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Dehghani P, Cantor WJ, Wang J, Wood DA, Storey RF, Mehran R, Bainey KR, Welsh RC, Rodés-Cabau J, Rao S, Lavi S, Velianou JL, Natarajan MK, Ziakas A, Guiducci V, Fernández-Avilés F, Cairns JA, Mehta SR. Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment-Elevation Myocardial Infarction: Insights From the COMPLETE Trial. Circ Cardiovasc Interv 2021; 14:e010458. [PMID: 34320839 DOI: 10.1161/circinterventions.120.010458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Canada (P.D.)
| | - Warren J Cantor
- Toronto Southlake Regional Health Centre, University of Toronto, Ontario, Canada (W.J.C.)
| | - Jia Wang
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - David A Wood
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Canada (J.R.-C.)
| | - Sunil Rao
- Duke University Medical Center, Durham, NC (S.R.)
| | - Shahar Lavi
- London Health Sciences Centre, University of Western Ontario, Canada (S.L.)
| | - James L Velianou
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
| | - Madhu K Natarajan
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - Antonios Ziakas
- AHEPA University Hospital, Aristotle University of Thessaloniki, Greece (A.Z.)
| | | | | | - John A Cairns
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
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The effects of interventional mitral valve repair using the MitraClip System on the results of pulmonary function testing, pulmonary pressure and diffusing capacity of the lung. BMC Cardiovasc Disord 2021; 21:235. [PMID: 33975538 PMCID: PMC8112049 DOI: 10.1186/s12872-021-02042-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The study analyzes changes in lung function, pulmonary pressure and diffusing capacity of the lung in patients with mitral valve regurgitation (MR) treated by MitraClip implantation. METHODS A total of 43 patients (19 women and 24 men with an average age of 78.0 ± 6.6 years) who were able to perform pulmonary function testing including diffusing capacity of the lung for carbon monoxide (DLCO), vital capacity (VC), total lung capacity (TLC), residual volume (RV) and forced expiratory volume in 1 s (FEV1) before and 6 weeks after MitraClip implantation participated in this study. Furthermore, clinical and echocardiographic parameters including systolic pulmonary artery pressure (sPAP), left ventricular ejection fraction (LVEF) and left atrial diameter (LAD) measurements were recorded in all patients. RESULTS The procedure was performed successfully in all 43 patients leading to a reduction of MR in 97.7% of cases. One patient died on day 4 after the intervention most likely due to pulmonary artery embolism. Six weeks after the implantation 79.1% of patients showed a MR of at most mild to moderate. Furthermore, we could demonstrate a significant reduction of systolic pulmonary artery pressure during follow-up (from 48.8 ± 11.4 mmHg to 42.9 ± 9.0 mmHg (t(41) = - 2.6, p = 0.01). However, no changes in LVEF were detected. Comparing pre and post implant lung function tests, no significant alterations were seen for VC, TLC, DLCO and FEV1. Though, in a subgroup of patients with moderate to severe preexisting deterioration of DLCO at the baseline (max. 50%) the MitraClip procedure resulted in a significant improvement in DLCO (37.8% ± 9.0 to 41.6% ± 10.0, p < 0.001). CONCLUSIONS Treatment of MR with the MitraClip system successfully reduces MR severity in the vast majority of patients. Consecutively, a reduction in pulmonary pressure could be observed, however no changes in LVEF were obvious. Lung function tests remained unaltered during follow-up. However, in a subgroup of patients with severe preexisting deterioration of DLCO the MitraClip procedure resulted in a significant improvement in DLCO. TRIAL REGISTRATION Name of the registry: Die Auswirkung der interventionellen Mitralklappenreparatur mit MitraClip-System auf die Ergebnisse der Lungenfunktionsmessung. TRIAL REGISTRATION NUMBER DRKS00022435; Date of registration: 09/07/2020 'Retrospectively registered'; URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022435 .
