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Sibbing D, Massberg S, Rizas KD. Spoiled for Choice: P2Y 12 Receptor Inhibition in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2024; 17:1371-1373. [PMID: 38866459 DOI: 10.1016/j.jcin.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Seeshaupt, Germany; Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany.
| | - Steffen Massberg
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
| | - Konstantinos D Rizas
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
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Neppala S, Rajan J, Yang E, DeFronzo RA. Unexplained Residual Risk In Type 2 Diabetes: How Big Is The Problem? Curr Cardiol Rep 2024; 26:623-633. [PMID: 38634964 DOI: 10.1007/s11886-024-02055-0] [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: 04/01/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE OF REVIEW What is new? Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes (T2D) individuals. Of the major risk factors for CVD, less than 10% of T2D people meet the American Diabetes Association/American Heart Association recommended goals of therapy. The present review examines how much of the absolute cardiovascular (CV) risk in type 2 diabetes patients can be explained by major CV intervention trials. RECENT FINDINGS Multiple long-term cardiovascular (CV) intervention trials have examined the effect of specific target-directed therapies on the MACE endpoint. Only one prospective study, STENO-2, has employed a multifactorial intervention comparing intensified versus conventional treatment of modifiable risk factors in T2D patients, and demonstrated a 20% absolute CV risk reduction. If the absolute CV risk reduction in these trials is added to that in the only prospective multifactorial intervention trial (STENO-2), the unexplained CV risk is 44.1%. What are the clinical implications? Potential explanations for the unaccounted-for reduction in absolute CV risk in type 2 diabetes (T2D) patients are discussed. HYPOTHESIS failure to take into account synergistic interactions between major cardiovascular risk factors is responsible for the unexplained CV risk in T2D patients. Simultaneous treatment of all major CV risk factors to recommended AHA/ADA guideline goals is required to achieve the maximum reduction in CV risk.
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Affiliation(s)
- Sivaram Neppala
- Divisions of Diabetes, UT Health San Antonio, Texas, TX, 75229, USA
- Texas Diabetes Institute, San Antonio, Texas, 78207, USA
| | - Jemema Rajan
- Divisions of Diabetes, UT Health San Antonio, Texas, TX, 75229, USA
- Texas Diabetes Institute, San Antonio, Texas, 78207, USA
| | - Eric Yang
- Divisions of Cardiology, UT Health San Antonio, Texas, TX, USA
| | - Ralph A DeFronzo
- Divisions of Diabetes, UT Health San Antonio, Texas, TX, 75229, USA.
- Texas Diabetes Institute, San Antonio, Texas, 78207, USA.
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3
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Kim SH, Shin S, Choo EH, Choi IJ, Lim S, Moon D, Kim CJ, Park MW, Kim MC, Hwang BH, Lee KY, Choi YS, Kim HY, Yoo KD, Jeon DS, Ahn Y, Chang K. Clinical Impact of Dyspnea after Ticagrelor Treatment and the Effect of Switching to Clopidogrel in Patients with Myocardial Infarction. Thromb Haemost 2024. [PMID: 38574757 DOI: 10.1055/a-2299-4537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
BACKGROUND Dyspnea is frequent during ticagrelor-based dual antiplatelet therapy (DAPT) for acute myocardial infarction (AMI). However, its clinical characteristics or management strategy remains uncertain. METHODS The study assessed 2,617 AMI patients from the Ticagrelor versus Clopidogrel in Stabilized Patients with AMI (TALOS-AMI) trial. Dyspnea during 1-month ticagrelor-based DAPT and following DAPT strategies with continued ticagrelor or de-escalation to clopidogrel from 1 to 12 months were evaluated for drug adherence, subsequent dyspnea, major adverse cardiovascular events (MACE), and bleeding events. RESULTS Dyspnea was reported by 538 patients (20.6%) during 1 month of ticagrelor-based DAPT. Adherence to allocated DAPT over the study period was lower in the continued ticagrelor arm than the de-escalation to clopidogrel, particularly among the dyspneic population (81.1% vs. 91.5%, p < 0.001). Among ticagrelor-treated patients with dyspnea, those switched to clopidogrel at 1 month had a lower frequency of dyspnea at 3 months (34.3% vs. 51.7%, p < 0.001) and 6 months (25.5% vs. 38.4%, p = 0.002) than those continued with ticagrelor. In patients with dyspnea in their 1-month ticagrelor-based DAPT, de-escalation was not associated with increased MACE (1.3% vs. 3.9%, hazard ratio [HR]: 0.31, 95% confidence interval [CI]: 0.08-1.11, p = 0.07) or clinically relevant bleeding (3.2% vs. 6.2%, HR: 0.51, 95% CI: 0.22-1.19, p = 0.12) at 1 year. CONCLUSION Dyspnea is a common side effect among ticagrelor-based DAPTs in AMI patients. Switching from ticagrelor to clopidogrel after 1 month in AMI patients may provide a reasonable option to alleviate subsequent dyspnea in ticagrelor-relevant dyspneic patients, without increasing the risk of ischemic events (NCT02018055).
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Affiliation(s)
- Sang Hyun Kim
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, Department of Internal Medicine, The Armed Forces Capital Hospital, Seongnam, Korea
| | - Sanghoon Shin
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Ik Jun Choi
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Sungmin Lim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Donggyu Moon
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Chan Joon Kim
- Division of Cardiology, The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Uijeongbu, Korea
| | - Mahn-Won Park
- Division of Cardiology, The Catholic University of Korea, Daejeon St. Mary's Hospital, Daejeon, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Byung-Hee Hwang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Kwan Yong Lee
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Yun Seok Choi
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
- Division of Cardiology, The Catholic University of Korea, Yeouido St. Mary's Hospital, Seoul, Korea
| | - Hee-Yeol Kim
- Division of Cardiology, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Ki-Dong Yoo
- Division of Cardiology, The Catholic University of Korea, St. Vincent's Hospital, Suwon, Korea
| | - Doo Soo Jeon
- Division of Cardiology, The Catholic University of Korea, Incheon St. Mary's Hospital, Incheon, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
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4
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Cenko E, Manfrini O, Bugiardini R. Net adverse clinical events with P2Y 12 inhibitor therapy in older patients after percutaneous coronary interventions. Atherosclerosis 2024; 390:117434. [PMID: 38233328 DOI: 10.1016/j.atherosclerosis.2023.117434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/20/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Edina Cenko
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Olivia Manfrini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna Sant'Orsola Hospital, Bologna, Italy
| | - Raffaele Bugiardini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Sim HW, Koh KWL, Poh SC, Chan SP, Marchesseau S, Singh D, Han Y, Ng F, Lim E, Prabath JF, Lee CH, Chen R, Carvalho L, Tan SH, Loh JPY, Tan JWC, Kuwelker K, Amanullah RM, Chin CT, Yip JWL, Lee CY, Gan J, Lo CY, Ho HH, Hausenloy DJ, Tai BC, Richards AM, Chan MY. Remote intensive management to improve antiplatelet adherence in acute myocardial infarction: a secondary analysis of the randomized controlled IMMACULATE trial. J Thromb Thrombolysis 2024; 57:408-417. [PMID: 38300500 DOI: 10.1007/s11239-023-02931-6] [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] [Accepted: 11/29/2023] [Indexed: 02/02/2024]
Abstract
This study aim to investigate if remote intensive coaching for the first 6 months post-AMI will improve adherence to the twice-a-day antiplatelet medication, ticagrelor. Between July 8, 2015, to March 29, 2019, AMI patients were randomly assigned to remote intensive management (RIM) or standard care (SC). RIM participants underwent 6 months of weekly then two-weekly consultations to review medication side effects and medication adherence coaching by a centralized nurse practitioner team, whereas SC participants received usual cardiologist face-to-face consultations. Adherence to ticagrelor were determined using pill counting and serial platelet reactivity measurements for 12 months. A total of 149 (49.5%) of participants were randomized to RIM and 152 (50.5%) to SC. Adherence to ticagrelor was similar between RIM and SC group at 1 month (94.4 ± 0.7% vs. 93.6±14.7%, p = 0.537), 6 months (91.0±14.6% vs. 90.6±14.8%, p = 0.832) and 12 months (87.4±17.0% vs. 89.8±12.5%, p = 0.688). There was also no significant difference in platelet reactivity between the RIM and SC groups at 1 month (251AU*min [212-328] vs. 267AU*min [208-351], p = 0.399), 6 months (239AU*min [165-308] vs. 235AU*min [171-346], p = 0.610) and 12 months (249AU*min [177-432] vs. 259AU*min [182-360], p = 0.678). Sensitivity analysis did not demonstrate any association of ticagrelor adherence with bleeding events and major adverse cardiovascular events. RIM, comprising 6 months of intensive coaching by nurse practitioners, did not improve adherence to the twice-a-day medication ticagrelor compared with SC among patients with AMI. A gradual decline in ticagrelor adherence over 12 months was observed despite 6 months of intensive coaching.
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Affiliation(s)
- Hui Wen Sim
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.
- Department of Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore.
| | - Karen W L Koh
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Sock-Cheng Poh
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Siew Pang Chan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Stephanie Marchesseau
- Clinical Imaging Research Centre, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Devinder Singh
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Yiying Han
- Clinical Imaging Research Centre, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- National Heart Centre Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
| | - Faclin Ng
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Eleanor Lim
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Joseph F Prabath
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Chi-Hang Lee
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
- Cardiovascular Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Ruth Chen
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Leonardo Carvalho
- Universidade Federal de São Paulo, R. Sena Madureira, 1500 - Vila Clementino, São Paulo, SP, 04021-001, Brazil
| | - Sock-Hwee Tan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Joshua P Y Loh
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Jack W C Tan
- National Heart Centre Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
| | - Karishma Kuwelker
- Betanien Hospital, Bjørnstjerne Bjørnsons gate 6, Skien, 3722, Norway
| | - R M Amanullah
- National Heart Centre Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
| | - Chee-Tang Chin
- National Heart Centre Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
| | - James W L Yip
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Choy-Yee Lee
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Juvena Gan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Chew-Yong Lo
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
| | - Hee-Hwa Ho
- Department of Cardiology, Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore, 308433, Singapore
| | - Derek J Hausenloy
- National Heart Centre Singapore, 5 Hospital Dr, Singapore, 169609, Singapore
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore, Singapore
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taichung, Taiwan
| | - Bee-Choo Tai
- Saw Swee Hock School of Public Health, 12 Science Drive 2, #10-01, Singapore, 117549, Singapore
| | - A Mark Richards
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore
- Cardiovascular Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
- Christchurch Heart Institute, University of Otago, 362 Leith Street, Dunedin North, Dunedin, 9016, New Zealand
| | - Mark Y Chan
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.
- Cardiovascular Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore.
- Department of Medicine, Yong Loo-Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 9, Singapore, 119228, Singapore.
