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Zabel KM, Blankenship JC. High BMI: Another Barrier to Rapid Platelet Inhibition After STEMI PCI. Cardiovasc Drugs Ther 2024; 38:9-11. [PMID: 37594651 DOI: 10.1007/s10557-023-07504-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 08/19/2023]
Affiliation(s)
- Kenneth M Zabel
- Department of Internal Medicine, University of New Mexico Health Sciences Center, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - James C Blankenship
- Division of Cardiology, University of New Mexico Health Sciences Center, MSC 10 5550, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
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2
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Komócsi A, Merkely B, Hadamitzky M, Massberg S, Rizas KD, Hein-Rothweiler R, Gross L, Trenk D, Sibbing D, Aradi D. Impact of body mass on P2Y12-inhibitor de-escalation in acute coronary syndromes-a substudy of the TROPICAL-ACS trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:608-616. [PMID: 37015874 PMCID: PMC10627813 DOI: 10.1093/ehjcvp/pvad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/10/2023] [Accepted: 04/03/2023] [Indexed: 04/06/2023]
Abstract
AIMS Clinical guidelines recommend de-escalation antiplatelet strategies to reduce bleeding risk in acute coronary syndrome (ACS) patients, albeit with a weak recommendation. This substudy of the TROPICAL-ACS trial aimed to determine the impact of body mass on the efficacy of a platelet function testing-guided de-escalation regimen in ACS patients after percutaneous coronary intervention. METHODS AND RESULTS Patients were randomized to prasugrel (control group) or a platelet function testing-guided regimen with clopidogrel or prasugrel defined after 1-week clopidogrel. The primary endpoint was the net clinical benefit [cardiovascular death, myocardial infarction, stroke, or Bleeding Academic Research Consortium (BARC) 2-5 bleeding] for 12 months. Overweight was defined as a body mass index >25 kg/m2.Patients without overweight showed a significant net clinical benefit from the de-escalation strategy, while in overweight cases de-escalation was comparable to prasugrel treatment [hazard ratio (HR): 0.52; 95% confidence interval (CI): 0.31-0.88; P = 0.013 and HR: 0.95; 95% CI: 0.69-1.31, P = 0.717, P-non-inferiority = 0.03, respectively, P-interaction = 0.053]. The benefit of de-escalation in terms of the risk of bleeding or of the ischaemic events did not reach statistical significance. Bleeding events with de-escalation were less frequent in non-overweight patients but comparable in overweight patients (HR: 0.55; 95% CI: 0.30-1.03; P = 0.057 and HR: 0.95; 95% CI: 0.64-1.41, respectively, P-interaction = 0.147). Non-overweight patients had lower ischaemic event rates with de-escalation, while overweight cases had slightly less (HR: 0.47; 95% CI: 0.18-1.25; P = 0.128 and HR: 0.89; 95% CI: 0.53-1.50, respectively, P-interaction = 0.261). CONCLUSION The strategy of guided dual antiplatelet therapy de-escalation was associated with a significant net clinical benefit in non-overweight patients, while the two strategies were equivalent in overweight patients.
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Affiliation(s)
- András Komócsi
- Heart Centre, Medical School, University of Pécs, Pécs, Hungary
| | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | | | | | | | | | - Lisa Gross
- Ludwig-Maximilians University, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology–Clinical Pharmacology, Medical Center–University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Germany
| | | | - Dániel Aradi
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
- Balatonfured State Cardiology Hospital, Balatonfured, Hungary
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3
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Puccini M, Rauch C, Jakobs K, Friebel J, Hassanein A, Landmesser U, Rauch U. Being Overweight or Obese Is Associated with an Increased Platelet Reactivity Despite Dual Antiplatelet Therapy with Aspirin and Clopidogrel. Cardiovasc Drugs Ther 2023; 37:833-837. [PMID: 35211819 PMCID: PMC10397124 DOI: 10.1007/s10557-022-07325-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Obese patients exhibit an overall increased platelet reactivity and a reduced sensitivity to antiplatelet therapy. The aim of this study is to evaluate the platelet reactivity measured by impedance aggregometry in overweight and obese patients and chronic coronary syndrome (CCS) that were treated with dual antiplatelet therapy (DAPT). METHODS Platelet aggregation was assessed by impedance aggregometry in patients with CCS receiving DAPT (aspirin plus clopidogrel). We compared the platelet reactivity in patients with a normal weight versus overweight or obese patients. Furthermore, the correlation between the body mass index (BMI) and adenosine diphosphate- (ADP-) or thrombin receptor-activating peptide- (TRAP-) dependent platelet aggregation was analyzed. RESULTS 64 patients were included in the study of which 35.9% were patients with normal weight. A higher ADP- and TRAP-dependent platelet reactivity was observed in overweight and obese patients (ADP: median 27 units (U) [IQR 13-39.5] vs. 7 U [6-15], p < 0.001 and TRAP: 97 U [73-118.5] vs. 85 U [36-103], p = 0.035). Significant positive correlations were observed between agonist-induced platelet reactivity and BMI. CONCLUSION Despite the use of DAPT, a higher platelet reactivity was found in overweight and obese patients with CCS. If these patients will benefit from treatment with more potent platelet inhibitors, it needs to be evaluated in future clinical trials.
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Affiliation(s)
- Marianna Puccini
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
| | - Christian Rauch
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
| | - Kai Jakobs
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Julian Friebel
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Adel Hassanein
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
| | - Ulf Landmesser
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Ursula Rauch
- Charité Center 11-Department of Cardiology, Charité-University Medicine, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Germany.
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4
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Scudiero F, Canonico ME, Sanna GD, Dossi F, Silverio A, Galasso G, Esposito G, Porto I, Parodi G. Dual Antiplatelet Therapy with 3 rd Generation P2Y 12 Inhibitors in STEMI Patients: Impact of Body Mass Index on Loading Dose-Response. Cardiovasc Drugs Ther 2023; 37:695-703. [PMID: 35175499 DOI: 10.1007/s10557-022-07322-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE This study aims to assess the association between body mass index (BMI) and platelet reactivity in STEMI patients treated with oral 3rd generation P2Y12 inhibitors. METHODS Overall, 429 STEMI patients were enrolled in this study. Patients were divided into two groups according to BMI (BMI < 25 vs ≥ 25 kg/m2). A propensity score matching (1:1) was performed to balance potential confounders in patient baseline characteristics. Platelet reactivity was assessed by VerifyNow at baseline and after 3rd generation P2Y12 inhibitor (ticagrelor or prasugrel) loading dose (LD). Blood samples were obtained at baseline (T0), 1 h (T1), 2 h (T2), 4-6 h (T3), and 8-12 h (T4) after the LD. High on-treatment platelet reactivity (HTPR) was defined as a platelet reactivity unit value ≥ 208 units. RESULTS After propensity score matching, patients with BMI ≥ 25 had similar values of baseline platelet reactivity, while they had higher level of platelet reactivity at 1 and 2 h after the LD and higher rate of HRPT. Furthermore, multivariate analysis demonstrated that BMI ≥ 25 was an independent predictor of HTPR at 2 h (OR 2.01, p = .009). Conversely, starting from 4 h after the LD, platelet reactivity values and HRPT rates were comparable among the two study groups. CONCLUSIONS A BMI ≥ 25 kg/m2 is associated with delayed pharmacodynamic response to oral 3rd generation P2Y12 inhibitor LD, and it is a strong predictor of HTPR in STEMI patients treated by dual antiplatelet therapy with ticagrelor or prasugrel.
