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Li Y, Li J, Wang B, Jing Q, Zeng Y, Hou A, Wang Z, Liu A, Zhang J, Zhang Y, Zhang P, Jiang D, Liu B, Fan J, Zhang J, Li L, Su G, Yang M, Jiang W, Qu P, Zeng H, Li L, Qiu M, Ru L, Chen S, Zhou Y, Qiao S, Stone GW, Angiolillo DJ, Han Y. Extended Clopidogrel Monotherapy vs DAPT in Patients With Acute Coronary Syndromes at High Ischemic and Bleeding Risk: The OPT-BIRISK Randomized Clinical Trial. JAMA Cardiol 2024; 9:523-531. [PMID: 38630489 PMCID: PMC11024736 DOI: 10.1001/jamacardio.2024.0534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 02/02/2024] [Indexed: 04/20/2024]
Abstract
Importance Purinergic receptor P2Y12 (P2Y12) inhibitor monotherapy after a certain period of dual antiplatelet therapy (DAPT) may be an attractive option of maintenance antiplatelet treatment for patients undergoing percutaneous coronary intervention (PCI) who are at both high bleeding and ischemic risk (birisk). Objective To determine if extended P2Y12 inhibitor monotherapy with clopidogrel is superior to ongoing DAPT with aspirin and clopidogrel after 9 to 12 months of DAPT after PCI in birisk patients with acute coronary syndromes (ACS). Design, Setting, and Participants This was a multicenter, double-blind, placebo-controlled, randomized clinical trial including birisk patients with ACS who had completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months at 101 China centers between February 2018 and December 2020. Study data were analyzed from April 2023 to May 2023. Interventions Patients were randomized either to clopidogrel plus placebo or clopidogrel plus aspirin for an additional 9 months. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) types 2, 3, or 5 bleeding 9 months after randomization. The key secondary end point was major adverse cardiac and cerebral events (MACCE; the composite of all-cause death, myocardial infarction, stroke or clinically driven revascularization). The primary end point was tested for superiority, and the MACCE end point was tested for sequential noninferiority and superiority. Results A total of 7758 patients (mean [SD] age, 64.8 [9.0] years; 4575 male [59.0%]) were included in this study. The primary end point of BARC types 2, 3, or 5 bleeding occurred in 95 of 3873 patients (2.5%) assigned to clopidogrel plus placebo and 127 of 3885 patients (3.3%) assigned to clopidogrel plus aspirin (hazard ratio [HR], 0.75; 95% CI, 0.57-0.97; difference, -0.8%; 95% CI, -1.6% to -0.1%; P = .03). The incidence of MACCE was 2.6% (101 of 3873 patients) in the clopidogrel plus placebo group and 3.5% (136 of 3885 patients) in the clopidogrel plus aspirin group (HR, 0.74; 95% CI, 0.57-0.96; difference, -0.9%; 95% CI, -1.7% to -0.1%; P < .001 for noninferiority; P = .02 for superiority). Conclusions and Relevance Among birisk patients with ACS who completed 9 to 12 months of DAPT after drug-eluting stent implantation and were free from adverse events for at least 6 months before randomization, an extended 9-month clopidogrel monotherapy regimen was superior to continuing DAPT with clopidogrel in reducing clinically relevant bleeding without increasing ischemic events. Trial Registration ClinicalTrials.gov Identifier: NCT03431142.
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Affiliation(s)
- Yi Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Li
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Bin Wang
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Quanmin Jing
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Yujie Zeng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Aijie Hou
- The People’s Hospital of Liaoning Province, Shenyang, China
| | | | - Aijun Liu
- Benxi Central Hospital, Benxi, China
| | | | | | - Ping Zhang
- Beijing Tsinghua Changgung Hospital, Beijing, China
| | | | - Bin Liu
- The Second Hospital of Jilin University, Changchun, China
| | | | - Jun Zhang
- Cangzhou Central Hospital, Cangzhou, China
| | - Li Li
- Guangzhou Red Cross Hospital, Guangzhou, China
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical University, Ji’nan, China
| | - Ming Yang
- Yingkou Central Hospital, Yingkou, China
| | - Weihong Jiang
- The Third Xiangya Hospital of Central South University, Changsha, China
| | - Peng Qu
- The Second Hospital of Dalian Medical University, Dalian, China
| | - Hesong Zeng
- Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Lu Li
- The Second Affiliated Hospital of Shenyang Medical College, Shenyang, China
| | - Miaohan Qiu
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Leisheng Ru
- Bethune International Peace Hospital, Shijiazhuang, China
| | | | - Yujie Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shubin Qiao
- Fuwai Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Yaling Han
- State Key Laboratory of Frigid Zone Cardiovascular Disease, General Hospital of Northern Theater Command, Shenyang, China
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Capranzano P, Moliterno D, Capodanno D. Aspirin-free antiplatelet strategies after percutaneous coronary interventions. Eur Heart J 2024; 45:572-585. [PMID: 38240716 DOI: 10.1093/eurheartj/ehad876] [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: 08/01/2023] [Revised: 11/20/2023] [Accepted: 12/20/2023] [Indexed: 02/23/2024] Open
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a platelet P2Y12 receptor inhibitor is the standard antithrombotic treatment after percutaneous coronary interventions (PCI). Several trials have challenged guideline-recommended DAPT after PCI by testing the relative clinical effect of an aspirin-free antiplatelet approach-consisting of P2Y12 inhibitor monotherapy after a short course (mostly 1-3 months) of DAPT-among patients undergoing PCI without a concomitant indication for oral anticoagulation (OAC). Overall, these studies have shown P2Y12 inhibitor monotherapy after short DAPT to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischaemic events compared with continued DAPT. Moreover, the effects of the P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies, of which one has recently reported unfavourable efficacy results associated with the aspirin-free approach compared with conventional DAPT. Finally, P2Y12 inhibitor alone has been compared with aspirin alone as chronic therapy after DAPT discontinuation, thus challenging the historical role of aspirin as a standard of care for secondary prevention following PCI. A thorough understanding of study designs, populations, treatments, results, and limitations of trials testing P2Y12 inhibitor monotherapy vs. DAPT or vs. aspirin is required to consider adopting this treatment in clinical practice. This review addresses the use of aspirin-free antiplatelet strategies among patients undergoing PCI without a concomitant indication for OAC, providing an overview of clinical evidence, guideline indications, practical implications, ongoing issues, and future perspectives.
