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Efficacy and Safety of Potent Oral P2Y12 Inhibitors in Medically Managed ACS Patients: a Meta-analysis. Cardiovasc Drugs Ther 2020; 34:199-208. [DOI: 10.1007/s10557-020-06940-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Gulizia MM, Colivicchi F, Abrignani MG, Ambrosetti M, Aspromonte N, Barile G, Caporale R, Casolo G, Chiuini E, Di Lenarda A, Faggiano P, Gabrielli D, Geraci G, La Manna AG, Maggioni AP, Marchese A, Massari FM, Mureddu GF, Musumeci G, Nardi F, Panno AV, Pedretti RFE, Piredda M, Pusineri E, Riccio C, Rossini R, di Uccio FS, Urbinati S, Varbella F, Zito GB, De Luca L. Consensus Document ANMCO/ANCE/ARCA/GICR-IACPR/GISE/SICOA: Long-term Antiplatelet Therapy in Patients with Coronary Artery Disease. Eur Heart J Suppl 2018; 20:F1-F74. [PMID: 29867293 PMCID: PMC5978022 DOI: 10.1093/eurheartj/suy019] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the cornerstone of pharmacologic management of patients with acute coronary syndrome (ACS) and/or those receiving coronary stents. Long-term (>1 year) DAPT may further reduce the risk of stent thrombosis after a percutaneous coronary intervention (PCI) and may decrease the occurrence of non-stent-related ischaemic events in patients with ACS. Nevertheless, compared with aspirin alone, extended use of aspirin plus a P2Y12 receptor inhibitor may increase the risk of bleeding events that have been strongly linked to adverse outcomes including recurrent ischaemia, repeat hospitalisation and death. In the past years, multiple randomised trials have been published comparing the duration of DAPT after PCI and in ACS patients, investigating either a shorter or prolonged DAPT regimen. Although the current European Society of Cardiology guidelines provide a backup to individualised treatment, it appears to be difficult to identify the ideal patient profile which could safely reduce or prolong the DAPT duration in daily clinical practice. The aim of this consensus document is to review contemporary literature on optimal DAPT duration, and to guide clinicians in tailoring antiplatelet strategies in patients undergoing PCI or presenting with ACS.
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Affiliation(s)
- Michele Massimo Gulizia
- U.O.C. di Cardiologia, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, Catania, Italy
| | - Furio Colivicchi
- U.O.C. Cardiologia e UTIC, Ospedale San Filippo Neri, Roma, Italy
| | | | - Marco Ambrosetti
- Servizio di Cardiologia Riabilitativa, Clinica Le Terrazze Cunardo, Varese, Italy
| | - Nadia Aspromonte
- U.O. Scompenso e Riabilitazione Cardiologica, Polo Scienze Cardiovascolari, Toraciche, Policlinico Agostino Gemelli, Roma, Italy
| | | | - Roberto Caporale
- U.O.C. Cardiologia Interventistica, Ospedale Annunziata, Cosenza, Italy
| | - Giancarlo Casolo
- S.C. Cardiologia, Nuovo Ospedale Versilia, Lido di Camaiore (LU), Italy
| | - Emilia Chiuini
- Specialista Ambulatoriale Cardiologo, ASL Umbria 1, Perugia, Italy
| | - Andrea Di Lenarda
- S.C. Cardiovascolare e Medicina dello Sport, Azienda Sanitaria Universitaria Integrata di Trieste, Italy
| | | | - Domenico Gabrielli
- ASUR Marche - Area Vasta 4 Fermo, Ospedale Civile Augusto Murri, Fermo, Italy
| | - Giovanna Geraci
- U.O.C. Cardiologia Azienda Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | | | | | | | - Ferdinando Maria Massari
- U.O.C. Malattie Cardiovascolari "Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | | | | | - Federico Nardi
- S.C. Cardiologia, Ospedale Santo Spirito, Casale Monferrato (AL), Italy
| | | | | | - Massimo Piredda
- Centro Cardiotoracico, Divisione di Cardiologia, Istituto Clinico Sant'Ambrogio, Milano, Italy
| | - Enrico Pusineri
- U.O.C. di Cardiologia, Ospedale Civile di Vigevano, A.S.S.T., Pavia, Italy
| | - Carmine Riccio
- Prevenzione e Riabilitazione Cardiopatico, AZ. Ospedaliera S. Anna e S. Sebastiano, Caserta, Italy
| | | | | | - Stefano Urbinati
- U.O.C. Cardiologia, Ospedale Bellaria, AUSL di Bologna, Bologna, Italy
| | | | | | - Leonardo De Luca
- U.O.C. Cardiologia, Ospedale San Giovanni Evangelista, Tivoli, Roma, Italy
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Bueno H, Pocock S, Medina J, Danchin N, Annemans L, Licour M, Gregson J, Vega AM, van de Werf F. Relación entre las situaciones clínicas que llevan al tratamiento exclusivamente farmacológico del SCASEST y su pronóstico. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.11.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bueno H, Pocock S, Medina J, Danchin N, Annemans L, Licour M, Gregson J, Vega AM, van de Werf F. Association Between Clinical Pathways Leading to Medical Management and Prognosis in Patients With NSTEACS. ACTA ACUST UNITED AC 2017; 70:817-824. [PMID: 28291730 DOI: 10.1016/j.rec.2016.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 11/30/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES A large proportion of patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis. METHODS Patient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality. RESULTS Medical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P < .001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR = 1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR = 1.90; 95%CI, 1.23-2.95) compared with revascularized patients. CONCLUSIONS Medically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population.