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Affiliation(s)
- Fernando Scudiero
- Medical Sciences Departement, Cardiology Unit, ASST Bergamo Est, Bolognini Hospital, Seriate, BG, Italy
| | - Mario E Canonico
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Giuseppe D Sanna
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Filippo Dossi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi (Salerno), Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Italo Porto
- Department of Internal Medicine and Medical Specialties (DIMI) Clinic of Cardiovascular Diseases, University of Genoa, Genoa, Italy
| | - Guido Parodi
- Cardiology Unit, ASL4 Liguria, Ospedali del Tigullio, Polo Di Lavagna, GE, Italy.
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Hong N, Kim SB, Yang HJ, Son YJ. Variability of response on prophylactic prasugrel for endovascular treatment of intracranial aneurysms: Clinical implications. PLoS One 2023; 18:e0287190. [PMID: 37352283 PMCID: PMC10289319 DOI: 10.1371/journal.pone.0287190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 05/31/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND AND PURPOSE Prophylactic prasugrel for endovascular treatment of intracranial aneurysms has been introduced and increased, but HTPR (high on-treatment platelet reactivity) or LTPR (low on-treatment platelet reactivity) of prasugrel is not uncommon in clinical circumstances. To investigate the predisposing factors of HTPR and LTPR on prasugrel premedication in the neurointerventional field and to determine its clinical implications. MATERIALS AND METHODS Between February 2016 and December 2020, 191 patients treated with coil embolization using prophylactic prasugrel in 234 intracranial aneurysms were the final candidates for this study. Patient and aneurysm characteristics, clinical status, and laboratory study values were carefully reviewed retrospectively. We performed risk factor analyses for HTPR and LTPR on prasugrel. RESULTS Ultimately, 20 patients (10.5%) had HTPR, and 74 patients (38.7%) were categorized as having LTPR. In multivariable analyses, the factors related to HTPR were BMI (adjusted OR 1.21, 95% CI 1.04-1.41, p = 0.01), history of antithrombotics (adjusted OR 3.79, 95% CI 1.39-10.34, p = 0.01), and hematocrit (adjusted OR 0.91, 95% CI 0.84-0.99, p = 0.03). Low BMI was the only risk factor for LTPR (adjusted OR 0.84, 95% CI 0.76-0.94, p = 0.001). CONCLUSION In the neurointerventional field, high BMI and prior use of antithrombotic agents were related to HTPR, and low BMI was associated with LTPR on prophylactic prasugrel. High hematocrit levels decreased the risk of HTPR. When preparing endovascular treatment for intracranial aneurysms, attention to patients with these clinical features is required to address the possibility of ischemic or bleeding complications.
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Affiliation(s)
- Noah Hong
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Seung Bin Kim
- Department of Critical Care Medicine, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Hee-Jin Yang
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
| | - Young-Je Son
- Department of Neurosurgery, Seoul National University-Seoul Metropolitan Government Boramae Medical Center, Seoul, Republic of Korea
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Bianchettin RG, Lavie CJ, Lopez-Jimenez F. Challenges in Cardiovascular Evaluation and Management of Obese Patients: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 81:490-504. [PMID: 36725178 DOI: 10.1016/j.jacc.2022.11.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/12/2022] [Accepted: 11/02/2022] [Indexed: 02/01/2023]
Abstract
Many unique clinical challenges accompany the diagnosis and treatment of cardiovascular disease (CVD) in people living with overweight/obesity. Similarly, physicians encounter numerous complicating factors when managing obesity among people with CVD. Diagnostic accuracy in CVD medicine can be hampered by the presence of obesity, and pharmacological treatments or cardiac procedures require careful adjustment to optimize efficacy. The obesity paradox concept remains a source of confusion within the clinical community that may cause important risk factors to go unaddressed, and body mass index is a misleading measure that cannot account for body composition (eg, lean mass). Lifestyle modifications that support weight loss require long-term commitment, but cardiac rehabilitation programs represent a potential opportunity for structured interventions, and bariatric surgery may reduce CVD risk factors in obesity and CVD. This review examines the key issues and considerations for physicians involved in the management of concurrent obesity and CVD.
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Affiliation(s)
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, Louisiana, USA
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7
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Castelijns MC, Hageman SHJ, Ruigrok YM, van der Meer MG, Teraa M, Westerink J, Visseren FLJ. Visceral adipose tissue quantity and dysfunction and the occurrence of major bleeding in patients with established cardiovascular disease. Obes Res Clin Pract 2023; 17:40-46. [PMID: 36464615 DOI: 10.1016/j.orcp.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/07/2022] [Accepted: 11/20/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To determine the association between both visceral fat quantity and adipose tissue dysfunction, and major bleeding in patients with established cardiovascular disease. METHODS Patients from the Second Manifestations of ARTerial disease study with established cardiovascular disease were included. Visceral fat was measured using ultrasound and adipose tissue dysfunction was depicted using metabolic syndrome criteria (revised National Cholesterol Education Program). Cox regression models were fitted to study the relation with major bleeding defined as Bleeding Academic Research Consortium (BARC) type 3 or 5, or International Society on Thrombosis and Haemostasis (ISTH) major bleeding. Sensitivity analyses were performed using C-reactive protein levels to reflect adipose tissue dysfunction. RESULTS In 6927 patients during a median follow up of 9.2 years, a total of 237 BARC type 3 or 5 bleedings and 224 ISTH major bleedings were observed. Visceral fat quantity was not related to major bleeding (HR 1.01, 95%CI 0.88-1.16 for BARC type 3 or 5 bleeding and HR 1.00, 95%CI 0.87-1.15 for ISTH major bleeding), nor was metabolic syndrome (HR 0.97, 95%CI 0.75-1.26 for BARC type 3 or 5 bleeding and HR 0.98, 95%CI 0.75-1.28 for ISTH major bleeding). Sensitivity analyses using C-reactive protein levels showed similar results. No effect modification was observed by sex, antithrombotic therapy, presence of metabolic syndrome or diabetes. CONCLUSION In patients with cardiovascular disease, no association was found between visceral fat quantity measured with ultrasound or measures of adipose tissue dysfunction and the risk of major bleeding, irrespective of antithrombotic agent use.
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Affiliation(s)
- Maria C Castelijns
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Steven H J Hageman
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht, the Netherlands
| | | | - Martin Teraa
- Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, the Netherlands.