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Gupta S, Belley-Cote EP, Eqbal A, McEwen C, Basha A, Wu N, Cerasuolo JO, Mehta S, Schwalm JD, Whitlock RP. Impact of provincial and national implementation strategies on P2Y12 inhibitor utilization for acute coronary syndrome in the elderly: an interrupted time series analysis from 2008 to 2018. Implement Sci 2021; 16:42. [PMID: 33882984 PMCID: PMC8059026 DOI: 10.1186/s13012-021-01117-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Background Guidelines recommend both acetylsalicylic acid and ticagrelor following acute coronary syndrome (ACS), but appropriate prescription practices lag. We analyzed the impact of government medication approval, national guideline updates, and publicly funded drug coverage plans on P2Y12 inhibitor utilization. Methods Accessing provincial databases, we obtained data for elderly ACS patients in Ontario, Canada, between 2008 and 2018. Using interrupted-time series with descriptive statistics and segmented regression analysis, we evaluated types of P2Y12 inhibitors prescribed at discharge and changes to their utilization in patients managed with percutaneous intervention (PCI), coronary artery bypass grafting (CABG) or medically, following national antiplatelet therapy guidelines (by the Canadian Cardiovascular Society), ticagrelor’s national approval by Health Canada, and ticagrelor’s coverage by a publicly funded medication plan. Results We included 114,142 patients (49.4%-PCI; mean age 75.71±6.94 and 62.3% male and 7.7%-CABG; mean age 74.11±5.63 and 73.5% male). Among PCI patients, clopidogrel utilization declined monthly after 2010 national guidelines were published (p<0.0001) and within the first month after ticagrelor’s national approval by Health Canada (p=0.03). Among PCI patients, ticagrelor utilization increased within the first month (p<0.0001) and continued increasing monthly (p<0.0001) after its coverage by a publicly funded medication plan. Among PCI patients, clopidogrel utilization declined within the first month (p=0.003) and ticagrelor utilization increased monthly (p=0.05) after 2012 CCS guidelines. Among CABG patients, ticagrelor’s coverage was associated with a monthly increase in its utilization (p<0.0001). Conclusion National guideline updates and drug coverage by a publicly funded medication plan significantly improved P2Y12 inhibitor utilization. Barriers to appropriate antiplatelet therapy in the surgical population must be explored.
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Affiliation(s)
- Saurabh Gupta
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Adam Eqbal
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Charlotte McEwen
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ameen Basha
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Wu
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Joshua O Cerasuolo
- ICES McMaster, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Shamir Mehta
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jon-David Schwalm
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Population Health Research Institute, Hamilton, Ontario, Canada
| | - Richard P Whitlock
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada. .,Population Health Research Institute, Hamilton, Ontario, Canada. .,David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E, Hamilton, Ontario, L8L 2X2, Canada.
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Lordkipanidzé M, Marquis-Gravel G, Tanguay JF, Mehta SR, So DY. Implications of the Antiplatelet Therapy Gap Left With Discontinuation of Prasugrel in Canada. CJC Open 2020; 3:814-821. [PMID: 34169260 PMCID: PMC8209390 DOI: 10.1016/j.cjco.2020.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Background The current Canadian Cardiovascular Society antiplatelet therapy guidelines recommend the use of ticagrelor or prasugrel over clopidogrel as first-line platelet P2Y12 receptor antagonists for treatment of moderate- to high-risk acute coronary syndromes. Recently, Effient (prasugrel [Eli Lilly Canada Inc, Toronto, Canada]) was discontinued by its distributor in Canada. Methods Five members of the Canadian Cardiovascular Society antiplatelet therapy 2018 guidelines committee undertook an independent, evidence-based review to outline patients for whom prasugrel should be the optimal P2Y12 agent and discuss alternative strategies to consider without prasugrel. Results Several clinical scenarios where prasugrel should be indicated are identified and discussed. Considerations to be undertaken for alternative therapies are summarized, including a review of national and international guidelines for de-escalation of P2Y12 receptor antagonists. Conclusions The discontinuation of prasugrel poses a challenge for clinicians. Clinicians must consider key factors in determining the best alternate therapy.