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Almendro-Delia M, Padilla-Rodríguez G, Hernández-Meneses B, Blanco-Ponce E, Arboleda-Sánchez JA, Rodríguez-Yáñez JC, Soto-Blanco JM, Fernández-García I, Castillo-Caballero JM, García-Rubira JC, Hidalgo-Urbano R. Nonadherence to ticagrelor versus clopidogrel and clinical outcomes in patients with ACS. Results from the CREA-ARIAM registry. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:113-124. [PMID: 37573968 DOI: 10.1016/j.rec.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/16/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Prior studies have not determined whether the effect of dual antiplatelet therapy (DAPT) cessation on the subsequent risk of major adverse cardiac events (MACE) varies by the choice of P2Y12-inhibitor after acute coronary syndrome (ACS). METHODS We performed a prespecified subanalysis of a multicenter, prospective registry of ACS patients discharged on ticagrelor or clopidogrel between 2015 and2019. Nonadherence to DAPT was categorized as physician-guided discontinuation and disruption due to adverse effects, nonadherence, or bleeding. The association between DAPT cessation and 1-year MACE was analyzed using multivariate time-updated Cox models with inverse probability of censoring weighted estimators. RESULTS Out of 2180 patients, 174 (8.3%) prematurely discontinued DAPT (physician-guided, n=126; disruption, n=48). Nonadherent patients were older and had more comorbidities than those on DAPT. Compared with physician-guided discontinuation, disruption occurred earlier after discharge and was more frequent with ticagrelor than with clopidogrel. In time-varying analysis, DAPT cessation was associated with an increased risk of MACE (adjusted HR, 1.32, 95%CI, 1.10-1.76), largely driven by disruption (adjusted HR, 1.47, 95%CI, 1.22-1.73). There was an exponential increase in MACE risk after DAPT cessation within 90 days after ACS, especially after disruption of ticagrelor compared with clopidogrel (Pinteraction<.001). After adjustment for DAPT duration, this interaction was not statistically significant on the additive scale (relative excess risk due to interaction 0.12, 95%CI,-0.99-1.24). CONCLUSIONS In this all-comers registry, 1 in 12 patients prematurely discontinued DAPT within 1 year after ACS. Compared with physician-recommended discontinuation, disruption resulted in a significantly higher risk of MACE. After adjustment for DAPT duration, this association was not moderated by the choice of P2Y12-inhibitor. Clinical trial registered at ClinicalTrials.gov (Identifier: NCT02500290).
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Affiliation(s)
- Manuel Almendro-Delia
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain.
| | | | | | - Emilia Blanco-Ponce
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | | | | | | | | | - Juan C García-Rubira
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rafael Hidalgo-Urbano
- Unidad de Agudos Cardiovascular, Hospital Universitario Virgen Macarena, Seville, Spain
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7
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Ortega-Paz L, Mehran R, Angiolillo DJ. Nonadherence to dual antiplatelet therapy: old problems without new solutions. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:125-128. [PMID: 37659651 DOI: 10.1016/j.rec.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States.
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Tamakauskas V, Žaliūnas R, Lesauskaitė V, Kupstytė-Krištaponė N, Čiapienė I, Šakalytė G, Plisienė J, Skipskis V, Tatarūnas V. The Effect of Platelet Activity, ABCB1 Genetic Polymorphism, and Renal Function on the Development of Ticagrelor-Related Dyspnea in Patients with Acute Coronary Syndrome. Drug Des Devel Ther 2024; 18:109-119. [PMID: 38287944 PMCID: PMC10822766 DOI: 10.2147/dddt.s435477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/21/2023] [Indexed: 01/31/2024] Open
Abstract
Purpose The aim of this study was to determine the effect of ABCB1 genetic polymorphism and renal function on the occurrence of ticagrelor-related dyspnea. Patients and Methods A total of 299 patients with acute with type 1, 2, or 3 myocardial infarction (with and without ST-segment elevation), who underwent coronary angiography and PTCA with stent implantation and were treated with antiplatelet drugs (ticagrelor and aspirin), were enrolled in this prospective study. For all enrolled patient's platelet aggregation (induction with high-sensitivity adenosine diphosphate, ADP HS) testing was performed using a MULTIPLATE® analyzer. Venous blood was also collected for genotyping. Results Patients experiencing ticagrelor-related dyspnea had lower ADP HS value (ADP HS ≤ 19.5 U; OR = 2.254; P = 0.009), higher creatinine concentration (>90 µmol/l; OR = 3.414; P = 0.019), and lower GFR value (<60 mL/min/1.73 m2; OR = 2.211; P = 0.035). ABCB1 T allele was associated with ticagrelor-related dyspnea (OR = 2.550; P = 0.04). Conclusion Ticagrelor-related dyspnea was found to be related to low platelet aggregation, increased plasma creatinine concentration, decreased GFR, and ABCB1 T allele. Carriers of the ABCB1 T allele had a higher plasma creatinine concentration that could be associated with an inhibitory effect of ticagrelor on P-glycoprotein function.
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Affiliation(s)
- Vytenis Tamakauskas
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
- Department of Cardiology, Faculty of Medicine, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Remigijus Žaliūnas
- Department of Cardiology, Faculty of Medicine, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Vaiva Lesauskaitė
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Nora Kupstytė-Krištaponė
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
- Department of Cardiology, Faculty of Medicine, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Ieva Čiapienė
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Gintarė Šakalytė
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
- Department of Cardiology, Faculty of Medicine, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Jurgita Plisienė
- Department of Cardiology, Faculty of Medicine, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Vilius Skipskis
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
| | - Vacis Tatarūnas
- Institute of Cardiology, Medical Academy, Lithuania University of Health Sciences, Kaunas, LT-50009, Lithuania
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9
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Andò G, Gragnano F, Pelliccia F, Calabrò P. Choice of P2Y12 Inhibitors After Acute Coronary Syndrome. Am J Cardiol 2024; 211:377. [PMID: 37944777 DOI: 10.1016/j.amjcard.2023.10.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina, AOU Policlinico "G. Martino", Messina, Italy
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
| | - Francesco Pelliccia
- Department of Cardiovascular Sciences, University of Rome "La Sapienza", Rome, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" and Division of Clinical Cardiology, AORN "Sant'Anna e San Sebastiano", Caserta, Italy
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Zheng S, Jie Q, Chen N, Chen X, Zhu Y. Ticagrelor Steady-State Trough Concentration in Chinese Patients Undergoing Percutaneous Coronary Intervention. Eur J Drug Metab Pharmacokinet 2024; 49:33-42. [PMID: 37999873 DOI: 10.1007/s13318-023-00867-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND AND OBJECTIVE: Platelets play a pivotal role in thrombotic events associated with acute coronary syndrome (ACS), making oral antiplatelet therapy a cornerstone in antithrombotic strategies. The dosing regimen for the oral antiplatelet drug ticagrelor warrants evaluation to ensure its appropriateness in clinical practice. Therefore, this study aimed to investigate the real-world clinical application of ticagrelor by determining the optimal therapeutic concentration of ticagrelor in Chinese patients undergoing percutaneous coronary intervention (PCI). METHODS We enrolled a cohort of 912 patients who underwent PCI with drug-eluting stent implantation for the treatment of ACS. We measured steady-state plasma drug concentrations using high-performance liquid chromatography-tandem mass spectrometry. The therapeutic drug concentration range at steady state was established on the basis of clinical pharmacodynamic indices, with verification of reliability through concentration-effect analysis and receiver operating characteristic curve assessment. RESULTS Analysis of plasma samples from the 912 patients revealed significant variations in the steady-state trough concentration of ticagrelor associated with factors such as gender, age, hypertension, and hyperlipidemia. On the basis of this analysis, the optimal therapeutic range for steady-state trough concentration was determined to be 240.65-335.83 ng/mL. Furthermore, the upper limit values for steady-state concentration were established at 439.97 ng/mL for male patients and 347.06 ng/mL for female patients. CONCLUSIONS This study provides robust and reliable insights into the optimal therapeutic steady-state trough concentrations of ticagrelor in Chinese patients with post-percutaneous coronary intervention. These findings have significant implications for guiding the rational use of antiplatelet drugs and facilitating precise drug administration in Chinese patients undergoing percutaneous coronary intervention.
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Affiliation(s)
- ShaoJun Zheng
- School of Biotechnology and Pharmaceutical Engineering, West Anhui University, Moon Island, West of Yunlu Bridge, Lu'an, 237012, People's Republic of China.
- Anhui Engineering Laboratory for Conservation and Sustainable Utilization of Traditional Chinese Medicine Resource, Lu'an, 237012, Anhui, People's Republic of China.
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, People's Republic of China.
| | - Qiong Jie
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210029, People's Republic of China
| | - NaiDong Chen
- School of Biotechnology and Pharmaceutical Engineering, West Anhui University, Moon Island, West of Yunlu Bridge, Lu'an, 237012, People's Republic of China
- Anhui Engineering Laboratory for Conservation and Sustainable Utilization of Traditional Chinese Medicine Resource, Lu'an, 237012, Anhui, People's Republic of China
| | - XiJing Chen
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, People's Republic of China
| | - YuBing Zhu
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210029, People's Republic of China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, People's Republic of China
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11
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Moon J, Ozaki AF, Chong A, Sud M, Fang J, Austin PC, Ko DT, Jackevicius CA. Trajectories of P2Y12 inhibitor adherence in patients with acute coronary syndromes. Pharmacoepidemiol Drug Saf 2024; 33:e5704. [PMID: 37771242 DOI: 10.1002/pds.5704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 09/09/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE P2Y12 inhibitors (P2Y12i) reduce cardiac events after acute coronary syndromes (ACS). However, suboptimal P2Y12i adherence persists. We aimed to examine P2Y12i non-adherence using group-based trajectory methods and to identify adherence predictors. METHODS We conducted a population-based, retrospective cohort study using administrative data in Ontario, Canada of patients ≥65 years admitted for ACS between April 2014 and March 2018 with a P2Y12i dispensed within 7 days of discharge. We used group-based trajectory models to characterize longitudinal 1-year adherence patterns. Predictors associated with each adherence trajectory were identified by multinomial logistic regression. RESULTS We included 11 917 patients using clopidogrel and 9763 using ticagrelor, aged [mean ± SD]: 77.33 ± 8.31/73.59 ± 6.79 years; men: 56.2%/65.4%, respectively. We identified 3 longitudinal adherence trajectories, that differed by agent: 75% of clopidogrel and 68% of ticagrelor patients showed a consistently adherent trajectory, while 13%/17% were gradually, and 12%/15% were rapidly non-adherent, respectively (p < 0.001). Differing baseline characteristics in each cohort were associated with observed adherence trajectories. Concomitant atrial fibrillation and prior bleeding history were associated with non-adherence among clopidogrel users. Among ticagrelor users, women and older persons were more likely to be rapidly non-adherent, adherence declining steeply starting 1 month post-ACS. CONCLUSIONS We identified distinct adherence trajectories for clopidogrel and ticagrelor post-ACS, with 3 out of 4 clopidogrel patients but only 2 out of 3 ticagrelor patients in the consistently adherent trajectory. Intensive interventions targeted to the period of steep adherence decline post-ACS, particularly for women and older persons initiating ticagrelor, and patients with atrial fibrillation on clopidogrel should be considered and investigated further.