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Blaško P, Samoš M, Bolek T, Stančiaková L, Škorňová I, Péč MJ, Jurica J, Staško J, Mokáň M. Resistance on the Latest Oral and Intravenous P2Y12 ADP Receptor Blockers in Patients with Acute Coronary Syndromes: Fact or Myth? J Clin Med 2022; 11:jcm11237211. [PMID: 36498785 PMCID: PMC9737839 DOI: 10.3390/jcm11237211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/12/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Novel P2Y12 ADP receptor blockers (ADPRB) should be preferred in dual-antiplatelet therapy in patients with acute coronary syndrome. Nevertheless, there are still patients who do not respond optimally to novel ADP receptor blocker therapy, and this nonoptimal response (so-called "high on-treatment platelet reactivity" or "resistance") could be connected with increased risk of adverse ischemic events, such as myocardial re-infarction, target lesion failure and stent thrombosis. In addition, several risk factors have been proposed as factors associated with the phenomenon of inadequate response on novel ADPRB. These include obesity, multivessel coronary artery disease, high pre-treatment platelet reactivity and impaired metabolic status for prasugrel, as well as elderly, concomitant therapy with beta-blockers, morphine and platelet count for ticagrelor. There is no literature report describing nonoptimal therapeutic response on cangrelor, and cangrelor therapy seems to be a possible approach for overcoming HTPR on prasugrel and ticagrelor. However, the optimal therapeutic management of "resistance" on novel ADPRB is not clear and this issue requires further research. This narrative review article discusses the phenomenon of high on-treatment platelet reactivity on novel ADPRB, its importance in clinical practice and approaches for its therapeutic overcoming.
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Affiliation(s)
- Peter Blaško
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
- Out-Patient Clinic of Cardiology, 957 01 Banovce nad Bebravou, Slovakia
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
- Correspondence: ; Tel.: +421-907-612-943 or +421-434-203-820
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Lucia Stančiaková
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Ingrid Škorňová
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Martin Jozef Péč
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Jakub Jurica
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Ján Staško
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 036 59 Martin, Slovakia
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Vauclard A, Bellio M, Valet C, Borret M, Payrastre B, Severin S. Obesity: Effects on bone marrow homeostasis and platelet activation. Thromb Res 2022. [DOI: 10.1016/j.thromres.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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10
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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:747-755. [PMID: 34961732 DOI: 10.1016/j.rec.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/12/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION AND OBJECTIVES The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. METHODS Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. RESULTS The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). CONCLUSIONS In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety. CLINICAL TRIAL REGISTRATION NCT01944800.
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Affiliation(s)
- Shqipdona Lahu
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Gjin Ndrepepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Dirk Sibbing
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Cardiology, Klinik der Universität München, Ludwig - Maximilians - University, Munich, Germany
| | - Isabell Bernlochner
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | | | - Katharina Mayer
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Gert Richardt
- Department of Cardiology and Angiology, Heart Center Bad Segeberg, Bad Segeberg, Germany
| | - Senta Gewalt
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - John Joseph Coughlan
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Alp Aytekin
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | | | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg Bad Krozingen, Bad Krozingen, Germany
| | - Salvatore Cassese
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Sebastian Kufner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Erion Xhepa
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Hendrik B Sager
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Michael Joner
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Massimiliano Fusaro
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Karl-Ludwig Laugwitz
- German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany; Medizinische Klinik und Poliklinik Innere Medizin I (Kardiologie, Angiologie, Pneumologie), Klinikum Rechts der Isar, Munich, Germany
| | - Heribert Schunkert
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Stefanie Schüpke
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany
| | - Adnan Kastrati
- Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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11
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Liu PY, Su CH, Kuo FY, Lee WL, Wang YC, Lin WS, Chu PH, Lu TM, Lo PH, Lee CH, Lan WR, Huang CL, Tsukiyama S, Yang WC, Cheng LC, Rafael V, Nikolajsen C, Yin WH. Prasugrel switching from clopidogrel after percutaneous coronary intervention for acute coronary syndrome in Taiwanese patients: an analysis of safety and efficacy. Cardiovasc Interv Ther 2022; 37:269-278. [PMID: 33813727 PMCID: PMC8926957 DOI: 10.1007/s12928-021-00771-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/20/2021] [Indexed: 11/25/2022]
Abstract
The recommended maintenance dose of prasugrel for East Asian populations (i.e., Japanese and Taiwanese) is 3.75 mg as part of dual antiplatelet therapy (DAPT) for the prevention of recurrent ischemia and stent thrombosis in acute coronary syndrome (ACS). This modified dosage regimen has been established in studies conducted in Japan; however, the efficacy and safety of switching from clopidogrel to prasugrel DAPT among Taiwanese patients remain to be explored. In this phase IV, multicenter, single-arm, open-label study, we evaluated the 4-week pharmacodynamic response, and the 48-week safety outcomes of prasugrel 3.75 mg after a switch from clopidogrel in Taiwanese ACS patients. A total of 203 prasugrel-naïve ACS patients (over 90% male) who had received post-PCI clopidogrel DAPT for at least 2 weeks were enrolled from ten medical centers in Taiwan and subsequently switched to prasugrel 3.75 mg DAPT. Four weeks after the switch, P2Y12 reaction unit (PRU) values were significantly decreased in the total cohort (mean - 18.2 ± 48.1; 95% confidence interval - 24.9 to - 11.5, p < 0.001), and there was an overall consistent antiplatelet response in the treated subjects. The proportion of patients with high on-treatment platelet reactivity (HPR; PRU > 208) dropped from 23.5 to 10% (p < 0.001). Female sex was associated with a greater PRU reduction with prasugrel, whereas HPR at baseline, age ≥ 65 years, and body mass index ≥ 25 best predicted HPR at Week 4. Throughout the 48-week treatment with prasugrel, the incidences of MACE (1.0%) and TIMI major bleeding (2.0%) were rather low, accompanying an acceptable safety profile of TIMI minor (6.4%) and non-major, non-minor clinically relevant bleeding (3.0%). Overall, switching to the maintenance dose of prasugrel (3.75 mg) was observed to be effective and well tolerated among post-PCI ACS patients in Taiwan. Clinical Trial Registration Number: NCT03672097.
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Affiliation(s)
- Ping-Yen Liu
- Department of Cardiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Cheng-Huang Su
- Cardiovascular Center, Department of Internal Medicine and Medical Research, Mackay Memorial Hospital, Taipei, Taiwan
- Mackay Medical College, New Taipei City, Taiwan
| | - Feng-Yu Kuo
- Division of Cardiology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Lieng Lee
- Division of Interventional Cardiology, Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Wei-Shiang Lin
- Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Tse-Min Lu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Healthcare & Service Center, Taipei Veterans General Hospital, Taipei, Taiwan
- Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Ping-Han Lo
- Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Cheng-Han Lee
- Department of Cardiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ren Lan
- Division of Cardiology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chien-Lung Huang
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | | | | | | | | | | | - Wei-Hsian Yin
- Faculty of Medicine, School of Medicine, National Yang Ming University, Taipei, Taiwan.
- Division of Cardiology, Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan.
