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Spartalis M, Tzatzaki E, Spartalis E, Paschou SA, Athanasiou A, Iliopoulos DC, Siasos G, Voudris V. Prasugrel in the treatment of acute coronary syndrome. Future Cardiol 2020; 16:559-568. [PMID: 32390477 DOI: 10.2217/fca-2020-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Dual antiplatelet therapy is the mainstay therapy in patients with acute coronary syndrome. The combination of aspirin and a P2Y12 inhibitor in patients who receive a coronary stent reduces the rate of stent thrombosis and the rates of major adverse cardiovascular events. The newer P2Y12 inhibitors (prasugrel and ticagrelor) have better efficacy than clopidogrel. Prasugrel provides greater inhibition of platelet aggregation and has a rapid onset of action. Current acute coronary syndrome guidelines recommend the use of both newer P2Y12 inhibitors. However, emerging data have shown that prasugrel is more efficient than ticagrelor in reducing the incidence of nonfatal myocardial infarction, stroke or cardiovascular death, without increased risk of major bleeding.
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Affiliation(s)
- Michael Spartalis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Stavroula A Paschou
- 1st Department of Cardiology, Hippokration Hospital, National & Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonios Athanasiou
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery & Surgical Research, University of Athens, Medical School, Athens, Greece
| | - Gerasimos Siasos
- 1st Department of Cardiology, Hippokration Hospital, National & Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
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Akita K, Inohara T, Yamaji K, Kohsaka S, Numasawa Y, Ishii H, Amano T, Kadota K, Nakamura M, Maekawa Y. Impact of reduced-dose prasugrel vs. standard-dose clopidogrel on in-hospital outcomes of percutaneous coronary intervention in 62 737 patients with acute coronary syndromes: a nationwide registry study in Japan. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:231-238. [DOI: 10.1093/ehjcvp/pvz056] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/01/2019] [Accepted: 10/02/2019] [Indexed: 11/14/2022]
Abstract
Abstract
Aims
In Japan, reduced-dose prasugrel (loading/maintenance dose, 20/3.75 mg) has been approved for use in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), because of the higher bleeding risk among East Asians. However, its safety in the real-world population has not been investigated. We aimed to evaluate the effectiveness and safety of reduced-dose prasugrel vs. standard-dose clopidogrel in ACS patients undergoing PCI.
Methods and results
Acute coronary syndrome patients who underwent PCI in 2016, who were treated with either reduced-dose prasugrel or standard-dose clopidogrel in addition to aspirin, were identified from the nationwide Japanese PCI registry. The primary outcome was in-hospital mortality following PCI. Secondary outcomes included stent thrombosis and bleeding complication after PCI. Among 62 737 ACS patients who underwent PCI at any of 986 participating centres across Japan (clopidogrel 31.9%; prasugrel 68.1%), we identified 12 016 propensity score-matched pairs (24 032 patients; age 69.4 ± 12.2 years; female 24.9%; ST-elevation myocardial infarction 42.3%). Compared with standard-dose clopidogrel, reduced-dose prasugrel was associated with increased risk of bleeding [odds ratio (OR) 1.65, 95% confidence interval (CI) 1.10–2.51; P = 0.016], but both had similar rates of mortality (OR 1.11, 95% CI 0.89–1.38; P = 0.371) and stent thrombosis (OR 1.29, 95% CI 0.73–2.30; P = 0.387) as well as similar falsification endpoints of cardiac tamponade and emergent operation.
Conclusion
In Japanese ACS patients undergoing PCI, the risk of bleeding is higher when using reduced-dose prasugrel than when using standard-dose clopidogrel, but there is no significant difference in in-hospital mortality and incidence of stent thrombosis between the two antiplatelet regimens.
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Affiliation(s)
- Keitaro Akita
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
- Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia V6N 3S9, Canada
| | - Kyohei Yamaji
- Division of Cardiology, Kokura Memorial Hospital, Kitakyushu 802-8555, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Yohei Numasawa
- Department of Cardiology, Japanese Red Cross Ashikaga Hospital, Ashikaga 326-0843, Japan
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya 466-8560, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Nagakute 480-1195, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki 710-8602, Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine, Toho University, Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu 431-3192, Japan
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Choi SY, Kim MH. Comparison of factors affecting platelet reactivity in various platelet function tests. Platelets 2018; 30:631-636. [PMID: 30059640 DOI: 10.1080/09537104.2018.1499887] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Previous studies have reported that various factors affect ADP-induced platelet reactivity during clopidogrel therapy. The aim of this study was to determine whether clinical and laboratory variables for platelet reactivity during dual antiplatelet therapy (DAPT) are dependent on the assay used. We enrolled 904 patients receiving DAPT following coronary intervention. Platelet reactivity was measured using three methods: the VerifyNow P2Y12 assay, multiple electrode aggregometry (MEA) ADP assay, and the light transmittance aggregometry (LTA) ADP assay at 24-48 h following coronary intervention. The VerifyNow results demonstrated a significant inverse correlation with hematocrit value (r = -0.268, p < 0.0001); however, MEA results had no such correlation with hematocrit (r = 0.044, p = 0.188). There was a positive correlation between the MEA results and platelet count (r = 0.255, p < 0.0001). LTA was weakly influenced by hematocrit (r = -0.064, p = 0.057) and platelet count (r = 0.069, p = 0.040). Gender (odds ratio 1.53, 95% CI 1.10-2.14, p = 0.013) and hematocrit (odds ratio 0.91,95% CI 0.88-0.94, p < 0.0001) were the independent variables for HPR by VerifyNow. Smoking (odds ratio 0.38, 95% CI 0.16-0.94, p = 0.036) and platelet count (odds ratio 1.01, 95% CI 1.00-1.01, p < 0.0001) were independent factors for HPR when using the MEA assay, whereas platelet count (odds ratio 1.00, 95% CI 1.00-1.01, p = 0.006) was identified as the only independent variable for HPR when using LTA. The incidence of HPR and the influencing variables involved are dependent on the platelet function test used.