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Affiliation(s)
- Jungyeon Moon
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Aya F Ozaki
- School of Pharmacy & Pharmaceutical Sciences, University of California Irvine, Irvine, California, USA
| | | | - Maneesh Sud
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Peter C Austin
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Schulich Heart Centre Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cynthia A Jackevicius
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
- ICES, Toronto, Canada
- University of Toronto, Toronto, Ontario, Canada
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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12
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Zheng S, Xu Y, Jie Q, Mu H, Zhang X, Zhu J, Zhu Y, Chen X, Chen S. A systematic study to evaluate the safety of ticagrelor combined with aspirin in the treatment of PCI patients in Chinese population: A single nucleotide polymorphisms study. Drug Metab Pharmacokinet 2023; 53:100468. [PMID: 38029471 DOI: 10.1016/j.dmpk.2022.100468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 11/29/2022]
Abstract
The aim of this study was to identify genes and their associated loci related to ticagrelor pharmacokinetics and pharmacodynamics in Chinese patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). The study included 1115 patients with ACS who received a drug-eluting stent implantation between October 2019 and January 2021. Among them, 98 cases of adverse reactions were observed; thus, 97 cases without adverse reactions were selected as the comparison group. The steady-state serum drug concentration was determined via high-performance liquid chromatography-mass spectrometry, and 15 single nucleotide polymorphism (SNP) loci were genotyped using the SNaPshot SNP Multiplex System. Our results showed that age and sex may affect ticagrelor serum concentration in patients with ACS. In particular, the SNPs CYP3A4∗1 (rs2242480 C > T), IGT2B (rs5911 A > C), P2Y12 (rs6787801) and CYP3A5 (rs776746 C > T) may affect the steady-state blood concentration of ticagrelor after PCI in ACS patients, and CYP3A4∗1 may also be related to adverse events. In addition, we found that the SNPs PEAR1 (rs4661012 T > G) and P2Y12 (rs6787801 A > G) may be associated with dyspnea. These findings can provide a useful reference to establish guidelines for future clinical individualized dosage regimens of ticagrelor after PCI.
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Affiliation(s)
- ShaoJun Zheng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.
| | - YiFan Xu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Qiong Jie
- Nanjing First Hospital, Nanjing, China
| | - HuiWen Mu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Xing Zhang
- The State Key Laboratory of Translational Medicine and Innovative Drug Development, Jiangsu Simcere Diagnostics Co., Ltd., Nanjing, China; Department of Medicine, Nanjing Simcere Medical Laboratory Science Co., Ltd., Nanjing, China
| | | | | | - XiJing Chen
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
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13
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Angiolillo DJ, Cao D, Sartori S, Baber U, Dangas G, Zhang Z, Vogel B, Kunadian V, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Ielasi A, Stefanini GG, Pivato CA, Mehta S, Moliterno DJ, Ohman EM, Escaned J, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Steg PG, Pocock S, Mehran R. Dyspnea-Related Ticagrelor Discontinuation After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:2514-2524. [PMID: 37879803 DOI: 10.1016/j.jcin.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Nearly 20% of patients on ticagrelor experience dyspnea, which may lead to treatment discontinuation in up to one-third of cases. OBJECTIVES The authors sought to evaluate the incidence, predictors, and outcomes of dyspnea-related ticagrelor discontinuation after percutaneous coronary intervention (PCI). METHODS In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, patients were maintained on ticagrelor and randomized to aspirin or placebo for 1 year. The occurrence of dyspnea associated with ticagrelor discontinuation was evaluated among all patients enrolled in the trial. A landmark analysis was performed at 3 months after PCI, that is, the time of randomization. Predictors of dyspnea-related ticagrelor discontinuation were obtained from multivariable Cox regression with stepwise selection of candidate variables. RESULTS The incidence of dyspnea-related ticagrelor discontinuation was 6.4% and 9.1% at 3 and 15 months after PCI, respectively. Independent predictors included Asian race (lower risk), smoking, prior PCI, hypercholesterolemia, prior coronary artery bypass, peripheral artery disease, obesity, and older age. Among 179 patients who discontinued ticagrelor because of dyspnea after randomization, ticagrelor monotherapy was not associated with a higher risk of subsequent ischemic events (composite of all-cause death, myocardial infarction, or stroke) compared with ticagrelor plus aspirin (5.0% vs 7.1%; P = 0.566). CONCLUSIONS In the TWILIGHT trial, dyspnea-related ticagrelor discontinuation occurred in almost 1 in 10 patients and tended to occur earlier rather than late after PCI. Several demographic and clinical conditions predicted its occurrence, and their assessment may help identify subjects at risk for therapy nonadherence.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, New York, USA; St. Francis Hospital, Roslyn, Roslyn, New York, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Kurt Huber
- 3rd Dept Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Carlo A Pivato
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Giora Weisz
- NewYork Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA
| | | | - P Gabriel Steg
- Université de Paris and Assistance Paris-Hôpitaux de Paris, Paris, France
| | - Stuart Pocock
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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14
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Gigante B, Levy JH, van Gorp E, Bartoloni A, Bochaton-Piallat ML, Bäck M, Ten Cate H, Christersson C, Ferreiro JL, Geisler T, Lutgens E, Schulman S, Storey RF, Thachil J, Vilahur G, Liaw PC, Rocca B. Management of patients on antithrombotic therapy with severe infections: a joint clinical consensus statement of the ESC Working Group on Thrombosis, the ESC Working Group on Atherosclerosis and Vascular Biology, and the International Society on Thrombosis and Haemostasis. Eur Heart J 2023; 44:3040-3058. [PMID: 37439553 DOI: 10.1093/eurheartj/ehad388] [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] [Received: 10/06/2022] [Revised: 05/01/2023] [Accepted: 05/29/2023] [Indexed: 07/14/2023] Open
Abstract
Patients with severe infections and a pre-existing indication for antithrombotic therapy, i.e. antiplatelet agents, anticoagulant drugs, or their combinations, require integrated clinical counselling among coagulation, infectious disease, and cardiology specialists, due to sepsis-induced coagulopathy that frequently occurs. Bacterial and viral pathogens constitute an increasing threat to global public health, especially for patients with ongoing antithrombotic treatment who have a high risk of thrombotic recurrences and high susceptibility to severe infections with increased morbidity and mortality. Similarly, sepsis survivors are at increased risk for major vascular events. Coagulopathy, which often complicates severe infections, is associated with a high mortality and obligates clinicians to adjust antithrombotic drug type and dosing to avoid bleeding while preventing thrombotic complications. This clinical consensus statement reviews the best available evidence to provide expert opinion and statements on the management of patients hospitalized for severe bacterial or viral infections with a pre-existing indication for antithrombotic therapy (single or combined), in whom sepsis-induced coagulopathy is often observed. Balancing the risk of thrombosis and bleeding in these patients and preventing infections with vaccines, if available, are crucial to prevent events or improve outcomes and prognosis.
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Affiliation(s)
- Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solnavägen 30. 17164 and Department of Cardiology, Danderyds Hospital, Entrévägen 2, 182 88, Stockholm, Sweden
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, United States; 2301 Erwin Road, Durham, NC 27710, USA
| | - Eric van Gorp
- Department of Viroscience, Erasmus MC, Rotterdam, PO box 2040 [Room Ee1726], 3000 CA Rotterdam, The Netherlands
| | - Alessandro Bartoloni
- Department of Experimental and Clinical Medicine, Infectious Diseases Unit, University of Florence, Largo Brambilla 3, 50100 Florence, Italy
| | - Marie-Luce Bochaton-Piallat
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, 1 rue Michel-Servet 1, CH-1211 Genève, Switzerland
| | - Magnus Bäck
- Department of Translational Cardiology, Karolinska Institutet and Karolinska University Hospital, CMM L8:01, 171 76 Stockholm, Sweden
- INSERM U1116, University of Lorraine, Nancy University Hospital, 2 rue Jean Lamour, 54505 Vandoeuvre les Nancy Cedex, France
| | - Hugo Ten Cate
- Department of Internal medicine, Thrombosis Expertise Center, Maastricht University Medical Center and CARIM school for cardiovascular diseases, Universiteitsingel 50, PO Box 616, 6200 MD Maastricht, The Netherlands
- Center for Thrombosis and Haemostasis, Gutenberg University Medical Center, Langenbeckstr. 1, Bldg. 403, 55131 Mainz, Germany
| | - Christina Christersson
- Department of Medical Sciences, Cardiology, Uppsala University, Akademiska Sjukhuset, 75185, Uppsala, Sweden
| | - José Luis Ferreiro
- Department of Cardiology and Bio-Heart Cardiovascular Diseases Research Group; Bellvitge University Hospital - Bellvitge Biomedical Research Institute (IDIBELL); CIBERCV; L'Hospitalet de Llobregat, Hospital Duran i Reynals - Edifici Terapèutic - 2a planta Gran Via de l'Hospitalet, 199, 08908 Hospitalet de Llobregat Barcelona -Spain
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Esther Lutgens
- Cardiovascular Medicine, Experimental CardioVascular Immunology Laboratory, Mayo Clinic, 200 First St SW, 55905, Rochester, MN, USA
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians Universität, München, Germany & German Center for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Pettenkoferstrasse 9, 80336, Munich, Germany
| | - Sam Schulman
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada HHS - General Hospital 237, Barton Street East, Hamilton, ON, L8L 2X2, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 2, стр. 4, Moscow 119435, Russia
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Pegasus House, 463a Glossop Road, Sheffield, S10 2QD, UK
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Oxford road, Manchester, M13 9WL, UK
| | - Gemma Vilahur
- Institut de Recerca Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBERCV, Avda. Sant Antoni Maria Claret 167, 08025 Barcelona, Spain
| | - Patricia C Liaw
- Department of Medicine, Thrombosis & Atherosclerosis Research Institute (TaARI), McMaster University, 237 Barton Street East Hamilton, Ontario L8L 2X2, Canada
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Largo F. Vito 1, 00168 Rome, Italy
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15
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Tubek S, Niewinski P, Langner-Hetmanczuk A, Jura M, Kuliczkowski W, Reczuch K, Ponikowski P. The effects of P2Y 12 adenosine receptors' inhibitors on central and peripheral chemoreflexes. Front Physiol 2023; 14:1214893. [PMID: 37538377 PMCID: PMC10394699 DOI: 10.3389/fphys.2023.1214893] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023] Open
Abstract
Introduction: The most common side effect of ticagrelor is dyspnea, which leads to premature withdrawal of this life-saving medication in 6.5% of patients. Increased chemoreceptors' sensitivity was suggested as a possible pathophysiological explanation of this phenomenon; however, the link between oversensitization of peripheral and/or central chemosensory areas and ticagrelor intake has not been conclusively proved. Methods: We measured peripheral chemoreceptors' sensitivity using hypoxic ventilatory response (HVR), central chemoreceptors' sensitivity using hypercapnic hyperoxic ventilatory response (HCVR), and dyspnea severity before and 4 ± 1 weeks following ticagrelor initiation in 11 subjects with chronic coronary syndrome undergoing percutaneous coronary intervention (PCI). The same tests were performed in 11 age-, sex-, and BMI-matched patients treated with clopidogrel. The study is registered at ClinicalTrials.com at NCT05080478. Results: Ticagrelor significantly increased both HVR (0.52 ± 0.46 vs. 0.84 ± 0.69 L min-1 %-1; p < 0.01) and HCVR (1.05 ± 0.64 vs. 1.75 ± 1.04 L min-1 mmHg-1; p < 0.01). The absolute change in HVR correlated with the change in HCVR. Clopidogrel administration did not significantly influence HVR (0.63 ± 0.32 vs. 0.58 ± 0.33 L min-1%-1; p = 0.53) and HCVR (1.22 ± 0.67 vs. 1.2 ± 0.64 L min-1 mmHg-1; p = 0.79). Drug-related dyspnea was reported by three subjects in the ticagrelor group and by none in the clopidogrel group. These patients were characterized by either high baseline HVR and HCVR or excessive increase in HVR following ticagrelor initiation. Discussion: Ticagrelor, contrary to clopidogrel, sensitizes both peripheral and central facets of chemodetection. Two potential mechanisms of ticagrelor-induced dyspnea have been identified: 1) high baseline HVR and HCVR or 2) excessive increase in HVR or HVR and HCVR. Whether other patterns of changes in chemosensitivities play a role in the pathogenesis of this phenomenon needs to be further investigated.