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12
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Peterson BE, Harrington RA, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Lopes RD, Leonardi S, Prats J, Deliargyris EN, Mahaffey KW, White HD, Bhatt DL. Effect of Platelet Inhibition by Cangrelor Among Obese Patients Undergoing Coronary Stenting: Insights From CHAMPION. Circ Cardiovasc Interv 2022; 15:e011069. [PMID: 35196863 DOI: 10.1161/circinterventions.121.011069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In randomized trials, cangrelor reduced periprocedural ischemic events related to percutaneous coronary intervention without increasing GUSTO severe bleeding. However, some antiplatelet agents have shown a differential treatment effect by body mass index (BMI). METHODS Patients from the 3 CHAMPION trials (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) who were randomized to cangrelor versus clopidogrel during percutaneous coronary intervention were stratified by BMI. The primary efficacy end point was a composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis within 48 hours. The principal safety outcome was GUSTO moderate or severe bleeding at 48 hours, although more sensitive bleeding measures such as Thrombolysis in Myocardial Infarction major bleeding were also assessed. We examined obese patients (defined as BMI≥30) versus nonobese patients. RESULTS There were 24 893 patients, with 8979 (36.1%) having BMI of ≥30. There was no significant difference in the primary efficacy end point among obese versus nonobese patients (4.3% versus 4.2%; rate ratio, 1.01 [95% CI, 0.89-1.15]; P=0.82). There was a consistent benefit in the primary efficacy end point in patients who received cangrelor versus placebo who were obese (3.9% versus 4.7%, rate ratio, 0.83 [95% CI, 0.68-1.02]; P=0.07) and not obese (3.8% versus 4.7%; rate ratio, 0.81 [95% CI, 0.69-0.94]; P=0.0053); interaction P=0.77. There was no difference in GUSTO moderate or severe bleeding among patients who received cangrelor versus placebo who were obese (0.6% versus 0.6%; rate ratio, 0.99 [95% CI, 0.58-1.67]; P=0.96). CONCLUSIONS Cangrelor at the time of percutaneous coronary intervention is effective and safe in obese and nonobese patients. There was no difference in short-term efficacy between obese and nonobese patients. Periprocedural cangrelor is an effective and safe antiplatelet agent, irrespective of BMI. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01156571, NCT00385138, NCT00305162.
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Affiliation(s)
- Benjamin E Peterson
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston (B.E.P., D.L.B.)
| | | | | | - Ph Gabriel Steg
- Université Paris Diderot, INSERM U_1148 and Hôpital Bichat Assistance Publique, Paris, France and Royal Brompton Hospital, Imperial College, London, United Kingdom (P.G.S.)
| | | | - Christian W Hamm
- Kerckhoff Klinik, Department of Cardiology, Bad Nauheim, Germany (C.W.H.)
| | | | | | - Sergio Leonardi
- Fondazione I.R.C.C.S. Policlinico San Matteo Pavia, Pavia, PV, Italy (S.L.)
| | | | | | | | | | - Deepak L Bhatt
- Brigham and Women's Hospital, Heart and Vascular Center, Harvard Medical School, Boston (B.E.P., D.L.B.)
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13
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Lahu S, Behnes M, Ndrepepa G, Neumann FJ, Sibbing D, Bernlochner I, Menichelli M, Mayer K, Richardt G, Gewalt S, Angiolillo DJ, Coughlan JJ, Aytekin A, Witzenbichler B, Hochholzer W, Cassese S, Kufner S, Xhepa E, Sager HB, Joner M, Fusaro M, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A, Akin I. Índice de masa corporal y eficacia y seguridad del ticagrelor frente al prasugrel en pacientes con síndrome coronario agudo. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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14
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Wiśniewski A, Sikora J, Karczmarska-Wódzka A, Sobczak P. A Combination of Aspirin and Clopidogrel Predict More Favorable Dynamics of Platelet Reactivity versus Clopidogrel Alone in the Acute Phase of Minor Stroke. Healthcare (Basel) 2021; 9:healthcare9060628. [PMID: 34070301 PMCID: PMC8225168 DOI: 10.3390/healthcare9060628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 05/19/2021] [Accepted: 05/23/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The combined use of clopidogrel and aspirin is recommended for the short-term (21 days) therapy of minor stroke or transient ischemic attack. Previous studies have demonstrated its efficacy and superiority over treatment with a single antiplatelet agent. However, there is insufficient support for the advantages of such therapy based on platelet function testing. We aimed to compare the effect of the concomitant use of clopidogrel and aspirin versus clopidogrel alone on the dynamics of platelet reactivity over time to determine the appropriate antiplatelet treatment strategy for minor strokes. METHODS We enrolled 74 ischemic stroke subjects, including 38 minor strokes. Platelet reactivity was assessed by impedance aggregometry (Multiplate Analyzer) 48 and 96 h after a first 75 mg dose of clopidogrel, using the acetylsalicylic acid platelet inhibition (ASPI) test and the adenosine diphosphate (ADP) test. Dual antiplatelet therapy was strictly reserved only to minor strokes, as the other strokes received clopidogrel alone in the secondary prevention. The dynamics of platelet reactivity refer to the difference between two assessments, and a decrease in values over time was considered favorable. RESULTS The incidence of clopidogrel non-responsiveness was 64.8%, and this was similar in the group of minor strokes and the group of more disabling strokes. We indicated diabetes mellitus as an independent predictor of high on-clopidogrel platelet reactivity (Odds ratio OR 5.69 95% Confidence Interval CI 1.13-41.26, p = 0.0386). Among minor strokes treated with dual antiplatelet therapy, in relation to clopidogrel, we reported a trend toward more favorable dynamics of platelet reactivity over time compared to the group using clopidogrel alone (p = 0.0652 vs. p = 0.3384, respectively). We identified five predictors (sex, female; small-vessel disease; no diabetes; no hyperlipidemia; and no alcohol abuse) related to a significant decrease in platelet reactivity over time with respect to clopidogrel. No significant dynamics of platelet reactivity when using aspirin were found. CONCLUSIONS Our findings, based on the favorable dynamics of platelet reactivity over time in relation to clopidogrel, confirm the usefulness of dual antiplatelet therapy in minor strokes and support the continuation of the secondary prevention with clopidogrel alone rather than aspirin, particularly among identified beneficiaries of such a strategy.
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Affiliation(s)
- Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland
- Correspondence: ; Tel.: +48-790813513
| | - Joanna Sikora
- Experimental Biotechnology Research and Teaching Team, Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (J.S.); (A.K.-W.); (P.S.)
| | - Aleksandra Karczmarska-Wódzka
- Experimental Biotechnology Research and Teaching Team, Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (J.S.); (A.K.-W.); (P.S.)
| | - Przemysław Sobczak
- Experimental Biotechnology Research and Teaching Team, Department of Transplantology and General Surgery, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 85-094 Bydgoszcz, Poland; (J.S.); (A.K.-W.); (P.S.)
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15
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Powell-Wiley TM, Poirier P, Burke LE, Després JP, Gordon-Larsen P, Lavie CJ, Lear SA, Ndumele CE, Neeland IJ, Sanders P, St-Onge MP. Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e984-e1010. [PMID: 33882682 PMCID: PMC8493650 DOI: 10.1161/cir.0000000000000973] [Citation(s) in RCA: 990] [Impact Index Per Article: 330.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation.
