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Wilschut JM, Vogel RF, Elscot JJ, Delewi R, Lemmert ME, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Vlachojannis GJ, Van Mieghem NM, Diletti R. Prehospital crushed versus integral prasugrel loading dose in STEMI patients with a large myocardial area. EUROINTERVENTION 2024; 20:e436-e444. [PMID: 38562070 PMCID: PMC10979386 DOI: 10.4244/eij-d-23-00618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The effect of administering a crushed prasugrel loading dose is uncertain in patients presenting with a large myocardial infarction and ST-segment elevation myocardial infarction (STEMI). AIMS The aim of this study was to investigate if patients with a large myocardial infarction may benefit from prehospital administration of a crushed prasugrel loading dose. METHODS Patients from the CompareCrush trial with an available ambulance electrocardiography (ECG) were included in the study. An independent core laboratory confirmed a prehospital large myocardial area. We compared pre- and postprocedural angiographic markers, including Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery, high thrombus burden, and myocardial blush grade 3, in STEMI patients with and without a prehospital large myocardial area. RESULTS Ambulance ECG was available for 532 patients, of whom 331 patients were identified with a prehospital large myocardial area at risk. Crushed prasugrel significantly improved postprocedural TIMI 3 flow rates in STEMI patients with a prehospital large myocardial area at risk (92% vs 79%, odds ratio [OR] 3.00, 95% confidence interval [CI]: 1.50-6.00) but not in STEMI patients without a prehospital large myocardial area at risk (91% vs 95%, OR 0.47, 95% CI: 0.14-1.57; pinteraction=0.009). CONCLUSIONS Administration of crushed prasugrel may improve postprocedural TIMI 3 flow in STEMI patients with signs of a large myocardial area at risk on the ambulance ECG. The practice of crushing tablets of prasugrel loading dose might, therefore, represent a safe, fast and cost-effective strategy to improve myocardial reperfusion in this high-risk STEMI subgroup undergoing primary percutaneous coronary intervention.
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Affiliation(s)
| | - Rosanne F Vogel
- University Medical Center Utrecht, Utrecht, the Netherlands
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Jacob J Elscot
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ronak Delewi
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Miguel E Lemmert
- Erasmus University Medical Center, Rotterdam, the Netherlands
- Isala Hospital, Zwolle, the Netherlands
| | | | - Rutger-Jan Nuis
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitié Salpêtrière (AP-HP), Paris, France
| | | | | | | | | | | | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
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2
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC, Vlachojannis GJ. Direct Stenting versus Conventional Stenting in Patients with ST-Segment Elevation Myocardial Infarction-A COMPARE CRUSH Sub-Study. J Clin Med 2023; 12:6645. [PMID: 37892785 PMCID: PMC10607208 DOI: 10.3390/jcm12206645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/10/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Direct stenting (DS) compared with conventional stenting (CS) after balloon predilatation may reduce distal embolization during percutaneous coronary intervention (PCI), thereby improving tissue reperfusion. In contrast, DS may increase the risk of stent underexpansion and target lesion failure. METHODS In this sub-study of the randomized COMPARE CRUSH trial (NCT03296540), we reviewed the efficacy of DS versus CS in a cohort of contemporary, pretreated ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI. We compared DS versus CS, assessing (1) stent diameter in the culprit lesion, (2) thrombolysis in myocardial infarction (TIMI) flow in the infarct-related artery post-PCI and complete ST-segment resolution (STR) one-hour post-PCI, and (3) target lesion failure at one year. For proportional variables, propensity score weighting was applied to account for potential treatment selection bias. RESULTS This prespecified sub-study included 446 patients, of whom 189 (42%) were treated with DS. Stent diameters were comparable between groups (3.2 ± 0.5 vs. 3.2 ± 0.5 mm, p = 0.17). Post-PCI TIMI 3 flow and complete STR post-PCI rates were similar between groups (DS 93% vs. CS 90%, adjusted OR 1.16 [95% CI, 0.56-2.39], p = 0.69, and DS 72% vs. CS 58%, adjusted OR 1.29 [95% CI 0.77-2.16], p = 0.34, respectively). Moreover, target lesion failure rates at one year were comparable (DS 2% vs. 1%, adjusted OR 2.93 [95% CI 0.52-16.49], p = 0.22). CONCLUSION In this contemporary pretreated STEMI cohort, we found no difference in early myocardial reperfusion outcomes between DS and CS. Moreover, DS seemed comparable to CS in terms of stent diameter and one-year vessel patency.
