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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024; 21:574-592. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Mostafa MR, Eid MM, Awad AK, Takla A, Hassan AR, Katamesh BE, AlBarakat MM, Ziada AR, Mohamed S, Al-Azizi KM, Goldsweig AM. Safety and Efficacy of Cangrelor in Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis. Am J Cardiovasc Drugs 2024; 24:71-81. [PMID: 37995040 DOI: 10.1007/s40256-023-00616-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION Cangrelor is a potent intravenous non-thienopyridine P2Y12 inhibitor. We conducted a network meta-analysis to study the efficacy and safety of cangrelor as compared with the oral P2Y12 inhibition, clopidogrel, or placebo in acute coronary syndromes. METHODS This meta-analysis followed the Cochrane collaboration guidelines and the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) protocols. Outcomes of interest included all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, major bleeding, minor bleeding, and the need for blood transfusion. RESULTS The analysis was comprised of 6 studies including 26,444 patients treated with cangrelor, clopidogrel, or placebo. There were no statistically significant differences in the incidence of all-cause mortality, myocardial infarction, stent thrombosis, target vessel revascularization, or major bleeding. Cangrelor was associated with a higher risk of minor bleeding than clopidogrel or placebo, with no difference in requiring blood transfusion. CONCLUSION Cangrelor has comparable outcomes to clopidogrel in patients with acute coronary syndromes and can be used as a reliable alternative in this population.
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Affiliation(s)
| | | | - Ahmed K Awad
- Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Andrew Takla
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | | | | | - Majd M AlBarakat
- Faculty of Medicine, Jordan University of Science and Technology, Amman, Jordan
| | | | | | - Karim M Al-Azizi
- Baylor Scott and White Health-The Heart Hospital, Plano, TX, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA, USA
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Ortega-Paz L, Giordano S, Franchi F, Rollini F, Pollack CV, Bhatt DL, Angiolillo DJ. Clinical and Pre-Clinical Pharmacokinetics and Pharmacodynamics of Bentracimab. Clin Pharmacokinet 2023; 62:673-692. [PMID: 37118383 DOI: 10.1007/s40262-023-01245-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/30/2023]
Abstract
Antiplatelet agents are among the most frequently used medications in cardiovascular medicine. Although in patients with atherosclerotic disease manifestations, in particular those treated by percutaneous coronary intervention, antiplatelet agents are beneficial for the prevention of ischemic events, they inevitably increase the risk of bleeding. Furthermore, 5-15% of patients treated by percutaneous coronary intervention may need a surgical procedure within 2 years, creating challenges to safe and effective antiplatelet drug management. Importantly, major spontaneous or procedural-related bleedings are associated with increased hospital admission, length, costs, and poor prognosis. Although the effects of other antithrombotic therapies, such as direct oral anticoagulants, can be reversed by approved specific agents, there are no approved reversal agents for any antiplatelet drugs. The fact that many antiplatelet agents, such as aspirin and thienopyridines (i.e., clopidogrel and prasugrel), bind irreversibly to their targets represents a challenge for the development of a drug-specific reversal agent. In contrast, ticagrelor is a non-thienopyridine with a plasma half-life of 7-9 h that reversely binds the P2Y12 receptor producing potent signaling blockage. In 2015, bentracimab (also known as PB2452 or MEDI2452), a neutralizing monoclonal antibody fragment that binds free plasma ticagrelor and its major active metabolite, was identified. This systematic overview provides a comprehensive summary of the drug development program of bentracimab, focusing on its pharmacodynamic, pharmacokinetic, and safety profiles.
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Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Salvatore Giordano
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
- Division of Cardiology, Department of Medical and Surgical Sciences, "Magna Graecia" University, Catanzaro, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MI, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, ACC Building 5th Floor, 655 West 8th Street, Jacksonville, FL, 32209, USA.
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Lim MJR, Zheng Y, Soh RYH, Foo QXJ, Djohan AH, Nga Diong Weng V, Ho JSY, Yeo TT, Sim HW, Yeo TC, Tan HC, Chan MYY, Loh JPY, Sia CH. Symptomatic intracerebral hemorrhage after non-emergency percutaneous coronary intervention: Incidence, risk factors, and association with cardiovascular outcomes. Front Cardiovasc Med 2022; 9:936498. [PMID: 36186990 PMCID: PMC9524143 DOI: 10.3389/fcvm.2022.936498] [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: 05/05/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Objective To investigate the incidence, risk factors, and association with cardiovascular outcomes of patients who developed symptomatic intracerebral hemorrhage (ICH) after non-emergency percutaneous coronary intervention (PCI). Methods We conducted a single-institution retrospective study of patients who developed symptomatic ICH after non-emergency PCI. To identify associations between clinical variables and outcomes, Cox-proportional hazards regression models were constructed. Outcomes analyzed include (1) all-cause mortality, (2) acute ischemic stroke (AIS) or transient ischemic attack (TIA), and (3) major adverse cardiovascular events (MACE). Results A total of 1,732 patients were included in the analysis. The mean (±SD) age was 61.1 (±11.3) years, and 1,396 patients (80.6%) were male. The cumulative incidence of symptomatic ICH after non-emergency PCI was 1.3% (22 patients). Age, chronic kidney disease, and prior coronary artery bypass graft surgery were independently associated with a higher risk of ICH after PCI, while hyperlipidemia was independently associated with a lower risk of ICH after PCI. ICH after PCI was independently associated with a higher risk of all-cause mortality and AIS or TIA after PCI. Conclusion Patients who are older, who have chronic kidney disease, and who have had prior coronary artery bypass graft surgery should be monitored for symptomatic ICH after non-emergency PCI.
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Affiliation(s)
- Mervyn Jun Rui Lim
- Division of Neurosurgery, National University Health System, Singapore, Singapore
- *Correspondence: Mervyn Jun Rui Lim
| | - Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Rodney Yu-Hang Soh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Qi Xuan Joel Foo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Jamie Sin-Ying Ho
- Academic Foundation Programme, North Middlesex University Hospital Trust, London, United Kingdom
| | - Tseng Tsai Yeo
- Division of Neurosurgery, National University Health System, Singapore, Singapore
| | - Hui-Wen Sim
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Huay-Cheem Tan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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O'Neill WW, Anderson M, Burkhoff D, Grines CL, Kapur NK, Lansky AJ, Mannino S, McCabe JM, Alaswad K, Daggubati R, Wohns D, Meraj PM, Pinto DS, Popma JJ, Moses JW, Schreiber TL, Magnus Ohman E. Improved outcomes in patients with severely depressed LVEF undergoing percutaneous coronary intervention with contemporary practices. Am Heart J 2022; 248:139-149. [PMID: 35192839 DOI: 10.1016/j.ahj.2022.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/16/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Contemporary practices for hemodynamically supported high-risk percutaneous coronary intervention have evolved over the last decade. This study sought to compare outcomes of the prospective, multicenter, PROTECT III study to historic patients treated with Impella in the PROTECT II randomized controlled trial. METHODS Of 1,134 patients enrolled in PROTECT III from March 2017 to March 2020, 504 were "PROTECT II-like" (met eligibility for PROTECT II randomized controlled trial) and are referred to as PROTECT III for comparative analysis. Major adverse cardiac and cerebrovascular events (MACCE), comprising all-cause mortality, stroke/transient ischemic attack, myocardial infarction, and repeat revascularization, were compared at hospital discharge and 90 days. RESULTS Compared with PROTECT II (N = 216), PROTECT III patients were less often Caucasian (77.1% vs 83.8%, P = .045), with less prior CABG (13.7% vs 39.4%; P < .001) and prior myocardial infarction (40.7% vs 69.3%; P < .001). More PROTECT III patients underwent rotational atherectomy (37.1% vs 14.8%, P < .001) and duration of support was longer (median 1.6 vs 1.3 hours; p<0.001), with greater improvement achieved in myocardial ischemia jeopardy scores (7.0±2.4 vs 4.4±2.9; P < .001) and SYNTAX scores (21.4±10.8 vs 15.7±9.5; P < .001). In-hospital bleeding requiring transfusion was significantly lower in PROTECT III (1.8% vs 9.3%; P < .001), as was procedural hypotension (2.2% vs 10.1%; P < .001) and cardiopulmonary resuscitation or ventricular arrhythmia (1.6% vs 6.9%; P < .001). At 90 days, MACCE was 15.1% and 21.9% in PROTECT III and PROTECT II, respectively (p=0.037). Following propensity score matching, Kaplan-Meier analysis showed improved 90-day MACCE rates in PROTECT III (10.4% vs 16.9%, P = .048). CONCLUSIONS The PROTECT III study demonstrates improved completeness of revascularization, less bleeding, and improved 90-day clinical outcomes compared to PROTECT II for Impella-supported high-risk percutaneous coronary intervention among patients with severely depressed LVEF.