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16
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Wiśniewski A. Multifactorial Background for a Low Biological Response to Antiplatelet Agents Used in Stroke Prevention. ACTA ACUST UNITED AC 2021; 57:medicina57010059. [PMID: 33435185 PMCID: PMC7827369 DOI: 10.3390/medicina57010059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022]
Abstract
Effective platelet inhibition is the main goal of the antiplatelet therapy recommended as a standard treatment in the secondary prevention of non-embolic ischemic stroke. Acetylsalicylic acid (aspirin) and clopidogrel are commonly used for this purpose worldwide. A low biological response to antiplatelet agents is a phenomenon that significantly reduces the therapeutic and protective properties of the therapy. The mechanisms leading to high on-treatment platelet reactivity are still unclear and remain multifactorial. The aim of the current review is to establish the background of resistance to antiplatelet agents commonly used in the secondary prevention of ischemic stroke and to explain the possible mechanisms. The most important factors influencing the incidence of a low biological response were demonstrated. The similarities and the differences in resistance to both drugs are emphasized, which may facilitate the selection of the appropriate antiplatelet agent in relation to specific clinical conditions and comorbidities. Despite the lack of indications for the routine assessment of platelet reactivity in stroke subjects, this should be performed in selected patients from the high-risk group. Increasing the detectability of low antiaggregant responders, in light of its negative impact on the prognosis and clinical outcomes, can contribute to a more individualized approach and modification of the antiplatelet therapy to maximize the therapeutic effect in the secondary prevention of stroke.
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Affiliation(s)
- Adam Wiśniewski
- Department of Neurology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Skłodowskiej 9 Street, 85-094 Bydgoszcz, Poland
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17
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De Luca G, Verdoia M, Savonitto S, Ferri LA, Piatti L, Grosseto D, Morici N, Bossi I, Sganzerla P, Tortorella G, Cacucci M, Ferrario M, Murena E, Sibilio G, Tondi S, Toso A, Bongioanni S, Ravera A, Corrada E, Mariani M, Di Ascenzo L, Petronio AS, Cavallini C, Vitrella G, Antonicelli R, Rogacka R, De Servi S. Impact of body mass index on clinical outcome among elderly patients with acute coronary syndrome treated with percutaneous coronary intervention: Insights from the ELDERLY ACS 2 trial. Nutr Metab Cardiovasc Dis 2020; 30:730-737. [PMID: 32127336 DOI: 10.1016/j.numecd.2020.01.001] [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] [Received: 08/07/2019] [Revised: 12/26/2019] [Accepted: 01/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIM Elderly patients are at increased risk of hemorrhagic and thrombotic complications after an acute coronary syndrome (ACS). Frailty, comorbidities and low body weight have emerged as conditioning the prognostic impact of dual antiplatelet therapy (DAPT). The aim of the present study was to investigate the prognostic impact of body mass index (BMI) on clinical outcome among patients included in the Elderly-ACS 2 trial, a randomized, open-label, blinded endpoint study comparing low-dose (5 mg) prasugrel vs clopidogrel among elderly patients with ACS. METHODS AND RESULTS Our population is represented by 1408 patients enrolled in the Elderly-ACS 2 trial. BMI was calculated at admission. The primary endpoint of this analysis was cardiovascular (CV) mortality. Secondary endpoints were all-cause death, recurrent MI, Bleeding Academic Research Consortium (BARC) type 2 or 3 bleeding, and re-hospitalization for cardiovascular reasons or stent thrombosis within 12 months after index admission. Patients were grouped according to median values of BMI (<or ≥ 25.7 kg/m2). BMI was associated with hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate and hemoglobin (p < 0.001), and inversely with age (p = 0.005). Overweight patients displayed larger use of diuretics at admission (p = 0.03), aspirin pre-randomization (p = 0.01) and radial access (p = 0.04). At a median follow-up of 367 [337-378] days, BMI did not affect CV mortality in the overall population 4% vs 3.8%; adjusted HR [95%CI] = 2.3 [0.8-6.5], p = 0.12. Similar findings were observed for our secondary efficacy and safety endpoints. Results did not change when considering separately higher risk subsets of patients, (female gender, diabetics, ST-segment elevation myocardial infarction or the type of DAPT treatment allocation), with no significant interaction between these population characteristics and BMI. CONCLUSIONS Among elderly patients with ACS, BMI did not condition the survival or the risk of major cardiovascular and bleeding complications. The results were consistent across several patient risk categories.
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Affiliation(s)
- Giuseppe De Luca
- Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy.
| | - Monica Verdoia
- Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | | | | | | | - Nuccia Morici
- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Irene Bossi
- ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | | | | | | | | | | | | | | | | | | | - Elena Corrada
- HumanitasClinical and Research Center, Rozzano, Italy
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18
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Sun Y, Venugopal J, Guo C, Fan Y, Li J, Gong Y, Chen YE, Zhang H, Eitzman DT. Clopidogrel Resistance in a Murine Model of Diet-Induced Obesity Is Mediated by the Interleukin-1 Receptor and Overcome With DT-678. Arterioscler Thromb Vasc Biol 2020; 40:1533-1542. [PMID: 32268786 DOI: 10.1161/atvbaha.120.314146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Clopidogrel is a commonly used P2Y12 inhibitor to treat and prevent arterial thrombotic events. Clopidogrel is a prodrug that requires bioactivation by CYP (cytochrome P450) enzymes to exert antiplatelet activity. Diabetes mellitus is associated with an increased risk of ischemic events, and impaired ability to generate the active metabolite (AM) from clopidogrel. The objective of this study is to identify the mechanism of clopidogrel resistance in a murine model of diet-induced obesity (DIO). Approach and Results: C57BL/6J mice and IL-1R-/- mice were given high-fat diet for 10 weeks to generate a murine model of diet-induced obesity. Platelet aggregation and carotid arterial thrombosis were assessed in response to clopidogrel treatment. Wild-type DIO mice exhibited resistance to antiplatelet and antithrombotic effects of clopidogrel that was associated with reduced hepatic expression of CYP genes and reduced generation of the AM. IL (Interleukin)-1 receptor-deficient DIO (IL1R-/- DIO) mice showed no resistance to clopidogrel. Lack of resistance was accompanied by increased exposure of the clopidogrel AM. This resistance was also absent when wild-type DIO mice were treated with the conjugate of the clopidogrel AM, DT-678. CONCLUSIONS These findings indicate that antiplatelet effects of clopidogrel may be impaired in the setting of diabetes mellitus due to reduced prodrug bioactivation related to IL-1 receptor signaling. Therapeutic targeting of P2Y12 in patients with diabetes mellitus using the conjugate of clopidogrel AM may lead to improved outcomes.
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Affiliation(s)
- Yifang Sun
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.).,Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, China (Y.S.)
| | - Jessica Venugopal
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.)
| | - Chiao Guo
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.)
| | - Yanbo Fan
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.)
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China (J.L., Y.G.)
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China (J.L., Y.G.)
| | - Y Eugene Chen
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.)
| | - Haoming Zhang
- Department of Pharmacology, University of Michigan, Ann Arbor (H.Z.)
| | - Daniel T Eitzman
- From the Department of Internal Medicine, Cardiovascular Research Center, University of Michigan Medical Center, Ann Arbor (Y.S., J.V., C.G., Y.F., Y.E.C., D.T.E.)