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Affiliation(s)
- Stanislaw Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Piotr Niewinski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Anna Langner-Hetmanczuk
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Maksym Jura
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
- Department of Physiology, Wroclaw Medical University, Wroclaw, Poland
| | - Wiktor Kuliczkowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Krzysztof Reczuch
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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16
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Kumbhani DJ, de Lemos JA. The Optimal Antiplatelet Agent for Secondary Prevention of Coronary Artery Disease: Ring Out the Old? J Am Coll Cardiol 2023; 82:106-108. [PMID: 37407109 DOI: 10.1016/j.jacc.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 07/07/2023]
Affiliation(s)
- Dharam J Kumbhani
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - James A de Lemos
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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17
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Cesarini D, Muraca I, Berteotti M, Gori AM, Sorrentino A, Bertelli A, Marcucci R, Valenti R. Pathophysiological and Molecular Basis of the Side Effects of Ticagrelor: Lessons from a Case Report. Int J Mol Sci 2023; 24:10844. [PMID: 37446022 DOI: 10.3390/ijms241310844] [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: 06/06/2023] [Revised: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/15/2023] Open
Abstract
Ticagrelor is currently considered a first-line choice in dual antiplatelet therapy (DAPT) following revascularization of acute coronary syndrome (ACS). However, its use is correlated with an increased incidence of two side effects, dyspnea and bradyarrhythmias, whose molecular mechanisms have not yet been defined with certainty and, consequently, neither of the therapeutic decisions they imply. We report the case of a patient with acute myocardial infarction treated with ticagrelor and aspirin as oral antithrombotic therapy after primary percutaneous coronary intervention (PCI), manifesting in a significant bradyarrhythmic episode that required a switch of antiplatelet therapy. Starting from this case report, this article aims to gather the currently available evidence regarding the molecular mechanisms underlying these side effects and propose possible decision-making algorithms regarding their management in clinical practice.
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Affiliation(s)
- Daniel Cesarini
- S.O.D. Cardiologia Interventistica d'Urgenza, AOU Careggi, 50134 Florence, Italy
| | - Iacopo Muraca
- S.O.D. Cardiologia Interventistica d'Urgenza, AOU Careggi, 50134 Florence, Italy
| | - Martina Berteotti
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy
| | - Anna Maria Gori
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy
| | - Andrea Sorrentino
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy
| | - Alessia Bertelli
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy
| | - Rossella Marcucci
- Atherothrombotic Center, Department of Experimental and Clinical Medicine, University of Florence, AOU Careggi, 50134 Florence, Italy
| | - Renato Valenti
- S.O.D. Cardiologia Interventistica d'Urgenza, AOU Careggi, 50134 Florence, Italy
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Zhao Z, Wang J, Lei M, Li Y, Yang Y, An L, Sun X, Li C, Xue Z. Effectiveness of dual antiplatelet de-escalation therapy on the prognosis of patients with ST segment elevation myocardial infarction undergoing percutaneous coronary intervention. BMC Cardiovasc Disord 2023; 23:168. [PMID: 36991321 PMCID: PMC10061818 DOI: 10.1186/s12872-023-03152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/27/2023] [Indexed: 03/31/2023] Open
Abstract
AIM To investigate the effectiveness of de-escalation of ticagrelor (from ticagrelor 90 mg to clopidogrel 75 mg or ticagrelor 60 mg) on the prognosis of patients with ST segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) after 3 months of oral dual antiplatelet therapy (DAPT). METHODS From March 2017 to August 2021, 1056 patients with STEMI in a single centre, through retrospective investigation and analysis, were divided into intensive (ticagrelor 90 mg), standard (clopidogrel 75 mg after PCI) and de-escalation groups (clopidogrel 75 mg or ticagrelor 60 mg after 3 months of treatment with 90 mg ticagrelor) based on the type and dose of P2Y12 inhibitor 3 months after PCI, and the patients had a ≥ 12-month history of oral DAPT. The primary end point was major adverse cardiovascular and cerebrovascular events (MACCEs) during the 12-month follow-up period, including composite end points of cardiac death, myocardial infarction, ischaemia-driven revascularization and stroke. The major safety endpoint was bleeding events. RESULTS The results showed that during the follow-up period, there was no statistically significant difference in the incidence of MACCEs between the intensive and de-escalation groups (P > 0.05). The incidence of MACCEs in the standard treatment group was higher than that in the intensive treatment group (P = 0.014), but the incidence of bleeding events in the de-escalation group was significantly lower than that in the standard group (9.3% vs. 18.4%, χ²=7.191, P = 0.027). The Cox regression analysis showed that increases in haemoglobin (HGB) (HR = 0.986) and estimated glomerular filtration rate (eGFR) (HR = 0.983) could reduce the incidence of MACCEs, while old myocardial infarction (OMI) (P = 0.023) and hypertension (P = 0.013) were independent predictors of MACCEs. CONCLUSION For STEMI patients undergoing PCI, the de-escalation scheme of ticagrelor to clopidogrel 75 mg or ticagrelor 60 mg at 3 months after PCI was related to the reduction of bleeding events, especially minor bleeding events, without an increase in ischaemic events.
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Affiliation(s)
- Zhigang Zhao
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Jingyao Wang
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Mengjie Lei
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Yachao Li
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Yanli Yang
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Lei An
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Xue Sun
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Cairong Li
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China
| | - Zengming Xue
- Department of Cardiology, Langfang Core Laboratory of Precision Treatment of CAD, Langfang People's Hospital, Hebei Medical University, Langfang, No. 37, Xinhua Road, 065000, Langfang, China.
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19
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Thomas CD, Williams AK, Lee CR, Cavallari LH. Pharmacogenetics of P2Y 12 receptor inhibitors. Pharmacotherapy 2023; 43:158-175. [PMID: 36588476 PMCID: PMC9931684 DOI: 10.1002/phar.2758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 01/03/2023]
Abstract
Oral P2Y12 inhibitors are commonly prescribed for cardiovascular disease and include clopidogrel, prasugrel, and ticagrelor. Each of these drugs has its strengths and weaknesses. Prasugrel and ticagrelor are more potent inhibitors of platelet aggregation and were shown to be superior to clopidogrel in preventing major adverse cardiovascular events after an acute coronary syndrome and percutaneous coronary intervention (PCI) in the absence of genotyping. However, both are associated with an increased risk for non-coronary artery bypass-related bleeding. Clopidogrel is a prodrug requiring bioactivation, primarily via the CYP2C19 enzyme. Approximately 30% of individuals have a CYP2C19 no function allele and decreased or no CYP2C19 enzyme activity. Clopidogrel-treated carriers of a CYP2C19 no function allele have decreased exposure to the clopidogrel active metabolite and lesser inhibition of platelet aggregation, which likely contributed to reduced clopidogrel efficacy in clinical trials. The pharmacogenetic data for clopidogrel are most robust in the setting of PCI, but evidence is accumulating for other indications. Guidance is available from expert consensus groups and regulatory agencies to assist with integrating genetic information into P2Y12 inhibitor prescribing decisions, and CYP2C19 genotype-guided antiplatelet therapy after PCI is one of the most common examples of clinical pharmacogenetic implementation. Herein, we review the evidence for pharmacogenetic associations with clopidogrel response and outcomes with genotype-guided P2Y12 inhibitor selection and describe guidance to assist with pharmacogenetic implementation. We also describe processes for applying genotype data for P2Y12 inhibitor therapy selection and remaining gaps in the field. Ultimately, consideration of both clinical and genetic factors may guide selection of P2Y12 inhibitor therapy that optimally balances the atherothrombotic and bleeding risks.
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Affiliation(s)
- Cameron D Thomas
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Alexis K Williams
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Craig R Lee
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Larisa H Cavallari
- Department of Pharmacotherapy and Translational Research and Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, Florida, USA
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20
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Andreotti F, Geisler T, Collet JP, Gigante B, Gorog DA, Halvorsen S, Lip GYH, Morais J, Navarese EP, Patrono C, Rocca B, Rubboli A, Sibbing D, Storey RF, Verheugt FWA, Vilahur G. Acute, periprocedural and longterm antithrombotic therapy in older adults: 2022 Update by the ESC Working Group on Thrombosis. Eur Heart J 2023; 44:262-279. [PMID: 36477865 DOI: 10.1093/eurheartj/ehac515] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022] Open
Abstract
The first international guidance on antithrombotic therapy in the elderly came from the European Society of Cardiology Working Group on Thrombosis in 2015. This same group has updated its previous report on antiplatelet and anticoagulant drugs for older patients with acute or chronic coronary syndromes, atrial fibrillation, or undergoing surgery or procedures typical of the elderly (transcatheter aortic valve implantation and left atrial appendage closure). The aim is to provide a succinct but comprehensive tool for readers to understand the bases of antithrombotic therapy in older patients, despite the complexities of comorbidities, comedications and uncertain ischaemic- vs. bleeding-risk balance. Fourteen updated consensus statements integrate recent trial data and other evidence, with a focus on high bleeding risk. Guideline recommendations, when present, are highlighted, as well as gaps in evidence. Key consensus points include efforts to improve medical adherence through deprescribing and polypill use; adoption of universal risk definitions for bleeding, myocardial infarction, stroke and cause-specific death; multiple bleeding-avoidance strategies, ranging from gastroprotection with aspirin use to selection of antithrombotic-drug composition, dosing and duration tailored to multiple variables (setting, history, overall risk, age, weight, renal function, comedications, procedures) that need special consideration when managing older adults.