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Affiliation(s)
| | - Mark Anderson
- Hackensack University Medical Center, Hackensack, NJ
| | | | | | | | | | | | | | | | | | - David Wohns
- Spectrum Health, Frederik Meijer Heart and Vascular Institute, Grand Rapids, MI
| | | | - Duane S Pinto
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Jeffrey J Popma
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Capodanno D, Bhatt DL, Gibson CM, James S, Kimura T, Mehran R, Rao SV, Steg PG, Urban P, Valgimigli M, Windecker S, Angiolillo DJ. Bleeding avoidance strategies in percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:117-132. [PMID: 34426673 DOI: 10.1038/s41569-021-00598-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 02/08/2023]
Abstract
For many years, bleeding has been perceived as an unavoidable consequence of strategies aimed at reducing thrombotic complications in patients undergoing percutaneous coronary intervention (PCI). However, the paradigm has now shifted towards bleeding being recognized as a prognostically unfavourable event to the same extent as having a new or recurrent ischaemic or thrombotic complication. As such, in parallel with progress in device and drug development for PCI, there is clinical interest in developing strategies that maximize not only the efficacy but also the safety (for example, by minimizing bleeding) of any antithrombotic treatment or procedural aspect before, during or after PCI. In this Review, we discuss contemporary data and aspects of bleeding avoidance strategies in PCI, including risk stratification, timing of revascularization, pretreatment with antiplatelet agents, selection of vascular access, choice of coronary stents and antithrombotic treatment regimens.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Deepak L Bhatt
- Department of Medicine, Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stefan James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University Hospital, Uppsala, Sweden
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sunil V Rao
- The Duke Clinical Research Institute, Durham, NC, USA
| | | | | | - Marco Valgimigli
- Cardiocentro Ticino Institute and Università della Svizzera italiana (USI), Lugano, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
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Cost-Consequence Analysis of Using Cangrelor in High Angiographic Risk Percutaneous Coronary Intervention Patients: A US Hospital Perspective. Am J Cardiovasc Drugs 2022; 22:93-104. [PMID: 34331235 PMCID: PMC8748330 DOI: 10.1007/s40256-021-00491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 10/30/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate a US hospital's cost implications and outcomes of cangrelor use in percutaneous coronary intervention (PCI) patients with two or more angiographic high-risk features (HRFs), including avoidance of oral P2Y12 inhibitor pretreatment in patients requiring cardiac surgery. Intravenous cangrelor provides direct, immediate onset and rapid-offset P2Y12 inhibition, which may reduce the necessity for oral P2Y12 pretreatment. METHODS A decision analytic model was developed, estimating the annual impact over 3 years of cangrelor availability. Ischemic and bleeding events (48 h) from randomized clinical trial data were extrapolated to 30 days. Event costs were from the CHAMPION PHOENIX Economics substudy. Rates of coronary artery disease (CAD) presentation, PCI, oral P2Y12 pretreatment, and inpatient hospitalization costs were from published literature and clinical experts. Scenario analyses evaluated the impact of cangrelor availability on potential reduced P2Y12 pretreatment rates by 50-100%. Drug costs were 2019 wholesale acquisition costs and, where necessary, all costs were adjusted to 2019 dollars. RESULTS In a hospital treating 1000 CAD PCI inpatients annually, increasing cangrelor use from 11 to 32% resulted in a reduction in 48-h ischemic events/year by 5.7%, while bleeding events increased by 2.9%. Total costs of $1,135,472 declined 12.8%, with a 50% reduction in P2Y12 pretreatment or 30% with no pretreatment. Savings were driven by a decrease in ischemic events, decrease in glycoprotein IIb/IIIa inhibitor use, and less need for and shorter oral P2Y12 inhibitor washout period for surgery patients. CONCLUSION Use of cangrelor in patients with two or more angiographic HRFs may improve outcomes and lower hospital budgets, mainly from avoiding surgery delays necessitated by oral P2Y12 inhibitor pretreatment.
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De Luca L, Steg PG, Bhatt DL, Capodanno D, Angiolillo DJ. Cangrelor: Clinical Data, Contemporary Use, and Future Perspectives. J Am Heart Assoc 2021; 10:e022125. [PMID: 34212768 PMCID: PMC8403274 DOI: 10.1161/jaha.121.022125] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cangrelor is the only currently available intravenous platelet P2Y12 receptor inhibitor. It is characterized by potent, predictable, and rapidly reversible antiplatelet effects. Cangrelor has been tested in the large CHAMPION (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) program, where it was compared with different clopidogrel regimens, and it is currently indicated for use in patients with coronary artery disease undergoing percutaneous coronary intervention. However, the uptake of cangrelor use varies across the globe and may also include patients with profiles different from those enrolled in the registration trials. These observations underscore the need to fully examine the safety and efficacy of cangrelor in postregistration studies. There are several ongoing and planned studies evaluating the use of cangrelor in real‐world practice which will provide important insights to this extent. The current article provides a review on the pharmacology, clinical studies, contemporary use of cangrelor in real‐world practice, a description of ongoing studies, and futuristic insights on potential strategies on how to improve outcomes of patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology Department of Cardiosciences Azienda Ospedaliera San Camillo-Forlanini Roma Italy
| | - Philippe Gabriel Steg
- FACT (French Alliance for Cardiovascular Trials) and INSERM U-1148 AP-HPHôpital BichatUniversité de Paris France.,NHLI (National Heart and Lung Institute)Imperial CollegeICMS Royal Brompton Hospital London United Kingdom
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center Harvard Medical School Boston MA
| | - Davide Capodanno
- Division of Cardiology A.O.U. Policlinico "G. Rodolico-San Marco" University of Catania Catania Italy
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van der Sangen NMR, Cheung HY, Verouden NJW, Appelman Y, Beijk MAM, Claessen BEPM, Delewi R, Knaapen P, Lemkes JS, Nap A, Vis MM, Kikkert WJ, Henriques JPS. Cangrelor Use in Routine Practice: A Two-Center Experience. J Clin Med 2021; 10:2829. [PMID: 34206905 PMCID: PMC8269409 DOI: 10.3390/jcm10132829] [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: 06/01/2021] [Revised: 06/18/2021] [Accepted: 06/24/2021] [Indexed: 12/04/2022] Open
Abstract
Cangrelor is the first and only intravenous P2Y12-inhibitor and is indicated when (timely) administration of an oral P2Y12 inhibitor is not feasible in patients undergoing percutaneous coronary intervention (PCI). Our study evaluated the first years of cangrelor use in two Dutch tertiary care centers. Cangrelor-treated patients were identified using a data-mining algorithm. The cumulative incidences of all-cause death, myocardial infarction, definite stent thrombosis and major bleeding at 48 h and 30 days were assessed using Kaplan-Meier estimates. Predictors of 30-day mortality were identified using uni- and multivariable Cox regression models. Between March 2015 and April 2021, 146 patients (median age 63.7 years, 75.3% men) were treated with cangrelor. Cangrelor was primarily used in ST-segment elevation myocardial infarction (STEMI) patients (84.2%). Approximately half required cardiopulmonary resuscitation (54.8%) or mechanical ventilation (48.6%). The cumulative incidence of all-cause death was 11.0% and 25.3% at 48 h and 30 days, respectively. Two cases (1.7%) of definite stent thrombosis, both resulting in myocardial infarction, occurred within 30 days, but after 48 h. No other cases of recurrent myocardial infarction transpired within 30 days. Major bleeding occurred in 5.6% and 12.5% of patients within 48 h and 30 days, respectively. Cardiac arrest at presentation was an independent predictor of 30-day mortality (adjusted hazard ratio 5.20, 95%-CI: 2.10-12.9, p < 0.01). Conclusively, cangrelor was used almost exclusively in STEMI patients undergoing PCI. Even though cangrelor was used in high-risk patients, its use was associated with a low rate of stent thrombosis.
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Affiliation(s)
- Niels M. R. van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ho Yee Cheung
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Niels J. W. Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Marcel A. M. Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Bimmer E. P. M. Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Jorrit S. Lemkes
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, 1081 HV Amsterdam, The Netherlands; (N.J.W.V.); (Y.A.); (P.K.); (J.S.L.); (A.N.)
| | - M. Marije Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
| | - Wouter J. Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, 1091 AC Amsterdam, The Netherlands
| | - José P. S. Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, 1105 AZ Amsterdam, The Netherlands; (N.M.R.v.d.S.); (H.Y.C.); (M.A.M.B.); (B.E.P.M.C.); (R.D.); (M.M.V.); (W.J.K.)
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Capranzano P, Angiolillo DJ. Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention. Expert Rev Cardiovasc Ther 2021; 19:519-535. [PMID: 33881367 DOI: 10.1080/14779072.2021.1920925] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Oral P2Y12 inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y12 inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y12 inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y12 inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y12 inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Policlinico Hospital, University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
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Kelly MA. Neurological complications of cardiovascular drugs. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:319-344. [PMID: 33632450 DOI: 10.1016/b978-0-12-819814-8.00020-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiovascular drugs are used to treat arterial hypertension, hyperlipidemia, arrhythmias, heart failure, and coronary artery disease. They also include antiplatelet and anticoagulant drugs that are essential for prevention of cardiogenic embolism. Most neurologic complications of the cardiovascular drugs are minor or transient and are far outweighed by the anticipated benefits of treatment. Other neurologic complications are more serious and require early recognition and management. Overtreatment of arterial hypertension may cause lightheadedness or fatigue but often responds readily to dose adjustment or an alternative drug. Other drug complications may be more troublesome as in myalgia associated with statins or headache associated with vasodilators. The recognized bleeding risk of the antithrombotics requires careful calculation of risk/benefit ratios for individual patients. Many neurologic complications of cardiovascular drugs are well documented in clinical trials with known frequency and severity, but others are rare and recognized only in isolated case reports or small case series. This chapter draws on both sources to report the adverse effects on muscle, nerve, and brain associated with commonly used cardiovascular drugs.
