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Wang ZD, Chen YX, Liu M, Li P, Liang XW, Zhu XZ, Xie WC, Liao W. Safety of Bivalirudin Combined with Ticagrelor in the Emergency PCI in Patients with Acute ST-Segment Elevation Myocardial Infarction. Clin Appl Thromb Hemost 2022; 28:10760296221077973. [PMID: 36520539 PMCID: PMC9768824 DOI: 10.1177/10760296221077973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE The present study aimed to investigate the application safety of bivalirudin combined with ticagrelor in the emergency percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). METHODS From October 1, 2018, to December 30, 2019, 210 patients with STEMI admitted to the Department of Cardiology who underwent emergency PCI were randomly divided into the bivalirudin group (group A, N = 105) and the unfractionated heparin group (group B, N = 105). Before the emergency PCI operation after admission, the loading dose of aspirin (300 mg) was given orally, and then 100 mg/d. At the same time, the loading dose of ticagrelor (180 mg) was administered orally, and then 90 mg/bid. The adverse events and the hemorrhage events 30 days after the operation were observed and recorded. RESULTS There were five hemorrhage cases in the bivalirudin group, with one case of secondary hemorrhage and four cases of mild hemorrhage. There were 14 hemorrhages in the unfractionated heparin group with one case of secondary hemorrhage and thirteen cases of mild hemorrhage. In terms of mild hemorrhage, the hemorrhage rate in the bivalirudin group was significantly lower than that in the unfractionated heparin group (3.8% vs. 12.4%, P = 0.040). One patient died in the unfractionated heparin group, while no deaths occurred in the bivalirudin group during the thirty days of follow-up. No myocardial infarction, revascularization, or stroke occurred in the two groups within 30 days after the operation. CONCLUSION Compared with unfractionated heparin combined with ticagrelor in patients with STEMI undergoing emergency PCI treatment, bivalirudin combined with ticagrelor could significantly reduce the occurrence of mild hemorrhage events, and it would not increase the incidence of MACE during the 30 days of follow-up.
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Affiliation(s)
- Zheng-Dong Wang
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Yu-Xiang Chen
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Ming Liu
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Ping Li
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China,Ping Li, Department of Cardiology,Yulin First People's Hospital(The Sixth Affiliated Hospital of Guangxi Medical University), No.495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China.
| | - Xiang-Wen Liang
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Xian-Zhang Zhu
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Wen-Chao Xie
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
| | - Wang Liao
- Yulin First People's Hospital (The Sixth Affiliated Hospital of Guangxi Medical University), No. 495 Education Middle Road, Yuzhou District, Yulin 537000, Guangxi, China
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Smits PC, Frigoli E, Vranckx P, Ozaki Y, Morice MC, Chevalier B, Onuma Y, Windecker S, Tonino PAL, Roffi M, Lesiak M, Mahfoud F, Bartunek J, Hildick-Smith D, Colombo A, Stankovic G, Iñiguez A, Schultz C, Kornowski R, Ong PJL, Alasnag M, Rodriguez AE, Paradies V, Kala P, Kedev S, Al Mafragi A, Dewilde W, Heg D, Valgimigli M. Abbreviated Antiplatelet Therapy After Coronary Stenting in Patients With Myocardial Infarction at High Bleeding Risk. J Am Coll Cardiol 2022; 80:1220-1237. [PMID: 36137672 DOI: 10.1016/j.jacc.2022.07.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/01/2022] [Accepted: 07/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The optimal duration of antiplatelet therapy (APT) after coronary stenting in patients at high bleeding risk (HBR) presenting with an acute coronary syndrome remains unclear. OBJECTIVES The objective of this study was to investigate the safety and efficacy of an abbreviated APT regimen after coronary stenting in an HBR population presenting with acute or recent myocardial infarction. METHODS In the MASTER DAPT trial, 4,579 patients at HBR were randomized after 1 month of dual APT (DAPT) to abbreviated (DAPT stopped and 11 months single APT or 5 months in patients with oral anticoagulants) or nonabbreviated APT (DAPT for minimum 3 months) strategies. Randomization was stratified by acute or recent myocardial infarction at index procedure. Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes events (NACE); major adverse cardiac and cerebral events (MACCE); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. RESULTS NACE and MACCE did not differ with abbreviated vs nonabbreviated APT regimens in patients with an acute or recent myocardial infarction (n = 1,780; HR: 0.83; 95% CI: 0.61-1.12 and HR: 0.86; 95% CI: 0.62-1.19, respectively) or without an acute or recent myocardial infarction (n = 2,799; HR: 1.03; 95% CI: 0.77-1.38 and HR: 1.13; 95% CI: 0.80-1.59; Pinteraction = 0.31 and 0.25, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding was significantly reduced in patients with or without an acute or recent myocardial infarction (HR: 0.65; 95% CI: 0.46-0.91 and HR: 0.71; 95% CI: 0.54-0.92; Pinteraction = 0.72) with abbreviated APT. CONCLUSIONS A 1-month DAPT strategy in patients with HBR presenting with an acute or recent myocardial infarction results in similar NACE and MACCE rates and reduces bleedings compared with a nonabbreviated DAPT strategy. (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).