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Affiliation(s)
- Piera Capranzano
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
| | - David Moliterno
- Gill Heart and Vascular Institute and Division of Cardiovascular Medicine, The University of Kentucky, Lexington, KY, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico 'G. Rodolico-San Marco', University of Catania, s Sofia, 78, Catania 95123, Italy
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Baber U, Spirito A, Sartori S, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dangas G, Dudek D, Escaned J, Gibson CM, Han YL, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Vogel B, Mehta SR, Moliterno D, Sardella G, Shlofmitz RA, Sharma S, Steg PG, Pocock S, Mehran R. Clinically Driven Revascularization in High-Risk Patients Treated With Ticagrelor Monotherapy After PCI: Insights from the Randomized TWILIGHT Trial. Am J Cardiol 2023; 208:16-24. [PMID: 37806185 DOI: 10.1016/j.amjcard.2023.09.008] [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: 05/16/2023] [Revised: 09/02/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023]
Abstract
Repeat coronary revascularization is a common adverse event after successful percutaneous coronary intervention. This analysis aimed to assess the effects of ticagrelor monotherapy on repeat clinically driven revascularization (CDR). In the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients after Coronary Intervention) trial, after 3 months of ticagrelor plus aspirin, high-risk patients were maintained on ticagrelor and randomly allocated to aspirin or placebo for 1 year. The primary end point of this analysis was CDR within 12 months after randomization. The key secondary end points were major adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, myocardial infarction, stroke, or CDR, and net adverse clinical events (NACEs), including the individual components of MACCEs and clinically relevant bleeding. The analysis was performed in the per-protocol population. CDR occurred in 473 of 7,039 patients and was associated with a significantly higher risk of subsequent all-cause death, myocardial infarction, or stroke (adjusted hazard ratios [HRs] 2.92, 95% confidence interval [CI] 1.82 to 4.67). Ticagrelor monotherapy was associated with a similar 12-month risk of CDR (7.1% vs 6.6%; HR 1.09, 95% CI 0.90 to 1.30, p = 0.363) and MACCEs (8.9% vs 8.6%; HR 1.04, 95% CI 0.89 to 1.22, p = 0.619), and a lower risk of NACEs (12.2% vs 14.6%; HR 0.83 95% CI 0.73 to 0.94, p = 0.004) than ticagrelor plus aspirin. In conclusion, among high-risk patients who underwent percutaneous coronary intervention, ticagrelor monotherapy after 3 months of ticagrelor-based dual antiplatelet therapy was associated with a similar risk of CDR and MACCEs and a decrease of NACEs (TWILIGHT: NCT02270242).
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Affiliation(s)
- Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Alessandro Spirito
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, New York; St. Francis Hospital, Roslyn, New York
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ya-Ling Han
- General Hospital of Northern Theater Command, Shenyang, China
| | - Kurt Huber
- Third Department Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria; Sigmund Freud University, Medical Faculty, Vienna, Austria
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi, India
| | | | - Mitchell Krucoff
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom; Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David Moliterno
- Division of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | | | | | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
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Günlü S, Arpa A, Kayan F, Güzel T, Kılıç R, Aktan A, Altintaş B, Karahan MZ. The prognostic value of ORBIT risk score in predicting major bleeding in patients with acute coronary syndrome. Thromb Res 2023; 229:258-262. [PMID: 37236868 DOI: 10.1016/j.thromres.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/24/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND The most significant adverse effect of antithrombotic medication in acute coronary syndrome (ACS) is major bleeding, which is related to increased mortality. Studies on ORBIT risk score in predicting major bleeding in ACS patients are limited. OBJECTIVE This research aimed to examine whether the ORBIT score calculated at the bedside can identify major bleeding risk in patients with ACS. METHODS This research was retrospective, observational, and conducted at a single center. Analyses of receiver operating characteristics (ROC) were utilized to define the diagnostic value of CRUSADE and ORBIT scores. The predictive performances of the two scores were compared using DeLong's method. Discrimination and reclassification performances were evaluated by the integrated discrimination improvement (IDI), and net reclassification improvement (NRI). RESULTS The study included 771 patients with ACS. The mean age was 68.7 ± 8.6 years, with 35.3 % females. 31 patients had major bleeding. Twenty-three of these patients were BARC 3 A, five were BARC 3 B, and three were BARC 3 C. Bleeding history [OR (95 % CI), 2.46 (1.02-5.94), p = 0.021], hemoglobin levels [OR (95 % CI), 0.54 (0.45-0.63), p < 0.001], and age > 74 years [OR (95 % CI), 1.03 (1.01-1.06), p = 0.039] were independent predictors of major bleeding. The ORBIT score was an independent predictor of major bleeding in the multivariate analysis: continuous variables [OR (95 % CI), 2.53 (2.61-3.95), p < 0.001] and risk categories [OR (95 % CI), 3.06 (1.69-5.52), p < 0.001]. Comparison of c-indexes for major bleeding events revealed a non-significant difference for the discriminative ability of the two tested scores (p = 0.07) with a continuous NRI of 6.6 % (p = 0.026) and an IDI of 4.2 % (p < 0.001). CONCLUSION In ACS patients, the ORBIT score independently predicted major bleeding.