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Affiliation(s)
- Héctor Bueno
- Grupo de Investigación Multidisciplinar Traslacional, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jesús Medina
- Departamento Médico Global, Evidencia Médica e Investigación Observacional, AstraZeneca, Madrid, Spain
| | - Nicolas Danchin
- Department of Cardiology, Hôpital Européen Georges Pompidou & René Descartes University, Paris, France
| | - Lieven Annemans
- Department of Public Health, Universiteit Gent, Vakgroep Maatschappelijke Gezondheidkunde, Gent, Belgium
| | - Muriel Licour
- Département Médical, AstraZeneca France, Rueil-Malmaison, France
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ana María Vega
- Departamento Médico Global, Evidencia Médica e Investigación Observacional, AstraZeneca, Madrid, Spain
| | - Frans van de Werf
- Departement Cardiovasculaire Wetenschappen, Universiteit van Leuven, Leuven, Belgium
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Gesheff T, Barbour C. Oral antiplatelet agents for the management of acute coronary syndromes: A review for nurses and allied healthcare professionals. J Am Assoc Nurse Pract 2017; 29:104-115. [PMID: 28139897 DOI: 10.1002/2327-6924.12438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/30/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE We review the use of oral antiplatelet (OAP) therapies in acute coronary syndrome (ACS) management for nurse practitioners (NPs), focusing on current guideline recommendations. DATA SOURCES Treatment guidelines and clinical articles from PubMed. CONCLUSIONS Guidelines recommend that dual antiplatelet therapy with a P2Y12 inhibitor and aspirin be initiated for ACS management. The P2Y12 inhibitor clopidogrel has established efficacy, but is associated with suboptimal and delayed platelet inhibition and variability in response. The newer P2Y12 inhibitors prasugrel and ticagrelor have demonstrated superior efficacy outcomes versus clopidogrel. Consequently, non-ST-segment elevation ACS (NSTE-ACS) guidelines now recommend that ticagrelor be used in preference to clopidogrel for patients treated with stents or managed medically. Because of their higher potency, prasugrel and ticagrelor are associated with increased bleeding rates versus clopidogrel, but with no increased risk of severe or life-threatening bleeding. Guidelines recommend dual antiplatelet therapy be continued ≥12 months in both medically managed and stented ACS patients, and in some cases beyond this, in absence of high bleeding risk. Updated guidelines assign preference to ticagrelor over clopidogrel for maintenance therapy in patients with NSTE-ACS and ST-elevation myocardial infarction. IMPLICATIONS FOR PRACTICE Enhanced NP understanding of OAP agents and current guidelines could contribute to improved ACS patient management.
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Affiliation(s)
- Tania Gesheff
- Kaufman Cancer Center, University of Maryland, Bel Air, Maryland
| | - Cescelle Barbour
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Fairfax, Virginia
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Danese E, Fava C, Beltrame F, Tavella D, Calabria S, Benati M, Gelati M, Gottardo R, Tagliaro F, Guidi GC, Cattaneo M, Minuz P. Relationship between pharmacokinetics and pharmacodynamics of clopidogrel in patients undergoing percutaneous coronary intervention: comparison between vasodilator-stimulated phosphoprotein phosphorylation assay and multiple electrode aggregometry. J Thromb Haemost 2016; 14:282-93. [PMID: 26576037 DOI: 10.1111/jth.13197] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 10/08/2015] [Indexed: 12/30/2022]
Abstract
UNLABELLED ESSENTIALS: The reliability of platelet tests as markers of the variable bioavailability of clopidogrel is not yet defined. Kinetics of clopidogrel active metabolite (CAM) and platelet response were studied in ischemic heart disease. CAM plasma maximum concentration (Cmax ) predicted vasodilator-stimulated phosphoprotein (VASP-P). Timely performed VASP-P, not an aggregation-based test, may be a surrogate for clopidogrel bioavailability. BACKGROUND The high inter-individual variability in the inhibition of platelet function by clopidogrel is mostly explained by high variability in its transformation to an active metabolite (CAM). Objective We investigated the relations between pharmacokinetics and pharmacodynamics of CAM by comparing two methods of platelet function. METHODS We enrolled 14 patients undergoing percutaneous coronary interventions for non-ST-segment elevation acute coronary syndrome or inducible myocardial ischemia. Plasma concentrations of clopidogrel and CAM, phosphorylation of vasodilator-stimulated phosphoprotein (VASP-P), expressed as a platelet reactivity index (PRI) and whole-blood platelet aggregation (multiple electrode aggregometer, MEA) were measured before and after a 