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Walker J, Cattaneo M, Badimon L, Agnelli G, Chan AT, Lanas A, Rocca B, Rothwell P, Patrignani P, Langley R, Vilahur G, Cosentino F. Highlights from the 2019 International Aspirin Foundation Scientific Conference, Rome, 28 June 2019: benefits and risks of antithrombotic therapy for cardiovascular disease prevention. Ecancermedicalscience 2020; 14:998. [PMID: 32153653 PMCID: PMC7032943 DOI: 10.3332/ecancer.2020.998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Indexed: 12/16/2022] Open
Abstract
At the 2019 International Aspirin Foundation Scientific Conference 'Benefits and Risks of Antithrombotic Therapy for Cardiovascular Disease Prevention', held in Rome, Italy, international experts sought to discuss and debate the optimal antithrombotic strategy for the secondary prevention of cardiovascular disease (CVD) and to seek agreement around dosing and target populations for aspirin use in primary disease prevention. Getting the best evidence to support real-life decisions in the clinic can be complex, and individualising management in order to balance both the risks and benefits of different disease prevention strategies appears to be the best approach. It is hoped that future decision-making tools and biomarkers will help direct treatments at those most likely to benefit.
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Affiliation(s)
- Jaqui Walker
- International Aspirin Foundation, 34 Bower Mount Road, Maidstone, Kent ME16 8AU, UK
| | - Marco Cattaneo
- Medicina 2, ASST Santi Paolo e Carlo, Milan, Italy - Dipartimento di Science della Salute, Università degli studi di Milano, 20122 Milan, Italy
| | - Lina Badimon
- Cardiovascular Program-ICCC, IR-Hospital de la Santa Creu, I Sant Pau and CiberCV, 08041 Barcelona, Spain
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine-Stroke Unit, University of Perugia, 06123 Perugia, Italy
| | - Andrew T Chan
- Clinical and Translational Epidemiology Unit, Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School
| | - Angel Lanas
- University of Zaragoza, 50009 Zaragoza, Spain
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Peter Rothwell
- Centre for the Prevention of Stroke and Dementia and Professor of Clinical Neurology, Oxford, UK
| | - Paola Patrignani
- Department of Neuroscience, Imaging and Clinical Sciences, and CeSI-MeT, 'G.d'Annunizio' University, School of Medicine, Chieti, Italy
| | - Ruth Langley
- MRC Clinical Trials Unit at UCL, WC1V 6LJ London, UK
| | - Gemma Vilahur
- Cardiovascular Program ICCC-Research Institute Hospital de la Santa Creu I Sant Pau, IIB-Sant Pau, 08041 Barcelona, Spain and CiberCV, Institute Carlos III, 28903 Madrid, Spain
| | - Francesco Cosentino
- Unit of Cardiology, Department of Medicine, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Deharo P, Cuisset T. Monitoring platelet function: what have we learned from randomized clinical trials? Cardiovasc Diagn Ther 2018; 8:621-629. [PMID: 30498686 PMCID: PMC6232346 DOI: 10.21037/cdt.2018.10.10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 01/27/2023]
Abstract
Dual antiplatelet therapy, with aspirin plus a P2Y12 inhibitor agent, remains the cornerstone treatment after percutaneous coronary intervention. However, significant proportion of patients did experience recurrent ischemic events on aspirin plus clopidogrel and the concept of non-response to P2Y12 inhibitor emerged. Evaluation of platelet reactivity has known a promising era aiming to improve platelet inhibition conferred by clopidogrel. Then, the development of more potent antiplatelet agents (i.e., prasugrel and ticagrelor) shifted the concern to excessive platelet inhibition and increased risk of bleeding. Therefore, personalized antiplatelet therapy according to platelet function testing has been tested in several randomized trials for both escalation and de-escalation of antiplatelet regimen. This review aims to report the evidence from randomized trials in this field and upcoming roles for platelet function testing.
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Affiliation(s)
- Pierre Deharo
- Département de Cardiologie, CHU Timone, Marseille, France
- UMR MD2, Aix-Marseille Université, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
| | - Thomas Cuisset
- Département de Cardiologie, CHU Timone, Marseille, France
- Faculté de Médecine, Aix-Marseille Université, Marseille, France
- Aix Marseille University, Inserm, Inra, C2VN, Marseille, France
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21
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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22
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Ma Y, Liu Y, Xu J, Wang Y, Wang Y, Du F. Effect of dual antiplatelet on recurrent stroke in minor stroke or TIA depends on bodyweight. Ther Clin Risk Manag 2018; 14:861-870. [PMID: 29773949 PMCID: PMC5947844 DOI: 10.2147/tcrm.s156694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective To assess whether bodyweight influences the efficacy and safety of dual antiplatelet therapy (DAT) in male patients with minor stroke or transient ischemic attack patients. Materials and methods All 3,420 male participants coming from the Clopidogrel in High-Risk Patients with Acute Non-disabling Cerebrovascular Events trial were divided into 3 groups based on bodyweight (<65 kg, 65–75 kg, and ≥75 kg). The stroke outcomes included stroke recurrence, combined vascular events, and bleeding events during 90 days of follow-up. The interaction of the treatment effects of DAT among patients with different bodyweight was assessed by Cox proportional hazards models. Results DAT is superior to mono antiplatelet therapy (MAT) for reducing stroke recurrence among patients with weight <65 kg (5.0% vs 11.7%; hazard ratio [HR], 0.41; 95% CI: 0.22–0.76) and 65–75 kg (6.7% vs 10.8%, HR, 0.62; 95% CI: 0.43–0.89). However, no significant difference was found in stroke recurrence between DAT and MAT in patients with weight ≥75 kg (9.4% vs 11.6%; HR, 0.80; 95% CI: 0.58–1.10). A significant interaction was observed between weight and antiplatelet therapy on stroke recurrence (p<0.05). Similar result was found for combined vascular events. More bleeding events were found in DAT group among patients with <65 kg (3.7% vs 2.2%), but with no significant difference. Conclusion DAT does not show benefit in patients with higher weight, compared with MAT. Bleeding events found in the DAT group were not more than the MAT group among patients with lower weight. Clinical trial registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00979589.