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Affiliation(s)
- Serhat Günlü
- Department of Cardiology, Mardin Artuklu University School of Medicine, Mardin, Turkey.
| | - Abdulkadir Arpa
- Department of Cardiology, Bismil State Hospital, Diyarbakır, Turkey
| | - Fethullah Kayan
- Department of Cardiology, Mardin Artuklu University School of Medicine, Mardin, Turkey
| | - Tuncay Güzel
- Department of Cardiology, Health Science University, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Raif Kılıç
- Department of Cardiology, Private Memorial Hospital, Diyarbakır, Turkey
| | - Adem Aktan
- Department of Cardiology, Mardin Training and Research Hospital, Mardin, Turkey
| | - Bernas Altintaş
- Department of Cardiology, Health Science University, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Mehmet Zülkif Karahan
- Department of Cardiology, Mardin Artuklu University School of Medicine, Mardin, Turkey
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Lee SY, Jeong YH, Yun KH, Cho JY, Gorog DA, Angiolillo DJ, Kim JW, Jang Y. P2Y 12 Inhibitor Monotherapy Combined With Colchicine Following PCI in ACS Patients: The MACT Pilot Study. JACC Cardiovasc Interv 2023; 16:1845-1855. [PMID: 37587591 DOI: 10.1016/j.jcin.2023.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/15/2023] [Accepted: 05/17/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND After a brief period of dual antiplatelet therapy, P2Y12 inhibitor monotherapy in the absence of aspirin effectively reduces bleeding without increasing recurrent ischemia in patients undergoing percutaneous coronary intervention (PCI). In addition, early anti-inflammatory therapies may have clinical benefits in acute coronary syndrome (ACS) patients. OBJECTIVES The aim of this study was to investigate the feasibility of ticagrelor or prasugrel P2Y12 inhibitor monotherapy combined with colchicine immediately after PCI in patients with ACS. METHODS This was a proof-of-concept pilot trial. ACS patients treated with drug-eluting stents were included. On the day after PCI, low-dose colchicine (0.6 mg daily) was administered in addition to ticagrelor or prasugrel maintenance therapy, whereas aspirin therapy was discontinued. The primary outcome was any stent thrombosis at 3 months. The key secondary outcomes were platelet reactivity measured by the VerifyNow assay (Accriva) before discharge and a reduction in high-sensitivity C-reactive protein (hs-CRP) over 1 month. RESULTS We enrolled 200 patients, 190 (95.0%) of whom completed the 3-month follow-up. The primary outcome occurred in 2 patients (1.0%): 1 definite and 1 probable stent thrombosis. The level of platelet reactivity overall was 27 ± 42 P2Y12 reaction units, and only 1 patient had high platelet reactivity (>208 P2Y12 reaction units). The hs-CRP levels decreased from 6.1 mg/L (IQR: 2.6-15.9 mg/L) at 24 hours after PCI to 0.6 mg/L (IQR: 0.4-1.2 mg/L) at 1 month (P < 0.001), and the prevalence of high-inflammation criteria (hs-CRP ≥2 mg/L) decreased from 81.8% to 11.8% (P < 0.001). CONCLUSIONS In ACS patients undergoing PCI, it is feasible to discontinue aspirin therapy and administer low-dose colchicine on the day after PCI in addition to ticagrelor or prasugrel P2Y12 inhibitors. This approach is associated with favorable platelet function and inflammatory profiles. (Mono Antiplatelet and Colchicine Therapy [MACT]; NCT04949516).
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Affiliation(s)
- Seung-Yul Lee
- CHA Bundang Medical Center, CHA University, Seongnam, Korea; Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea.