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Affiliation(s)
- Rosanne F. Vogel
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen M. Wilschut
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Miguel E. Lemmert
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
- Department of Cardiology, Isala Hospital, 8025 AB Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | | | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Gilles Montalescot
- ACTION Group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Sorbonne University, 75013 Paris, France
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32610, USA
| | - Mitchell W. Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
| | - Nicolas M. Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Pieter C. Smits
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
| | - Georgios J. Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Cardiology, Maasstad Hospital, 3079 DZ Rotterdam, The Netherlands
- Department of Cardiology, Euroclinic Athens, 11521 Athens, Greece
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3
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Aarts BRA, Groenland FTW, Elscot J, Neleman T, Wilschut JM, Kardys I, Nuis RJ, Diletti R, Daemen J, Van Mieghem NM, den Dekker WK. Long-term clinical outcomes in patients with non-ST-segment Elevation Acute Coronary Syndrome and ST-segment elevation myocardial infarction with thrombolysis in myocardial infarction 0 flow. IJC HEART & VASCULATURE 2023; 48:101254. [PMID: 37680547 PMCID: PMC10481279 DOI: 10.1016/j.ijcha.2023.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/02/2023] [Accepted: 06/18/2023] [Indexed: 09/09/2023]
Abstract
Background Thrombolysis in Myocardial Infarction (TIMI) 0 flow often characterizes ST-segment Elevation Myocardial Infarction (STEMI) patients, but may also feature in non-ST-segment Elevation Acute Coronary Syndrome (NSTE-ACS). Since recanalization usually occurs later in NSTE-ACS patients, the aim of this study was to assess whether patients presenting with NSTE-ACS and TIMI 0 flow have worse clinical outcomes as compared to patients presenting with STEMI and TIMI 0 flow. Methods A single-center retrospective cohort study was conducted with patients treated for NSTE-ACS and STEMI with TIMI 0 flow at diagnostic angiogram between January 2015 and December 2019. The two patient groups were 1:1 matched using a propensity score logistic regression model. The primary outcome was Major Adverse Cardiac Events (MACE), a composite of all-cause mortality, any myocardial infarction, coronary artery bypass graft, urgent target vessel revascularization or stroke during long term follow-up. Results The total population consisted of 1255 ACS patients, of which 249 NSTE-ACS and 1006 STEMI patients. After propensity score matching, 234 NSTE-ACS patients were matched with 234 STEMI patients. In this matched population, the mean age was 62.6 (±12.4) years and 75.2 % of the patients was male. The median follow-up time was 3.2 years. MACE rates during follow-up were similar between the two matched groups (HR = 0.84 [95 % CI 0.60 - 1.12] with p = 0.33) with cumulative event-free survival of 63.3 % in the NSTE-ACS group vs 59.3 % in the STEMI group at 6 year follow-up. Conclusion In this retrospective study, a culprit lesion with TIMI 0 flow has similar clinical outcome in NSTE-ACS and STEMI patients. Further research is warranted to determine optimal the timing of PCI in NSTE-ACS patients with TIMI 0 flow.