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Affiliation(s)
- Marie Lordkipanidzé
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Guillaume Marquis-Gravel
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-François Tanguay
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Shamir R. Mehta
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y.F. So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Corresponding author: Dr Derek Y.F. So, University of Ottawa Heart Institute, 40 Ruskin St, Room H3408, Ottawa, Ontario K1Y 4W7, Canada. Tel: +1-613-761-5387.
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Montenegro Sá F, Carvalho R, Santos L, Ruivo C, Antunes A, Belo A, Soares F, Morais J. Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease – insights from a nationwide registry. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Montenegro Sá F, Carvalho R, Santos L, Ruivo C, Antunes A, Belo A, Soares F, Morais J. Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease - insights from a nationwide registry. Rev Port Cardiol 2020; 39:679-684. [PMID: 33234352 DOI: 10.1016/j.repc.2020.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 04/21/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA. METHODS The authors analyzed a cohort of patients from a multicenter national registry enrolling patients who suffered their first MI between 2010 and 2017, and underwent coronary angiography revealing absence of stenosis ≥50%. Individual antithrombotic therapy was identified. A logistic regression analysis was applied to search for predictors of DAPT. RESULTS From a total of 16 237 patients analyzed, 709 (4.4%) were categorized as MINOCA. Mean age was 64±13 years, 46.3% (n=409) were females. 390 (55.0%) of MINOCA patients were discharged on DAPT. Males (OR 1.67, CI 95 [1.05-2.38], p=0.027), active smokers (OR=1.82, CI 95 [1.05-3.16], p=0.033), previous percutaneous intervention (OR 3.18, CI 95 [1.48-6.81], p=0.003), ST elevation MI (OR 2.70, CI 95 [1.59-4.76], p<0.001) and sinus rhythm at admission (OR=3.94, CI 95 [2.07-7.48], p<0.001) were independent predictors of DAPT use. CONCLUSION In this nationwide registry, DAPT was prescribed at discharge in 55% of MINOCA patients. Beyond sinus rhythm, the variables presented as independent predictors for DAPT use identify subgroups of patients who are classified as more prone to thrombotic events. The issue of how to handle antithrombotic agents in MINOCA patients is a topic open for discussion.
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Affiliation(s)
| | - Rita Carvalho
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Luís Santos
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Catarina Ruivo
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Alexandre Antunes
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Adriana Belo
- Portuguese Society of Cardiology, Lisboa, Portugal
| | - Francisco Soares
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
| | - João Morais
- Cardiology Department, Centro Hospitalar de Leiria, Leiria, Portugal
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Orban M, Trenk D, Geisler T, Rieber J, Hadamitzky M, Gross L, Orban M, Kupka D, Baylacher M, Müller S, Huber K, Koltowski L, Huczek Z, Heyn J, Jacobshagen C, Aradi D, Massberg S, Sibbing D, Hein R. Smoking and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients: a substudy from the randomized TROPICAL-ACS trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:372-381. [DOI: 10.1093/ehjcvp/pvz084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/24/2019] [Accepted: 12/13/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Prior analyses disclosed variations in antiplatelet drug response and clinical outcomes between smokers and non-smokers, thus the safety and efficacy of any dual antiplatelet therapy (DAPT) de-escalation strategy may differ in relation to smoking status. Hence, we assessed the impact of smoking on clinical outcomes and adenosine diphosphate-induced platelet aggregation following guided de-escalation of DAPT in invasively managed acute coronary syndrome (ACS) patients.
