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Costa H, Espírito-Santo M, Fernandes R, Bispo J, Guedes J, Azevedo P, Carvalho D, Vinhas H, Gonçalves RB, Mimoso J. Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes in contemporaneous clinical practice. Hellenic J Cardiol 2023:S1109-9666(23)00222-1. [PMID: 37956770 DOI: 10.1016/j.hjc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/07/2023] [Accepted: 11/09/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes (NSTE-ACS) during hospitalization is still a matter of contention within the cardiology community. Our aim was to analyze in-hospital and one-year follow-up outcomes of patients with NSTE-ACS pretreated with dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT). METHODS A retrospective study was carried out with NSTE-ACS patients who planned to undergo an invasive strategy and were included in the Portuguese Registry of ACS between 2018 and 2021. A composite primary outcome (in-hospital re-infarction, stroke, heart failure, hemorrhage, death) was compared regarding antiplatelet strategy (DAPT versus SAPT). Secondary outcomes were defined as one-year all-cause mortality and one-year cardiovascular rehospitalization. RESULTS A total of 1469 patients were included, with a mean age of 66 ± 12 years, and 73.9 % were male. The DAPT regime was used in 38.2 % of patients and SAPT in 61.8 % of patients. NSTE myocardial infarction was the most frequent presentation (88.5 %). Revascularization was performed within 24 h in 55.2% of patients. Time until revascularization >24 h occurred in 44.8% of patients, with 16.5% of these between [24 h-48 h], 10.6% in [48 h-72 h] and 17.6% > 72 h. The primary outcome was more frequently observed in the SAPT group (10.4 %, p = 0.033), mainly driven by more ischemic events. Time until revascularization >72 h and the SAPT regime were independent predictors of the primary outcome (OR 3.09, p = 0.005, and OR 2.03, p = 0.008, respectively). CONCLUSION NSTE-ACS patients pretreated with SAPT had worse in-hospital outcomes. This difference can probably be explained by time until revascularization delay.
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Affiliation(s)
- Hugo Costa
- Algarve University and Hospital Center, Faro, Algarve, Portugal.
| | | | | | - João Bispo
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | - João Guedes
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | - Pedro Azevedo
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | | | - Hugo Vinhas
- Algarve University and Hospital Center, Faro, Algarve, Portugal
| | | | - Jorge Mimoso
- Algarve University and Hospital Center, Faro, Algarve, Portugal
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Angiolillo DJ, Erlinge D, Ferreiro JL, Gale CP, Huber K, Musumeci G, Collet JP. European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on acute antiPlatelet treatment (READAPT) survey. Int J Cardiol 2023:S0167-5273(23)00717-9. [PMID: 37201617 DOI: 10.1016/j.ijcard.2023.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 05/08/2023] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy. OBJECTIVE To assess the implementation of this recommendation in the real-life setting. METHODS A web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%. RESULTS Among the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines. CONCLUSIONS This survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - José Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, CIBERCV, L'Hospitalet de Llobregat, Spain; Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL); L'Hospitalet de Llobregat, Spain
| | - Chris P Gale
- Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trusts, Leeds, UK
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Clinic Ottakring (Wilhelminenhospital), Sigmund Freud University, Medical School, Vienna, Austria
| | - Giuseppe Musumeci
- Cardiology Division, Ospedale Mauriziano, Torino, Italy; Past President Italian Society of Interventional Cardiology (GISE), Italy
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris 75013, France
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Early Versus Late Administration of P2Y 12 Inhibitors in Non-ST Segment Elevation Myocardial Infarction and Delayed Cardiac Catheterization. J Cardiovasc Pharmacol 2022; 80:270-275. [PMID: 35580315 DOI: 10.1097/fjc.0000000000001302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022]
Abstract
ABSTRACT Regardless of early invasive or ischemia-guided approaches to non-ST segment elevation myocardial infarction (NSTEMI) management, P2Y 12 inhibitors remain the backbone in therapy. The ideal timing of administration remains unclear. The purpose of this study was to determine the safety and effectiveness of early versus late administration of P2Y 12 inhibitors in patients presenting with an NSTEMI who go to the catheterization laboratory beyond 24 hours from presentation. We performed a single center, retrospective cohort study. Patients were classified into groups depending on whether they received early versus late administration of a P2Y 12 inhibitor. The primary outcome was the rate of major and clinically relevant, nonmajor bleeding (CRNMB). Secondary outcomes included troponin peak and length of stay after cardiac catheterization. Of the 121 patients included, 53 patients were in the early and 68 patients were in the late group. The number of bleeding events were similar between both groups ( P = 1.00). There were 3 (5.7%) major bleeding events in the early group and 5 (7.4%) bleeding events in the late group. There were 5 (9.4%) CRNMB events in the early group and 6 (8.8%) CRNMB events in the late group. There was a significant difference in troponin peak, 4.56 ng/mL in the early group and 1.77 ng/mL in the late group ( P = 0.02). The rate of bleeding did not differ between patients who received early or late administration of P2Y 12 inhibitors for NSTEMI management who undergo delayed cardiac catheterization.