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Affiliation(s)
- Bart R A Aarts
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Frederik T W Groenland
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Jaimy Elscot
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Tara Neleman
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Joost Daemen
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
| | - Wijnand K den Dekker
- Department of Cardiology, Erasmus MC Cardiovascular Institute, University Medical Center Rotterdam, The Netherlands
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Delewi R, Vogel RF, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Doevendans PA, Van Mieghem NM, Smits PC, Vlachojannis GJ. Sex-stratified differences in early antithrombotic treatment response in patients presenting with ST-segment elevation myocardial infarction. Am Heart J 2023; 258:17-26. [PMID: 36596332 DOI: 10.1016/j.ahj.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND The mechanisms underlying the increased risk of bleeding that female patients with ST-segment Elevation Myocardial Infarction (STEMI) exhibit, remains unclear. The present report assessed sex-related differences in response to pre-hospital dual antiplatelet therapy (DAPT) initiation in patients with STEMI. METHODS The COMPARE CRUSH trial randomized patients presenting with STEMI to receive a pre-hospital loading dose of crushed or integral prasugrel tablets in the ambulance. In this substudy, we compared platelet reactivity levels and the occurrence of high platelet reactivity (HPR; defined as platelet reactivity ≥208) between sexes at 4 prespecified time points after DAPT initiation, and evaluated post-PCI bleeding between groups. RESULTS Out of 633 STEMI patients, 147 (23%) were female. Females compared with males presented with significantly higher levels of platelet reactivity and higher HPR rates at baseline (232 [IQR, 209-256] vs 195 [IQR, 171-220], P < .01, and 76% vs 41%, OR 4.58 [95%CI, 2.52-8.32], P < .01, respectively). Moreover, female sex was identified as the sole independent predictor of HPR at baseline (OR 5.67 [95%CI, 2.56-12.53], P < .01). Following DAPT initiation, levels of platelet reactivity and the incidence of HPR were similar between sexes. Post-PCI bleeding occurred more frequently in females compared with males (10% vs 2%, OR 6.02 [95%CI, 2.61-11.87], P < .01). Female sex was an independent predictor of post-PCI bleeding (OR 3.25 [95%CI, 1.09-9.72], P = .04). CONCLUSIONS In this contemporary STEMI cohort, female STEMI patients remain at risk of bleeding complications after primary PCI. However, this is not explained by sex-specific differences in the pharmacodynamic response to pre-hospital DAPT initiation.
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Affiliation(s)
- Ronak Delewi
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Rosanne F Vogel
- Department of cardiology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands; Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jeroen M Wilschut
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Miguel E Lemmert
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Roberto Diletti
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Rutger-Jan Nuis
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- Department of cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- ACTION group, Sorbonne University, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | | | | | - Pieter A Doevendans
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nicolas M Van Mieghem
- Department of cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Georgios J Vlachojannis
- Department of cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Maasstad Hospital, Rotterdam, the Netherlands.
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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Van Mieghem NM, Vlachojannis GJ. Pre-hospital treatment with crushed versus integral tablets of prasugrel in patients presenting with ST-Segment Elevation Myocardial Infarction-1-year follow-up results of the COMPARE CRUSH trial. Am Heart J 2022; 252:26-30. [PMID: 35671829 DOI: 10.1016/j.ahj.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/31/2022] [Accepted: 05/31/2022] [Indexed: 06/15/2023]
Abstract
The present research letter reports the 1-year clinical outcomes of the randomized COMPARE CRUSH trial, which allocated STEMI patients at first medical contact in the ambulance to receive either crushed or integral tablets of prasugrel loading dose. This trial aimed to investigate whether early enhanced antiplatelet effect constituted by the crushed potent oral P2Y12 inhibitor prasugrel could lead to improved early myocardial reperfusion and clinical outcomes.
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Affiliation(s)
- Rosanne F Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands; Department of Cardiology, Isala Hospital, Zwolle, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Dimitrios Alexopoulos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands.
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Current and Future Insights for Optimizing Antithrombotic Therapy to Reduce the Burden of Cardiovascular Ischemic Events in Patients with Acute Coronary Syndrome. J Clin Med 2022; 11:jcm11195605. [PMID: 36233469 PMCID: PMC9573364 DOI: 10.3390/jcm11195605] [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: 07/15/2022] [Revised: 09/06/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
The pharmacological treatment strategies for acute coronary syndrome (ACS) in recent years are constantly evolving to develop more potent antithrombotic agents, as reflected by the introduction of more novel P2Y12 receptor inhibitors and anticoagulants to reduce the ischemic risk among ACS patients. Despite the substantial improvements in the current antithrombotic regimen, a noticeable number of ACS patients continue to experience ischemic events. Providing effective ischemic risk reduction while balancing bleeding risk remains a clinical challenge. This updated review discusses the currently approved and widely used antithrombotic agents and explores newer antithrombotic treatment strategies under development for the initial phase of ACS.