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Affiliation(s)
- Sun Young Choi
- a Department of Cardiology , Dong-A University Hospital , Busan , South Korea.,b Department of Biomedical Laboratory Science , Daegu Health College , Daegu , South Korea
| | - Moo Hyun Kim
- a Department of Cardiology , Dong-A University Hospital , Busan , South Korea
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4
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Larsen PD, Holley AS, Sasse A, Al-Sinan A, Fairley S, Harding SA. Comparison of Multiplate and VerifyNow platelet function tests in predicting clinical outcome in patients with acute coronary syndromes. Thromb Res 2017; 152:14-19. [DOI: 10.1016/j.thromres.2017.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 01/31/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
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Helsby NA. CYP2C19 and CYP2D6 genotypes in Pacific peoples. Br J Clin Pharmacol 2016; 82:1303-1307. [PMID: 27304207 DOI: 10.1111/bcp.13045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 06/10/2016] [Accepted: 06/14/2016] [Indexed: 01/08/2023] Open
Abstract
The study of pharmacogenetic variants in populations which reside in Oceania has been focused mainly on CYP2C19 and CYP2D6. Statements about the high prevalence of CYP2C19 no function genotype in 'Pacific Islanders' can be found in the literature. This review article summarizes the published information about these pharmacogenes in this geographical region and highlights the differences observed between Melanesian and Polynesian populations. It is not appropriate to combine the prevalence data of pharmacogenetic variants, particularly CYP2C19, across this region. Indeed, apocryphal assumptions about CYP2C19 no function alleles and possible effect on the therapeutic activity of clopidogrel are unhelpful and reiterate the importance of assessing the individual patient rather than relying on inappropriate ethnicity-based assumptions for drug dosing decisions.
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Affiliation(s)
- Nuala A Helsby
- School of Medical Sciences, University of Auckland, New Zealand.
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6
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Larsen PD, Johnston LR, Holley A, La Flamme AC, Smyth L, Chua EW, Kennedy MA, Harding SA. Prevalence and significance of CYP2C19*2 and CYP2C19*17 alleles in a New Zealand acute coronary syndrome population. Intern Med J 2016; 45:537-45. [PMID: 25583161 DOI: 10.1111/imj.12698] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 01/04/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND High on-treatment platelet reactivity has been associated with poor outcomes following acute coronary syndromes (ACS). Both the loss of function CYP2C19*2 allele and the gain of function CYP2C19*17 allele along with a range of clinical characteristics have been associated with variation in the response to clopidogrel. AIM The study aims to examine the frequency of CYP2C19 variants and understand the factors associated with on-treatment platelet reactivity in a New Zealand ACS population. METHODS We prospectively enrolled 312 ACS patients. We collected clinical characteristics and measured on-treatment platelet reactivity using two validated point-of-care assays, VerifyNow and Multiplate. DNA was extracted and CYP2C19*2 and *17 alleles were identified using real-time polymerase chain reaction. RESULTS CYP2C19*2 or CYP2C19*17 alleles were observed in 101 (32%) and 106 (34%) of patients, respectively, with significant differences in distribution by ethnicity. In Maori and Pacific Island patients, 47% (confidence interval (CI) 31-63%) had CYP2C19*2 and 11% (CI 4-19%) CYP2C19*17 compared with 26% (CI 19-32%) and 41% (CI 32-49%) in white people. Carriage of CYP2C19*2 alleles was associated with higher levels of platelet reactivity measured by either assay, but we observed no relationship between platelet reactivity and CYP2C19*17. In multivariate analysis diabetes, clopidogrel dose and CYP2C19*2 status were all significant independent predictors of platelet reactivity. CONCLUSIONS Both CYP2C19*2 and *17 were common in a New Zealand ACS population, with CYP2C19*2 observed in almost half the Maori and Pacific Island patients. CYP2C19*2, diabetes and clopidogrel dose were independent contributors to on-treatment platelet reactivity.