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Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Largo F Vito 1, 00168 Rome, Italy.,Department of Cardiovascular and Pneumological Sciences, Catholic University, Rome, Italy
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital, Eberhard-Karls-University Tuebingen, Otfried-Müller-Straße 10, 72076 Tuebingen, Germany
| | - Jean-Philippe Collet
- Paris Sorbonne Université (UPMC), ACTION Study Group, INSERM UMR_S 1166, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet and Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, UK.,Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Oslo, Norway
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Joao Morais
- Serviço de Cardiologia, Centro Hospitalar de Leiria and Center for Innovative Care and Health Technology (ciTechCare), Leiria Polytechnic Institute, Leiria, Portugal
| | - Eliano Pio Navarese
- Department of Cardiology, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,SIRIO MEDICINE Network and Faculty of Medicine University of Alberta, Edmonton, Canada
| | - Carlo Patrono
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Bianca Rocca
- Department of Safety and Bioethics, Section on Pharmacology, Catholic University School of Medicine, Rome, Italy.,Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Seeshaupt, Germany & Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Program-ICCC, Research Institute-Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV, Instituto Salud Carlos III, Madrid, Spain
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21
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Kang MG, Ahn JH, Kim K, Koh JS, Park JR, Hwang SJ, Park Y, Tantry US, Gurbel PA, Hwang JY, Jeong YH. Prevalence of adverse events during ticagrelor versus clopidogrel treatment and its association with premature discontinuation of dual antiplatelet therapy in East Asian patients with acute coronary syndrome. Front Cardiovasc Med 2022; 9:1053867. [PMID: 36578832 PMCID: PMC9791044 DOI: 10.3389/fcvm.2022.1053867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background Clinical evidence raises the issues regarding the high risk of adverse events and serious bleeding in East Asian patients receiving standard-dose ticagrelor treatment. We sought to evaluate the association between adverse events and their associations with premature discontinuation of dual antiplatelet therapy (DAPT). Methods We enrolled East Asian patients presented with acute coronary syndrome who took DAPT with 90-mg ticagrelor (n = 270) or 75-mg clopidogrel (n = 674). During 1-month treatment, antiplatelet effect was evaluated with the VerifyNow P2Y12 assay, and the occurrence of Bleeding Academic Research Consortium (BARC) bleeding and modified Medical Research Council (mMRC) dyspnea was assessed with the dedicated questionnaire. Results During 1-month follow-up, patients on ticagrelor showed the higher risks of bleeding (any BARC type: 45.6% vs. 23.6%; odds ratio [OR], 2.71 and BARC 1 or 2 type: 45.2% vs. 22.1%; OR, 2.90, respectively) and dyspnea (26.3% vs. 13.6%; OR, 2.25) compared with those on clopidogrel. In a receiver-operating characteristics curve analysis to predict bleeding risk, ticagrelor showed a lower cutoff of low platelet reactivity (LPR) (P2Y12 reaction unit [PRU] ≤ 20) than clopidogrel (PRU ≤ 110). Early occurrence of bleeding episode was significantly associated with LPR phenotype (OR, 2.68), not type of P2Y12 inhibitor. In multivariate analysis, type of P2Y12 inhibitor (ticagrelor vs. clopidogrel: OR, 2.19) and bleeding episode (OR, 2.94) were independent predictors for dyspnea occurrence. During 1-year follow-up, DAPT with ticagrelor showed a higher risk of premature discontinuation compared to DAPT with clopidogrel (27.8% vs. 4.7%; adjusted HR, 8.84), which risk appeared frequent during the first month (14.4%) during DAPT with ticagrelor. Early occurrence of bleeding and dyspnea synergistically increased a risk of DAPT non-adherence, irrespective of type of P2Y12 inhibitor. Conclusion This analysis is the first evidence to show the different cutoff of low platelet reactivity during the reversible (ticagrelor) versus irreversible P2Y12 inhibitor (clopidogrel). Early occurrence of bleeding and dyspnea is very common during standard-dose ticagrelor treatment in East Asian patients, which show a close association with premature DAPT discontinuation. Clinical trial registration [https://www.clinicaltrials.gov], identifier[NCT046 50529].
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Affiliation(s)
- Min Gyu Kang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea,Division of Cardiology, Department of Medicine, Irvine Medical Center, University of California, Irvine, Irvine, CA, United States
| | - Jong Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Kyehwan Kim
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Jin-Sin Koh
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Joeng Rang Park
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Seok Jae Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, South Korea
| | - Udaya S. Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
| | - Paul A. Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, United States
| | - Jin-Yong Hwang
- Division of Cardiology, Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, South Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, South Korea,Division of Cardiology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, South Korea,*Correspondence: Young-Hoon Jeong, ,
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22
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Xiang Q, Wang Z, Mu G, Xie Q, Liu Z, Zhou S, Zhang H, Wang Z, Hu K, Song H, Yuan D, Xia Q, Huang Y, Cui Y. PROK2, HRNR, and FIG4 as potential genetic biomarkers of high bleeding propensity in East Asian patients with acute coronary syndrome using ticagrelor. Pharmacotherapy 2022; 42:872-879. [PMID: 36263704 DOI: 10.1002/phar.2736] [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: 07/07/2022] [Revised: 09/26/2022] [Accepted: 10/01/2022] [Indexed: 12/13/2022]
Abstract
STUDY OBJECTIVE East Asians have a higher risk of bleeding than Europeans when treated with ticagrelor. This study aimed to explore genetic indicators related to the high bleeding propensity in East Asian patients with acute coronary syndrome (ACS) using ticagrelor. DESIGN A multicenter prospective cohort study. SETTING Four sub center hospitals participating the study. PATIENTS Between March 2018 and July 2021, 208 patients with ACS were administered ticagrelor and underwent genetic testing. INVERTENTION Patients were enrolled and followed up for bleeding events for 12 months. Single-nucleotide polymorphisms (SNPs) were detected using whole-exome sequencing. SNPs significantly associated with cumulative bleeding events within 1-, 6-, and 12-month follow-ups were selected (p < 0.01). Among these, SNPs showing a difference of ≥2 fold in their distribution frequency among East Asians and Europeans were selected. MEASUREMENTS AND MAIN RESULTS Among all patients, 96.60% received ticagrelor plus aspirin or cilostazol, and 42.3% suffered from bleeding events during 12-month follow-up. Furthermore, 22 SNPs of 15 genes were found to have a significant association with cumulative bleeding events within 1-, 6-, and 12-month follow-ups. Among these SNPs, FIG4 rs2295837 (A>T) variant had the strongest association with bleeding events within 1 month (p = 1.28 × 10-4 ), with an increased risk of bleeding in T allele carriers (odds ratio [OR]: 3.07, 95% confidence interval [CI]: 1.68-5.63). PROK2 rs3796224 (C>T) variant was most strongly associated with cumulative bleeding events within 6 months (p = 4.57 × 10-4 ) with an increased risk of bleeding in T allele carriers (OR: 2.16, 95% CI: 1.20-3.89). Moreover, HRNR rs6662450 (C>T) variant showed the strongest relation with cumulative bleeding events within 12 months (p = 4.86 × 10-4 ) with a reduced risk of bleeding in T allele carriers (OR: 0.48, 95% CI: 0.24-0.95). CONCLUSION Fifteen genes, including PROK2, HRNR, and FIG4, were potential biomarkers of high bleeding propensity in East Asian patients with ACS using ticagrelor.
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Affiliation(s)
- Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hanxu Zhang
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hongtao Song
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Dongdong Yuan
- Department of Pharmacy, Zhengzhou Seventh People's Hospital, Zhengzhou, China
| | - Quan Xia
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yan Huang
- Department of Pharmacy, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.,Institute of Clinical Pharmacology, Peking University, Beijing, China
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23
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Zhou X, Angiolillo DJ, Ortega-Paz L. P2Y 12 Inhibitor Monotherapy after Percutaneous Coronary Intervention. J Cardiovasc Dev Dis 2022; 9:jcdd9100340. [PMID: 36286292 PMCID: PMC9604207 DOI: 10.3390/jcdd9100340] [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: 09/11/2022] [Revised: 10/05/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
In patients with acute and chronic coronary artery disease undergoing percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) has been the cornerstone of pharmacotherapy for the past two decades. Although its antithrombotic benefit is well established, DAPT is associated with an increased risk of bleeding, which is independently associated with poor prognosis. The improvement of the safety profiles of drug-eluting stents has been critical in investigating and implementing shorter DAPT regimens. The introduction into clinical practice of newer generation oral P2Y12 inhibitors such as prasugrel and ticagrelor, which provide more potent and predictable platelet inhibition, has questioned the paradigm of standard DAPT durations after coronary stenting. Over the last five years, several trials have assessed the safety and efficacy of P2Y12 inhibitor monotherapy after a short course of DAPT in patients treated with PCI. Moreover, ongoing studies are testing the role of P2Y12 inhibitor monotherapy immediately after PCI in selected patients. In this review, we provide up-to-date evidence on the efficacy and safety of P2Y12 inhibitor monotherapy after a short period of DAPT compared to DAPT in patients undergoing PCI as well as outcomes associated with P2Y12 inhibitor monotherapy compared to aspirin for long-term prevention.
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Affiliation(s)
- Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Department of Internal Medicine, University of Alabama at Birmingham Montgomery, Montgomery, AL 36116, USA
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
- Correspondence: ; Tel.: +1-904-244-3378; Fax: +1-904-244-3102
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
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24
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Fiocca L, Rossini R, Carioli G, Carobbio A, Piazza I, Collaku E, Giubilato S, Amico F, Molfese M, De Benedictis M, Calabria P, Limbruno U, Valente S, Ferlini M, Spezzano T, Senni M, Gavazzi A. Adherence of ticagrelOr in real world patients with aCute coronary syndrome: The AD-HOC study. IJC HEART & VASCULATURE 2022; 42:101092. [PMID: 35873861 PMCID: PMC9301572 DOI: 10.1016/j.ijcha.2022.101092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/19/2022] [Accepted: 07/13/2022] [Indexed: 10/24/2022]
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25
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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: 3] [Impact Index Per Article: 1.5] [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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26
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Almendro-Delia M, Blanco-Ponce E, Carmona-Carmona J, Arboleda Sánchez JA, Rodríguez Yáñez JC, Soto Blanco JM, Fernández García I, Castillo Caballero JM, García-Rubira JC, Hidalgo-Urbano RJ. Comparative Safety and Effectiveness of Ticagrelor versus Clopidogrel in Patients With Acute Coronary Syndrome: An On-Treatment Analysis From a Multicenter Registry. Front Cardiovasc Med 2022; 9:887748. [PMID: 35711382 PMCID: PMC9197128 DOI: 10.3389/fcvm.2022.887748] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background: The net clinical benefit of ticagrelor over clopidogrel in acute coronary syndrome (ACS) has recently been questioned by observational studies which did not account for time-dependent confounders. We aimed to assess the comparative safety and effectiveness of ticagrelor vs. clopidogrel accounting for non-adherence in a real-life setting. Methods This is a prospective, multicenter cohort study of patients with ACS discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, and the use of prasugrel or oral anticoagulation. Association of P2Y12 inhibitor therapy with 1-year risk of Bleeding Academic Research Consortium Type 3 or 5 bleeding; major adverse cardiac events (MACEs), a composite endpoint of all-cause death, nonfatal myocardial infarction (MI), nonfatal stroke, or urgent target lesion revascularization; definite/probable stent thrombosis; vascular death; and net adverse clinical event (a composite endpoint of major bleeding and MACE) were analyzed according to the “on-treatment” principle, using fully adjusted Cox and Fine-Gray regression models with doubly robust inverse probability of censoring weighted estimators. Results Among 2,070 patients (mean age 63 years, 27% women, 62.5% ST-elevation MI), 1,035 were discharged on ticagrelor and clopidogrel, respectively. Ticagrelor-treated patients were younger and had few comorbidities, but high rates of medication non-compliance, compared with clopidogrel users. After comprehensive multivariate adjustments, ticagrelor did not increase the risk of major bleeding compared with clopidogrel [subhazard ratio, 1.40; 95% confidence interval (CI), 0.96–2.05], while proved superior in reducing MACE (hazard ratio 0.62; 95% CI, 0.43–0.90), vascular death (subhazard ratio, 0.71; 95% CI, 0.52–0.97) and definite/probable stent thrombosis (subhazard ratio, 0.54; 95% CI, 0.30-0.79); thereby resulting in a favorable net clinical benefit (hazard ratio 0.78; 95% CI, 0.60–0.98) compared with clopidogrel. Results from sensitivity analyses were consistent with those from the primary analysis, whereas those from the intention-to-treat (ITT) analysis went in the opposite direction. Conclusion Among all-comers with ACS, ticagrelor did not significantly increase the risk of major bleeding, while resulting in a net clinical benefit compared with clopidogrel. Further research is warranted to confirm these findings in high bleeding risk populations. CREA-ARIAM Andalucía (ClinicalTrials.gov Identifier: NCT02500290); Current pre-specified analysis (ClinicalTrials.gov Identifier: NCT04630288).