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Heart and Brain Hospital, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Kyeong Ho Yun
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Jae Young Cho
- Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan, Korea
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom; Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Jin Won Kim
- Multimodal Imaging and Theranostic Laboratory, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Yangsoo Jang
- CHA Bundang Medical Center, CHA University, Seongnam, Korea
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van der Sangen NMR, Claessen BEPM, Küçük IT, den Hartog AW, Baan J, Beijk MAM, Delewi R, van de Hoef TP, Knaapen P, Lemkes JS, Marques KM, Nap A, Verouden NJW, Vis MM, de Winter RJ, Kikkert WJ, Appelman Y, Henriques JPS. Single antiplatelet therapy directly after percutaneous coronary intervention in non-ST-segment elevation acute coronary syndrome patients: the OPTICA study. EUROINTERVENTION 2023; 19:63-72. [PMID: 36734020 PMCID: PMC10173755 DOI: 10.4244/eij-d-22-00886] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/11/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early P2Y12 inhibitor monotherapy has emerged as a promising alternative to 12 months of dual antiplatelet therapy following percutaneous coronary intervention (PCI). AIMS In this single-arm pilot study, we evaluated the feasibility and safety of ticagrelor or prasugrel monotherapy directly following PCI in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). METHODS Patients received a loading dose of ticagrelor or prasugrel before undergoing platelet function testing and subsequent PCI using new-generation drug-eluting stents. The stent result was adjudicated with optical coherence tomography in the first 35 patients. Ticagrelor or prasugrel monotherapy was continued for 12 months. The primary ischaemic endpoint was the composite of all-cause mortality, myocardial infarction, definite or probable stent thrombosis or stroke within 6 months. The primary bleeding endpoint was Bleeding Academic Research Consortium type 2, 3 or 5 bleeding within 6 months. RESULTS From March 2021 to March 2022, 125 patients were enrolled, of whom 75 ultimately met all in- and exclusion criteria (mean age 64.5 years, 29.3% women). Overall, 70 out of 75 (93.3%) patients were treated with ticagrelor or prasugrel monotherapy directly following PCI. The primary ischaemic endpoint occurred in 3 (4.0%) patients within 6 months. No cases of stent thrombosis or spontaneous myocardial infarction occurred. The primary bleeding endpoint occurred in 7 (9.3%) patients within 6 months. CONCLUSIONS This study provides first-in-human evidence that P2Y12 inhibitor monotherapy directly following PCI for NSTE-ACS is feasible, without any overt safety concerns, and highlights the need for randomised controlled trials comparing direct P2Y12 inhibitor monotherapy with the current standard of care.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jan Baan
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Marcel A M Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Paul Knaapen
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jorrit S Lemkes
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Koen M Marques
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Alexander Nap
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Niels J W Verouden
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - M Marije Vis
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, Vrije University (VU), Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Jose P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Gurbel P, Tantry U, Guimarães PO, Lemos PA. Aspirin should be stopped at day 0 after PCI: pros and cons. EUROINTERVENTION 2023; 18:e1304-e1306. [PMID: 37025087 PMCID: PMC10068855 DOI: 10.4244/eij-e-23-00001] [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] [Indexed: 04/05/2023]
Affiliation(s)
- Paul Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Udaya Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | | | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, Brazil
- Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil
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Cordero A, Escribano D, García-Acuña JM, Alvarez-Alvarez B, Cid-Alvarez B, Rodriguez-Mañero M, Agra-Bermejo R, Quintanilla MA, Zuazola P, González-Juanatey JR. Differential prognosis of patients that are candidates for standard, short or prolonged dual antiplatelet treatment discharged after an acute coronary syndrome. Thromb Res 2023; 224:46-51. [PMID: 36841157 DOI: 10.1016/j.thromres.2023.02.008] [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: 12/06/2022] [Revised: 02/03/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Current evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT) for patients at high-ischemic risk and low bleeding risk as well as the efficacy and safety of short DAPT in high-bleeding risk (HBR) patients. METHODS We evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of the BARC consortium definitions. RESULTS We included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119 (37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences were observed between the 3 categories beyond the bleeding risk. Median follow-up was 57 months. Multivariate analysis identified higher risk of all-cause mortality (HR: 1.96 95 % CI 1.45-2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI 1.39-3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50-2.02; p < 0.001) and MB (sHR: 3.41 95 % CI 1.45-8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02-1.35; p = 0.027). CONCLUSIONS Almost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality.
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Affiliation(s)
- Alberto Cordero
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - David Escribano
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - José Mª García-Acuña
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Belén Alvarez-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Belén Cid-Alvarez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Moisés Rodriguez-Mañero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Rosa Agra-Bermejo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
| | - Mª Amparo Quintanilla
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - Pilar Zuazola
- Cardiology Department. Hospital Universitario de San Juan, Alicante, Spain; Unidad de Investigación de Cardiología, Fundación para el Fomento de la Investigación Sanitaria y Biomédica de la Comunitat Valenciana (FISABIO), Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Cardiology Department, Complejo Hospital Universitario de Santiago, Santiago de Compostela, Spain
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9
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Verheugt FWA, Huber K, Clemmensen P, Collet JP, Cuisset T, Andreotti F. Platelet P2Y12 Inhibitor Monotherapy after Percutaneous Coronary Intervention: An Emerging Option for Antiplatelet Therapy De-escalation. Thromb Haemost 2023; 123:159-165. [PMID: 36584699 DOI: 10.1055/s-0042-1755330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Antiplatelet therapy is considered essential for secondary prevention of ischemic heart disease. After percutaneous coronary intervention (PCI), temporary dual antiplatelet therapy (DAPT), a combination consisting of aspirin and an oral P2Y12 receptor blocker, is recommended. In the long term, this strategy results in more bleeding than antiplatelet therapy with aspirin alone. Therefore, to reduce bleeding, an increasing trend has been to keep DAPT as short as clinically acceptable, after which aspirin monotherapy is continued. Another option to diminish bleeding is to discontinue aspirin at the moment of DAPT cessation after PCI, and to continue on P2Y12 blocker monotherapy. This survey reviews the evidence on P2Y12 blocker monotherapy. Some clinical guidance will be provided on when and in whom P2Y12 inhibitor monotherapy may be applied after DAPT cessation following PCI.