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Affiliation(s)
- Michael A Kelly
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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Angiolillo DJ, Bhatt DL, Cannon CP, Eikelboom JW, Gibson CM, Goodman SG, Granger CB, Holmes DR, Lopes RD, Mehran R, Moliterno DJ, Price MJ, Saw J, Tanguay JF, Faxon DP. Antithrombotic Therapy in Patients With Atrial Fibrillation Treated With Oral Anticoagulation Undergoing Percutaneous Coronary Intervention: A North American Perspective: 2021 Update. Circulation 2021; 143:583-596. [PMID: 33555916 DOI: 10.1161/circulationaha.120.050438] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A growing number of patients undergoing percutaneous coronary intervention (PCI) with stent implantation also have atrial fibrillation. This poses challenges for their optimal antithrombotic management because patients with atrial fibrillation undergoing PCI require oral anticoagulation for the prevention of cardiac thromboembolism and dual antiplatelet therapy for the prevention of coronary thrombotic complications. The combination of oral anticoagulation and dual antiplatelet therapy substantially increases the risk of bleeding. Over the last decade, a series of North American Consensus Statements on the Management of Antithrombotic Therapy in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention have been reported. Since the last update in 2018, several pivotal clinical trials in the field have been published. This document provides a focused updated of the 2018 recommendations. The group recommends that in patients with atrial fibrillation undergoing PCI, a non-vitamin K antagonist oral anticoagulant is the oral anticoagulation of choice. Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor should be given to all patients during the peri-PCI period (during inpatient stay, until time of discharge, up to 1 week after PCI, at the discretion of the treating physician), after which the default strategy is to stop aspirin and continue treatment with a P2Y12 inhibitor, preferably clopidogrel, in combination with a non-vitamin K antagonist oral anticoagulant (ie, double therapy). In patients at increased thrombotic risk who have an acceptable risk of bleeding, it is reasonable to continue aspirin (ie, triple therapy) for up to 1 month. Double therapy should be given for 6 to 12 months with the actual duration depending on the ischemic and bleeding risk profile of the patient, after which patients should discontinue antiplatelet therapy and receive oral anticoagulation alone.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - Christopher P Cannon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
| | - John W Eikelboom
- Department of Medicine, Population Health Research Institute, Thrombosis & Atherosclerosis Research Institute, Hamilton, Canada (J.W.E.)
| | - C Michael Gibson
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.)
| | - Shaun G Goodman
- St Michael's Hospital, University of Toronto, Canada (S.G.G.).,The Canadian Heart Research Centre, Toronto, Canada (S.G.G.).,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.G.G.)
| | | | - David R Holmes
- Division of Cardiology, Mayo Clinic, Rochester, MN (D.R.H.)
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G., R.D.L.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (R.M.)
| | - David J Moliterno
- Division of Cardiovascular Medicine and Gill Heart Institute, University of Kentucky, Lexington (D.J.M.)
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada (J.S.)
| | - Jean-Francois Tanguay
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Canada (J.-F.T.)
| | - David P Faxon
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B., C.P.C., D.P.F.)
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2020 ACC Expert Consensus Decision Pathway for Anticoagulant and Antiplatelet Therapy in Patients With Atrial Fibrillation or Venous Thromboembolism Undergoing Percutaneous Coronary Intervention or With Atherosclerotic Cardiovascular Disease. J Am Coll Cardiol 2021; 77:629-658. [DOI: 10.1016/j.jacc.2020.09.011] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abo-Aly M, George B, Shokri E, Chelvarajan L, El-Helw M, Smyth SS, Abdel-Latif A, Ziada K. Cangrelor in addition to standard therapy reduces cardiac damage and inflammatory markers in patients with ST-segment elevation myocardial infarction. J Thromb Thrombolysis 2020; 52:934-940. [PMID: 33258102 DOI: 10.1007/s11239-020-02345-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 01/01/2023]
Abstract
Although P2Y12 receptor blockers have become a standard, adjunctive therapy in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI), the optimal regimen has not been established. We performed a prospective, open-label, randomized study to investigate the effect of cangrelor administration on platelet function and inflammation in patients with primary PCI (PPCI). Twenty-two patients were randomized to receive either cangrelor and ticagrelor or ticagrelor alone (standard group) before PPCI. Platelet reactivity was evaluated at baseline (before PCI), 10 min and the end of the procedure. At baseline, there was no significant difference in platelet reactivity between both groups, whereas platelets were significantly inhibited at 10 min after initiating cangrelor vs. standard (adenosine-diphosphate-induced aggregation 102.2 ± 24.88 vs. 333.4 ± 63.3, P < 0.05 and thrombin-receptor-activating-peptide-induced aggregation 285.8 ± 86.1 vs. 624.8 ± 106.0, P < 0.05). Lower platelet aggregation in the cangrelor group persisted but the difference was reduced by the end of the procedure. Circulating inflammatory cells, pro-inflammatory cytokines, total elastase, and surrogates of neutrophil extracellular traps (total elastase-myeloperoxidase complexes) were significantly lower in the cangrelor compared to the standard therapy group at 6 h after randomization. There was a trend towards reduction in cardiac damage in the cangrelor group as reflected by the changes in late gadolinium enhancement between 48 h and 3 months after STEMI. Early administration of cangrelor in STEMI patients was associated with more effective platelet inhibition during PPCI and significantly dampened the deleterious inflammatory response compared to standard therapy (NCT03043274).
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Affiliation(s)
- Mohamed Abo-Aly
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Bennet George
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Elica Shokri
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Lakshman Chelvarajan
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Mohamed El-Helw
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Susan S Smyth
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Ahmed Abdel-Latif
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Khaled Ziada
- Cardiovascular Interventions, Coronary Artery Disease Center, Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, USA.
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Zhao C, Li S, Zhang J, Huang Y, Zhang L, Zhao F, Du X, Hou J, Zhang T, Shi C, Wang P, Huo R, Woodman OL, Qin CX, Xu H, Huang L. Current state and future perspective of cardiovascular medicines derived from natural products. Pharmacol Ther 2020; 216:107698. [PMID: 33039419 DOI: 10.1016/j.pharmthera.2020.107698] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 02/06/2023]
Abstract
The contribution of natural products (NPs) to cardiovascular medicine has been extensively documented, and many have been used for centuries. Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. Over the past 40 years, approximately 50% of newly developed cardiovascular drugs were based on NPs, suggesting that NPs provide essential skeletal structures for the discovery of novel medicines. After a period of lower productivity since the 1990s, NPs have recently regained scientific and commercial attention, leveraging the wealth of knowledge provided by multi-omics, combinatorial biosynthesis, synthetic biology, integrative pharmacology, analytical and computational technologies. In addition, as a crucial part of complementary and alternative medicine, Traditional Chinese Medicine has increasingly drawn attention as an important source of NPs for cardiovascular drug discovery. Given their structural diversity and biological activity NPs are one of the most valuable sources of drugs and drug leads. In this review, we briefly described the characteristics and classification of NPs in CVDs. Then, we provide an up to date summary on the therapeutic potential and the underlying mechanisms of action of NPs in CVDs, and the current view and future prospect of developing safer and more effective cardiovascular drugs based on NPs.
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Affiliation(s)
- Chunhui Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Sen Li
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Junhong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Yuanyun Huang
- Biology Department, Cornell University, Ithaca, NY 14850, United States of America
| | - Luoqi Zhang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; College of Chinese Medicinal Materials, Jilin Agricultural University, Changchun 130118, China
| | - Feng Zhao
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Xia Du
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; Shaanxi Academy of Traditional Chinese Medicine, Xi'an 710003, China
| | - Jinli Hou
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Tong Zhang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Chenjing Shi
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ping Wang
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Ruili Huo
- China Academy of Chinese Medical Sciences, Beijing 100700, China
| | - Owen L Woodman
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia
| | - Cheng Xue Qin
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3800, Australia; School of Pharmaceutical Science, Shandong University, Shandong 250100, China; Qilu Hospital, Cheeloo College of Medicine, Shandong University, Shandong 250100, China.
| | - Haiyu Xu
- Institute of Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China.
| | - Luqi Huang
- National Resource Center for Chinese Materia Medica, China Academy of Chinese Medical Sciences, Beijing 100700, China; China Academy of Chinese Medical Sciences, Beijing 100700, China.