Methods and results
The multicentre TROPICAL-ACS trial randomized 2610 biomarker-positive ACS patients 1:1 to standard treatment with prasugrel for 12 months (control group) or a platelet function testing guided de-escalation of DAPT. Current smokers (n = 1182) showed comparable event rates between study groups [6.6% vs. 6.6%; hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.64–1.56, P > 0.99]. In non-smokers (n = 1428), a guided DAPT de-escalation was associated with a lower 1-year incidence of the primary endpoint [cardiovascular death, myocardial infarction, stroke, or bleeding ≥ Grade 2 according to Bleeding Academic Research Consortium (BARC) criteria] compared with control group patients (7.9% vs. 11.0%; HR 0.71, 95% CI 0.50–0.99, P = 0.048). This reduction was mainly driven by a lower rate of BARC ≥ Grade 2 bleedings (5.2% vs. 7.7%; HR 0.68, 95% CI 0.45–1.03, P = 0.066). There was no significant interaction of smoking status with treatment effects of guided DAPT de-escalation (Pint = 0.23). Adenosine diphosphate-induced platelet aggregation values were higher in current smokers [median 28 U, interquartile range (IQR: 20–40)] vs. non-smoker [median 24 U (16–25), P < 0.0001] in the control group and in current smokers [median 42 U, IQR (27–68)] vs. non-smoker [median 37 U, IQR (25–55), P < 0.001] in the monitoring group.
Conclusion
Guided DAPT de-escalation appears to be equally safe and effective in smokers and non-smokers. Regardless of smoking status and especially for those patients deemed unsuitable for 1 year of potent platelet inhibition this DAPT strategy might be used as an alternative antiplatelet treatment regimen.
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Affiliation(s)
- Martin Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Johannes Rieber
- Department of Cardiology and Intensive Care Medicine, Heart Centre Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany
| | - Martin Hadamitzky
- Department of Radiology, German Heart Center of Munich, Lazarettstraße 36, 80636 München, Germany
| | - Lisa Gross
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Mathias Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Danny Kupka
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Monika Baylacher
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Susan Müller
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Kurt Huber
- 3 Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Montleartstrasse 35-37, 1160 Vienna, Austria
| | - Lukasz Koltowski
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Zenon Huczek
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Jens Heyn
- Department of Anesthesiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, Heart Centre/Georg-August-University Göttingen, 37073 Göttingen, Germany
| | - Dániel Aradi
- Department of Cardiology, Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Gyógy tér 2 8230 Balatonfüred, Budapest, Hungary
| | - Steffen Massberg
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Ralph Hein
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
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Prasugrel vs. Ticagrelor for Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis. Am J Cardiovasc Drugs 2019; 19:465-476. [PMID: 30828769 DOI: 10.1007/s40256-019-00337-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The newer P2Y12 inhibitors have better efficacy than clopidogrel. However, whether ticagrelor or prasugrel have a better comparative safety and efficacy profile, especially in the long-term, remains inconclusive. OBJECTIVE We compared prasugrel and ticagrelor in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). METHODS MEDLINE and the Cochrane library were queried for randomized controlled trials (RCTs) or observational studies comparing prasugrel with ticagrelor in patients with ACS undergoing PCI. Random-effects pooling was used to calculate odds ratios (ORs) with 95% confidence intervals (CI). Analyses were stratified by duration of follow-up (short term [≤ 3 months] and long term [≥ 1 year]) and study design. RESULTS In total, 14 studies (six RCTs, eight observational studies), including 40,188 patients, met eligibility criteria. Pooled analysis did not indicate that prasugrel significantly decreased all-cause mortality compared with ticagrelor in the short term (OR 0.49; 95% CI 0.20-1.20; p = 0.11) or long term (OR 0.74; 95% CI 0.48-1.15; p = 0.38). Pooled observational studies showed significantly lower long-term all-cause mortality (OR 0.63; 95% CI 0.43-0.92; p = 0.02) and short-term stent thrombosis (OR 0.46; 95% CI 0.28-0.75; p = 0.002) with prasugrel. No significant difference was observed in the risk of nonfatal myocardial infarction, ischemic stroke, bleeding, or repeat revascularization between the two groups. Results remained similar after stratification according to follow-up and study design. CONCLUSIONS The present analysis suggests that prasugrel might have a better efficacy profile than ticagrelor in patients with ACS undergoing PCI. However, this advantage was only seen in pooled observational studies and is likely to be affected by selection bias.