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Affiliation(s)
- Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Clemmensen
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine, Nykøbing F Hospital, Nykøbing Falster, Denmark
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, HÔpital Pitié-Salpêtrière (AP-HP), Institut de Cardiologie, Paris, France
| | - Thomas Cuisset
- Department of Cardiology, La Timone Hospital, Marseille, France
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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10
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Wang N, Lan C, Lu H, Li L, Liao D, Xu K, Sun H, Tang Y, Wang Y, Mei J, Wei M, Wu T, Zhu H. Preventive effect and mechanism of Tibetan tea extract on thrombosis in arachidonic acid-induced zebrafish determined via RNA-seq transcriptome profiles. PLoS One 2023; 18:e0285216. [PMID: 37205684 DOI: 10.1371/journal.pone.0285216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/17/2023] [Indexed: 05/21/2023] Open
Abstract
Thrombosis is a key pathological event in cardiovascular diseases and is also the most important targeting process for their clinical management. In this study, arachidonic acid (AA) was used to induce thrombus formation in zebrafish larvae. Blood flow, red blood cell (RBCs) aggregation and cellular oxidative stress were measured to evaluate the antithrombotic effect of Tibetan tea (TT). Meanwhile, the potential molecular mechanism was further explored by transcriptome sequencing (RNA-seq). The results indicated that TT could significantly restore heart RBCs intensity of thrombotic zebrafish, whilst decreasing RBCs accumulation in the caudal vein. The transcriptome analysis revealed that the preventive effect of TT on thrombosis could be mostly attributed to changes in lipid metabolism related signaling pathways, such as fatty acid metabolism, glycerollipid metabolism, ECM-receptor interaction and steroid biosynthesis signaling pathway. This study demonstrated that Tibetan tea could alleviate thrombosis by reducing oxidative stress levels and regulating lipid metabolism.
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Affiliation(s)
- Ning Wang
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
- Luzhou Laojiao Co. Ltd, Luzhou, PR China
- College of Horticulture, Hunan Agricultural University, Changsha, China
- Chengdu Chongqing Shuangcheng Economic Circle (Luzhou) Advanced Technology Research Institute, Luzhou, China
| | - Chaohua Lan
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
| | - Huiqiang Lu
- Center for Drug Screening and Research, School of Geography and Environmental Engineering, Gannan Normal University, Ganzhou, China
| | - Linman Li
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
| | - Dalong Liao
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
| | - Kewei Xu
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
| | - Haiyan Sun
- Chengdu Chongqing Shuangcheng Economic Circle (Luzhou) Advanced Technology Research Institute, Luzhou, China
| | - Yongqing Tang
- Chengdu Chongqing Shuangcheng Economic Circle (Luzhou) Advanced Technology Research Institute, Luzhou, China
| | - Yumeng Wang
- Bristol Myers Squibb, Princeton, NJ, United States of America
| | - Jie Mei
- Sichuan Jixiang Tea Co., Ltd., Ya'an, China
| | - Mengting Wei
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
| | - Tao Wu
- School of Food and Biological Engineering, Xihua University, Chengdu, China
| | - Hui Zhu
- College of Bioengineering, Sichuan University of Science and Engineering, Zigong, China
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11
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P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary intervention. Nat Rev Cardiol 2022; 19:829-844. [PMID: 35697777 DOI: 10.1038/s41569-022-00725-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 12/15/2022]
Abstract
For 20 years, dual antiplatelet therapy (DAPT), consisting of the combination of aspirin and a platelet P2Y12 receptor inhibitor, has been the gold standard of antithrombotic pharmacology after percutaneous coronary intervention (PCI). In the past 5 years, several investigations have challenged this paradigm by testing the efficacy and safety of P2Y12 inhibitor monotherapy (that is, without aspirin) following a short course of DAPT. Collectively, these studies suggested a reduction in the risk of major bleeding and no significant increase in thrombotic or ischaemic events compared with guideline-recommended DAPT. Current recommendations are evolving to inform clinical practice on the ideal candidates for P2Y12 inhibitor monotherapy after PCI. Generalizing the results of studies of P2Y12 inhibitor monotherapy requires a thorough understanding of their design, populations, interventions, comparators and results. In this Review, we provide an up-to-date overview on the use of P2Y12 inhibitor monotherapy after PCI, including supporting pharmacodynamic and clinical evidence, practical recommendations and future directions.
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12
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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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13
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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14
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van der Sangen NM, Küçük IT, Ten Berg JM, Beijk MA, Delewi R, den Hartog AW, Appelman Y, Verouden NJ, Kikkert WJ, Henriques JP, Claessen BE. P2Y 12-inhibitor monotherapy after coronary stenting: are all P2Y 12-inhibitors equal? Expert Rev Cardiovasc Ther 2022; 20:637-645. [PMID: 35916833 DOI: 10.1080/14779072.2022.2104248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION P2Y12-inhibitor monotherapy following 1-3 months of dual antiplatelet therapy (DAPT) reduces (major) bleeding without an apparent increase in ischemic events and has therefore emerged as an alternative to 6-12 months of DAPT following percutaneous coronary intervention (PCI). However, there are important differences between the available P2Y12-inhibitors (clopidogrel, prasugrel, and ticagrelor) as agents of choice for P2Y12-inhibitor monotherapy. AREAS COVERED This review critically appraises the evidence for P2Y12-inhibitor monotherapy after PCI using either clopidogrel, prasugrel, or ticagrelor. Furthermore, we discuss ongoing trials and future directions for research. EXPERT OPINION P2Y12-inhibitor monotherapy following 1-3 months of DAPT is an alternative to 6-12 months of DAPT following PCI. Ticagrelor may be considered the current preferred option due to its reliable effect on platelet reactivity and its predominant use in clinical trials. Prasugrel could serve as a useful substitute for those not tolerating ticagrelor, but more research into prasugrel monotherapy is warranted. Alternatively, clopidogrel can be used, although there are concerns of high platelet reactivity, especially when genotyping and/or platelet function testing are not used. Future research will need to address the minimal duration of DAPT before switching to P2Y12-inhibitor monotherapy and what the optimal antithrombotic therapy beyond 12 months is.