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Chioncel O, Parissis J, Mebazaa A, Thiele H, Desch S, Bauersachs J, Harjola V, Antohi E, Arrigo M, Gal TB, Celutkiene J, Collins SP, DeBacker D, Iliescu VA, Jankowska E, Jaarsma T, Keramida K, Lainscak M, Lund LH, Lyon AR, Masip J, Metra M, Miro O, Mortara A, Mueller C, Mullens W, Nikolaou M, Piepoli M, Price S, Rosano G, Vieillard‐Baron A, Weinstein JM, Anker SD, Filippatos G, Ruschitzka F, Coats AJ, Seferovic P. Epidemiology, pathophysiology and contemporary management of cardiogenic shock – a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1315-1341. [DOI: 10.1002/ejhf.1922] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - John Parissis
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
- National Kapodistrian University of Athens Medical School Athens Greece
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP Paris France
| | - Holger Thiele
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Steffen Desch
- Department of Internal Medicine/Cardiology Heart Center Leipzig at University of Leipzig Leipzig Germany
- Heart Institute Leipzig Germany
| | - Johann Bauersachs
- Department of Cardiology & Angiology, Hannover Medical School Hannover Germany
| | - Veli‐Pekka Harjola
- Emergency Medicine University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Elena‐Laura Antohi
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Mattia Arrigo
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Tuvia B. Gal
- Department of Cardiology, Rabin Medical Center Petah Tiqwa Israel
- Sackler Faculty of Medicine, Tel Aviv University Tel Aviv Israel
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Medical Faculty of Vilnius University Vilnius Lithuania
| | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Daniel DeBacker
- Department of Intensive Care CHIREC Hospitals, Université Libre de Bruxelles Brussels Belgium
| | - Vlad A. Iliescu
- Emergency Institute for Cardiovascular Diseases ‘Prof. C.C. Iliescu’ Bucharest Romania
- University of Medicine Carol Davila Bucharest Romania
| | - Ewa Jankowska
- Department of Heart Disease Wroclaw Medical University, University Hospital, Center for Heart Disease Wroclaw Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences Linköping University Linköping Sweden
- Julius Center University Medical Center Utrecht Utrecht The Netherlands
| | - Kalliopi Keramida
- National Kapodistrian University of Athens Medical School Athens Greece
- Department of Cardiology Attikon University Hospital Athens Greece
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota Murska Sobota Slovenia
- Faculty of Medicine, University of Ljubljana Ljubljana Slovenia
| | - Lars H Lund
- Heart and Vascular Theme, Karolinska University Hospital Stockholm Sweden
- Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Alexander R. Lyon
- Imperial College London National Heart & Lung Institute London UK
- Royal Brompton Hospital London UK
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona Barcelona Spain
- Hospital Sanitas CIMA Barcelona Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University of Brescia Brescia Italy
| | - Oscar Miro
- Emergency Department Hospital Clinic, Institut d'Investigació Biomèdica August Pi iSunyer (IDIBAPS) Barcelona Spain
- University of Barcelona Barcelona Spain
| | - Andrea Mortara
- Department of Cardiology Policlinico di Monza Monza Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Basel Switzerland
| | - Wilfried Mullens
- Department of Cardiology Ziekenhuis Oost Genk Belgium
- Biomedical Research Institute Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek Belgium
| | - Maria Nikolaou
- Heart Failure Unit, Department of Cardiology Attikon University Hospital Athens Greece
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, Emergency Department Guglielmo da Saliceto Hospital, Piacenza, University of Parma; Institute of Life Sciences, Sant'Anna School of Advanced Studies Pisa Italy
| | - Susana Price
- Royal Brompton Hospital & Harefield NHS Foundation Trust London UK
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, Department of Medical Sciences, IRCCS San Raffaele Pisana Rome Italy
| | - Antoine Vieillard‐Baron
- INSERM U‐1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ Villejuif France
- University Hospital Ambroise Paré, AP‐, HP Boulogne‐Billancourt France
| | - Jean M. Weinstein
- Cardiology Department Soroka University Medical Centre Beer Sheva Israel
| | - Stefan D. Anker
- Department of Cardiology (CVK) Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin Berlin Germany
- Charité Universitätsmedizin Berlin Germany
| | - Gerasimos Filippatos
- University of Athens, Heart Failure Unit, Attikon University Hospital Athens Greece
- School of Medicine, University of Cyprus Nicosia Cyprus
| | - Frank Ruschitzka
- Department of Cardiology University Hospital Zurich Zurich Switzerland
| | - Andrew J.S. Coats
- Pharmacology, Centre of Clinical and Experimental Medicine IRCCS San Raffaele Pisana Rome Italy
| | - Petar Seferovic
- Faculty of Medicine University of Belgrade Belgrade, Serbia
- Serbian Academy of Sciences and Arts Belgrade Serbia
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Grimfjärd P, Lagerqvist B, Erlinge D, Varenhorst C, James S. Clinical use of cangrelor: nationwide experience from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR). EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 5:151-157. [PMID: 30698669 DOI: 10.1093/ehjcvp/pvz002] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/28/2018] [Accepted: 01/13/2019] [Indexed: 01/06/2023]
Abstract
AIMS This nationwide study aimed to analyse the first 2 years of routine clinical use of cangrelor in all Swedish patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS This observational Swedish Coronary Angiography and Angioplasty Registry (SCAAR) study identified 915 cangrelor-treated patients. As 899 were ST-segment elevation myocardial infarction (STEMI)-patients undergoing primary PCI, we decided to exclude all non-STEMI patients (n = 16) from the following analysis. We then identified all primary PCI patients, January 2016 to January 2018 (n = 10 816). Excluding hospitals without cangrelor use, tailoring time frames from first cangrelor use per hospital, patients treated with cangrelor (n = 899) were compared with those without cangrelor treatment (n = 4614). A separate analysis was performed for cardiac arrest STEMI patients (n = 273). Cangrelor-use in primary PCI varied greatly between hospitals (4-36%, mean 16%). At variance with randomized trials, cangrelor was used nearly exclusively in STEMI, often with cardiac arrest (19%). Cangrelor was combined with ticagrelor in two-thirds of patients, among which >50% was prehospital. Cangrelor was used more frequently in high-risk patients: left main PCI, thrombus aspiration, and cardiac arrest. Despite cangrelor being used in more high-risk patients, crude definite stent thrombosis rates at 30 days were low and similar in cangrelor (0.7%) and non-cangrelor treated patients (0.8%). CONCLUSION Cangrelor was used nearly exclusively in primary PCI STEMI patients, predominantly with ticagrelor. Despite being used in very high-risk patients, often with cardiac arrest, cangrelor treatment was associated with low stent thrombosis rates.
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Affiliation(s)
- Per Grimfjärd
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Department of Cardiology, Västerås Hospital, Sigtunagatan, 721 89 Västerås, Sweden
| | - Bo Lagerqvist
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Box 117, Skåne University Hospital, Block EA, 22100 Lund, Sweden
| | - Christoph Varenhorst
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden.,Pfizer AB Sverige, Vetenskapsvägen 10, Sollentuna, Sweden
| | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Sjukhusvägen 7, 752 09 Uppsala, Sweden
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Vaduganathan M, Qamar A, Badreldin HA, Faxon DP, Bhatt DL. Cangrelor Use in Cardiogenic Shock: A Single-Center Real-World Experience. JACC Cardiovasc Interv 2020; 10:1712-1714. [PMID: 28838482 DOI: 10.1016/j.jcin.2017.07.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
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Abstract
Inadequate antiplatelet effects can result in substantial morbidity and mortality in patients with acute coronary syndrome and percutaneous coronary intervention (PCI). Cangrelor is a rapid onset and potent intravenous P2Y12 inhibitor that has been shown in large randomized controlled trials to reduce periprocedural complications for PCI compared with clopidogrel, the most commonly used P2Y12 inhibitor. Cangrelor should be considered in the setting of PCI to reduce the risk of periprocedural complications such as myocardial infarction, repeat coronary revascularization and stent thrombosis in patients not yet treated with another P2Y12 inhibitor or glycoprotein IIb/IIIa inhibitor. In this review, the importance of adequate P2Y12 inhibition, cangrelor's pharmacology and clinical profiles, and future directions for the cangrelor are discussed.
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Affiliation(s)
- Kent Y Feng
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA 94304, USA
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20
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Franchi F, Rollini F, Rivas A, Wali M, Briceno M, Agarwal M, Shaikh Z, Nawaz A, Silva G, Been L, Smairat R, Kaufman M, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Bass TA, Angiolillo DJ. Platelet Inhibition With Cangrelor and Crushed Ticagrelor in Patients With ST-Segment-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Circulation 2020; 139:1661-1670. [PMID: 30630341 DOI: 10.1161/circulationaha.118.038317] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The platelet inhibitory effects induced by oral P2Y12 receptor antagonists are delayed in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (P-PCI). In turn, this leads to a gap in platelet inhibition, exposing patients to an increased risk of early thrombotic complications and underscoring the need to define strategies associated with more effective platelet inhibition in the peri-primary percutaneous coronary intervention period. Cangrelor is an intravenous P2Y12 inhibitor with prompt and potent antiplatelet effects. However, to date, there are limited data on the effects of cangrelor used in combination with ticagrelor in patients undergoing primary percutaneous coronary intervention. Moreover, questions have emerged on the potential for drug-drug interactions during the transition from cangrelor to oral P2Y12 inhibitors. METHODS This was a prospective, randomized, double-blind, placebo-controlled pharmacodynamic study conducted in patients undergoing primary percutaneous coronary intervention (n=50) who were randomized to treatment with either cangrelor or matching placebo (bolus followed by 2-hour infusion). All patients received ticagrelor 180-mg loading dose administered as crushed tablets at the time of cangrelor/placebo bolus administration. Pharmacodynamic analyses were performed at 8 time points. Pharmacodynamic effects were measured as P2Y12 reaction units by VerifyNow and platelet reactivity index by vasodilator-stimulated phosphoprotein. RESULTS Compared with placebo, cangrelor was associated with reduced P2Y12 reaction units as early as 5 minutes after bolus, which persisted during the entire duration of drug infusion, including at 30 minutes (63 [32-93] versus 214 [183-245]; mean difference, 152 [95% CI, 108-195]; P<0·001; primary end point). Parallel findings were shown with platelet reactivity index. Accordingly, high on-treatment platelet reactivity rates were reduced with cangrelor. After discontinuation of cangrelor/placebo infusion, there were no differences in levels of platelet reactivity between groups, ruling out a drug-drug interaction when cangrelor and ticagrelor are concomitantly administered. CONCLUSIONS In patients undergoing primary percutaneous coronary intervention, cangrelor is an effective strategy to bridge the gap in platelet inhibition associated with the use of oral P2Y12 inhibition induced by ticagrelor. Ticagrelor can be administered as a crushed formulation concomitantly with cangrelor without any apparent drug-drug interaction. The clinical implications of these pharmacodynamic findings warrant investigation in an adequately powered clinical trial. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT03247738.