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Affiliation(s)
- Manuel Almendro-Delia
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
- *Correspondence: Manuel Almendro-Delia
| | - Emilia Blanco-Ponce
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Jesús Carmona-Carmona
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
| | | | | | | | | | | | - Juan C. García-Rubira
- Acute Cardiovascular Care Unit, Hospital Universitario Virgen Macarena, Seville, Spain
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Joseph JJ, Deedwania P, Acharya T, Aguilar D, Bhatt DL, Chyun DA, Di Palo KE, Golden SH, Sperling LS. Comprehensive Management of Cardiovascular Risk Factors for Adults With Type 2 Diabetes: A Scientific Statement From the American Heart Association. Circulation 2022; 145:e722-e759. [PMID: 35000404 DOI: 10.1161/cir.0000000000001040] [Citation(s) in RCA: 185] [Impact Index Per Article: 92.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.
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Passacquale G, Sharma P, Perera D, Ferro A. Antiplatelet therapy in cardiovascular disease: current status and future directions. Br J Clin Pharmacol 2022; 88:2686-2699. [PMID: 35001413 PMCID: PMC9303765 DOI: 10.1111/bcp.15221] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022] Open
Abstract
Antiplatelet medications remain a cornerstone of therapy for atherosclerotic cardiovascular and cerebrovascular diseases. In primary prevention (patients with cardiovascular risk factors but no documented events, symptoms or angiographic disease), there is little evidence of benefit of any antiplatelet therapy, and such therapy carries the risk of excess bleeding. Where there is documented disease (secondary prevention), stable patients benefit from long-term antiplatelet monotherapy, aspirin being first choice in those with coronary heart disease and clopidogrel in those with cerebrovascular disease; moreover, recent evidence shows that low-dose rivaroxaban in combination with aspirin confers added benefit, in patients with stable cardiovascular and peripheral arterial disease. In patients with acute cerebrovascular disease, aspirin combined with clopidogrel reduces subsequent risk, while in acute coronary syndrome, dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel or ticagrelor) confers greater protection than aspirin monotherapy, with prasugrel and ticagrelor offering greater antiplatelet efficacy with faster onset of action than clopidogrel. Although greater antiplatelet efficacy is advantageous in preventing thrombotic events, this must be tempered by increased risk of bleeding which may be a particular issue in certain patient groups, as will be discussed. We will also discuss possible future approaches to personalisation of antiplatelet therapy.
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Affiliation(s)
- Gabriella Passacquale
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
| | - Pankaj Sharma
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, Surrey, UK
| | - Divaka Perera
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
| | - Albert Ferro
- School of Cardiovascular Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King's College London, London, UK
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29
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Butt JH, Fosbøl EL, Gerds TA, Iversen K, Bundgaard H, Bruun NE, Larsen AR, Petersen A, Andersen PS, Skov RL, Østergaard L, Havers-Borgersen E, Gislason GH, Torp-Pedersen C, Køber L, Olesen JB. Ticagrelor and the risk of Staphylococcus aureus bacteraemia and other infections. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:13-19. [PMID: 32750138 DOI: 10.1093/ehjcvp/pvaa099] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/30/2020] [Indexed: 01/12/2023]
Abstract
AIMS To investigate the 1-year risks of Staphylococcus aureus bacteraemia (SAB), sepsis, and pneumonia in patients who underwent percutaneous coronary intervention and were treated with ticagrelor vs. clopidogrel. METHODS AND RESULTS In this nationwide observational cohort study, 26 606 patients who underwent urgent or emergent percutaneous coronary intervention (January 2011-December 2017) and initiated treatment with ticagrelor [N = 20 073 (75.5%); median age 64 years (25th-75th percentile 55-72 years); 74.8% men] or clopidogrel [N = 6533 (24.5%); median age 68 years (25th-75th percentile 58-77 years); 70.2% men] were identified using Danish nationwide registries. The 1-year standardized absolute risks of outcomes was calculated based on cause-specific Cox regression models, and average treatment effects between treatment groups were obtained as standardized differences in absolute 1-year risks. The absolute 1-year risk of SAB was 0.10% [95% confidence interval (CI), 0.05-0.15%] in the ticagrelor group and 0.29% (95% CI, 0.17-0.42%) in the clopidogrel group. Compared with clopidogrel, treatment with ticagrelor was associated with a significantly lower absolute 1-year risk of SAB [absolute risk difference -0.19% (95% CI, -0.32% to -0.05%), P value 0.006]. Likewise, treatment with ticagrelor was associated with a significantly lower absolute 1-year risk of sepsis [0.99% (95% CI, 0.83-1.14%) vs. 1.49% (95% CI, 1.17-1.80%); absolute risk difference -0.50% (95% CI, -0.86% to -0.14%), P value 0.007] and pneumonia [3.13% (95% CI, 2.86-3.39%) vs. 4.56% (95% CI, 4.03-5.08%); absolute risk difference -1.43% (95% CI, -2.03% to -0.82%), P value < 0.001] compared with clopidogrel. CONCLUSION Treatment with ticagrelor was associated with a significantly lower 1-year risk of SAB, sepsis, and pneumonia compared with clopidogrel.
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Affiliation(s)
- Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas A Gerds
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Eske Bruun
- Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.,Institute of Clinical Medicine, Copenhagen University, Copenhagen, Denmark.,Clinical Institute, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Lauge Østergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Eva Havers-Borgersen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gunnar H Gislason
- The Danish Heart Foundation, Copenhagen, Denmark.,Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology and Clinical Investigation, Nordsjællands Hospital, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jonas B Olesen
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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30
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Moon H, Jo YS, Kim SJ, Jo S, Park K. Comparison of ticagrelor with clopidogrel on quality of life in patients with acute coronary syndrome. Health Qual Life Outcomes 2021; 19:242. [PMID: 34656119 PMCID: PMC8520288 DOI: 10.1186/s12955-021-01875-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 10/02/2021] [Indexed: 11/22/2022] Open
Abstract
Background Ticagrelor has a Class I recommendation for use following percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). However, ticagrelor needs to be taken twice a day, as compared to clopidogrel. Its adverse effects, such as dyspnea or bleeding, are known to be more common than with clopidogrel. Dyspnea may tend to be uncomfortable and limit activity. Major bleeding often leads to hospitalization or transfusions, and frequent minor bleeding, which might not result in patients seeking medical care, can make ACS patients feel unhealthy. Thus, these characteristics may affect the health-related quality of life (HQOL). Methods In the PLEIO (comParison of ticagreLor and clopidogrEl on mIcrocirculation in patients with acute cOronary syndrome) trial, we randomized 120 participants to receive ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily for at least 12 months. We carried out an HQOL assessment with the Short Form 36 Health Survey (SF-36) questionnaire on the day of discharge following PCI, as well as six months later. Results At discharge, the HQOL measures were similar in the ticagrelor and clopidogrel groups, both having a physical component summary (PCS) and a mental component summary (MCS) score. A six-month HQOL follow-up assessment showed that there were no differences between the two study groups in either the PCS or the MCS scores. In both groups, the PCS scores significantly increased over six months of treatment (both p < 0.01). However, the MCS score did not differ significantly. A baseline MCS score is an independent predictor of better physical and mental health status at six months. Conclusions Ticagrelor, as compared to clopidogrel, did not significantly reduce the HQOL during the six months following PCI in patients with ACS. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT02618733.
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Affiliation(s)
- Hyeyeon Moon
- Regional Cardiovascular Center, Dong-A University Hospital, Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Daesingongwon 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Yoon-Sung Jo
- Regional Cardiovascular Center, Dong-A University Hospital, Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Daesingongwon 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Soo-Jin Kim
- Regional Cardiovascular Center, Dong-A University Hospital, Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Daesingongwon 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Sua Jo
- Regional Cardiovascular Center, Dong-A University Hospital, Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Daesingongwon 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Kyungil Park
- Regional Cardiovascular Center, Dong-A University Hospital, Division of Cardiology, Department of Internal Medicine, Dong-A University College of Medicine, Daesingongwon 26, Seo-gu, Busan, 49201, Republic of Korea.
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Antiplatelets in acute coronary syndrome in Poland - from guidelines to clinical practice. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2021; 17:141-154. [PMID: 34400916 PMCID: PMC8356830 DOI: 10.5114/aic.2021.107492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 05/26/2021] [Indexed: 11/17/2022] Open
Abstract
Acute coronary syndrome is a factor for poor prognosis and recurrent cardiovascular events. Adequate antiplatelet therapy is crucial in patients with the acute coronary syndrome for risk reduction. Such treatment is well described in four documents issued by the European Society of Cardiology, which precisely illustrate the use of antiplatelets in the settings of ST-elevated and non-ST elevated myocardial infarction. Despite its unquestioned role in the treatment of acute coronary syndrome, recent real-world-data from Polish registries reveal poor adherence to the guidelines-recommended antiplatelet treatment in Poland. Thus, we present here a comprehensive review of the use of antiplatelets in the settings of the acute coronary syndrome. Each phase of the treatment, i.e. pre-hospital, in-hospital and post-hospital, is discussed separately for a better understanding of the decision-making process at each step. We also present unpublished data from Polish registries (e.g. PL-ACS 2019, National Registry of Procedures of Invasive Cardiology, RECEPTOmetrPEX panel) regarding adherence to the guidelines-recommended treatment in Poland, thus highlighting the points of care which should be immediately improved. It has to be stressed here that careful assessment of ischaemic and bleeding risk has to be performed in each patient with acute coronary syndrome individually and repeated at successive phases of the treatment. Only such an approach allows for appropriate antiplatelet therapy tailoring.