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Angiolillo DJ, Patti G, Chan KT, Han Y, Huang WC, Yakovlev A, Paek D, Del Aguila M, Girotra S, Sibbing D. De-escalation from ticagrelor to clopidogrel in acute coronary syndrome patients: a systematic review and meta-analysis. J Thromb Thrombolysis 2019; 48:1-10. [PMID: 31004312 PMCID: PMC6556170 DOI: 10.1007/s11239-019-01860-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
De-escalation from ticagrelor to clopidogrel in acute coronary syndrome (ACS) may occur for a variety of reasons, including side effects (bleeding and non-bleeding) and costs. This study sought to assess the prevalence of de-escalation from ticagrelor to clopidogrel and the occurrence of adverse clinical outcomes following de-escalation. We conducted a systematic review of clinical trials and real-world studies in ACS patients treated with ticagrelor. Real-world data on the prevalence of de-escalation during hospitalization or at discharge, after hospital discharge, and during the whole study period were included for meta-analysis. Major adverse cardiovascular events (MACE) and bleeding events occurring after de-escalation were also assessed. A total of 12 studies were eligible for meta-analysis of the prevalence of de-escalation. De-escalation from ticagrelor to clopidogrel therapy occurred with a mean prevalence of 19.8% [95% confidence interval (CI) 11.2-28.4%]. De-escalation occurred more frequently in-hospital or at discharge than after hospital discharge (23.7% vs. 15.8%). For assessment of clinical outcomes, a total of six studies were eligible for meta-analysis. Mean rate of MACE for patients with de-escalation was 2.1% (95% CI 1.1-4.1%) and the rate of major bleeding events was 1.3% (95% CI 0.4-4.5%). In conclusion, de-escalation commonly occurs in real-world practice. Although rates of major cardiovascular and bleeding events in this analysis were generally low, the profile of patients suitable for de-escalation, the impact of de-escalation on adverse clinical outcomes and how this is affected by the timing after index ACS warrants further large-scale investigation.
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Affiliation(s)
- Dominick J Angiolillo
- Department of Medicine, Division of Cardiology, University of Florida, ACC Building 5th floor, 655 West 8th Street, Jacksonville, FL, 32209, USA.
| | - Giuseppe Patti
- Chair of Cardiology, University of L'Aquila, Via Camponeschi, 19, L'Aquila, Italy
| | - Kam Tim Chan
- Director of Cardiac Catheterization and Interventional Laboratory, Consultant Cardiologist, Queen Elizabeth Hospital, 30 Gascoigne Rd, King's Park, Hong Kong, Hong Kong
| | - Yaling Han
- Department of Cardiology, The General Hospital of Shenyang Military Region, 83 Wenhua Rd, Shenhe District, Shenyang City, Liaoning, China
| | - Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, No. 386 Dazhong 1st Road, Zuoying District, Kaohsiung City, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Alexey Yakovlev
- Almazov National Medical Research Centre, 12 Mayakovsky St, Saint Petersburg, Russia
| | - Dara Paek
- Doctor Evidence, 301 Arizona Ave #301, Santa Monica, CA, USA
| | | | - Shalini Girotra
- Sanofi, General Medicine and Emerging Markets, 38 Beach Road, Singapore, Singapore
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Marchioninistraße 15, 81377, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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10
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Valle JA, Josey K, Prouse AF, Zimmet J, Waldo SW. Dual antiplatelet therapy in non-ST elevation acute coronary syndromes at Veterans Affairs Hospitals. Heart 2019; 105:1575-1582. [PMID: 31092547 DOI: 10.1136/heartjnl-2018-314553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/10/2019] [Accepted: 04/19/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Current guidelines recommend that patients with non-ST elevation acute coronary syndromes (NSTEACS) receive dual antiplatelet therapy (DAPT) early in hospitalisations. However, observational studies suggest that this rarely occurs. We evaluated site-specific variation and clinical outcomes associated with early DAPT among patients undergoing angiography for NSTEACS. METHODS In this observational analysis, we identified patients undergoing angiography for NSTEACS in Veterans Affairs hospitals from 2008 to 2016 and assessed characteristics