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Affiliation(s)
- Pieter C Smits
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands.
| | - Enrico Frigoli
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | | | - Bernard Chevalier
- Ramsay Générale de Santé, Interventional Cardiology Department, Institut Cardiovasculaire Paris Sud, Massy, France
| | | | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Marco Roffi
- Division of Cardiology, Geneva University Hospitals, Geneva, Switzerland
| | - Maciej Lesiak
- 1st Department of Cardiology, University of Medical Sciences, Poznan, Poland
| | - Felix Mahfoud
- Department of Cardiology, Angiology, Intensive Care Medicine, Saarland University, Homburg, Germany
| | | | - David Hildick-Smith
- Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Antonio Colombo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan and Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Carl Schultz
- Department of Cardiology, Royal Perth Hospital Campus, University of Western Australia, Perth, Western Australia, Australia
| | - Ran Kornowski
- Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Mirvat Alasnag
- Cardiac Center, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Alfredo E Rodriguez
- Cardiac Unit Otamendi Hospital, Buenos Aires School of Medicine Cardiovascular Research Center (CECI), Buenos Aires, Argentina
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Petr Kala
- University Hospital Brno, Brno, Czech Republic
| | - Sasko Kedev
- University Clinic of Cardiology, Ss Cyril and Methodius University, Skopje, Macedonia
| | - Amar Al Mafragi
- Department of Cardiology, Zorgsaam Hospital, Terneuzen, the Netherlands
| | - Willem Dewilde
- Department of Cardiology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Dik Heg
- Clinical Trial Unit, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Università della Svizzera Italiana (USI), CH-6900 Lugano, Switzerland
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Yan Y, Gong W, Huang X, Li S, Wang G, Ma Y, Hao Y, Liu J, Nie S. Dual Loading Antiplatelet Therapy in Patients With Acute Coronary Syndrome and High Bleeding Risk Undergoing Percutaneous Coronary Intervention: Findings From the Improving Care for Cardiovascular Disease in China Project. Front Cardiovasc Med 2022; 9:774123. [PMID: 35402551 PMCID: PMC8984244 DOI: 10.3389/fcvm.2022.774123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveLoading dose of dual antiplatelet therapy (LD) is supported by the guidelines for patients with acute coronary syndrome (ACS). However, limited data is provided in the series of high bleeding risk (HBR) patients with ACS and percutaneous coronary intervention (PCI).MethodsUsing data from the Improving Care for Cardiovascular Disease in China—Acute Coronary Syndrome registry, conducted between 2014 and 2019, we stratified all ACS patients with HBR and PCI according to LD used within 24 h of first medical contact or not. Inverse probability of treatment weighting (IPTW) and Cox proportional hazards model with hospital as random effect were used to analyze differences in in-hospital clinical outcomes: the primary efficacy endpoint was mortality, and the primary safety endpoint was bleeding.ResultsOf 21,654 evaluable patients 14,322 (66.2%) were treated with LD, and were on average older, less likely to have comorbidities and higher hemoglobin, more often treated GPI and anticoagulant during hospitalization than those without LD. After IPTW adjustment for baseline differences, LD was associated with significantly increased risk of in-hospital mortality [1.89 vs. 1.02%; hazard ratio (HR): 1.71 (95% confidence interval 1.12, 2.42); p < 0.001] and in-hospital bleeding [3.89 vs. 3.3%; HR: 1.25 (1.03, 1.53); p = 0.03].ConclusionsIn ACS patients with HBR, LD was associated with an increased risk of in-hospital mortality and bleeding complications after PCI. Dedicated randomized trials with contemporary ACS management are needed to confirm these findings.