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Ideal P2Y12 Inhibitor in Acute Coronary Syndrome: A Review and Current Status. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19158977. [PMID: 35897347 PMCID: PMC9331944 DOI: 10.3390/ijerph19158977] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 02/05/2023]
Abstract
Dual antiplatelet therapy (DAPT) has remained the cornerstone for management of acute coronary syndrome (ACS) over the years. Clopidogrel has been the quintessential P2Y12 receptor (platelet receptor for Adenosine 5′ diphosphate) inhibitor for the past two decades. With the demonstration of unequivocal superior efficacy of prasugrel/ticagrelor over clopidogrel, guidelines now recommend these agents in priority over clopidogrel in current management of ACS. Cangrelor has revived the interest in injectable antiplatelet therapy too. Albeit the increased efficacy of these newer agents comes at the cost of increased bleeding and this becomes more of a concern when combined with aspirin. Which P2Y12i is superior over another has been intensely debated over last few years after the ISAR-REACT 5 study with inconclusive data. Three novel antiplatelet agents are already in the pipeline for ACS with all of them succeeding in phase II studies. The search for an ideal antiplatelet remains a need of the hour for optimal reduction of ischemic events in ACS.
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De Luca L, Pugliese M, Putini RL, Natale E, Piazza V, Biffani E, Petrolati S, Musumeci F, Gabrielli D. Periprocedural Myocardial Injury in High-Risk Patients With NSTEMI Pretreated With Ticagrelor for Less or More Than 6 Hours Before PCI. J Clin Pharmacol 2021; 62:770-776. [PMID: 34907543 DOI: 10.1002/jcph.2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/09/2021] [Indexed: 11/12/2022]
Abstract
We assessed the impact on periprocedural myocardial injury of a ticagrelor loading dose given <6 or >6 hours before percutaneous coronary intervention (PCI) in non-ST-elevation myocardial infarction (NSTEMI) patients at high risk. All consecutive patients pretreated with ticagrelor and undergoing PCI for a high-risk NSTEMI have been included in the present analysis. Propensity-score matching was performed to compare the outcomes between patients pretreated with ticagrelor for >6 hours or ≤6 hours. The primary outcome was the rate of periprocedural myocardial injury after PCI. We also recorded clinical outcomes, including major adverse cardiovascular events and major bleedings at 1 month. A total of 1216 patients with NSTEMI were deemed eligible for the study: 481 received a ticagrelor loading dose ≤6 hours (mean time, 4.3 ± 1.2 h) and 735 >6 hours (16.1 ± 8.4 hours) before PCI. Patients pretreated with ticagrelor for >6 hours presented more risk factors and comorbidities compared to others. In patients pretreated with ticagrelor for >6 hours, the rate of periprocedural myocardial injury was significantly lower compared to the other group, in the overall population (19.6% vs 37.8%; P < .0001) and in the matched cohort of 644 patients (18.9% vs 33.5%; P < .0001). The rate of major adverse cardiovascular events and major bleeding events did not differ between the two groups, in both unmatched and matched populations. The present study suggests that ticagrelor pretreatment reduces periprocedural myocardial injury in high-risk patients with NSTEMI undergoing PCI with expected time intervals >6 hours.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy.,UniCamillus-Saint Camillus International University of Health Sciences, Rome, Italy
| | - Marco Pugliese
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy
| | - Rita Lucia Putini