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Rowland B, Batty JA, Dangas GD, Mehran R, Kunadian V. Oral Antiplatelet Agents in Percutaneous Coronary Intervention. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Guo C, Zhao JR, Chen MJ, Zhang Y, Wu RY, Li QQ, Zhao H, Wei J. Crushed/chewed administration of potent P2Y 12 inhibitors in ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: Systematic review and meta-analysis. Platelets 2021; 33:679-686. [PMID: 34472997 DOI: 10.1080/09537104.2021.1974370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Crushed or chewed potent P2Y12 inhibitors are commonly used in the hope of bridging the gap of platelet inhibition in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). The study aimed to investigate the efficacy and safety of this alternative oral administration strategy by performing a meta-analysis of available randomized clinical trials (RCTs). PubMed, Embase, the Cochrane Library and Web of Science medical literature databases were searched for RCTs comparing crushed/chewed vs. integral administration of loading dose potent P2Y12 inhibitors in patients with STEMI undergoing pPCI with no language restrictions from inception to January 20th, 2021. The primary efficacy endpoints of high on treatment platelet reactivity (HPR) and P2Y12 reaction units (PRU) at 1 hour together with safety and additional clinical endpoints were evaluated by pooled odds ratio (OR) or mean differences (MD) with 95% confidence intervals (95% CI). A total of 973 patents in six RCTs were eligible for analysis, while 876 patients present baseline and procedural characteristics. HPR and PRU at 1 hour were significantly reduced in the group receiving crushed/chewed P2Y12 inhibitors compared with integral tablets (OR 0.28, 95% CI 0.16 to 0.49, P < .0001; MD -60.62, 95% CI -97.06 to -24.19, P = .001, respectively). Safety endpoints of major bleeding (OR 0.54, 95% CI 0.11 to 2.73, P = .46) and any bleeding (OR 0.84, 95% CI 0.43 to 1.64, P = .61), as well as additional clinical endpoints of cardiovascular death, myocardial infarction, and stroke were not affected by the oral administration strategy. In STEMI patients undergoing pPCI, crushed or chewed administration of potent P2Y12 inhibitors are associated with enhanced early platelet inhibition and appear to be safe. The clinical profile transformed from this pharmacodynamic benefit need to be determined by further researches.
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Affiliation(s)
- Chen Guo
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jin-Rui Zhao
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Meng-Jie Chen
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Yue Zhang
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Rui-Yun Wu
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Qiang-Qiang Li
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Hong Zhao
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
| | - Jin Wei
- Department of Cardiology, The Second Affiliated Hospital of Xi'an Jiaotong University, Shaanxi, China
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Vogel RF, Delewi R, Angiolillo DJ, Wilschut JM, Lemmert ME, Diletti R, van Vliet R, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Krucoff MW, van Mieghem NM, Smits PC, Vlachojannis GJ. Pharmacodynamic Effects of Pre-Hospital Administered Crushed Prasugrel in Patients With ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2021; 14:1323-1333. [PMID: 34167672 DOI: 10.1016/j.jcin.2021.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/01/2021] [Accepted: 04/09/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVES This study sought to compare the pharmacodynamic effects of pre-hospitally administered P2Y12 inhibitor prasugrel in crushed versus integral tablet formulation in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). BACKGROUND Early dual antiplatelet therapy is recommended in STEMI patients. Yet, onset of oral P2Y12 inhibitor effect is delayed and varies according to formulation administered. METHODS The COMPARE CRUSH (Comparison of Pre-hospital Crushed Versus Uncrushed Prasugrel Tablets in Patients With STEMI Undergoing Primary Percutaneous Coronary Interventions) trial randomized patients with suspected STEMI to crushed or integral prasugrel 60-mg loading dose in the ambulance. Pharmacodynamic measurements were performed at 4 time points: before antiplatelet treatment, at the beginning and end of pPCI, and 4 h after study treatment onset. The primary endpoint was high platelet reactivity at the end of pPCI. The secondary endpoint was impact of platelet reactivity status on markers of coronary reperfusion. RESULTS A total of 441 patients were included. In patients with crushed prasugrel, the occurrence of high platelet reactivity at the end of pPCI was reduced by almost one-half (crushed 34.7% vs. uncrushed 61.6%; odds ratio [OR] = 0.33; 95% confidence interval [CI] = 0.22 to 0.50; p < 0.01). Platelet reactivity <150 P2Y12 reactivity units at the beginning of coronary angiography correlated with improved Thrombolysis In Myocardial Infarction flow grade 3 in the infarct artery pre-pPCI (OR: 1.78; 95% CI: 1.08 to 2.94; p = 0.02) but not ST-segment resolution (OR: 0.80; 95% CI: 0.48 to 1.34; p = 0.40). CONCLUSIONS Oral administration of crushed compared with integral prasugrel significantly improves platelet inhibition during the acute phase in STEMI patients undergoing pPCI. However, a considerable number of patients still exhibit inadequate platelet inhibition at the end of pPCI, suggesting the need for alternative agents to bridge the gap in platelet inhibition.