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Affiliation(s)
- Yan Ma
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jie Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Fenghe Du
- Department of Cardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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23
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The effect of CYP2C19 genetic polymorphism and non-genetic factors on clopidogrel platelets inhibition in East Asian coronary artery disease patients. Thromb Res 2017; 158:22-24. [PMID: 28802144 DOI: 10.1016/j.thromres.2017.07.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/29/2017] [Accepted: 07/31/2017] [Indexed: 11/20/2022]
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24
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Olędzki S, Kornacewicz-Jach Z, Safranow K, Kiedrowicz R, Gawrońska-Szklarz B, Jastrzębska M, Gorący J. Variability of platelet response to clopidogrel is not related to adverse cardiovascular events in patients with stable coronary artery disease undergoing percutaneous coronary intervention. Eur J Clin Pharmacol 2017; 73:1085-1094. [PMID: 28589365 DOI: 10.1007/s00228-017-2271-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/22/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Antiplatelet response to clopidogrel and its influence upon the risk of cardiovascular adverse events among patients with stable coronary artery disease undergoing percutaneous coronary intervention (PCI) has not been investigated fully. METHODS Two hundred eleven patients treated with aspirin and clopidogrel were included in the study. Immediately before PCI, residual platelet reactivity testing with impedance aggregometry assay and a single-nucleotide polymorphism genotyping analysis targeting variants of CYP2C19, ABCB1, and PON1 genes was performed. After the index PCI, the patients were screened for cardiovascular events 6 months following bare-metal stent implantation or 12 months following drug-eluting stent implantation. RESULTS High on-treatment platelet reactivity (HTPR) was observed in 19.43% individuals and low-TPR (LTPR) in 26.54%. In multivariate analysis, HTPR was significantly (p < 0.05) associated with a history of diabetes, higher systolic blood pressure, and platelet count comparing to that of other patients. LTPR was significantly associated with no history of hypertension, younger age, lower platelet count, absence of the CYP2C19*2 variant, and lower CRP plasma level. Overall, cardiac adverse events were noted in 14.23% patients. Survival analysis with the Cox proportional hazard model showed no influence of residual platelet reactivity during clopidogrel therapy upon both ischemic and hemorrhagic events. However, significant predictors for composite of major adverse cardiac events and hospitalization for cardiovascular causes were identified (the higher CCS class prior to coronary intervention and the higher creatinine serum concentration). CONCLUSIONS The platelet response to clopidogrel has no impact upon post-procedural adverse events at mid-term follow-up in patients with stable CAD undergoing PCI. This finding suggests that routine platelet reactivity testing is not beneficial in this group of patients.
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Affiliation(s)
- Szymon Olędzki
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland.
| | - Zdzisława Kornacewicz-Jach
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Krzysztof Safranow
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Radosław Kiedrowicz
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Barbara Gawrońska-Szklarz
- Department of Pharmacokinetics and Therapeutic Drug Monitoring, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Maria Jastrzębska
- Department of Laboratory Diagnostics and Molecular Medicine, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
| | - Jarosław Gorący
- Department of Cardiology, Pomeranian Medical University, 72 Powstancow Wlkp Str, 70-111, Szczecin, Poland
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25
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Winter MP, Grove EL, De Caterina R, Gorog DA, Ahrens I, Geisler T, Gurbel PA, Tantry U, Navarese EP, Siller-Matula JM. Advocating cardiovascular precision medicine with P2Y12 receptor inhibitors. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2017; 3:221-234. [DOI: 10.1093/ehjcvp/pvw044] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 12/30/2016] [Indexed: 12/13/2022]
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26
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Platelet reactivity after administration of third generation P2Y12-antagonists does not depend on body weight in contrast to clopidogrel. J Thromb Thrombolysis 2016; 42:84-9. [DOI: 10.1007/s11239-016-1340-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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27
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Schoos MM, Dangas GD, Mehran R, Kirtane AJ, Yu J, Litherland C, Clemmensen P, Stuckey TD, Witzenbichler B, Weisz G, Rinaldi MJ, Neumann FJ, Metzger DC, Henry TD, Cox DA, Duffy PL, Brodie BR, Mazzaferri EL, Maehara A, Stone GW. Impact of Hemoglobin A1c Levels on Residual Platelet Reactivity and Outcomes After Insertion of Coronary Drug-Eluting Stents (from the ADAPT-DES Study). Am J Cardiol 2016; 117:192-200. [PMID: 26639039 DOI: 10.1016/j.amjcard.2015.10.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/24/2015] [Accepted: 10/24/2015] [Indexed: 11/19/2022]
Abstract
An increasing hemoglobin A1c (HbA1c) level portends an adverse cardiovascular prognosis; however, the association between glycemic control, platelet reactivity, and outcomes after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is unknown. We sought to investigate whether HbA1c levels are associated with high platelet reactivity (HPR) in patients loaded with clopidogrel and aspirin, thereby constituting an argument for intensified antiplatelet therapy in patients with poor glycemic control. In the prospective, multicenter Assessment of Dual Antiplatelet Therapy With Drug Eluting Stents registry, HbA1c levels were measured as clinically indicated in 1,145 of 8,582 patients, stratified by HbA1c <6.5% (n = 551, 48.12%), 6.5% to 8.5% (n = 423, 36.9%), and >8.5% (n = 171, 14.9%). HPR on clopidogrel and aspirin was defined after PCI as P2Y12 reaction units (PRU) >208 and aspirin reaction units >550, respectively. HPR on clopidogrel was frequent (48.3%), whereas HPR on aspirin was not (3.9%). Patients with HbA1c >8.5% were younger, more likely non-Caucasian, had a greater body mass index, and more insulin-treated diabetes and acute coronary syndromes. Proportions of PRU >208 (42.5%, 50.2%, and 62.3%, p <0.001) and rates of definite or probable stent thrombosis (ST; 0.9%, 2.7%, and 4.2%, p = 0.02) increased progressively with HbA1c groups. Clinically relevant bleeding was greatest in the intermediate HbA1c group (8.2% vs 13.1% vs 9.5%, p = 0.04). In adjusted models that included PRU, high HbA1c levels (>8.5) remained associated with ST (hazard ratio 3.92, 95% CI 1.29 to 12.66, p = 0.02) and cardiac death (hazard ratio 4.24, 95% CI 1.41 to 12.70) but not bleeding at 2-year follow-up. There was no association between aspirin reaction units >550 and HbA1c levels. In conclusion, in this large-scale study, HbA1c and HPR were positively associated, but the clinical effect on adverse outcome was driven by poor glycemic control, which predicted ST and cardiac death after PCI regardless of PRU levels, warranting efforts to improve glycemic control after DES implantation in patients with diabetes mellitus.
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Affiliation(s)
- Mikkel M Schoos
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Ajay J Kirtane
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Jennifer Yu
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Prince of Wales Clinical School, Randwick, New South Wales, Australia
| | - Claire Litherland
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Peter Clemmensen
- Department of Cardiology, Nykoebing F Hospital, Institute of Regional Health Research, University of Southern Denmark, Denmark
| | - Thomas D Stuckey
- LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina
| | | | - Giora Weisz
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York; Els & Charles Bendheim Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Michael J Rinaldi
- Sanger Heart & Vascular Institute/Carolinas HealthCare System, Charlotte, North Carolina
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany
| | | | - Timothy D Henry
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota; Cedars-Sinai Medical Center, Los Angeles, California
| | - David A Cox
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Peter L Duffy
- Reid Heart Center, FirstHealth of the Carolinas, Pinehurst, North Carolina
| | - Bruce R Brodie
- LeBauer Cardiovascular Research Foundation/Cone Health, Greensboro, North Carolina
| | | | - Akiko Maehara
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Center for Interventional Vascular Therapy, Division of Cardiology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York.