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32
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Zeitouni M, Guedeney P. Aspirin-Free Strategies in ACS: Is It the Drug or the Stent? JACC Cardiovasc Interv 2021; 14:441-443. [PMID: 33602440 DOI: 10.1016/j.jcin.2020.12.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 12/22/2020] [Accepted: 12/30/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Michel Zeitouni
- ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne University, Paris, France.
| | - Paul Guedeney
- ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Sorbonne University, Paris, France
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33
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Sanmartin-Fernandez M, Zamorano JL. Theophylline for Attenuating Ticagrelor-Related Dyspnea. Arq Bras Cardiol 2021; 117:146-148. [PMID: 34320085 PMCID: PMC8294732 DOI: 10.36660/abc.20201076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/24/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
| | - Jose Luis Zamorano
- Hospital Universitario Ramon y Cajal - Serviço de Cardiologia,Madri - Espanha
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34
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Abstract
Cardiovascular disease is the leading cause of death globally. While pharmacological advancements have improved the morbidity and mortality associated with cardiovascular disease, non-adherence to prescribed treatment remains a significant barrier to improved patient outcomes. A variety of strategies to improve medication adherence have been tested in clinical trials, and include the following categories: improving patient education, implementing medication reminders, testing cognitive behavioral interventions, reducing medication costs, utilizing healthcare team members, and streamlining medication dosing regimens. In this review, we describe specific trials within each of these categories and highlight the impact of each on medication adherence. We also examine ongoing trials and future lines of inquiry for improving medication adherence in patients with cardiovascular diseases.
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Affiliation(s)
- Steven T Simon
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vinay Kini
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrew E Levy
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Division of Cardiology, Denver Health Medical Center, Denver, CO, USA
| | - P Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Cardiology Section, VA Eastern Colorado Health Care System, Aurora, CO, USA
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35
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Aminoshariae A, Donaldson M, Horan M, Kulild JC, Baur D. Perioperative Antiplatelet and Anticoagulant Management with Endodontic Microsurgical Techniques. J Endod 2021; 47:1557-1565. [PMID: 34265324 DOI: 10.1016/j.joen.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/23/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The purpose of this study was to review evidence-based recommendations for the safe perioperative management of patients undergoing endodontic microsurgery who are currently taking antiplatelet or anticoagulant medications. Using the PICO (Population, Intervention, Comparison, Outcome) format, the following scientific question was asked: In patients taking anticoagulant or antiplatelet agents, what is the available evidence in the management of endodontic microsurgery? METHODS MEDLINE, Scopus, Cochrane Library, and ClinicalTrials.gov databases were searched to identify current recommendations regarding the management of antiplatelet and anticoagulant medications in the context of outpatient dental surgical procedures. Additionally, the authors hand searched the bibliographies of all relevant articles, the gray literature, and textbooks. Because of the lack of clinical studies and evidence on this subject, articles and guidelines from other organizations and association position statements were included. RESULTS Because any minor surgery can become a major surgery, the treating doctor needs to best assess the risk of bleeding, especially if the surgery is anticipated to take longer than 45 minutes. Every patient should be stratified on a case-by-case basis. Consultation with the patient's physician is highly recommended. CONCLUSIONS In order to maximize the effects of these medications (to prevent thrombosis) while minimizing the potential risks (procedural hemorrhage), clinicians should be aware of the best available evidence when considering continuation or discontinuation of antiplatelet and anticoagulant agents perioperatively for endodontic microsurgery. Ideally, a joint effort from an expert panel for microsurgery would be warranted.
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Affiliation(s)
- Anita Aminoshariae
- Departments of Endodontics, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio.
| | - Mark Donaldson
- School of Pharmacy, University of Montana, Missoula, Montana; School of Dentistry, Oregon Health and Sciences University, Portland, Oregon
| | - Michael Horan
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
| | - James C Kulild
- UKMC Dental School, University of Missouri-Kansas City, Kansas City, Missouri
| | - Dale Baur
- Oral and Maxillofacial Surgery, Case Western Reserve University, School of Dental Medicine, Cleveland, Ohio
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36
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Galani J, Mulder H, Rockhold FW, Weissler EH, Baumgartner I, Berger JS, Blomster JI, Fowkes FGR, Hiatt WR, Katona BG, Norgren L, Mahaffey KW, Quint JK, Patel MR, Jones WS. Association of Chronic Obstructive Pulmonary Disease with Morbidity and Mortality in Patients with Peripheral Artery Disease: Insights from the EUCLID Trial. Int J Chron Obstruct Pulmon Dis 2021; 16:841-851. [PMID: 33824584 PMCID: PMC8018572 DOI: 10.2147/copd.s292978] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of developing lower extremity peripheral artery disease (PAD) and suffering PAD-related morbidity and mortality. However, the effect and burden of COPD on patients with PAD is less well defined. This post hoc analysis from EUCLID aimed to analyze the risk of major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with PAD and concomitant COPD compared with those without COPD, and to describe the adverse events specific to patients with COPD. Methods EUCLID randomized 13,885 patients with symptomatic PAD to monotherapy with either ticagrelor or clopidogrel for the prevention of MACE. In this analysis, MACE, MALE, mortality, and adverse events were compared between groups with and without COPD using unadjusted and adjusted Cox proportional hazards model. Results Of the 13,883 patients with COPD status available at baseline, 11% (n=1538) had COPD. Patients with COPD had a higher risk of MACE (6.02 vs 4.29 events/100 patient-years; p<0.001) due to a significantly higher risk of myocardial infarction (MI) (3.55 vs 1.85 events/100 patient-years; p<0.001) when compared with patients without COPD. These risks persisted after adjustment (MACE: adjusted hazard ratio (aHR) 1.30, 95% confidence interval [CI] 1.11–1.52; p<0.001; MI: aHR 1.45, 95% CI 1.18–1.77; p<0.001). However, patients with COPD did not have an increased risk of MALE or major bleeding. Patients with COPD were more frequently hospitalized for dyspnea and pneumonia (2.66 vs 0.9 events/100 patient-years; aHR 2.77, 95% CI 2.12–3.63; p<0.001) and more frequently discontinued study drug prematurely (19.36 vs 12.54 events/100 patient-years; p<0.001; aHR 1.34, 95% CI 1.22–1.47; p<0.001). Conclusion In patients with comorbid PAD and COPD, the risks of MACE, respiratory-related adverse events, and premature study drug discontinuation were higher when compared with patients without COPD. Registration ClinicalTrials.gov: NCT01732822.
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Affiliation(s)
- Jemi Galani
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Frank W Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - E Hope Weissler
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.,Department of Surgery, Division of Vascular Surgery, Duke University Health System, Durham, NC, USA
| | - Iris Baumgartner
- Department of Medicine, Swiss Cardiovascular Center, University of Bern, Bern, Switzerland
| | - Jeffrey S Berger
- Departments of Medicine and Surgery, New York University School of Medicine, New York, NY, USA
| | | | - F Gerry R Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA.,CPC Clinical Research, Aurora, CO, USA
| | | | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer K Quint
- Respiratory Epidemiology, Occupational Medicine and Public Health, National Heart and Lung Institute, Imperial College London, London, UK
| | - Manesh R Patel
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - W Schuyler Jones
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Lordkipanidzé M, Marquis-Gravel G, Tanguay JF, Mehta SR, So DY. Implications of the Antiplatelet Therapy Gap Left With Discontinuation of Prasugrel in Canada. CJC Open 2020; 3:814-821. [PMID: 34169260 PMCID: PMC8209390 DOI: 10.1016/j.cjco.2020.11.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 11/18/2020] [Indexed: 11/19/2022] Open
Abstract
Background The current Canadian Cardiovascular Society antiplatelet therapy guidelines recommend the use of ticagrelor or prasugrel over clopidogrel as first-line platelet P2Y12 receptor antagonists for treatment of moderate- to high-risk acute coronary syndromes. Recently, Effient (prasugrel [Eli Lilly Canada Inc, Toronto, Canada]) was discontinued by its distributor in Canada. Methods Five members of the Canadian Cardiovascular Society antiplatelet therapy 2018 guidelines committee undertook an independent, evidence-based review to outline patients for whom prasugrel should be the optimal P2Y12 agent and discuss alternative strategies to consider without prasugrel. Results Several clinical scenarios where prasugrel should be indicated are identified and discussed. Considerations to be undertaken for alternative therapies are summarized, including a review of national and international guidelines for de-escalation of P2Y12 receptor antagonists. Conclusions The discontinuation of prasugrel poses a challenge for clinicians. Clinicians must consider key factors in determining the best alternate therapy.
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Affiliation(s)
- Marie Lordkipanidzé
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Guillaume Marquis-Gravel
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-François Tanguay
- Montreal Heart Institute, Montreal, Quebec, Canada
- Faculty of medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Shamir R. Mehta
- McMaster University, Hamilton, Ontario, Canada
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Derek Y.F. So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Corresponding author: Dr Derek Y.F. So, University of Ottawa Heart Institute, 40 Ruskin St, Room H3408, Ottawa, Ontario K1Y 4W7, Canada. Tel: +1-613-761-5387.
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Krakowiak A, Kuleta J, Plech I, Zarębiński M, Wojciechowska M, Wretowski D, Cudnoch-Jędrzejewska A. Ticagrelor-Related Severe Dyspnoea: Mechanisms, Characteristic Features, Differential Diagnosis and Treatment. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2020; 13:1179547620956634. [PMID: 33100831 PMCID: PMC7550933 DOI: 10.1177/1179547620956634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/13/2020] [Indexed: 11/17/2022]
Abstract
With a growing number of patients on ticagrelor therapy after stent
implantation, we observe many cases of side effects of the drug,
mostly dyspnoea and bradycardia. In our article we present 2 patients,
in which the symptoms were particularly severe. Then we describe
possible mechanisms of these complications, explain how to carry out
differential diagnosis, discuss when to switch ticagrelor to other
antiplatelet drug and finally we present the way to deal with the
symptoms.
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Affiliation(s)
- Alicja Krakowiak
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Jakub Kuleta
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Plech
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Zarębiński
- Invasive Cardiology Unit, Independent Public Specialist Western Hospital John Paul II in Grodzisk Mazowiecki, Poland
| | - Małgorzata Wojciechowska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland.,Invasive Cardiology Unit, Independent Public Specialist Western Hospital John Paul II in Grodzisk Mazowiecki, Poland
| | - Dominik Wretowski
- Department of Internal Medicine and Cardiology with the Centre for Management of Venous Thromboembolic Disease, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Center for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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Affiliation(s)
- Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
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40
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Rocca B, Rubboli A, Zaccardi F. Antithrombotic therapy and revascularisation strategies in people with diabetes and coronary artery disease. Eur J Prev Cardiol 2020; 26:92-105. [PMID: 31766921 DOI: 10.1177/2047487319880045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetes mellitus, largely type 2, affects nearly 10% of the global adult population according to the World Health Organization. Diabetes is an independent risk factor for atherosclerotic cardiovascular diseases, including coronary artery disease. Diabetes patients experience a two to three-fold increased incidence of coronary artery disease, despite improved metabolic control and management of other cardiovascular risk factors. DISCUSSION Platelet abnormalities and activation as well as reduced antiplatelet drug responsiveness characterise diabetes mellitus. Mechanisms linking diabetes to platelet and vascular abnormalities, atherogenesis and atherosclerotic cardiovascular disease are still only partially known, highlighting the unique complexity of the pro-atherogenic clinical scenario and its treatment. Consistently, a higher residual cardiovascular risk characterises patients with diabetes compared with those without, in spite of improved antiplatelet and antithrombotic treatment combinations. Randomised clinical trials aimed at optimising antiplatelet treatment specifically in patients with diabetes are lacking, both in acute and chronic coronary artery disease settings. Thus, patients with diabetes are treated with regimens validated in studies including only variable proportions of diabetes patients. Myocardial revascularisation appears to confer a comparable relative benefit between diabetes patients and patients without diabetes, and generally coronary artery bypass grafting has a better outcome in diabetes mellitus versus peripheral coronary intervention. New glucose-lowering drugs have been shown to reduce the incidence of major cardiovascular events in secondary prevention. Type 1 diabetes mellitus remains less explored than type 2 in this context. CONCLUSION Diabetes-tailored antithrombotic strategies in acute and chronic coronary artery disease remain an unmet clinical need, requiring ad-hoc trials and precision pharmacological strategies.