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Affiliation(s)
- Niels Mr van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - I Tarik Küçük
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Marcel Am Beijk
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Ronak Delewi
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander W den Hartog
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Yolande Appelman
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Niels Jw Verouden
- Department of Cardiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - José Ps Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Bimmer Epm Claessen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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15
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Cao D, Camaj A, Mehran R. Balance of Ischemia and Bleeding in Selecting Intensity and Duration of Antithrombotic Regimens. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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16
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Santos‐Gallego CG, Requena‐Ibanez JA, Badimon J. Per‐Protocol Versus Intention‐to‐Treat in Clinical Trials: The Example of GLOBAL‐LEADERS Trial. J Am Heart Assoc 2022; 11:e025561. [PMID: 35574954 PMCID: PMC9238553 DOI: 10.1161/jaha.122.025561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Carlos G. Santos‐Gallego
- AtheroThrombosis Research Unit, Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Juan Antonio Requena‐Ibanez
- AtheroThrombosis Research Unit, Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Juan Badimon
- AtheroThrombosis Research Unit, Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
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17
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Feng WH, Chang YC, Lin YH, Chen HL, Chang HM, Chu CS. Comparative Efficacy and Safety of P2Y12 Inhibitor Monotherapy and Dual Antiplatelet Therapy in Patients with and without Diabetes Mellitus Undergoing Percutaneous Coronary Intervention. Int J Mol Sci 2022; 23:4549. [PMID: 35562942 PMCID: PMC9099862 DOI: 10.3390/ijms23094549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/17/2022] Open
Abstract
Increasing evidence has shown P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) with stent implantation in the modern era. However, patients with diabetes mellitus (DM) have a higher risk of ischemic events and more complex coronary artery disease. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with DM and those without DM. We conducted a systematic review and meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12 months of dual antiplatelet therapy (DAPT) in patients who underwent PCI with stent implantation. PubMed, Embase, Cochrane library database, ClinicalTrials.gov, and three other websites were searched for our data from the earliest report to January 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE): a composite of all-cause mortality, myocardial infarction, stent thrombosis, and stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE) which are defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. A total of four randomized controlled trials with 29,136 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy compared to standard DAPT (OR: 0.68, 95% CI: 0.46-0.99, p = 0.04) without increasing the risk of MACCE (OR: 0.96, 95% CI: 0.85-1.09, p = 0.50). The number of NACE was significantly lower in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.84, 95% CI: 0.72-0.97, p = 0.019). In DM patients, P2Y12 inhibitor monotherapy was associated with a lower risk of MACCE compared to standard DAPT (OR: 0.85, 95% CI: 0.74-0.98, p = 0.02). Furthermore, P2Y12 inhibitor monotherapy was accompanied by a favorable reduction in major or minor bleeding events (OR: 0.80, 95% CI: 0.64-1.05, p = 0.107). In non-DM patients, P2Y12 inhibitor monotherapy showed a significant reduction in major or minor bleeding events (OR: 0.58, 95% CI: 0.38-0.88, p = 0.01), but without increasing the risk of MACCE (OR: 0.99, 95% CI: 0.82-1.19, p = 0.89). Based on these findings, P2Y12 inhibitor monotherapy could significantly decrease bleeding events without increasing the risk of stent thrombosis or myocardial infarction in the general population. The benefit of reducing bleeding events was much more significant in non-DM patients than in DM patients. Surprisingly, P2Y12 inhibitor monotherapy could lower the risk of MACCE in DM patients. Our study supports that P2Y12 inhibitor monotherapy is a promising alternative choice of medical treatment for patients with DM undergoing PCI with stent implantation in the modern era.
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Affiliation(s)
- Wen-Han Feng
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan;
| | - Yong-Chieh Chang
- Department of Pharmacy, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 80145, Taiwan; (Y.-C.C.); (H.-L.C.); (H.-M.C.)
| | - Yi-Hsiung Lin
- Department of Internal Medicine, Division of Cardiology, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan;
- Center for Lipid Biosciences, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan
| | - Hsiao-Ling Chen
- Department of Pharmacy, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 80145, Taiwan; (Y.-C.C.); (H.-L.C.); (H.-M.C.)
| | - Hsiu-Mei Chang
- Department of Pharmacy, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung 80145, Taiwan; (Y.-C.C.); (H.-L.C.); (H.-M.C.)