600-mg clopidogrel loading dose (nine time-points) and before and after 75-mg maintenance doses on days 2, 7 and 30. RESULTS Plasma concentrations of clopidogrel and CAM were highly variable. CAM reached maximal concentration (Cmax ) (median, 110.8 nm; range, 41.9-484.8) 0.5-2 h after the loading dose. A sigmoid dose-response curve defined the relations between CAMCmax and PRI after 3 to 24 h (IC50 , 459.6 nm; 95% confidence interval, 453.4-465.7; R(2) = 0.82). PRI was unchanged from baseline in patients with the lowest CAMCmax (< 83 nm, n = 7), indicating low sensitivity of VASP-P. PRI values were also predicted by CAMCmax at days 2, 7 and 30. Platelet aggregation measured by MEA did not show significant relations with either PRI or with CAM pharmacokinetics at any time-point. CONCLUSIONS After 600 mg clopidogrel, VASP-P, but not whole-blood platelet aggregation measured by MEA, is almost entirely predicted by CAMCmax . VASP-P could be useful in studies aimed at investigating relations between CAM bioavailability and clinical events.
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Affiliation(s)
- E Danese
- Section of Clinical Biochemistry, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - C Fava
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - F Beltrame
- Division of Cardiology, AOUI Verona, Verona, Italy
| | - D Tavella
- Division of Cardiology, AOUI Verona, Verona, Italy
| | - S Calabria
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - M Benati
- Section of Clinical Biochemistry, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - M Gelati
- Section of Clinical Biochemistry, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - R Gottardo
- Unit of Forensic Medicine, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - F Tagliaro
- Unit of Forensic Medicine, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - G C Guidi
- Section of Clinical Biochemistry, Department of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - M Cattaneo
- Unità di Medicina 3, Ospedale San Paolo, Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - P Minuz
- Section of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
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De Luca L, Leonardi S, Smecca IM, Formigli D, Lucci D, Gonzini L, Tuccillo B, Olivari Z, Gulizia MM, Bovenzi FM, De Servi S. Contemporary antithrombotic strategies in patients with acute coronary syndromes managed without revascularization: insights from the EYESHOT study. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 1:168-78. [PMID: 27533991 DOI: 10.1093/ehjcvp/pvv006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 02/18/2015] [Indexed: 02/05/2023]
Affiliation(s)
- Leonardo De Luca
- Department of Cardiovascular Sciences, European Hospital, Via Portuense 700, Rome, Italy
| | - Sergio Leonardi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Dario Formigli
- Division of Cardiology, Azienda Ospedaliera 'G. Rummo', Benevento, Italy
| | | | | | | | - Zoran Olivari
- Department of Cardiology, Ca' Foncello Hospital, Treviso, Italy
| | | | | | - Stefano De Servi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Huo Y, Thompson P, Buddhari W, Ge J, Harding S, Ramanathan L, Reyes E, Santoso A, Tam LW, Vijayaraghavan G, Yeh HI. Challenges and solutions in medically managed ACS in the Asia-Pacific region: expert recommendations from the Asia-Pacific ACS Medical Management Working Group. Int J Cardiol 2014; 183:63-75. [PMID: 25662044 DOI: 10.1016/j.ijcard.2014.11.195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/12/2014] [Accepted: 11/24/2014] [Indexed: 12/26/2022]
Abstract
Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations.
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Affiliation(s)
| | - Yong Huo
- Peking University First Hospital, Beijing, China.
| | - Peter Thompson
- University of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - Wacin Buddhari
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Junbo Ge
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Scott Harding
- Wellington Cardiovascular Research Group and School of Biological Sciences, Victoria University, Wellington, New Zealand
| | | | - Eugenio Reyes
- University of the Philippines, Philippine General Hospital-Section of Cardiology, Manila, Philippines
| | - Anwar Santoso
- Department of Cardiology - Vascular Medicine, Faculty of Medicine, University of Indonesia and National Cardiovascular Center, Harapan Kita, Indonesia
| | | | | | - Hung-I Yeh
- Mackay Memorial Hospital, Mackay Medical College, New Taipei City, Taiwan
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Alfonso F, Angiolillo DJ. Targeting P-Selectin During Coronary Interventions. J Am Coll Cardiol 2013; 61:2056-9. [DOI: 10.1016/j.jacc.2013.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 03/04/2013] [Indexed: 11/26/2022]
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