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy
| | - Enrico Natale
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy
| | - Vito Piazza
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy
| | | | - Sandro Petrolati
- Department of Cardiosciences, A. O. San Camillo-Forlanini, Rome, Italy
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Dawson LP, Chen D, Dagan M, Bloom J, Taylor A, Duffy SJ, Shaw J, Lefkovits J, Stub D. Assessment of Pretreatment With Oral P2Y12 Inhibitors and Cardiovascular and Bleeding Outcomes in Patients With Non-ST Elevation Acute Coronary Syndromes: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2134322. [PMID: 34797371 PMCID: PMC8605486 DOI: 10.1001/jamanetworkopen.2021.34322] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The practice of pretreatment with oral P2Y12 inhibitors in non-ST elevation acute coronary syndromes (NSTEACS) remains common; however, its association with improved cardiovascular outcomes is unclear. OBJECTIVE To assess the association between oral P2Y12 inhibitor pretreatment and cardiovascular and bleeding outcomes in patients with NSTEACS. DATA SOURCES On March 20, 2021, PubMed, MEDLINE, Embase, Scopus, Web of Science, Science Direct, clinicaltrials.gov, and the Cochrane Central Register for Controlled Trials were searched from database inception. STUDY SELECTION Randomized clinical trials of patients with NSTEACS randomized to either oral P2Y12 inhibitor pretreatment (defined as prior to angiography) or no pretreatment (defined as following angiography, once coronary anatomy was known) among patients undergoing an invasive strategy. DATA EXTRACTION AND SYNTHESIS This study followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data on publication year, sample size, clinical characteristics, revascularization strategy, P2Y12 inhibitor type and dosage, time from pretreatment to angiography, and end point data were independently extracted by 2 authors. A random-effects model was used, including stratification by (1) P2Y12 inhibitor type, (2) revascularization strategy, and (3) access site. MAIN OUTCOMES AND MEASURES The primary end point was 30-day major adverse cardiac events (MACEs). Secondary end points were 30-day myocardial infarction (MI) and cardiovascular death. The primary safety end point was 30-day major bleeding (defined according to individual studies). RESULTS A total of 7 trials randomizing 13 226 patients to either pretreatment (6603 patients) or no pretreatment (6623 patients) were included. The mean age of patients was 64 years and 3598 (27.2%) were female individuals. Indication for P2Y12 inhibitors was non-ST elevation myocardial infarction in 7430 patients (61.7%), radial access was used in 4295 (32.6%), and 10 945 (82.8%) underwent percutaneous coronary intervention. Pretreatment was not associated with a reduction in 30-day MACE (odds ratio [OR], 0.95; 95% CI, 0.78-1.15; I2 = 28%), 30-day MI (OR, 0.90; 95% CI, 0.72-1.12; I2 = 19%), or 30-day cardiovascular death (OR, 0.79; 95% CI, 0.49-1.27; I2 = 0%). The risk of 30-day major bleeding was increased among patients who underwent pretreatment (OR, 1.51; 95% CI, 1.16-1.97; I2 = 41%). The number needed to harm to bring about 1 major bleeding event with oral P2Y12 inhibitor pretreatment was 63 patients. CONCLUSIONS AND RELEVANCE In this study, pretreatment with oral P2Y12 inhibitors among patients with NSTEACS prior to angiography, compared with treatment once coronary anatomy is known, was associated with increased bleeding risk and no difference in cardiovascular outcomes. Routine pretreatment with oral P2Y12 inhibitors in patients with NSTEACS receiving an early invasive strategy is not supported by this study.