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Affiliation(s)
- Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Mustafa Wali
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Maryuri Briceno
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Malhar Agarwal
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Zubair Shaikh
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ahmed Nawaz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Gabriel Silva
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Ramez Smairat
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Marc Kaufman
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
| | - Theodore A Bass
- Division of Cardiology, University of Florida College of Medicine-Jacksonville
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Affiliation(s)
- David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skåne University Hospital Lund, Sweden
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22
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Cohen MV, Downey JM. What Are Optimal P2Y12 Inhibitor and Schedule of Administration in Patients With Acute Coronary Syndrome? J Cardiovasc Pharmacol Ther 2019; 25:121-130. [DOI: 10.1177/1074248419882923] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Guidelines recommend treatment with a P2Y12 platelet adenosine diphosphate receptor inhibitor in patients undergoing elective or urgent percutaneous coronary intervention (PCI), but the optimal agent or timing of administration is still not clearly specified. The P2Y12 inhibitor was initially used for its platelet anti-aggregatory action to block thrombosis of the recanalized coronary artery or deployed stent. It is now recognized that these agents also offer potent cardioprotection against a reperfusion injury that occurs in the first minutes of reperfusion if platelet aggregation is blocked at the time of reperfusion. But this is difficult to achieve with oral agents which are slowly absorbed and often require time-consuming metabolic activation. Patients with ST-segment elevation myocardial infarction who usually have a large mass of myocardium at risk of infarction seldom have sufficient time for upstream-administered oral agents to achieve a therapeutic P2Y12 level of inhibition by the time of balloon inflation. However, optimal treatment could be assured by initiating an IV cangrelor infusion shortly prior to stenting followed by subsequent post-PCI transition to an oral agent, that is, ticagrelor, once success of the recanalization and absence of need for surgical intervention are confirmed. Not only should this sequence provide optimal protection against infarction, it should also negate bleeding if coronary artery bypass grafting should be required since stopping the cangrelor infusion at any time will quickly restore platelet reactivity. It is anticipated that cangrelor-induced myocardial salvage will help preserve myocardial function and significantly diminish postinfarction heart failure.
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Affiliation(s)
- Michael V. Cohen
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
- Department of Medicine, University of South Alabama College of Medicine, Mobile, AL, USA
| | - James M. Downey
- Department of Physiology and Cell Biology, University of South Alabama College of Medicine, Mobile, AL, USA
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23
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Ratcliffe FM, Kharbanda R, Foëx P. Perioperative ST-elevation myocardial infarction: with time of the essence, is there a case for guidelines? Br J Anaesth 2019; 123:548-554. [PMID: 31543267 DOI: 10.1016/j.bja.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/02/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022] Open
Affiliation(s)
- Fiona M Ratcliffe
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.
| | | | - Pierre Foëx
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK
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24
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Groves EM, Bhatt DL, Steg PG, Deliargyris EN, Stone GW, Gibson CM, Hamm CW, Mahaffey KW, White HD, Angiolillo DJ, Prats J, Harrington RA, Price MJ. Incidence, Predictors, and Outcomes of Acquired Thrombocytopenia After Percutaneous Coronary Intervention: A Pooled, Patient-Level Analysis of the CHAMPION Trials (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition). Circ Cardiovasc Interv 2019; 11:e005635. [PMID: 29632238 DOI: 10.1161/circinterventions.117.005635] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 02/15/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The influence of cangrelor on the incidence and outcomes of post-percutaneous coronary intervention (PCI) thrombocytopenia is not defined. We aimed to explore the incidence, predictors, and clinical impact of thrombocytopenia after PCI in cangrelor-treated patients. METHODS AND RESULTS This was a pooled, patient-level analysis of the CHAMPION trials (Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition), which compared cangrelor with clopidogrel for prevention of thrombotic complications during and after PCI. Acquired thrombocytopenia was defined as either a drop in platelet count to <100 000 after PCI or a drop of >50% between baseline and a follow-up. The main efficacy outcome was major adverse cardiac events. The primary safety outcome was noncoronary artery bypass grafting-related Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries-defined severe bleeding at 48 hours. Patients (23 783) were enrolled, and 3009 (12.7%) received a GPI (glycoprotein IIb/IIIa inhibitor). Acquired thrombocytopenia occurred in 200 patients (0.8%). The adjusted rate of major adverse cardiovascular events at 48 hours was significantly higher in patients who developed thrombocytopenia compared with those who did not (odds ratio, 3.00; 95% confidence interval, 1.89-4.69; P<0.001), as was major bleeding (odds ratio, 14.71; 95% confidence interval, 5.96-36.30; P<0.001). GPI use was the strongest independent predictor of acquired thrombocytopenia (odds ratio, 2.93; 95% confidence interval, 2.15-3.97; P<0.0001). There was no difference in the rate of acquired thrombocytopenia in patients randomized to cangrelor or clopidogrel. CONCLUSIONS Acquired thrombocytopenia after PCI is strongly associated with substantial early morbidity and mortality, as well as major bleeding. GPI use is a significant predictor of thrombocytopenia. Cangrelor is not associated with acquired thrombocytopenia, and its clinical efficacy and safety is consistent irrespective of thrombocytopenia occurrence. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00305162, NCT00385138, and NCT01156571.
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Affiliation(s)
- Elliott M Groves
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Deepak L Bhatt
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Philippe Gabriel Steg
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Efthymios N Deliargyris
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Gregg W Stone
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - C Michael Gibson
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Christian W Hamm
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Kenneth W Mahaffey
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Harvey D White
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Dominick J Angiolillo
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Jayne Prats
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Robert A Harrington
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.)
| | - Matthew J Price
- From the Division of Cardiology, Scripps Clinic, La Jolla, CA (E.M.G., M.J.P.); Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.); FACT (French Alliance for Cardiovascular clinical Trials), DHU FIRE, INSERM Unité 1148, Université Paris-Diderot, and Hôpital Bichat, Assistance-Publique-Hôpitaux de Paris, France (P.G.S.); NHLI, Imperial College, Royal Brompton Hospital, London, United Kingdom (P.G.S.); Science and Strategy Consulting Group, Basking Ridge, NJ (E.N.D.); Columbia University Medical Center and the Cardiovascular Research Foundation, New York City, NY (G.W.S.); Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA (C.M.G.); Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany (C.W.H.); Division of Cardiology (K.W.M.), Department of Medicine, Division of Cardiology (R.A.H.), Stanford University Medical School, CA; Green Lane Cardiovascular Service, Auckland, New Zealand (H.D.W.); Division of Cardiology, University of Florida, Jacksonville (D.A.); and Elysis, Llc, Carlisle, MA (J.P.).
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Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI. J Am Coll Cardiol 2019; 74:83-99. [DOI: 10.1016/j.jacc.2019.05.016] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
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Affiliation(s)
- Mamas A Mamas
- From the Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, United Kingdom (M.A.M.); Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom (M.A.M.); and Department of Cardiology, University Hospital Southampton, University of Southampton, United Kingdom (N.C.).
| | - Nick Curzen
- From the Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, United Kingdom (M.A.M.); Academic Department of Cardiology, Royal Stoke Hospital, Stoke-on-Trent, United Kingdom (M.A.M.); and Department of Cardiology, University Hospital Southampton, University of Southampton, United Kingdom (N.C.)
