Clopidogrel resistance - a clear problem with an unclear solution

Genotype-guided antiplatelet therapy compared with standard therapy for patients with acute coronary syndromes or undergoing percutaneous coronary intervention: A systematic review and meta-analysis

OBJECTIVE

To determine, in patients with acute coronary syndromes (ACS) or undergoing percutaneous coronary intervention (PCI), the effectiveness and safety between personalized P2Y12 inhibitors treatment based on genotypes and standard treatment.

METHODS

We systematically searched for articles from PubMed, Cochrane Library, Embase and Web of science from their inception to March 4, 2020, with no language restrictions. The search was performed to identify all randomized clinical trials (RCTs) in which genotype-guided versus standard treatment with P2Y12 inhibitors among patients with ACS or those undergoing PCI. The primary clinical outcomes were major adverse cardiovascular events (MACEs) including death, myocardial infarction (MI), stroke, stent thrombosis (ST), and targeted vessel revascularization (TVR). The secondary outcomes were high on-treatment platelet reactivity (HTPR) and safety outcomes including major bleeding events.

RESULTS

A total of 4859 patients from 7 RCTs were included in the meta-analysis. There were 2430 patients (50.01%) allocated to the genotype-guided group and 2429 (49.99%) allocated to the standard group. Pooled result showed that compared with the standard treatment group, the genotype-guided group had a significantly lower risk of HTPR (Risk Ratio [RR]: 0.35, 95% confidence interval [CI]: 0.14-0.83, P = 0.02, I² = 58%), MI (RR: 0.52, 95% CI: 0.36-0.74, P = 0.0004, I² = 0%) and ST (RR: 0.41, 95% CI: 0.17-0.98, P = 0.05, I² = 0%). No significant difference was found between two groups for the risk of death (RR: 0.78, 95% CI: 0.54-1.12, P = 0.18, I² = 34%), stroke (RR = 0.67, 95% CI: 0.35-1.30, P = 0.24, I² = 0%), TVR (RR: 0.83, 95% CI: 0.46-1.50, P = 0.54, I² = 0%) and major bleeding events (RR: 0.83, 95% CI: 0.60-1.15, P = 0.25, I² = 0%).

CONCLUSIONS

Genotype-guided antiplatelet treatment could reduce the risk of HTPR, MI and ST compared with standard therapy in patients with ACS or undergoing PCI, and no significant difference was found between two groups in the major bleeding events.

A Review of Danshen Combined with Clopidogrel in the Treatment of Coronary Heart Disease

OBJECTIVE

Danshen, the root of Salvia miltiorrhiza Bunge, is a traditional herbal medicine in China, which has been used to treat irregular menstruation, cold hernia, and abdominal pain for thousands of years. Danshen is frequently used in combination with drugs to treat cardiovascular diseases. Clopidogrel is a commonly used drug for treating coronary heart disease, but clopidogrel resistance restricts its development. Therefore, the clinical efficacy of Danshen combined with clopidogrel treats coronary heart disease and the relationship between Danshen and clopidogrel metabolism enzymes is suggested for future investigations.

MATERIALS AND METHODS

The information was collected by searching online databases, and the RevMan 5.3 software was used to perform meta-analysis.

RESULTS

Twenty-two articles, including 2587 patients, were enrolled after the evaluation. Meta-analysis showed that Danshen combined with clopidogrel was more effective than clopidogrel alone in treating coronary heart disease by improving clinical curative effect, reducing the frequency of angina pectoris, improving electrocardiogram results, shortening the duration of angina pectoris, and easing adverse reactions. Danshen inhibited carboxylesterase 1 and most enzyme of cytochrome P450, especially cytochrome P450 1A2, which may affect the metabolism of clopidogrel.

CONCLUSION

Danshen combined with clopidogrel may compensate for individual differences of clopidogrel resistance among individuals in the treatment of coronary heart disease. Meanwhile, the inhibitory effect of Danshen on cytochrome P450 and carboxylesterase 1 could be partly responsible for the synergistic and attenuating effects of Danshen combined with clopidogrel.