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Affiliation(s)
- Rosanne F Vogel
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dominick J Angiolillo
- Department of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jeroen M Wilschut
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Miguel E Lemmert
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Isala Hospital, Zwolle, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ria van Vliet
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | | | - Rutger-Jan Nuis
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Dimitrios Alexopoulos
- Department of Cardiology, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Department of Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- Department of Cardiology, ACTION Group, Groupe Hospitalier Pitié-Salpêtrière Hospital (Assistance Publique-Hôpitaux de Paris), Sorbonne University, Paris, France
| | - Mitchell W Krucoff
- Department of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Georgios J Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands.
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Fernando H, Shaw JA, Myles PS, Peter K, Stub D. The opioid-P2Y12 inhibitor interaction: Potential strategies to mitigate the interaction and consideration of alternative analgesic agents in myocardial infarction. Pharmacol Ther 2021; 217:107665. [DOI: 10.1016/j.pharmthera.2020.107665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/13/2020] [Indexed: 01/04/2023]
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Vlachojannis GJ, Wilschut JM, Vogel RF, Lemmert ME, Delewi R, Diletti R, van der Waarden NW, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC. Effect of Prehospital Crushed Prasugrel Tablets in Patients With ST-Segment–Elevation Myocardial Infarction Planned for Primary Percutaneous Coronary Intervention. Circulation 2020; 142:2316-2328. [DOI: 10.1161/circulationaha.120.051532] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background:
Early treatment with a potent oral platelet P2Y
12
inhibitor is recommended in patients presenting with ST-segment–elevation myocardial infarction scheduled to undergo primary percutaneous coronary intervention (pPCI). The impact on coronary reperfusion of crushed P2Y
12
inhibitor tablets, which lead to more prompt and potent platelet inhibition, is unknown.
Methods:
We conducted a randomized controlled, multicenter trial in the Netherlands, enrolling patients with ST-segment–elevation myocardial infarction scheduled to undergo pPCI. Patients were randomly allocated to receive in the ambulance, before transfer, a 60-mg loading dose of prasugrel either as crushed or integral tablets. The independent primary end points were thrombolysis in myocardial infarction (TIMI) 3 flow in the infarct-related artery at initial coronary angiography, and complete (≥70%) ST-segment resolution 1 hour after pPCI. The safety end points were TIMI major and Bleeding Academic Research Consortium ≥3 bleedings. Secondary end points included platelet reactivity and ischemic outcomes.
Results:
A total of 727 patients were assigned to either crushed or integral tablets of prasugrel loading dose. The median time from study treatment to wire-crossing during pPCI was 57 (47–70) minutes. The primary end point TIMI 3 flow in the infarct-related artery before pPCI occurred in 31.0% in the crushed group versus 32.7% in the integral group (odds ratio, 0.92 [95% CI, 0.65–1.30],
P
=0.64). Complete ST-segment resolution 1 hour after pPCI was present in 59.9% in the crushed group versus 57.3% in the integral group (odds ratio, 1.11 [95% CI, 0.78–1.58],
P
=0.55). Platelet reactivity at the beginning of pPCI, measured as P2Y
12
reactivity unit, differed significantly between groups (crushed, 192 [132–245] versus integral, 227 [184–254],
P
≤0.01). TIMI major and Bleeding Academic Research Consortium ≥3 bleeding occurred in 0% in the crushed group versus 0.8% in the integral group, and in 0.3% in the crushed group versus 1.1% in the integral group, respectively. There were no differences observed between groups regarding ischemic events at 30 days.
Conclusions:
Prehospital administration of crushed prasugrel tablets does not improve TIMI 3 flow in the infarct-related artery before pPCI or complete ST-segment resolution 1 h after pPCI in patients presenting with ST-segment–elevation myocardial infarction scheduled for pPCI.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03296540.
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Affiliation(s)
- Georgios J. Vlachojannis
- University Medical Center Utrecht, The Netherlands (G.J.V., R.F.V.)