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Lu H, Guan W, Zhou Y, Tang Z, Bao H. Cangrelor or Clopidogrel in Patients with Type 2 Diabetes Mellitus Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials. Diabetes Ther 2019; 10:937-950. [PMID: 30905057 PMCID: PMC6531549 DOI: 10.1007/s13300-019-0593-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION With recent advances in interventional cardiology where percutaneous coronary intervention (PCI) has become the most preferred invasive strategy and with advances in adjunctive pharmacotherapy, several newer oral P2Y12 inhibitors have reached the market. In this analysis, we aimed to compare the cardiovascular outcomes and bleeding events which were associated with the use of cangrelor versus clopidogrel in patients with type 2 diabetes mellitus (T2DM) 48 h after PCI. METHODS The electronic databases MEDLINE (PubMed), www.ClinicalTrials.gov , EMBASE, and Cochrane central were searched for relevant publications comparing canagrelor with clopidogrel during PCI. Patients with T2DM were extracted. Adverse cardiovascular outcomes and bleeding events at 48 h follow-up were considered as the end points. This meta-analysis was carried out with the latest RevMan software (5.30). Odds ratios (OR) and 95% confidence intervals (CI) were used to represent the data. RESULTS This analysis consisted of a total number of 5031 participants with T2DM (enrolled between the years 2006 and 2012). Compared to clopidgrel, use of cangrelor in these patients with T2DM was not associated with significantly different primary end point (OR 0.94, 95% CI 0.75-1.16; P = 0.55), myocardial infarction (OR 0.96, 95% CI 0.76-1.20; P = 0.71), all-cause death (OR 0.70, 95% CI 0.25-1.96; P = 0.49), ischemia-driven revascularization (OR 0.66, 95% CI 0.32-1.36; P = 0.26), and stent thrombosis (OR 0.45, 95% CI 0.17-1.17; P = 0.10). Thrombolysis in myocardial infarction (TIMI)-defined major and minor bleedings were similarly manifested: (OR 1.02, 95% CI 0.38-2.74; P = 0.96) and (OR 1.39, 95% CI 0.70-2.79; P = 0.35), respectively. Global use of strategies to open occluded arteries (GUSTO)-defined moderate and severe bleeding were also not significantly different: (OR 1.36, 95% CI 0.70-2.67; P = 0.37) and (OR 1.21, 95% CI 0.41-3.59; P = 0.74), respectively. However, GUSTO-defined mild bleeding and acute catheterization and urgent intervention triage strategy (ACUITY)-defined major and minor bleedings were significantly in favor of clopidogrel in comparison to cangrelor in these patients with T2DM: (OR 1.28, 95% CI 1.09-1.50; P = 0.003), (OR 1.43, 95% CI 1.05-1.94; P = 0.02), and (OR 1.23, 95% CI 1.04-1.46; P = 0.02), respectively. Other bleeding outcomes were not significantly different. CONCLUSIONS In these patients with T2DM, cangrelor was comparable to clopidogrel in terms of efficacy at 48 h following PCI. However, it was associated with significantly higher mild GUSTO bleeding and major and minor ACUITY bleeding, therefore requiring further workups on its safety side. This hypothesis should be explored further and confirmed in other forthcoming trials based strictly on patients with T2DM.
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Affiliation(s)
- Hongtao Lu
- Jingzhou Central Hospital of Cardiology, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, People's Republic of China
| | - Wenjun Guan
- Jingzhou Central Hospital of Cardiology, The Second Clinical Medical College, Yangtze University, Jingzhou, Hubei, People's Republic of China
| | - Yanhua Zhou
- Department of Hematology, Jingzhou First People's Hospital, The First Affiliated Hospital of Yangtze University, Jingzhou, People's Republic of China
| | - Zhangui Tang
- Institute of Cardiovascular Disease, Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Hong Bao
- Jiangling County People's Hospital of Cardiology, Jingzhou, Hubei, People's Republic of China.
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Effects of Cangrelor as Adjunct Therapy to Percutaneous Coronary Intervention. Am J Cardiol 2019; 123:1228-1238. [PMID: 30738570 DOI: 10.1016/j.amjcard.2019.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/03/2019] [Accepted: 01/07/2019] [Indexed: 11/21/2022]
Abstract
Percutaneous coronary intervention (PCI) in patients with angiographic evidence of intracoronary thrombus is associated with in-hospital and 30-day adverse clinical outcomes. Cangrelor, a direct, rapid-onset acting intravenous P2Y12 receptor inhibitor, has been proved to be effective by reducing peri-PCI ischemic complications in subjects who underwent PCI. This study aimed to assess the angiographic and in-hospital clinical outcomes in all-comer patients receiving cangrelor immediately before PCI at a tertiary care center. The study analyzed consecutive unselected subjects treated with cangrelor at the time the decision was made to proceed with PCI. At the end of the procedure, all patients were transitioned to oral antiplatelet therapy. The target lesion angiographic assessment of Thrombolysis in myocardial infarction flow grade (TIMI-Flow), TIMI-thrombus grade (TIMI-Thrombus), myocardial blush grade, and TIMI-myocardial perfusion grade (TMPG) was performed before and post-PCI. Clinical events were recorded during the procedure and at discharge. In total, 223 patients (244 lesions) were included in the analysis (106, 97, and 20 patientswith TIMI-Flow 0/1, TIMI-Flow 2/3, and cardiogenic shock, respectively). The overall mean age was 63 ± 12 years, 70% men and 38% with diabetes mellitus. Acute myocardial infarction was the main presentation (72%). The use of cangrelor improved TIMI-Flow, MGB, TMPG, and TIMI-Thrombus in patients with initial TIMI-Flow 0 to 2. Major bleeding rate was 2.0%. In conclusion, cangrelor was effective and safe in restoring TIMI-Flow 3, reducing thrombus burden and improving myocardial blush grade and TMPG when administered to unselected subjects who underwent PCI. Therefore, cangrelor should be considered in patients presenting with intracoronary thrombus before intervention.
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Majithia A, Bhatt DL. Novel Antiplatelet Therapies for Atherothrombotic Diseases. Arterioscler Thromb Vasc Biol 2019; 39:546-557. [PMID: 30760019 PMCID: PMC6445601 DOI: 10.1161/atvbaha.118.310955] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/20/2019] [Indexed: 01/03/2023]
Abstract
Antiplatelet therapies are an essential tool to reduce the risk of developing clinically apparent atherothrombotic disease and are a mainstay in the therapy of patients who have established cardiovascular, cerebrovascular, and peripheral artery disease. Strategies to intensify antiplatelet regimens are limited by concomitant increases in clinically significant bleeding. The development of novel antiplatelet therapies targeting additional receptor and signaling pathways, with a focus on maintaining antiplatelet efficacy while preserving hemostasis, holds tremendous potential to improve outcomes among patients with atherothrombotic diseases.
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Affiliation(s)
- Arjun Majithia
- From the Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- From the Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA
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Cangrelor in cardiogenic shock and after cardiopulmonary resuscitation: A global, multicenter, matched pair analysis with oral P2Y 12 inhibition from the IABP-SHOCK II trial. Resuscitation 2019; 137:205-212. [PMID: 30790690 DOI: 10.1016/j.resuscitation.2019.02.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 02/01/2019] [Accepted: 02/11/2019] [Indexed: 01/06/2023]
Abstract
AIMS Cangrelor has a potentially favorable pharmacodynamic profile in cardiogenic shock (CS). We aimed to evaluate the clinical course of CS patients undergoing percutaneous coronary intervention (PCI) treated with cangrelor. METHODS AND RESULTS We retrospectively identified 136 CS patients treated with cangrelor. Patients were 1:1 matched to CS patients from the IABP-SHOCK II trial not receiving cangrelor by age, sex, cardiac arrest, type of myocardial infarction, culprit lesion, glycoprotein IIb/IIIa inhibitor, and oral P2Y12-receptor inhibitor and followed-up for 12 months. The study cohort consisted of 88 matched pairs. Thirty-day and 12-month mortality was 29.5% and 34.1% in cangrelor-treated patients and 36.4% and 47.1% in control group (P = 0.34 and P = 0.08, respectively). The rate of definite acute stent thrombosis was 2.3% in both groups. Moderate and severe bleeding events occurred in 21.6% in the cangrelor and 19.3% in the control group (P = 0.71). Patients treated with cangrelor more frequently experienced ≥1 TIMI flow grade improvement during PCI (92.9% vs. 81.2%, P = 0.02). CONCLUSION Cangrelor treatment was associated with similar bleeding risk and significantly better TIMI flow improvement compared with oral P2Y12 inhibitors in CS patients undergoing PCI. The use of cangrelor in CS offers a potentially safe and effective antiplatelet option and should be evaluated in randomized trials.
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Brar SS. Cangrelor: The Paradox of Choice. J Am Coll Cardiol 2019; 69:186-188. [PMID: 28081828 DOI: 10.1016/j.jacc.2016.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Somjot S Brar
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
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Vaduganathan M, Qamar A, Badreldin HA, Faxon DP, Bhatt DL. Reply: Cangrelor or Abciximab as First Choice in Cardiogenic Shock. JACC Cardiovasc Interv 2019; 10:2468-2469. [PMID: 29217013 DOI: 10.1016/j.jcin.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 11/18/2022]
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Capodanno D, Milluzzo RP, Angiolillo DJ. Intravenous antiplatelet therapies (glycoprotein IIb/IIIa receptor inhibitors and cangrelor) in percutaneous coronary intervention: from pharmacology to indications for clinical use. Ther Adv Cardiovasc Dis 2019; 13:1753944719893274. [PMID: 31823688 PMCID: PMC6906352 DOI: 10.1177/1753944719893274] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 08/16/2019] [Indexed: 12/20/2022] Open
Abstract
Oral antiplatelet drugs are crucially important for patients with acute coronary syndrome or stable coronary artery disease undergoing percutaneous coronary intervention (PCI). In recent decades, several clinical trials have focused on reducing periprocedural ischemic events in patients undergoing PCI by means of more rapid platelet inhibition with the use of intravenous antiplatelet drugs. Glycoprotein IIb/IIIa receptor inhibitors (GPIs) block the final common pathway of platelet aggregation and enable potent inhibition in the peri-PCI period. In recent years, however, the use of GPIs has decreased due to bleeding concerns and the availability of more potent oral P2Y12 inhibitors. Cangrelor is an intravenous P2Y12 receptor antagonist. In a large-scale regulatory trial, cangrelor administration during PCI allowed for rapid, potent and rapidly reversible inhibition of platelet aggregation, with an anti-ischemic benefit and no increase in major bleeding. This article aims to provide an overview of general pharmacology, supporting evidence and current status of intravenous antiplatelet therapies (GPIs and cangrelor), with a focus on contemporary indications for their clinical use.