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Affiliation(s)
- Yan Yan
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Wei Gong
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Xin Huang
- Department of Cardiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Siyi Li
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Ge Wang
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Youcai Ma
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Shaoping Nie
- Department of Cardiology, Center for Coronary Artery Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
- *Correspondence: Shaoping Nie
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Wei P, Zhuo S, Fu Q, Wang H, Zong B, Cao B, Wang L. The efficacy and safety of the short-term combination therapy with ticagrelor and PPIs or H2RA in patients with acute STEMI who underwent emergency PCI. Clin Transl Sci 2021; 15:477-489. [PMID: 34670024 PMCID: PMC8841456 DOI: 10.1111/cts.13165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 08/31/2021] [Accepted: 09/05/2021] [Indexed: 11/27/2022] Open
Abstract
Combination therapy with platelet inhibitors and acid-suppressive agents is recommended for patients with acute ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI), but there remains a paucity of data to evaluate both the efficacy and safety of these combinations. In this prospective study, a total of 170 patients with acute STEMI who underwent PCI were divided into four groups: pantoprazole + ticagrelor, omeprazole + ticagrelor, ranitidine + ticagrelor, and ticagrelor only. The risk of PCI, antithrombotic efficacy, cardiac function, and main end points were evaluated and compared. No significant differences were found in infarction-related artery perfusion indexes (thrombolysis in myocardial infarction [TIMI], corrected TIMI frame count), the incidence of stent thrombosis after PCI, platelet indicators (platelet count, mean platelet volume, and platelet distribution width), platelet activation (P-selectin and glycoprotein IIb/IIIa levels), platelet aggregation (thrombelastography indicators, such as ADP% and MAADP ), myocardial necrosis biomarker (creatine kinase isoenzyme-MB and cardiac troponin I) levels, brain natriuretic peptide levels, the incidence of ischemic end point events, and the incidence of other tissue and organ bleeding events among the four groups. The incidence of gastrointestinal (GI) bleeding events in the proton pump-inhibitor (PPI) group was significantly lower than that in the control group, whereas in the H2 receptor antagonist (H2RA) group it was not significantly different from the control group. The short-term combination therapy with ticagrelor and PPIs or H2RA is safe and effective in patients with acute STEMI after PCI. In addition, the PPIs combined with ticagrelor could reduce the incidence of GI bleeding events without increasing the incidence of ischemic events.
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Affiliation(s)
- Peng Wei
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Shujiang Zhuo
- Department of Cardiology, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, China
| | - Qiang Fu
- Department of Cardiology, The Xuzhou School of Clinical Medicine of Nanjing Medical University, Xuzhou, Jiangsu, China
| | - Haibo Wang
- Department of Cardiology, The Xuzhou School of Clinical Medicine of Nanjing Medical University, Xuzhou, Jiangsu, China
| | - Bin Zong
- Department of Cardiology, The Xuzhou School of Clinical Medicine of Nanjing Medical University, Xuzhou, Jiangsu, China
| | - Bangming Cao
- Department of Cardiology, Yantai Affiliated Hospital of Binzhou Medical University, Yantai, China
| | - Liansheng Wang
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
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P2Y12 Inhibitor Monotherapy Versus Conventional Dual Antiplatelet Therapy or Aspirin Monotherapy in Acute Coronary Syndrome: A Pooled Analysis of the SMART-DATE and SMART-CHOICE Trials. Am J Cardiol 2021; 150:47-54. [PMID: 34011436 DOI: 10.1016/j.amjcard.2021.03.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 11/21/2022]