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Affiliation(s)
- P D Larsen
- Wellington Cardiovascular Research Group, Wellington Hospital, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, New Zealand
| | - L R Johnston
- Wellington Cardiovascular Research Group, Wellington Hospital, Wellington, New Zealand.,School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - A Holley
- Wellington Cardiovascular Research Group, Wellington Hospital, Wellington, New Zealand.,School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - A C La Flamme
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - L Smyth
- Carney Centre for Pharmacogenomics, University of Otago, Christchurch, New Zealand
| | - E W Chua
- Carney Centre for Pharmacogenomics, University of Otago, Christchurch, New Zealand
| | - M A Kennedy
- Carney Centre for Pharmacogenomics, University of Otago, Christchurch, New Zealand
| | - S A Harding
- Wellington Cardiovascular Research Group, Wellington Hospital, Wellington, New Zealand.,Cardiology Department, Wellington Hospital, Wellington, New Zealand
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Anwar MS, Iskandar MZ, Parry HM, Doney AS, Palmer CN, Lang CC. The future of pharmacogenetics in the treatment of heart failure. Pharmacogenomics 2015; 16:1817-27. [DOI: 10.2217/pgs.15.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Heart failure is a common disease with high levels of morbidity and mortality. Current treatment comprises β-blockers, ACE inhibitors, aldosterone antagonists and diuretics. Variation in clinical response seen in patients begs the question of whether there is a pharmacogenetic component yet to be identified. To date, the genes most studied involve the β-1, β-2, α-2 adrenergic receptors and the renin-angiotensin-aldosterone pathway, mainly focusing on SNPs. However results have been inconsistent. Genome-wide association studies and next-generation sequencing are seen as alternative approaches to discovering genetic variations influencing drug response. Hopefully future research will lay the foundations for genotype-led drug management in these patients with the ultimate aim of improving their clinical outcome.
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Affiliation(s)
- Mohamed Subhan Anwar
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Muhammad Zaid Iskandar
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Helen M Parry
- Department of Pharmacogenetics & Pharmacogenomics, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Alex S Doney
- Department of Pharmacogenetics & Pharmacogenomics, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Colin N Palmer
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
| | - Chim C Lang
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, University of Dundee, Dundee, UK
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Huo Y, Thompson P, Buddhari W, Ge J, Harding S, Ramanathan L, Reyes E, Santoso A, Tam LW, Vijayaraghavan G, Yeh HI. Challenges and solutions in medically managed ACS in the Asia-Pacific region: expert recommendations from the Asia-Pacific ACS Medical Management Working Group. Int J Cardiol 2014; 183:63-75. [PMID: 25662044 DOI: 10.1016/j.ijcard.2014.11.195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 11/12/2014] [Accepted: 11/24/2014] [Indexed: 12/26/2022]
Abstract
Acute coronary syndromes (ACS) remain a leading cause of mortality and morbidity in the Asia-Pacific (APAC) region. International guidelines advocate invasive procedures in all but low-risk ACS patients; however, a high proportion of ACS patients in the APAC region receive solely medical management due to a combination of unique geographical, socioeconomic, and population-specific barriers. The APAC ACS Medical Management Working Group recently convened to discuss the ACS medical management landscape in the APAC region. Local and international ACS guidelines and the global and APAC clinical evidence-base for medical management of ACS were reviewed. Challenges in the provision of optimal care for these patients were identified and broadly categorized into issues related to (1) accessibility/systems of care, (2) risk stratification, (3) education, (4) optimization of pharmacotherapy, and (5) cost/affordability. While ACS guidelines clearly represent a valuable standard of care, the group concluded that these challenges can be best met by establishing cardiac networks and individual hospital models/clinical pathways taking into account local risk factors (including socioeconomic status), affordability and availability of pharmacotherapies/invasive facilities, and the nature of local healthcare systems. Potential solutions central to the optimization of ACS medical management in the APAC region are outlined with specific recommendations.
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Affiliation(s)
| | - Yong Huo
- Peking University First Hospital, Beijing, China.
| | - Peter Thompson
- University of Western Australia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - Wacin Buddhari
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Junbo Ge
- Zhongshan Hospital, Fudan University, Shanghai, China
| | - Scott Harding
- Wellington Cardiovascular Research Group and School of Biological Sciences, Victoria University, Wellington, New Zealand
| | | | - Eugenio Reyes
- University of the Philippines, Philippine General Hospital-Section of Cardiology, Manila, Philippines
| | - Anwar Santoso
- Department of Cardiology - Vascular Medicine, Faculty of Medicine, University of Indonesia and National Cardiovascular Center, Harapan Kita, Indonesia
| | | | | | - Hung-I Yeh
- Mackay Memorial Hospital, Mackay Medical College, New Taipei City, Taiwan
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