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Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Italy
| | - Andrea Rubboli
- Department of Cardiovascular Diseases, S Maria delle Croci Hospital, Italy
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41
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Petersohn S, Pouwels X, Ramaekers B, ten Cate-Hoek A, Joore M. Rivaroxaban plus aspirin for the prevention of ischaemic events in patients with cardiovascular disease: a cost-effectiveness study. Eur J Prev Cardiol 2020; 27:1354-1365. [PMID: 32223323 PMCID: PMC7457457 DOI: 10.1177/2047487320913380] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/26/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Dual pathway inhibition with 2.5 mg rivaroxaban twice daily plus 100 mg aspirin once daily may be a promising alternative to 100 mg aspirin antiplatelet therapy for the prevention of cardiovascular events in patients with coronary artery disease and/or peripheral arterial disease. However, treatment costs and bleeding risks are higher, and there is another treatment option for peripheral arterial disease, 75 mg clopidogrel. A comprehensive assessment of benefits, risks and costs of dual pathway inhibition versus standard of care is needed. METHODS We used a state transition model including cardiovascular, ischaemic limb and bleeding events to compare dual pathway inhibition to aspirin antiplatelet therapy in coronary artery disease, and additionally to clopidogrel antiplatelet therapy in peripheral arterial disease patients. We calculated the incremental cost-effectiveness ratio from costs and quality-adjusted life-years of lifelong treatment, and the cost-effectiveness probability at a €50,000/quality-adjusted life-year threshold. RESULTS Quality-adjusted life-years and costs of dual pathway inhibition were highest, the incremental cost-effectiveness ratios versus aspirin were €32,109 in coronary artery disease and €26,381 in peripheral arterial disease patients, with 92% and 56% cost-effectiveness probability, respectively (clopidogrel was extendedly dominated). Incremental cost-effectiveness ratios were below €20,000 in comorbid peripheral arterial disease patients and coronary artery disease patients younger than 65 years, incremental cost-effectiveness ratios were above €50,000 in carotid artery disease patients and coronary artery disease patients older than 75 years. CONCLUSION Lifelong preventive treatment of coronary artery disease and peripheral arterial disease patients at risk of cardiovascular events with dual pathway inhibition improves health outcomes and seems overall cost-effective relative to aspirin antiplatelet therapy and also to clopidogrel antiplatelet therapy for peripheral arterial disease, particularly in comorbid patients, but not in older patients and in carotid artery disease patients. These findings may warrant a targeted approach.
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Affiliation(s)
- Svenja Petersohn
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Xavier Pouwels
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
| | - Arina ten Cate-Hoek
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, The Netherlands
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, The Netherlands
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Giannoni A, Borrelli C, Gentile F, Mirizzi G, Coceani M, Paradossi U, Vergaro G, Bramanti F, Iudice G, Emdin M, Passino C. Central apnoeas and ticagrelor-related dyspnoea in patients with acute coronary syndrome. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 7:180-188. [PMID: 32667975 DOI: 10.1093/ehjcvp/pvaa089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/16/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022]
Abstract
AIMS Dyspnoea often occurs in patients with acute coronary syndrome (ACS) treated with ticagrelor compared with other anti-platelet agents and is a cause of drug discontinuation. We aimed to explore the contribution of central apnoeas (CA) and chemoreflex sensitization to ticagrelor-related dyspnoea in patients with ACS. METHODS AND RESULTS Sixty consecutive patients with ACS, preserved left ventricular ejection fraction, and no history of obstructive sleep apnoea, treated either with ticagrelor 90 mg b.i.d. (n = 30) or prasugrel 10 mg o.d. (n = 30) were consecutively enrolled. One week after ACS, all patients underwent two-dimensional Doppler echocardiography, pulmonary static/dynamic testing, carbon monoxide diffusion capacity assessment, 24-h cardiorespiratory monitoring for hypopnoea-apnoea detection, and evaluation of the chemosensitivity to hypercapnia by rebreathing technique. No differences were found in baseline demographic and clinical characteristics, echocardiographic, and pulmonary data between the two groups. Patients on ticagrelor, when compared with those on prasugrel, reported more frequently dyspnoea (43.3% vs. 6.7%, P = 0.001; severe dyspnoea 23.3% vs. 0%, P = 0.005), and showed higher apnoea-hypopnoea index (AHI) and central apnoea index (CAI) during the day, the night and the entire 24-h period (all P < 0.001). Similarly, they showed a higher chemosensitivity to hypercapnia (P = 0.001). Among patients treated with ticagrelor, those referring dyspnoea had the highest AHI, CAI, and chemosensitivity to hypercapnia (all P < 0.05). CONCLUSION Central apnoeas are a likely mechanism of dyspnoea and should be screened for in patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability and breathlessness in this setting.
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Affiliation(s)
- Alberto Giannoni
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Chiara Borrelli
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Francesco Gentile
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Gianluca Mirizzi
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Michele Coceani
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Umberto Paradossi
- Cardiology and Cardiac Surgery Department, Fondazione Toscana G. Monasterio, Massa, Italy
| | - Giuseppe Vergaro
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Francesca Bramanti
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Giovanni Iudice
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy
| | - Michele Emdin
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Passino
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana G. Monasterio, via Giuseppe Moruzzi 1, 56124 Pisa, Italy.,Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
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Rohman MS, Purnamasari Y, Ilmawan M, Mahdi BA, Tamara F, Mahendra AI, Mazen M, Heriansyah T, Yamin M, Pikir BS, Fajar JK. Comparison of major bleeding in patients with acute coronary syndrome that underwent coronary artery bypass grafting treated with clopidogrel or ticagrelor: a systematic review and meta-analysis. F1000Res 2020; 9:99. [PMID: 33732438 PMCID: PMC7885293 DOI: 10.12688/f1000research.21925.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 01/21/2023] Open
Abstract
Background: There is controversy among physicians regarding the use of dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients treated with coronary artery bypass grafting (CABG). Moreover, the evidence of previous studies about this topic remained inconclusive. This study aimed to perform a meta-analysis concerning the relation between the risk of major bleeding and the use of different DAPT (clopidogrel or ticagrelor) in ACS patients treated with CABG. Methods: A meta-analysis was conducted during March to October 2019. Searches were carried out in Pubmed, Embase, Cochrane, and Web of Science. The predictor covariate in our present study was DAPT (clopidogrel or ticagrelor), and the outcome measure was the risk of major bleeding. Sub-group analysis was also performed, where data were classified into pre- and post-CABG. Furthermore, to determine the correlation and effect estimation, data were analyzed using fixed or random effect model. Results: A total of 13 studies consisting 34,015 patients treated with clopidogrel and 32,661 patients treated with ticagrelor was included in our study. Our pooled calculation revealed that the incidence of major bleeding was not different significantly between clopidogrel and ticagrelor. In pre- and post-CABG sub-groups, our results also found no significant difference in major bleeding incidence between clopidogrel and ticagrelor groups. Conclusions: Our meta-analysis clarifies that clopidogrel, compared to ticagrelor, or vice versa, is not associated with the risk of major bleeding in ACS patients treated with CABG.
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Affiliation(s)
- Mohammad Saifur Rohman
- Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Yeni Purnamasari
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Muhammad Ilmawan
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Bagus Aulia Mahdi
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Fredo Tamara
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Aditya Indra Mahendra
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Mazen Mazen
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Teuku Heriansyah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
| | - Muhammad Yamin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Jakarta, 16424, Indonesia
| | - Budi Susetio Pikir
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Jonny Karunia Fajar
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
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Rohman MS, Purnamasari Y, Ilmawan M, Mahdi BA, Tamara F, Mahendra AI, Mazen M, Heriansyah T, Yamin M, Pikir BS, Fajar JK. Comparison of major bleeding in patients with acute coronary syndrome that underwent coronary artery bypass grafting treated with clopidogrel or ticagrelor: a systematic review and meta-analysis. F1000Res 2020; 9:99. [PMID: 33732438 PMCID: PMC7885293 DOI: 10.12688/f1000research.21925.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 04/01/2024] Open
Abstract
Background: There is controversy among physicians regarding the use of dual antiplatelet therapy (DAPT) in acute coronary syndrome (ACS) patients treated with coronary artery bypass grafting (CABG). Moreover, the evidence of previous studies about this topic remained inconclusive. This study aimed to perform a meta-analysis concerning the relation between the risk of major bleeding and the use of different DAPT (clopidogrel or ticagrelor) in ACS patients treated with CABG. Methods: A meta-analysis was conducted during March to October 2019. Searches were carried out in Pubmed, Embase, Cochrane, and Web of Science. The predictor covariate in our present study was DAPT (clopidogrel or ticagrelor), and the outcome measure was the risk of major bleeding. Sub-group analysis was also performed, where data were classified into pre- and post-CABG. Furthermore, to determine the correlation and effect estimation, data were analyzed using fixed or random effect model. Results: A total of 13 studies consisting 34,015 patients treated with clopidogrel and 32,661 patients treated with ticagrelor was included in our study. Our pooled calculation revealed that the incidence of major bleeding was not different significantly between clopidogrel and ticagrelor. In pre- and post-CABG sub-groups, our results also found no significant difference in major bleeding incidence between clopidogrel and ticagrelor groups. Conclusions: Our meta-analysis clarifies that clopidogrel, compared to ticagrelor, or vice versa, is not associated with the risk of major bleeding in ACS patients treated with CABG.
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Affiliation(s)
- Mohammad Saifur Rohman
- Brawijaya Cardiovascular Research Center, Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Yeni Purnamasari
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Muhammad Ilmawan
- Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Bagus Aulia Mahdi
- Department of Internal Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Fredo Tamara
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Aditya Indra Mahendra
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Mazen Mazen
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
| | - Teuku Heriansyah
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh, Aceh, 23111, Indonesia
| | - Muhammad Yamin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Jakarta, 16424, Indonesia
| | - Budi Susetio Pikir
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, 60115, Indonesia
| | - Jonny Karunia Fajar
- Brawijaya Internal Medicine Research Center, Department of Internal Medicine, Faculty of Medicine, Universitas Brawijaya, Malang, East Java, 65145, Indonesia
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Li J, Sheng Z, Tan Y, Liu C, Zhou P, Zhou J, Chen R, Chen Y, Song L, Zhao H, Yan H. Combined with ticagrelor, 50 mg aspirin daily can reduce bleeding events without increasing ischemic risk compared with 75–100 mg aspirin daily in coronary artery disease patients: insights from the TIFU (Ticagrelor in Fuwai Hospital) study. Platelets 2019; 31:788-794. [PMID: 31645164 DOI: 10.1080/09537104.2019.1680825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jiannan Li
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Zhaoxue Sheng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yu Tan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Chen Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Jinying Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Runzhen Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chen
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Li Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hanjun Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Hongbing Yan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
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