Abstract
Controversy remains regarding the optimal antiplatelet regimen in patients with acute coronary syndrome (ACS). This study sought to investigate the efficacy and safety of P2Y12 inhibitor monotherapy compared with conventional dual antiplatelet therapy (DAPT) and aspirin monotherapy in patients with ACS undergoing percutaneous coronary intervention. Data on 4,453 patients were pooled from SMART-DATE and SMART-CHOICE randomized trials. Antiplatelet therapy regimens were categorized as P2Y12 inhibitor monotherapy (P2Y12 inhibitor monotherapy after 3-month DAPT), conventional DAPT (12-month or longer DAPT), and aspirin monotherapy (aspirin monotherapy after 6-month DAPT). The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE, a composite of all-cause death, myocardial infarction, and stroke). Inverse-probability of treatment-weighted (IPTW) analysis was performed. At 1 year, patients in the P2Y12 inhibitor monotherapy had a comparable risk of MACCE compared with those in the conventional DAPT (IPTW-adjusted hazard ratio [HR], 0.655; 95% confidence interval [CI] 0.393 to 1.094; p = 0.106), and tended to have a lower risk of MACCE than those in the aspirin monotherapy (IPTW-adjusted HR, 0.606; 95% CI, 0.347 to 1.058; p = 0.078). The adjusted hazard for the Bleeding Academic Research Consortium (BARC) type 2 to 5 bleeding was significantly lower in P2Y12 inhibitor monotherapy than in conventional DAPT (IPTW-adjusted HR, 0.341; 95% CI, 0.190 to 0.614; p < 0.001) and in aspirin monotherapy (IPTW-adjusted HR, 0.359; 95% CI, 0.182 to 0.708; p = 0.003). In conclusion, among patients with ACS undergoing PCI, P2Y12 inhibitor monotherapy after 3-month DAPT reduced risk of bleeding compared with conventional DAPT and aspirin monotherapy after 6-month DAPT without increasing MACCE.
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Shima Y, Miura K, Shimada T, Ohya M, Murai R, Kubo S, Tada T, Tanaka H, Fuku Y, Kadota K. Impact of ischemic risk factors on long-term outcomes in patients with and without high bleeding risk. Int J Cardiol 2020; 326:12-18. [PMID: 33152414 DOI: 10.1016/j.ijcard.2020.10.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
Background The current guidelines have recommended to shorten the dual antiplatelet therapy duration in patients at high bleeding risk (HBR) to minimize the bleeding complications. The impact of ischemic risk factors (IRF) on long-term ischemic events in patients with and without HBR after percutaneous coronary intervention remains unclear. Methods The study population comprised 1219 patients who were treated with everolimus-eluting stents between 2010 and 2011. The mean follow-up period was 2996 ± 433 days. HBR was defined as set by the Academic Research Consortium. IRF was defined as high-risk features of stent-driven recurrent ischemic events endorsed in the 2017 European Society of Cardiology Guidelines. Major bleeding was defined as the occurrence of Bleeding Academic Research Consortium type 3 or 5 bleeding. Primary ischemic events included myocardial infarction, definite stent thrombosis, and cardiac death. Results The 1219 patients were divided into two groups: 614 patients at HBR (HBR group) and 605 patients at no HBR (non-HBR group). The rate of IRF patients was significantly higher in the HBR group than in the non-HBR group (81.4% versus 47.6%, P < 0.001). The cumulative rate of ischemic events in the HBR group was significantly higher in IRF patients than in non-IRF patients (21.0% versus 7.0%, log rank P < 0.001), whereas that in the non-HBR group was not significantly different between IRF and non-IRF patients (10.1% versus 6.3%, log rank P = 0.09). Conclusions More than 80% of HBR patients treated with everolimus-eluting stents were at IRF. A combination of HBR and IRF may increase the risk of long-term ischemic events.
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Affiliation(s)
- Yuki Shima
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan.