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Affiliation(s)
- Luke P. Dawson
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David Chen
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Misha Dagan
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jason Bloom
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Andrew Taylor
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Stephen J. Duffy
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - James Shaw
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
| | - Jeffrey Lefkovits
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dion Stub
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
- The Baker Institute, Melbourne, Victoria, Australia
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Galli M, Angiolillo DJ. Antiplatelet therapy in percutaneous coronary intervention: latest evidence from randomized controlled trials. Curr Opin Cardiol 2021; 36:390-396. [PMID: 33973929 DOI: 10.1097/hco.0000000000000879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Antiplatelet therapy is key to reduce systemic and local thrombotic events among patients undergoing percutaneous coronary interventions (PCI). Antiplatelet treatment regimens have been subject to continuous changes over the years, with a dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor representing the cornerstone of treatment in these patients. RECENT FINDINGS The need for less aggressive antithrombotic drugs to prevent local ischemic events with newer generation drug-eluting stent together with the increased understanding of the prognostic relevance of bleeding events in PCI patients, have prompted investigations aimed at identifying antiplatelet treatment regimens associated with a more favorable balance between ischemic and bleeding risks. Several key randomized controlled trials (RCTs) on antiplatelet regimens in patients undergoing PCI have been recently reported resulting in updates in practice guidelines. SUMMARY This manuscript provides an overview of the advancements in the field deriving from key RCTs on antiplatelet regimens in patients undergoing PCI.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
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Valina C, Neumann FJ, Menichelli M, Mayer K, Wöhrle J, Bernlochner I, Aytekin A, Richardt G, Witzenbichler B, Sibbing D, Cassese S, Angiolillo DJ, Kufner S, Liebetrau C, Hamm CW, Xhepa E, Hapfelmeier A, Sager HB, Wustrow I, Joner M, Trenk D, Laugwitz KL, Schunkert H, Schüpke S, Kastrati A. Ticagrelor or Prasugrel in Patients With Non–ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol 2020; 76:2436-2446. [DOI: 10.1016/j.jacc.2020.09.584] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
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Timing of Oral P2Y 12 Inhibitor Administration in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 2020; 76:2450-2459. [PMID: 32882390 DOI: 10.1016/j.jacc.2020.08.053] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although oral P2Y12 inhibitors are key in the management of patients with non-ST-segment elevation acute coronary syndrome, the optimal timing of their administration is not well defined. OBJECTIVES The purpose of this study was to compare downstream and upstream oral P2Y12 inhibitors administration strategies in patients with non-ST-segment elevation acute coronary syndrome undergoing invasive treatment. METHODS We performed a randomized, adaptive, open-label, multicenter clinical trial. Patients were randomly assigned to receive pre-treatment with ticagrelor before angiography (upstream group) or no pre-treatment (downstream group). Patients in the downstream group undergoing percutaneous coronary intervention were further randomized to receive ticagrelor or prasugrel. The primary hypothesis was the superiority of the downstream versus the upstream strategy on the combination of efficacy and safety events (net clinical benefit). RESULTS We randomized 1,449 patients to downstream or upstream oral P2Y12 inhibitor administration. A pre-specified stopping rule for futility at interim analysis led the trial to be stopped. The rate of the primary endpoint, a composite of death due to vascular causes; nonfatal myocardial infarction or nonfatal stroke; and Bleeding Academic Research Consortium type 3, 4, and 5 bleeding through day 30, did not differ significantly between the downstream and upstream groups (percent absolute risk reduction: -0.46; 95% repeated confidence interval: -2.90 to 1.90). These results were confirmed among patients undergoing percutaneous coronary intervention (72% of population) and regardless of the timing of coronary angiography (within or after 24 h from enrollment). CONCLUSIONS Downstream and upstream oral P2Y12 inhibitor administration strategies were associated with low incidence of ischemic and bleeding events and minimal numeric difference of event rates between treatment groups. These findings led to premature interruption of the trial and suggest the unlikelihood of enhanced efficacy of 1 strategy over the other. (Downstream Versus Upstream Strategy for the Administration of P2Y12 Receptor Blockers In Non-ST Elevated Acute Coronary Syndromes With Initial Invasive Indication [DUBIUS]; NCT02618837).
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Tersalvi G, Biasco L, Cioffi GM, Pedrazzini G. Acute Coronary Syndrome, Antiplatelet Therapy, and Bleeding: A Clinical Perspective. J Clin Med 2020; 9:E2064. [PMID: 32630233 PMCID: PMC7408729 DOI: 10.3390/jcm9072064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 02/06/2023] Open
Abstract
Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described.
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Affiliation(s)
- Gregorio Tersalvi
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Internal Medicine, Hirslanden Klinik St. Anna, 6006 Lucerne, Switzerland
| | - Luigi Biasco
- Azienda Sanitaria Locale Torino 4, Ospedale di Ciriè, 10073 Ciriè, Italy;
- Department of Biomedical Sciences, University of Italian Switzerland, 6900 Lugano, Switzerland
| | - Giacomo Maria Cioffi
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Cardiology, Kantonsspital Luzern, 6000 Lucerne, Switzerland
| | - Giovanni Pedrazzini
- Division of Cardiology, Fondazione Cardiocentro Ticino, 6900 Lugano, Switzerland;
- Department of Biomedical Sciences, University of Italian Switzerland, 6900 Lugano, Switzerland
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