopidogrel. Several reasons including clinical, pharmacological and genetic factors have been identified. High on-clopidogrel platelet reactivity has been linked to adverse clinical outcome, in particular to stent thrombosis after percutaneous coronary interventions. New antiplatelet drugs including prasugrel and ticagrelor have been advocated to overcome the limitations of clopidogrel. Several studies addressed the concept of tailored antiplatelet treatment according to the results of platelet function testing. Within this review, we summarize the current status of personalized antiplatelet therapy for cardiovascular disease.
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Affiliation(s)
- Sabine Steiner
- Department of Internal Medicine II, Division of Angiology, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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