| | - Katsuya Miura
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takenobu Shimada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Syunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Takeshi Tada
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Hiroyuki Tanaka
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Yasushi Fuku
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710-8602, Japan
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Kim HS, Kang J, Hwang D, Han JK, Yang HM, Kang HJ, Koo BK, Rhew JY, Chun KJ, Lim YH, Bong JM, Bae JW, Lee BK, Park KW. Prasugrel-based de-escalation of dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (HOST-REDUCE-POLYTECH-ACS): an open-label, multicentre, non-inferiority randomised trial. Lancet 2020; 396:1079-1089. [PMID: 32882163 DOI: 10.1016/s0140-6736(20)31791-8] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND A potent P2Y12 inhibitor-based dual antiplatelet therapy is recommended for up to 1 year in patients with acute coronary syndrome receiving percutaneous coronary intervention (PCI). The greatest benefit of the potent agent is during the early phase, whereas the risk of excess bleeding continues in the chronic maintenance phase. Therefore, de-escalation of antiplatelet therapy might achieve an optimal balance between ischaemia and bleeding. We aimed to investigate the safety and efficacy of a prasugrel-based dose de-escalation therapy. METHODS HOST-REDUCE-POLYTECH-ACS is a randomised, open-label, multicentre, non-inferiority trial done at 35 hospitals in South Korea. We enrolled patients with acute coronary syndrome receiving PCI. Patients meeting the core indication for prasugrel were randomly assigned (1:1) to the de-escalation group or conventional group using a web-based randomisation system. The assessors were masked to the treatment allocation. After 1 month of treatment with 10 mg prasugrel plus 100 mg aspirin daily, the de-escalation group received 5 mg prasugrel, while the conventional group continued to receive 10 mg. The primary endpoint was net adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, repeat revascularisation, stroke, and bleeding events of grade 2 or higher according to Bleeding Academic Research Consortium [BARC] criteria) at 1 year. The absolute non-inferiority margin for the primary endpoint was 2·5%. The key secondary endpoints were efficacy outcomes (cardiovascular death, myocardial infarction, stent thrombosis, and ischaemic stroke) and safety outcomes (bleeding events of BARC grade ≥2). The primary analysis was in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, NCT02193971. RESULTS From Sept 30, 2014, to Dec 18, 2018, 3429 patients were screened, of whom 1075 patients did not meet the core indication for prasugrel and 16 were excluded due to randomisation error. 2338 patients were randomly assigned to the de-escalation group (n=1170) or the conventional group (n=1168). The primary endpoint occurred in 82 patients (Kaplan-Meier estimate 7·2%) in the de-escalation group and 116 patients (10·1%) in the conventional group (absolute risk difference -2·9%, pnon-inferiority<0·0001; hazard ratio 0·70 [95% CI 0·52-0·92], pequivalence=0·012). There was no increase in ischaemic risk in the de-escalation group compared with the conventional group (0·76 [0·40-1·45]; p=0·40), and the risk of bleeding events was significantly decreased (0·48 [0·32-0·73]; p=0·0007). INTERPRETATION In east Asian patients with acute coronary syndrome patients receiving PCI, a prasugrel-based dose de-escalation strategy from 1 month after PCI reduced the risk of net clinical outcomes up to 1 year, mainly driven by a reduction in bleeding without an increase in ischaemia. FUNDING Daiichi Sankyo, Boston Scientific, Terumo, Biotronik, Qualitech Korea, and Dio.
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Affiliation(s)
- Hyo-Soo Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jeehoon Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Doyeon Hwang
- Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Jae Kang
- Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Seoul National University Hospital, Seoul, South Korea
| | | | - Kook-Jin Chun
- Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Young-Hyo Lim
- Hanyang University Seoul Hospital, Seoul, South Korea
| | | | | | - Bong Ki Lee
- Kangwon National University, Chuncheon, South Korea
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Khalid N, Shlofmitz E, Chen Y, Case BC, Dheendsa A, Hashim H, Waksman R. Return of the Left Internal Mammary Artery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 23:119-120. [PMID: 32952076 DOI: 10.1016/j.carrev.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/14/2020] [Indexed: 10/23/2022]
Abstract
Competitive flow from a non-critical native vessel leading to longitudinal narrowing/atresia of the left internal mammary artery (LIMA) is described as "the string phenomenon." We describe spontaneous recanalization of an atretic LIMA following coronary artery bypass grafting for multivessel coronary artery disease.
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Affiliation(s)
- Nauman Khalid
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Evan Shlofmitz
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Yuefeng Chen
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Brian C Case
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Aaphtaab Dheendsa
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Hayder Hashim
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America.
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Lawson LO, Kirresh A, Shintre N. Letter by Lawson et al Regarding Article, "Clinical Usefulness of PRECISE-DAPT Score for Predicting Bleeding Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: An Analysis From the SMART-DATE Randomized Trial". Circ Cardiovasc Interv 2020; 13:e009612. [PMID: 32674677 DOI: 10.1161/circinterventions.120.009612] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Lucy Olivia Lawson
- Cardiology Department, Royal Free London NHS Foundation Trust, United Kingdom
| | - Ali Kirresh
- Cardiology Department, Royal Free London NHS Foundation Trust, United Kingdom
| | - Nidhi Shintre
- Cardiology Department, Royal Free London NHS Foundation Trust, United Kingdom
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