| | - Chih-Sheng Chu
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 80145, Taiwan;
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18
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He M, Yan W, Zhang Y, Kong Y, Han X, Ren J, Zhao Z, Liu G, Shi J, Li Y. Effects of ticagrelor monotherapy vs. clopidogrel monotherapy on platelet reactivity: a randomized, crossover clinical study (SINGLE study). Platelets 2022; 33:1146-1152. [PMID: 35379064 DOI: 10.1080/09537104.2022.2052036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Increasing clinical trials demonstrated that the discontinuation of aspirin while maintaining a P2Y12 inhibitor monotherapy could decrease the risk of bleeding without losing the antithrombotic effect. However, no data are available on the platelet reactivity of patients undergoing ticagrelor monotherapy vs. clopidogrel. Therefore, we performed this study to observe the efficacy of ticagrelor monotherapy vs. clopidogrel in Chinese patients with chronic coronary syndrome. This randomized, single-blinded, crossover trial enrolled 50 patients who were administered with ticagrelor (90 mg twice daily for 2 weeks) or clopidogrel (75 mg once daily for 2 weeks). Followed by a 2-week washout period, the two groups of patients underwent a crossover trial. Light transmission aggregometry (LTA) and thromboelastography (TEG) assays were used to test platelet reactivity. The platelet aggregation rate (PAgR) of ADP and AA was significantly lower with ticagrelor than clopidogrel (PAgR of ADP, 27.30% (7.30%-42.635%) vs. 35.55% (12.03%-69.25%), P = .0254; PAgR of AA, 77.80% (21.60%-86.43%) vs. 83.10% (67.13%-87.20%), P = .0400). There was no significant difference in PAgR of collagen and epinephrine between the two groups. The TEG assay showed that ADP and AA, which induced the inhibition of platelet aggregation, were significantly higher in the ticagrelor group than those in the clopidogrel group [ADP%, 69.00% (59.68%-88.95%) vs. 60.55% (35.98%-78.35%), P = .0020; AA%, 53.65% (22.75%-79.28%) vs. 15.15% (5.75%-70.25%), P = .0127]. High on-treatment platelet reactivity (HTPR) on ADP was 2.17% with ticagrelor and 19.57% with clopidogrel. HTPR on AA was 50.00% with ticagrelor and 69.57% with clopidogrel. Ticagrelor and clopidogrel caused the inhibition of ADP and AA-induced platelet aggregation. Moreover, ticagrelor monotherapy had a stronger inhibitory effect than clopidogrel monotherapy (except on collagen and epinephrine).
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Affiliation(s)
- Meijiao He
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Wei Yan
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Yun Zhang
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Yihui Kong
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Xuejie Han
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Jie Ren
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Zhongyang Zhao
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Guangzhong Liu
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Jing Shi
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China
| | - Yue Li
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, P.R. China.,Institute of Metabolic Disease, Heilongjiang Academy of Medical Science, Harbin, P.R. China.,Heilongjiang Key Laboratory for Metabolic Disorder & Cancer Related Cardiovascular Diseases, Harbin, P.R. China
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19
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Han Y, Claessen BE, Chen SL, Chunguang Q, Zhou Y, Xu Y, Hailong L, Chen J, Qiang W, Zhang R, Luo S, Li Y, Zhu J, Zhao X, Cheng X, Wang J, Su X, Tao J, Sun Y, Wang G, Li Y, Bian L, Goel R, Sartori S, Zhang Z, Angiolillo DJ, Cohen DJ, Gibson CM, Kastrati A, Krucoff M, Mehta SR, Ohman EM, Steg PG, Liu Y, Dangas G, Sharma S, Baber U, Mehran R. Ticagrelor With or Without Aspirin in Chinese Patients Undergoing Percutaneous Coronary Intervention: A TWILIGHT China Substudy. Circ Cardiovasc Interv 2022; 15:e009495. [PMID: 35317615 DOI: 10.1161/circinterventions.120.009495] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The risk/benefit tradeoff of dual antiplatelet therapy after percutaneous coronary intervention may vary in East Asian patients as compared with their non-East Asian counterparts. METHODS The double-blind, placebo-controlled, randomized TWILIGHT trial (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) enrolled patients undergoing high-risk percutaneous coronary intervention. After 3 months of treatment with ticagrelor plus aspirin, event-free and adherent patients remained on ticagrelor and were randomly assigned to receive aspirin or placebo for 1 year. The primary end point was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding; the key secondary end point was the first occurrence of death from any cause, nonfatal myocardial infarction, or nonfatal stroke. RESULTS Of 9006 enrolled and 7119 randomized patients in TWILIGHT, 1169 patients (13.0%) were enrolled at 27 Chinese sites in this prespecified substudy, of whom 1028 (14.4%) patients were randomized after 3 months. The incidence of the primary end point was 6.2% in the ticagrelor+aspirin group versus 3.5% in the ticagrelor+placebo group between randomization and 1 year (hazard ratio, 0.56 [95% CI, 0.31-0.99]; P=0.048). The key secondary end point occurred in 3.4% of patients in the ticagrelor+aspirin group versus 2.4% in the ticagrelor+placebo group (hazard ratio, 0.70 [95% CI, 0.33-1.46]; P=0.34). There was no interaction between the region of randomization (China versus the rest of the world) and randomized treatment assignment in terms of the primary or key secondary end points. CONCLUSIONS Ticagrelor monotherapy significantly reduced clinically relevant bleeding without increasing ischemic events as compared with ticagrelor plus aspirin in Chinese patients undergoing high-risk percutaneous coronary intervention. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02270242.
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Affiliation(s)
- Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Bimmer E Claessen
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital Jiangsu, China (S.-L.C.)
| | - Qiu Chunguang
- Department of Cardiology' The First Affiliated Hospital of Zhengzhou University, China (Q.C.)
| | - Yujie Zhou
- Department of Cardiology' Beijing Anzhen Hospital Capital Medical University, China (Y.Z.)
| | - Yawei Xu
- Department of Cardiology' Shanghai Tenth Peoples Hospital, China (Y.X.)
| | - Lin Hailong
- Department of Cardiology' Dalian Municipal Central Hospital Affiliated of Dalian Medical University, China (L.H.)
| | - Jiyan Chen
- Department of Cardiology' Guangdong Provincial People's Hospital, Guangzhou, China (J.C.)
| | - Wu Qiang
- Department of Cardiology' Guizhou Provincial People's Hospital, Guiyang, China (W.Q.)