and site variation associated with early DAPT (administration <24 hours of admission). Using propensity matching, we compared time to revascularisation, recurrent myocardial infarction (MI) and mortality between those receiving early DAPT and those not receiving early DAPT (administration ≥24 hours). RESULTS Of 45 569 patients undergoing angiography for NSTEACS, 15 084 (33%) received early DAPT. Early DAPT was more frequent in patients with non-ST elevation MI, prior surgical revascularisation and among patients undergoing revascularisation. There was a greater than twofold difference in early DAPT across sites, independent of patient characteristics (median OR 2.43, 95% CI 2.28 to 2.55). There was no difference in time topercutaneous coronary intervention (PCI) between groups, but a significant delay to surgical revascularisation with early DAPT (median 4 vs 3 days, p<0.001) without reduction in hazard of death or MI (HR 1.08, 95% CI 1.00 to 1.16) and similar results demonstrated in the subgroup of patients undergoing revascularisation (HR 1.02, 95% CI 0.91 to 1.13). CONCLUSION Among NSTEACS patients undergoing coronary angiography, early DAPT was not associated with improvement of outcomes but was associated with delays in surgical revascularisation.
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Affiliation(s)
- Javier Alfonso Valle
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA.,Department of Medicine, Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Kevin Josey
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
| | - Andrew F Prouse
- Department of Medicine, Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, Colorado, USA.,Department of Medicine, Division of Cardiology, Denver Health Medical Center, Denver, Colorado, USA
| | - Jeffrey Zimmet
- Department of Medicine Division of Cardiology, San Francisco VA Medical Center, San Francisco, California, USA
| | - Stephen W Waldo
- Department of Medicine, Division of Cardiology, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, USA
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11
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Ghosh‐Swaby OR, Tan M, Bagai A, Yan AT, Goodman SG, Mehta SR, Fisher HN, Cohen EA, Huynh T, Cantor WJ, Le May MR, Déry J, Welsh RC, Udell JA. Marital status and outcomes after myocardial infarction: Observations from the Canadian Observational Antiplatelet Study (COAPT). Clin Cardiol 2018; 41:285-292. [PMID: 29574993 PMCID: PMC6490065 DOI: 10.1002/clc.22901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 11/10/2022] Open
Abstract
While divorced or living alone, patients with stable cardiovascular disease are at increased risk for adverse cardiovascular events. The importance of marital status following a myocardial infarction (MI) is less clear. We hypothesized that marital status may affect cardiovascular outcomes following MI. We analyzed outcomes among patients with MI who underwent percutaneous coronary intervention from the Canadian Observational Antiplatelet Study (COAPT). Marital status was categorized into 3 groups: married/common-law patients living together; never married; and divorced, separated, or widowed patients. Patients were followed for 15 months and our primary outcome was the occurrence of a major adverse cardiovascular event (MACE), defined as a composite of mortality, repeat acute MI, stroke, or urgent coronary revascularization. Multivariable logistic regression models were performed, with married/common-law patients living together considered the reference group. Among 2100 patients included in analyses, 1519 (72.3%) were married/common-law patients living together, 358 (17.1%) were separated/divorced/widowed, and 223 (10.6%) patients were never married. Dual antiplatelet therapy use after 15 months was similar across groups (75.4%, 77.8%, and 73.6%, respectively). The risk of MACE after 15 months was similar among married patients living together (12.7%; referent) compared with patients who were never married (13.9%; adjusted odds ratio: 1.09, 95% confidence interval: 0.58-2.07, P = 0.79) and patients separated/divorced/widowed (14.3%; adjusted odds ratio: 0.71, 95% confidence interval: 0.40-1.25, P = 0.23). Similarly, the risk of individual endpoints, including mortality, was similar across the 3 groups. Among patients stabilized following an MI, we found no association between marital status and 15-month outcomes.