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28
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Body Mass Index and Platelet Reactivity During Dual Antiplatelet Therapy With Clopidogrel or Ticagrelor. J Cardiovasc Pharmacol 2015; 66:364-70. [DOI: 10.1097/fjc.0000000000000288] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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29
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Abstract
Antiplatelet therapy has become a cornerstone in the management of many vascular diseases. With growing antiplatelet options, attention has focused on their comparative effectiveness in specific patient populations. Perhaps one of the least defined factors influencing efficacy of these agents is body mass and obesity. Evidence from preclinical models established that obesity promotes inflammation that in turn enhances platelet reactivity. Thus, adiposity has the potential to diminish or alter the therapeutic effect of antiplatelet therapy. Pharmacodynamic analyses suggest a potential need for dose adjustments of antiplatelet therapy in obese patients. Yet, obese patients paradoxically have better outcomes after acute coronary syndromes. In this review, we identify a critical need for clinical studies with outcome data to enable the development of recommendations for optimal antiplatelet regimens in obese individuals. Until such data exists, healthcare providers should be aware of the potential impact of obesity on the efficacy of anti-platelet therapy.
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30
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Kupstyte N, Zaliunas R, Tatarunas V, Skipskis V, Zaliaduonyte-Peksiene D, Grabauskyte I, Dovidaitiene D, Bumblauskas K, Gustiene O, Lesauskaite V. Effect of clinical factors and gene polymorphism of CYP2C19*2, *17 and CYP4F2*3 on early stent thrombosis. Pharmacogenomics 2015; 16:181-9. [DOI: 10.2217/pgs.14.165] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim: To determine the main clinical and genetic factors having impact on early coronary stent thrombosis. Materials & methods: Genotyping of CYP2C19*2, *17 and CYP4F2*3 in patients with (n = 31) and without stent thrombosis (n = 456) was performed. Clinical and genetic data were analyzed by binary logistic regression. Results: Smoking (OR: 0.317; 95% CI: 0.131–0.767), high-density lipoprotein level in mmol/l (OR: 0.142; 95% CI: 0.040–0.506), CYP2C19*2*2 versus *1*1 and *1*2 genotype (OR: 11.625; 95% CI: 3.498–38.633), CYP4F2 AA versus GA and GG genotype (OR: 3.532; 95% CI: 1.153–10.822) were associated with early stent thrombosis. Conclusion: For the first time we have identified a clinically important polymorphism (CYP4F2 G1347A) that was independently associated with early stent thrombosis. Original submitted 18 August 2014; Revision submitted 10 November 2014
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Affiliation(s)
- Nora Kupstyte
- Institute of Cardiology of Lithuanian University of Health Sciences, Sukileliu 17, Kaunas, LT 50009, Lithuania
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Remigijus Zaliunas
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Vacis Tatarunas
- Institute of Cardiology of Lithuanian University of Health Sciences, Sukileliu 17, Kaunas, LT 50009, Lithuania
| | - Vilius Skipskis
- Institute of Cardiology of Lithuanian University of Health Sciences, Sukileliu 17, Kaunas, LT 50009, Lithuania
| | - Diana Zaliaduonyte-Peksiene
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Ingrida Grabauskyte
- Institute of Cardiology of Lithuanian University of Health Sciences, Sukileliu 17, Kaunas, LT 50009, Lithuania
| | - Dovile Dovidaitiene
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Karolis Bumblauskas
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Olivija Gustiene
- Department of Cardiology of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas, LT 50009, Lithuania
| | - Vaiva Lesauskaite
- Institute of Cardiology of Lithuanian University of Health Sciences, Sukileliu 17, Kaunas, LT 50009, Lithuania
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31
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Obesity and coronary artery disease: evaluation and treatment. Can J Cardiol 2014; 31:184-94. [PMID: 25661553 DOI: 10.1016/j.cjca.2014.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 12/10/2014] [Accepted: 12/10/2014] [Indexed: 02/06/2023] Open
Abstract
With the increasing prevalence of obesity, clinicians are now facing a growing population of patients with specific features of clinical presentation, diagnostic challenges, and interventional, medical, and surgical management. After briefly discussing the effect of obesity on atherosclerotic burden in this review, we will focus on strategies clinicians might use to ensure better outcomes when performing revascularization in obese and severely obese patients. These patients tend to present comorbidities at a younger age, and their anthropometric features might limit the use of traditional cardiovascular risk stratification approaches for ischemic disease. Alternative techniques have emerged, especially in nuclear medicine. Positron emission tomography-computed tomography might be the diagnostic imaging technique of choice. When revascularization is considered, features associated with obesity must be considered to guide therapeutic strategies. In percutaneous coronary intervention, a radial approach should be favoured, and adequate antiplatelet therapy with new and more potent agents should be initiated. Weight-based anticoagulation should be contemplated if needed, with the use of drug-eluting stents. An "off-pump" approach for coronary artery bypass grafting might be preferable to the use of cardiopulmonary bypass. For patients who undergo bilateral internal thoracic artery grafting, harvesting using skeletonization might prevent deep sternal wound infections. In contrast to percutaneous coronary intervention, lower surgical bleeding has been observed when lean body mass is used for perioperative heparin dose determination.
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32
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Deharo P, Pankert M, Bonnet G, Quilici J, Bassez C, Morange P, Alessi MC, Bonnet JL, Cuisset T. Body mass index has no impact on platelet inhibition induced by ticagrelor after acute coronary syndrome, conversely to prasugrel. Int J Cardiol 2014; 176:1200-2. [DOI: 10.1016/j.ijcard.2014.07.228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022]
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33
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Single nucleotide polymorphism of CYP3A5*3 contributes to clopidogrel resistance in coronary artery disease patients among Tamilian population. Mol Biol Rep 2014; 41:7265-71. [PMID: 25112801 DOI: 10.1007/s11033-014-3613-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
Clopidogrel is an antiplatelet drug. It is used for the treatment as well as for the prophylaxis of coronary artery disease. Clopidogrel resistance is an emerging problem in clinical settings. The aim of the present study was to evaluate the effect of CYP3A5*3 genetic polymorphism on clopidogrel resistance. One hundred and forty-seven patients from outpatient Department of Cardiology on 75 mg/day of clopidogrel as maintenance dose were recruited from April 2010 to July 2011. All subjects gave written informed consent to participate in the study. DNA extraction was performed using phenol chloroform extraction procedure and genotyping by standard Taqman based RT-PCR method. Platelet aggregation was done at the end of 7th and 14th day by using chronolog lumi Aggregometer which is expressed as impedance in ohms. Impedance values of >5 ohms at the end of 6 min were considered as clopidogrel resistance. Subjects (N = 147) were analysed for CYP3A5*3 polymorphism, of which 49 (33%) were found to be clopidogrel resistant. Homomutants of CYP3A5*3 gene had 2.78 (0.97-7.98; p < 0.05) fold risk and heteromutants had 2.4 (0.93-6.46; p < 0.05) fold risk of developing clopidogrel resistance. Carriers of defective allele G of CYP3A5*3 had higher propensity to cause clopidogrel resistance with an odds ratio of 1.63. Variant alleles and genotypes of CYP3A5*3 polymorphism contributed significantly to clopidogrel resistance with a higher odds ratio. Thus, pharmacogenomics paves way for the emergence of stratified medicine in clopidogrel therapy and personalised pharmacotherapy in ischaemic heart disease.
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