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Affiliation(s)
- Davide Capodanno
- Division of Cardiology, A.O.U.
‘Policlinico-Vittorio Emanuele’, University of Catania, P.O. Rodolico, Ed.
8, Via Santa Sofia 78, 95123 Catania, Sicilia, Italy
| | - Rocco P. Milluzzo
- Division of Cardiology, A.O.U.
‘Policlinico-Vittorio Emanuele’, University of Catania, Catania, Sicilia,
Italy
| | - Dominick J. Angiolillo
- Division of Cardiology, Department of Medicine,
University of Florida College of Medicine, Jacksonville, FL, USA
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Bulluck H, Chan MHH, Bryant JA, Chai P, Chawla A, Chua TS, Chung YC, Fei G, Ho HH, Ho AFW, Hoe AJ, Imran SS, Lee CH, Lim SH, Liew BW, Yun PLZ, Hock MOE, Paradies V, Roe MT, Teo L, Wong AS, Wong E, Wong PE, Watson T, Chan MY, Tan JW, Hausenloy DJ. Platelet inhibition to target reperfusion injury trial: Rationale and study design. Clin Cardiol 2018; 42:5-12. [PMID: 30421441 DOI: 10.1002/clc.23110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND In ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI), current oral P2Y12 platelet inhibitors do not provide maximal platelet inhibition at the time of reperfusion. Furthermore, administration of cangrelor prior to reperfusion has been shown in pre-clinical studies to reduce myocardial infarct (MI) size. Therefore, we hypothesize that cangrelor administered prior to reperfusion in STEMI patients will reduce the incidence of microvascular obstruction (MVO) and limit MI size in STEMI patients treated with PPCI. METHODS The platelet inhibition to target reperfusion injury (PITRI) trial, is a phase 2A, multi-center, double-blinded, randomized controlled trial, in which 210 STEMI patients will be randomized to receive either an intravenous (IV) bolus of cangrelor (30 μg/kg) followed by a 120-minute infusion (4 μg/kg/min) or matching saline placebo, initiated prior to reperfusion (NCT03102723). RESULTS The study started in October 2017 and the anticipated end date would be July 2020. The primary end-point will be MI size quantified by cardiovascular magnetic resonance (CMR) on day 3 post-PPCI. Secondary endpoints will include markers of reperfusion, incidence of MVO, MI size, and adverse left ventricular remodeling at 6 months, and major adverse cardiac and cerebrovascular events. SUMMARY The aim of the PITRI trial is to assess whether cangrelor administered prior to reperfusion would reduce acute MI size and MVO, as assessed by CMR.
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Affiliation(s)
- Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, UK.,Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Mervyn H H Chan
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore, Singapore
| | - Jennifer A Bryant
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Ping Chai
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Ashish Chawla
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Terrance S Chua
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | | | - Gao Fei
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Hee H Ho
- Department of Cardiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Andrew F W Ho
- SingHealth Emergency Medicine Residency Programme, Singapore, Singapore.,SingHealth Duke-NUS Emergency Medicine Academic Clinical Programme, Singapore, Singapore
| | - Andrew J Hoe
- Department of Cardiology, Mount Elizabeth Hospital, Novena, Singapore
| | - Syed S Imran
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Swee H Lim
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Boon W Liew
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Patrick L Z Yun
- Department of Cardiology, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Marcus O E Hock
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Valeria Paradies
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Lynette Teo
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Aaron S Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Evelyn Wong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Philip E Wong
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Timothy Watson
- Department of Cardiology, Mount Elizabeth Hospital, Novena, Singapore
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Jack W Tan
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore.,Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore, Singapore.,Tecnologico de Monterrey, Escuela de Ingenieria y Ciencias, Centro de Biotecnologia-FEMSA, Nuevo Leon, México.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
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Characteristics and outcomes of patients requiring bailout use of glycoprotein IIb/IIIa inhibitors for thrombotic complications of percutaneous coronary intervention: An analysis from the CHAMPION PHOENIX trial. Int J Cardiol 2018; 278:217-222. [PMID: 30563770 DOI: 10.1016/j.ijcard.2018.11.114] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/08/2018] [Accepted: 11/22/2018] [Indexed: 11/21/2022]
Abstract
AIMS To describe the characteristics and outcomes of patients receiving bailout glycoprotein IIb/IIIa inhibitors (GPI) for thrombotic complications of percutaneous coronary intervention (PCI) in a large, contemporary trial. METHODS AND RESULTS In the CHAMPION PHOENIX trial, the use of GPI was restricted to bailout for thrombotic complications. We describe the characteristics and outcomes of patients requiring bailout GPI compared to patients not receiving GPIs, with adjustment through propensity-score. A multivariable model was constructed to identify independent correlates associated with bailout GPI use. A total of 380 out of 10,942 patients received GPI (3.5%); GPI patients were younger, more frequently male, more likely to present with ST segment elevation myocardial infarction and less frequently treated with cangrelor. At 48 h, GPI patients experienced higher rates of the primary composite outcome of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis (ST) (19.2% vs 4.8%; adjusted OR: 5.65(4.08, 7.82), p < 0.0001) and a higher rate of GUSTO severe or moderate bleeding (2.6% vs 0.4% adjusted OR: 4.90 (1.98, 12.18), p = 0.0006) compared with non GPI patients. Independent correlates of GPI use were STEMI, use of unfractionated heparin, drug-eluting stents and longer procedure duration. CONCLUSIONS In a large contemporary trial, patients receiving bailout GPI for thrombotic complications of PCI experienced very high risks of both ischemic and bleeding complications, suggesting that prevention of periprocedural complications rather than bailout GPI may be preferable. CLINICAL TRIAL REGISTRATION http://www.clinicaltrials.gov identifier: NCT01156571.
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Cavender MA, Bhatt DL, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Prats J, Elkin S, Deliargyris EN, Mahaffey KW, White HD, Harrington RA. Cangrelor in Older Patients Undergoing Percutaneous Coronary Intervention: Findings From CHAMPION PHOENIX. Circ Cardiovasc Interv 2018; 10:CIRCINTERVENTIONS.117.005257. [PMID: 28801539 DOI: 10.1161/circinterventions.117.005257] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/14/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Older patients treated with percutaneous coronary intervention are at increased risk of periprocedural events. METHODS AND RESULTS CHAMPION (cangrelor versus standard therapy to achieve optimal management of platelet inhibition) PHOENIX randomized 11 145 patients to cangrelor or clopidogrel. We sought to determine the outcomes in the prespecified subgroup of patients ≥75 years old (n=2010; 18%). Cangrelor resulted in directionally consistent effects on the primary end point (death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) in patients ≥75 years old (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.50-1.02) and in those <75 years old (OR, 0.81; 95% CI, 0.67-0.98; P [interaction]=0.55). Age ≥75 years was an independent predictor of GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries) moderate/severe bleeding (1.0% versus 0.3%; adjusted OR, 2.94; 95% CI, 1.28-6.77; P=0.01) when compared with patients <75 years old. There was no significant difference in GUSTO moderate/severe bleeding with cangrelor versus clopidogrel (1.1% versus 1.0%; OR, 1.07; 95% CI 0.45-2.53) in patients ≥75 years old or in those <75 years old (0.4% versus 0.2%; OR, 2.24; 95% CI, 1.02-4.93; P [interaction]=0.21). For the net composite end point of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis plus GUSTO moderate/severe bleeding, the OR for cangrelor in those ≥75 years old was 0.75 (6.4% versus 8.3%; 95% CI, 0.54-1.05; P=0.09). The effects were similar in those <75 years old (4.9% versus 5.8%; OR, 0.85; 95% CI, 0.70-1.02; P=0.08; P [interaction]=0.53). CONCLUSIONS Patients ≥75 years old have an overall ≈3-fold increased odds of moderate/severe bleeding. Cangrelor, when compared with clopidogrel, provides similar efficacy and in patients ≥75 years old as in those <75 years old but does not increase the risk of major bleeding. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01156571.
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Affiliation(s)
- Matthew A Cavender
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Deepak L Bhatt
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.).
| | - Gregg W Stone
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Ph Gabriel Steg
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - C Michael Gibson
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Christian W Hamm
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Matthew J Price
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Jayne Prats
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Steven Elkin
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Efthymios N Deliargyris
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Kenneth W Mahaffey
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Harvey D White
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
| | - Robert A Harrington
- From the University of North Carolina, Chapel Hill; (M.A.C.); Brigham and Women's Hospital, Heart and Vascular Center (D.L.B.) and Beth Israel Deaconess Medical Center (C.M.G.), Harvard Medical School, Boston, MA; Columbia University, New York, NY (G.W.S.); Université Paris-Diderot, Sorbonne Paris Cité, INSERM U-1148, DHU FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, France (G.S.); Institute of Cardiovascular Medicine and Science, National Lung and Heart Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom (G.S.); Kerckhoff Clinic and Thoraxcenter, Bad Nauheim, Germany (C.W.H.); Scripps Clinic, La Jolla, CA (M.J.P.); The Medicines Company, Parsippany, NJ (J.P., S.E., E.N.D.); Stanford University, CA (K.W.M., R.A.H.); and University of Auckland, Auckland City Hospital, New Zealand (H.D.W.)