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Affiliation(s)
- Olivia R. Ghosh‐Swaby
- Cardiovascular Division, Department of Medicine and Women's College Research InstituteWomen's College HospitalTorontoOntario
- Faculty of Medical Science, Schulich School of Medicine and DentistryWestern UniversityLondonOntario
| | - Mary Tan
- Canadian Heart Research CentreTorontoOntario
| | - Akshay Bagai
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Andrew T. Yan
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Shaun G. Goodman
- Canadian Heart Research CentreTorontoOntario
- Terrence Donnelly Heart CenterSt. Michael's Hospital, University of TorontoTorontoOntario
| | - Shamir R. Mehta
- Population Health Research Institute, Hamilton General HospitalMcMaster UniversityHamiltonOntario
| | - Harold N. Fisher
- Department of Clinical Research, Eli Lilly Canada Inc.TorontoOntario
| | - Eric A. Cohen
- Schulich Heart Program, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntario
| | - Thao Huynh
- Department of Medicine, McGill University Health CentreMcGill UniversityMontréalQuébec
| | - Warren J. Cantor
- Division of Cardiology, Department of MedicineSouthlake Regional Health Centre and University of TorontoTorontoOntario
| | - Michel R. Le May
- Division of Cardiology, Department of MedicineUniversity of Ottawa Heart InstituteOttawaOntario
| | - Jean‐Pierre Déry
- Division of Cardiology, Québec Heart and Lung InstituteLaval HospitalQuébec CityQuébec
| | - Robert C. Welsh
- Department of Medicine, Mazankowski Alberta Heart InstituteUniversity of Alberta Hospital, Canadian VIGOUR CentreEdmontonAlberta
| | - Jacob A. Udell
- Cardiovascular Division, Department of Medicine and Women's College Research InstituteWomen's College HospitalTorontoOntario
- Peter Munk Cardiac CentreUniversity Health NetworkTorontoOntario
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12
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Watti H, Dahal K, Zabher HG, Katikaneni P, Modi K, Abdulbaki A. Comparison of prasugrel and ticagrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A meta-analysis of randomized and non-randomized studies. Int J Cardiol 2017; 249:66-72. [DOI: 10.1016/j.ijcard.2017.07.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/19/2023]
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13
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Sibbing D, Aradi D, Jacobshagen C, Gross L, Trenk D, Geisler T, Orban M, Hadamitzky M, Merkely B, Kiss RG, Komócsi A, Dézsi CA, Holdt L, Felix SB, Parma R, Klopotowski M, Schwinger RHG, Rieber J, Huber K, Neumann FJ, Koltowski L, Mehilli J, Huczek Z, Massberg S. Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet 2017; 390:1747-1757. [PMID: 28855078 DOI: 10.1016/s0140-6736(17)32155-4] [Citation(s) in RCA: 380] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 07/23/2017] [Accepted: 07/25/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current guidelines recommend potent platelet inhibition with prasugrel or ticagrelor for 12 months after an acute coronary syndrome managed with percutaneous coronary intervention (PCI). However, the greatest anti-ischaemic benefit of potent antiplatelet drugs over the less potent clopidogrel occurs early, while most excess bleeding events arise during chronic treatment. Hence, a stage-adapted treatment with potent platelet inhibition in the acute phase and de-escalation to clopidogrel in the maintenance phase could be an alternative approach. We aimed to investigate the safety and efficacy of early de-escalation of antiplatelet treatment from prasugrel to clopidogrel guided by platelet function testing (PFT). METHODS In this investigator-initiated, randomised, open-label, assessor-blinded, multicentre trial (TROPICAL-ACS) done at 33 sites in Europe, patients were enrolled if they had biomarker-positive acute coronary syndrome with successful PCI and a planned duration of dual antiplatelet treatment of 12 months. Enrolled