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Pereira NL, Cresci S, Angiolillo DJ, Batchelor W, Capers Q, Cavallari LH, Leifer D, Luzum JA, Roden DM, Stellos K, Turrise SL, Tuteja S. CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e129-e150. [PMID: 38899464 PMCID: PMC11300169 DOI: 10.1161/cir.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.
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Rajachandran M, Lange RA. Role of Cyp2c19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention. Curr Cardiol Rep 2024; 26:675-680. [PMID: 38806977 DOI: 10.1007/s11886-024-02071-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Identification of a reliable discriminatory test to accurately stratify patient responses to antiplatelet therapy following coronary revascularization has become increasingly desirable to optimize therapeutic efficacy and safety. RECENT FINDINGS The expansion of platelet function testing to include genotype assessment has been an evolutionary journey, initially fraught with confounding results. However, more recent and rigorous data analysis suggests that genotype testing- guided, tailored antiplatelet therapy may hold promise in optimizing treatment of patients after coronary intervention. Current evidence increasingly supports the use of genotype guided CYP2C19 testing to better match the post coronary intervention patient with the most efficacious and least risky antiplatelet inhibitor. The risk stratification of poor, intermediate, and good metabolizers of these drugs with such testing promises to yield clinical dividends in terms of morbidity, mortality and cost control, in this growing patient population.
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Affiliation(s)
- Manu Rajachandran
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA.
| | - Richard A Lange
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, 4800 Alberta Avenue, El Paso, TX, 79905, USA
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Olie RH, Hensgens RRK, Wijnen PAHM, Veenstra LF, de Greef BTA, Vries MJA, van der Meijden PEJ, ten Berg JM, ten Cate H, Bekers O, Henskens YMC. Differential Impact of Cytochrome 2C19 Allelic Variants on Three Different Platelet Function Tests in Clopidogrel-Treated Patients. J Clin Med 2021; 10:3992. [PMID: 34501440 PMCID: PMC8432532 DOI: 10.3390/jcm10173992] [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: 07/19/2021] [Revised: 08/23/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022] Open
Abstract
On-treatment platelet reactivity in clopidogrel-treated patients can be measured with several platelet function tests (PFTs). However, the agreement between different PFTs is only slight to moderate. Polymorphisms of the CYP2C19 gene have an impact on the metabolization of clopidogrel and, thereby, have an impact on on-treatment platelet reactivity. The aim of the current study is to evaluate the differential effects of the CYP2C19 genotype on three different PFTs. METHODS From a prospective cohort study, we included patients treated with clopidogrel following percutaneous coronary intervention (PCI). One month after PCI, we simultaneously performed three different PFTs; light transmission aggregometry (LTA), VerifyNow P2Y12, and Multiplate. In whole EDTA blood, genotyping of the CYP2C19 polymorphisms was performed. RESULTS We included 308 patients treated with clopidogrel in combination with aspirin (69.5%) and/or anticoagulants (33.8%) and, based on CYP2C19 genotyping, classified them as either extensive (36.4%), rapid (34.7%), intermediate (26.0%), or poor metabolizers (2.9%). On-treatment platelet reactivity as measured by LTA and VerifyNow is significantly affected by CYP2C19 metabolizer status (p < 0.01); as metabolizer status changes from rapid, via extensive and intermediate, to poor, the mean platelet reactivity increases accordingly (p < 0.01). On the contrary, for Multiplate, no such ordering of metabolizer groups was found (p = 0.10). CONCLUSIONS For VerifyNow and LTA, the on-treatment platelet reactivity in clopidogrel-treated patients correlates well with the underlying CYP2C19 polymorphism. For Multiplate, no major effect of genetic background could be shown, and effects of other (patient-related) variables prevail. Thus, besides differences in test principles and the influence of patient-related factors, the disagreement between PFTs is partly explained by differential effects of the CYP2C19 genotype.
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Affiliation(s)
- Renske H. Olie
- Department of Internal Medicine, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (R.R.K.H.); (H.t.C.)
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (M.J.A.V.); (P.E.J.v.d.M.); (Y.M.C.H.)
- Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Rachelle R. K. Hensgens
- Department of Internal Medicine, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (R.R.K.H.); (H.t.C.)
- Central Diagnostic Laboratory, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (P.A.H.M.W.); (O.B.)
| | - Petal A. H. M. Wijnen
- Central Diagnostic Laboratory, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (P.A.H.M.W.); (O.B.)
| | - Leo F. Veenstra
- Department of Cardiology, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (L.F.V.); (J.M.t.B.)
| | - Bianca T. A. de Greef
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands;
| | - Minka J. A. Vries
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (M.J.A.V.); (P.E.J.v.d.M.); (Y.M.C.H.)
| | - Paola E. J. van der Meijden
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (M.J.A.V.); (P.E.J.v.d.M.); (Y.M.C.H.)
- Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Jurriën M. ten Berg
- Department of Cardiology, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (L.F.V.); (J.M.t.B.)
- Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands
| | - Hugo ten Cate
- Department of Internal Medicine, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (R.R.K.H.); (H.t.C.)
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (M.J.A.V.); (P.E.J.v.d.M.); (Y.M.C.H.)
- Thrombosis Expertise Center, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands
| | - Otto Bekers
- Central Diagnostic Laboratory, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (P.A.H.M.W.); (O.B.)
| | - Yvonne M. C. Henskens
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6200 MD Maastricht, The Netherlands; (M.J.A.V.); (P.E.J.v.d.M.); (Y.M.C.H.)
- Central Diagnostic Laboratory, Maastricht University Medical Center+ (MUMC+), 6229 HX Maastricht, The Netherlands; (P.A.H.M.W.); (O.B.)
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You J, Li H, Guo W, Li J, Gao L, Wang Y, Geng L, Wang X, Wan Q, Zhang Q. Platelet function testing guided antiplatelet therapy reduces cardiovascular events in Chinese patients with ST‐segment elevation myocardial infarction undergoing percutaneous coronary intervention: The PATROL study. Catheter Cardiovasc Interv 2020; 95 Suppl 1:598-605. [DOI: 10.1002/ccd.28712] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 12/28/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Jieyun You
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Hongda Li
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Wei Guo
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Jiming Li
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Liming Gao
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Yunkai Wang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Liang Geng
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Xingxu Wang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Qing Wan
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
| | - Qi Zhang
- Department of Cardiovascular Medicine, Shanghai East HospitalTongji University School of Medicine Shanghai China
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Sibbing D, Aradi D, Alexopoulos D, ten Berg J, Bhatt DL, Bonello L, Collet JP, Cuisset T, Franchi F, Gross L, Gurbel P, Jeong YH, Mehran R, Moliterno DJ, Neumann FJ, Pereira NL, Price MJ, Sabatine MS, So DY, Stone GW, Storey RF, Tantry U, Trenk D, Valgimigli M, Waksman R, Angiolillo DJ. Updated Expert Consensus Statement on Platelet Function and Genetic Testing for Guiding P2Y12 Receptor Inhibitor Treatment in Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2019; 12:1521-1537. [DOI: 10.1016/j.jcin.2019.03.034] [Citation(s) in RCA: 250] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/22/2022]
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Williams DM, Hodge A, Catino J, DiMaggio C, Marshall G, Ayoung-Chee P, Frangos S, Bukur M. Correlation of thromboelastography with conventional coagulation testing in elderly trauma patients on pre-existing blood thinning medications. Am J Surg 2018. [DOI: 10.1016/j.amjsurg.2018.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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