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Alexopoulos D, Katogiannis K, Sfantou D, Lekakis J. Combination antiplatelet treatment in coronary artery disease patients: A necessary evil or an overzealous practice? Platelets 2017; 29:228-237. [PMID: 29022423 DOI: 10.1080/09537104.2017.1353685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In seeking to improve care in coronary artery disease patients, further platelet inhibition has been occasionally applied beyond that provided by aspirin and a P2Y12 receptor antagonist. This review aims to offer insights about the rationale, the efficacy and safety of combination antiplatelet therapy, involving three or more agents. Overall, the use of glycoprotein (GP) IIb/IIIa inhibitors did not significantly modify the treatment effect of different antiplatelet strategies, including double vs standard clopidogrel, prasugrel vs clopidogrel, ticagrelor vs clopidogrel, cangrelor vs clopidogrel, and vorapaxar vs placebo. With the caveat that the use of GP IIb/IIIa inhibitor was not randomized, adding such an agent to aspirin and a P2Y12 receptor antagonist appears to carry a significantly increased bleeding potential. Moreover, adding vorapaxar to aspirin- and clopidogrel-treated patients is associated with more bleeding events, while the bleeding potential is further exacerbated in cases of quadruplicate antiplatelet treatment including aspirin, clopidogrel, vorapaxar, and a GP IIb/IIIa inhibitor. In ST-segment elevation, myocardial infarction patients' administration of an intravenous antiplatelet agent (GP IIb/IIIa inhibitor or cangrelor), in addition to aspirin and a P2Y12 receptor antagonist, efficiently bridges the pharmacodynamic gap of oral agents. Cilostazol on top of aspirin and clopidogrel appears to be safe, although of questionable clinical benefit. In conclusion, combination antiplatelet therapy should be reserved only for selected cases and following thoughtful consideration of the associated risk/benefit ratio.
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Affiliation(s)
- Dimitrios Alexopoulos
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
| | - Konstantinos Katogiannis
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
| | - Danai Sfantou
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
| | - John Lekakis
- a 2nd Department of Cardiology , Attikon University Hospital, National and Capodistrian University of Athens Medical School , Athens , Greece
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Vaduganathan M, Harrington RA, Stone GW, Steg PG, Gibson CM, Hamm CW, Price MJ, Deliargyris EN, Prats J, Mahaffey KW, White HD, Bhatt DL. Cangrelor Versus Clopidogrel on a Background of Unfractionated Heparin (from CHAMPION PHOENIX). Am J Cardiol 2017; 120:1043-1048. [PMID: 28802512 DOI: 10.1016/j.amjcard.2017.06.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/04/2017] [Accepted: 06/20/2017] [Indexed: 01/08/2023]
Abstract
Cangrelor is approved for use during percutaneous coronary intervention (PCI) and is administered with different parenteral anticoagulants. We examined the efficacy and safety of cangrelor in the subgroup of patients who received unfractionated heparin (UFH) during PCI in the modified intention-to-treat population of the randomized CHAMPION PHOENIX trial (cangrelor vs clopidogrel; n = 10,939). The primary efficacy end point was the composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis (ST) at 48 hours. The key secondary efficacy end point was ST. UFH was used in 69.2% (7,569/10,939) of patients. In the UFH subgroup, cangrelor reduced the primary composite efficacy end point at 48 hours compared with clopidogrel (4.8% vs 5.9%; odds ratio [OR] 0.80 [0.65 to 0.98]; p = 0.03). Cangrelor consistently reduced ST at 2 hours (0.7% vs 1.3%; OR 0.56 [0.35 to 0.90]; p = 0.01) and 48 hours (0.9% vs 1.4%; OR 0.70 [0.45 to 1.07]; p = 0.10). There was no difference in GUSTO (Global Use of Strategies to Open Occluded Coronary Arteries)-defined severe or life-threatening bleeding (0.1% vs 0.1%; OR 1.24 [0.33 to 4.61]; p = 0.75) or blood transfusion requirement at 48 hours (0.4% vs 0.2%; OR 1.87 [0.83 to 4.21]; p = 0.12). In conclusion, cangrelor reduces early ischemic periprocedural complications without increasing severe bleeding compared with clopidogrel in patients undergoing PCI with UFH.
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Badreldin HA, Carter D, Cook BM, Qamar A, Vaduganathan M, Bhatt DL. Safety and Tolerability of Transitioning from Cangrelor to Ticagrelor in Patients Who Underwent Percutaneous Coronary Intervention. Am J Cardiol 2017; 120:359-361. [PMID: 28576266 DOI: 10.1016/j.amjcard.2017.04.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/25/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
The 3 phase 3 CHAMPION (Cangrelor vs Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials collectively demonstrated the safety of transitioning from cangrelor, a potent, parenteral rapidly-acting P2Y12 inhibitor, to clopidogrel in patients who underwent percutaneous coronary intervention (PCI). However, variation in timing of therapy, site-specific binding, and drug half-lives may theoretically complicate switching to other oral P2Y12 inhibitors. Since regulatory approval, limited data are available regarding the "real-world" safety and tolerability of transitioning to these more potent oral P2Y12 antagonists. From November 2015 to January 2017, we evaluated the clinical profiles and efficacy and safety outcomes in cangrelor-treated patients who underwent PCI transitioned to clopidogrel (n = 42) or ticagrelor (n = 82) at a large, tertiary care center. Most patients receiving cangrelor underwent PCI with a drug-eluting stent for acute coronary syndrome via a radial approach in the background of unfractionated heparin. Stent thrombosis within 48 hours was rare and occurred in 1 patient treated with ticagrelor. Global Use of Strategies to Open Occluded Coronary Arteries-defined bleeding occurred in 20% of patients switched to ticagrelor and 29% of patients switched to clopidogrel, but none were severe or life-threatening. In conclusion, rates of stent thrombosis and severe/life-threatening bleeding were low and comparable with those identified in the CHAMPION program, despite use of more potent oral P2Y12 inhibition.
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Alexopoulos D, Pappas C, Sfantou D, Lekakis J. Cangrelor in Percutaneous Coronary Intervention: Current Status and Perspectives. J Cardiovasc Pharmacol Ther 2017; 23:13-22. [PMID: 29228817 DOI: 10.1177/1074248417715004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cangrelor is an intravenously administered P2Y12 receptor antagonist with very fast, potent, and quickly reversible action. In the CHAMPION PHOENIX trial, cangrelor provided an improved anti-ischemic protection compared with clopidogrel, without increasing the risk of severe bleeding. Cangrelor is currently approved by drug regulating authorities for patients undergoing percutaneous coronary intervention (PCI) without prior treatment with a P2Y12 receptor antagonist and not receiving a glycoprotein IIb/IIIa inhibitor, while its use is endorsed with a class IIb recommendation by the European Society of Cardiology guidelines. Several subanalyses of CHAMPION PHOENIX trial have tried to elucidate the role of cangrelor in PCI, including its usefulness during a 2-hour landmark analysis, impact on intraprocedural stent thrombosis, and reduction in myocardial infarction (MI) rate. The influence of gender, geographic region, access site, and bivalirudin use on cangrelor's effects has also been reported. In patients with ST elevation MI and in clinical scenarios of disturbed absorption of oral antiplatelet agents or in need of an intravenous agent, cangrelor may surpass oral agents' drawbacks. Transitioning to an oral agent is mandatory following cangrelor infusion discontinuation, although ticagrelor may be administered earlier without any pharmacodynamic interaction. Nevertheless, the clinical role of cangrelor in conjunction with administration of prasugrel or ticagrelor remains unclear. Accruing real-life experience is expected to improve our understanding of cangrelor's role in everyday clinical practice.
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Affiliation(s)
- Dimitrios Alexopoulos
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - Christos Pappas
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - Danai Sfantou
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
| | - John Lekakis
- 1 2nd Department of Cardiology, Attikon University Hospital, National and Capodistrian University of Athens Medical School, Athens, Greece
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Leonardi S, Bhatt DL. Practical considerations for cangrelor use in patients with acute coronary syndromes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 8:39-44. [PMID: 28574274 DOI: 10.1177/2048872617707960] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cangrelor, the first and currently only available intravenous P2Y12 receptor antagonist, has been approved and is now being used in patients with coronary artery disease requiring percutaneous coronary intervention. The rationale for cangrelor use is most robust in patients requiring an immediate, profound, and predictable level of P2Y12 inhibition - especially in patients with acute coronary syndromes. Herein we summarize the drug development program and reflect on practical considerations for clinicians on cangrelor use in the acute setting surrounding percutaneous coronary intervention, including selection of patients, concomitant administration of glycoprotein IIb/IIIa inhibitors and transition strategies from intravenous to oral P2Y12 receptor antagonists.
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Affiliation(s)
| | - Deepak L Bhatt
- 2 Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, USA
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Vaduganathan M, Qamar A, Singh A, Venkateswaran RV, Szumita PM, Croce KJ, Mauri L, Leopold JA, Shah PB, Sobieszczyk P, Faxon DP, Bhatt DL. Cangrelor Use Since FDA Approval: A Single-Center, Real-World Experience at a Tertiary Care Hospital. J Am Coll Cardiol 2016; 69:463-464. [PMID: 27914699 DOI: 10.1016/j.jacc.2016.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 10/31/2016] [Accepted: 11/07/2016] [Indexed: 11/17/2022]
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