patients were randomly assigned (1:1) using an internet-based randomisation procedure with a computer-generated block randomisation with stratification across study sites to either standard treatment with prasugrel for 12 months (control group) or a step-down regimen (1 week prasugrel followed by 1 week clopidogrel and PFT-guided maintenance therapy with clopidogrel or prasugrel from day 14 after hospital discharge; guided de-escalation group). The assessors were masked to the treatment allocation. The primary endpoint was net clinical benefit (cardiovascular death, myocardial infarction, stroke or bleeding grade 2 or higher according to Bleeding Academic Research Consortium [BARC]) criteria) 1 year after randomisation (non-inferiority hypothesis; margin of 30%). Analysis was intention to treat. This study is registered with ClinicalTrials.gov, number NCT01959451, and EudraCT, 2013-001636-22. FINDINGS Between Dec 2, 2013, and May 20, 2016, 2610 patients were assigned to study groups; 1304 to the guided de-escalation group and 1306 to the control group. The primary endpoint occurred in 95 patients (7%) in the guided de-escalation group and in 118 patients (9%) in the control group (pnon-inferiority=0·0004; hazard ratio [HR] 0·81 [95% CI 0·62-1·06], psuperiority=0·12). Despite early de-escalation, there was no increase in the combined risk of cardiovascular death, myocardial infarction, or stroke in the de-escalation group (32 patients [3%]) versus in the control group (42 patients [3%]; pnon-inferiority=0·0115). There were 64 BARC 2 or higher bleeding events (5%) in the de-escalation group versus 79 events (6%) in the control group (HR 0·82 [95% CI 0·59-1·13]; p=0·23). INTERPRETATION Guided de-escalation of antiplatelet treatment was non-inferior to standard treatment with prasugrel at 1 year after PCI in terms of net clinical benefit. Our trial shows that early de-escalation of antiplatelet treatment can be considered as an alternative approach in patients with acute coronary syndrome managed with PCI. FUNDING Klinikum der Universität München, Roche Diagnostics, Eli Lilly, and Daiichi Sankyo.
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Affiliation(s)
- Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany.
| | - Dániel Aradi
- Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Claudius Jacobshagen
- Department of Cardiology und Pneumology, Heart Centre/Georg-August-University Göttingen, Göttingen, Germany
| | - Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Tobias Geisler
- University Hospital Tübingen, Department of Cardiology and Cardiovascular Disease, Tübingen, Germany
| | - Martin Orban
- Department of Cardiology, LMU München, Munich, Germany
| | | | - Béla Merkely
- Heart and Vascular Centre, University of Semmelweis, Budapest, Hungary
| | | | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, University of Pécs, Pécs, Hungary
| | - Csaba A Dézsi
- Department of Cardiology, Petz Aladár County Teaching Hospital, Győr, Hungary
| | - Lesca Holdt
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Germany and DZHK, Greifswald, Germany
| | - Radoslaw Parma
- 3rd Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Mariusz Klopotowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Robert H G Schwinger
- Medizinische Klinik II, Klinikum Weiden, Kliniken Nordoberpfalz AG, Weiden, Germany
| | - Johannes Rieber
- Heart Centre Munich-Bogenhausen, Department of Cardiology and Intensive Care Medicine, Munich, Germany
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, and Sigmund Freud Private University, Medical School, Wien, Austria
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Lukasz Koltowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Julinda Mehilli
- Department of Cardiology, LMU München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany; DZHK (German Centre for Cardiovascular Research), Munich Heart Alliance, Munich, Germany
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