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
| | - Jeroen M. Wilschut
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Rosanne F. Vogel
- University Medical Center Utrecht, The Netherlands (G.J.V., R.F.V.)
| | - Miguel E. Lemmert
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
- Isala Hospital, Zwolle, The Netherlands (M.E.L.)
| | - Ronak Delewi
- Amsterdam University Medical Center, The Netherlands (R. Delewi). Ambulance Zorg Rotterdam-Rijnmond, Barendrecht, The Netherlands (N.W.P.L.v.d.W.)
| | - Roberto Diletti
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Nancy W.P.L. van der Waarden
- Amsterdam University Medical Center, The Netherlands (R. Delewi). Ambulance Zorg Rotterdam-Rijnmond, Barendrecht, The Netherlands (N.W.P.L.v.d.W.)
| | - Rutger-Jan Nuis
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Valeria Paradies
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
| | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Greece (D.A.)
| | - Felix Zijlstra
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Gilles Montalescot
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
- Sorbonne University, ACTION group, Groupe Hospitalier Pitie-Salpetriere Hospital (AP-HP), Paris, France (G.M.)
| | | | | | - Nicolas M. Van Mieghem
- Erasmus Medical Center, Rotterdam, The Netherlands (J.M.W., M.E.L., R. Diletti, R.-J.N., F.Z., G.M., N.M.V.M.)
| | - Pieter C. Smits
- Maasstad Hospital, Rotterdam, The Netherlands (G.J.V., V.P., P.C.S.)
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Tavenier AH, Hermanides RS, Ottervanger JP, Tolsma R, van Beurden A, Slingerland RJ, ter Horst PGJ, Gosselink ATM, Dambrink JHE, van Leeuwen MAH, Roolvink V, Kedhi E, Klungel OH, Belitser SV, Angiolillo DJ, Pustjens T, Rasoul S, Gho B, Stein M, Ruiters L, van ‘t Hof AWJ. Impact of opioids on P2Y12 receptor inhibition in patients with ST-elevation myocardial infarction who are pre-treated with crushed ticagrelor: Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:4-12. [PMID: 32730628 PMCID: PMC8728016 DOI: 10.1093/ehjcvp/pvaa095] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/19/2020] [Accepted: 07/23/2020] [Indexed: 01/09/2023]
Abstract
Aims Platelet inhibition induced by P2Y12 receptor antagonists in patients with ST-elevation myocardial infarction (STEMI) can be affected by concomitant use of opioids. The aim of this trial was to examine the effect of intravenous (iv) acetaminophen compared with iv fentanyl on P2Y12 receptor inhibition in patients with STEMI. Methods and results The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial randomized 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to iv acetaminophen (N = 98) or iv fentanyl (N = 97) in the ambulance. The primary endpoint, consisting of the level of platelet reactivity units (PRU) measured immediately after primary PCI, was not significantly different between the study arms [median PRU 104 (IQR 37–215) vs. 175 (63–228), P = 0.18]. However, systemic levels of ticagrelor were significantly higher in the acetaminophen arm at the start of primary PCI [151 ng/mL (32–509) vs. 60 ng/mL (13–206), P = 0.007], immediately after primary PCI [326 ng/mL (94–791) vs. 115 ng/mL (38–326), P = 0.002], and at 1 h after primary PCI [488 ng/mL (281–974) vs. 372 ng/mL (95–635), P = 0.002]. Acetaminophen resulted in the same extent of pain relief when compared with fentanyl [reduction of 3 points on 10-step-pain scale before primary PCI (IQR 1–5)] in both study arms (P = 0.67) and immediately after PCI [reduction of 5 points (3–7); P = 0.96]. Conclusion The iv acetaminophen in comparison with iv fentanyl was not associated with significantly lower platelet reactivity in STEMI patients but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.
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Affiliation(s)
| | - Renicus S Hermanides
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan Paul Ottervanger
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Rudolf Tolsma
- Ambulancedienst IJsselland, Voltastraat 3-A, 8013 PM Zwolle, The Netherlands
| | | | | | | | - A T Marcel Gosselink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Jan-Henk E Dambrink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Maarten A H van Leeuwen
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Vincent Roolvink
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Elvin Kedhi
- Department of Cardiology, AZ Sint-Jan, Brugge, Belgium
| | - Olaf H Klungel
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Svetlana V Belitser
- Department of Pharmacoepidemiology, University of Utrecht, Utrecht, The Netherlands
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Tobias Pustjens
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Saman Rasoul
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Ben Gho
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Mera Stein
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Lex Ruiters
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - Arnoud W J van ‘t Hof
- Department of Cardiology, Isala Hospital, dr. van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Department of Cardiology, Zuyderland Medical Centre, Heerlen, The Netherlands
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