| | - Ruiyan Zhang
- Department of Cardiology' Rui Jin Hospital Shanghai Jiaotong University School of Medicine, Changhai, China (R.Z.)
| | - Suxin Luo
- Department of Cardiology' The First Affiliated Hospital of Chongqing Medical University, China (S.L.)
| | - Yongjun Li
- Department of Cardiology' The Second Hospital of Hebei Medical University (4th Ward), Shijiazhuang, China (Yongjun Li)
| | - Jianhua Zhu
- Department of Cardiology' The First Affiliated Hospital College of Medicine of Zheijang University, Hangzhou, China (J.Z.)
| | - Xianxian Zhao
- Department of Cardiology' Shanghai Changhai Hospital, China (X.Z.)
| | - Xiang Cheng
- Department of Cardiology' Wuhan Union Hospital, China (X.C.)
| | - Jian'an Wang
- Department of Cardiology' The Second Affiliated Hospital of Zhejiang University of Medicine, Hangzhou, China (J.W.)
| | - Xi Su
- Department of Cardiology' WuHan Asia Heart Hospital, China (X.S.)
| | - Jianhong Tao
- Department of Cardiology' Sichuan Provincial People's Hospital, Chengdu, China (J.T.)
| | - Yingxian Sun
- Department of Cardiology' The First Hospital of China Medical University, Shenyang (Y.S.)
| | - Geng Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Yi Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Liya Bian
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China (Y.H., G.W., Yi Li, L.B.)
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
| | - David J Cohen
- Department of Cardiology' University of Missouri-Kansas City (D.J.C.)
| | - C Michael Gibson
- Department of Cardiology' Beth Israel Deaconess Medical Center' Boston' MA (C.M.G.)
| | - Adnan Kastrati
- Department of Cardiology' Deutsches Herzzentrum München, Munich, Germany (A.K.)
| | - Mitchell Krucoff
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Shamir R Mehta
- Department of Cardiology' Duke University Medical Center, Durham' NC (S.R.M.)
| | - E Magnus Ohman
- Department of Cardiology' Hamilton Health Sciences, Canada (M.K., E.M.O.)
| | - Philippe Gabriel Steg
- Department of Cardiology' Université de Paris, Assistance Publique-Hôpitaux de Paris, France (P.G.S.)
| | - Yuqi Liu
- Department of Cardiology, People's Liberation Army General Hospital, Beijing (Y. Liu)
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (B.E.C., R.G., S. Sartori, Z.Z., G.D., S. Sharma, U.B., R.M.)
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20
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Angiolillo DJ, Galli M, Collet JP, Kastrati A, O'Donoghue ML. Antiplatelet therapy after percutaneous coronary intervention. EUROINTERVENTION 2022; 17:e1371-e1396. [PMID: 35354550 PMCID: PMC9896394 DOI: 10.4244/eij-d-21-00904] [Citation(s) in RCA: 92] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022]
Abstract
Antiplatelet therapy is key to reducing local thrombotic complications and systemic ischaemic events among patients undergoing percutaneous coronary interventions (PCI), but it is inevitably associated with increased bleeding. The continuous refinement in stent technologies, together with the high incidence of ischaemic recurrences after PCI and the understanding of prognostic implications associated with bleeding, have led to a substantial evolution in antiplatelet treatment regimens over the past decades. Numerous investigations have been conducted to better stratify patients undergoing PCI according to their ischaemic and bleeding risks and to implement antithrombotic regimens accordingly. Evidence from these investigations have resulted in a number of antithrombotic treatment options as recommended by recent guidelines. In this State-of-the-Art review we provide the rationale, summarise the evidence, and discuss current and future directions of antiplatelet treatment regimens after PCI.
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Affiliation(s)
- Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Michelle L O'Donoghue
- TIMI Study Group, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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21
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Galli M, Franchi F, Rollini F, Been L, Jaoude PA, Rivas A, Zhou X, Jia S, Maaliki N, Lee CH, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Geisler T, Jennings LK, Bass TA, Angiolillo DJ. Platelet P2Y12 inhibiting therapy in adjunct to vascular dose of rivaroxaban or aspirin: A pharmacodynamic study of dual pathway inhibition versus dual antiplatelet therapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2022; 8:728-737. [PMID: 35353154 DOI: 10.1093/ehjcvp/pvac022] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/01/2022] [Accepted: 03/27/2022] [Indexed: 12/25/2022]
Abstract
AIM Dual-pathway inhibition (DPI) by adding a vascular dose of rivaroxaban to a single antiplatelet agent has emerged as a promising antithrombotic strategy. However, in most studies the antiplatelet agent of choice used in adjunct to a vascular dose of rivaroxaban was aspirin, and data with a P2Y12 inhibitor and how this DPI regimen compares with standard dual antiplatelet therapy (DAPT) is limited. METHODS AND RESULTS This investigation was a sub-study analysis conducted in selected cohorts of patients with stable atherosclerotic disease enrolled from a larger prospective, open-label, parallel-group pharmacodynamics (PD) study. We analyzed data from 40 patients treated with either clopidogrel or ticagrelor-based DAPT first, and clopidogrel or ticagrelor-based DPI thereafter. PD measures explored key pathways involved in thrombus formation and included markers of: 1) P2Y12 reactivity, 2) platelet-mediated global thrombogenicity, 3) cyclooxygenase-1 activity, 3) TRAP-induced platelet aggregation; 4) tissue factor (TF)-induced platelet aggregation, and 5) thrombin generation. As compared to DAPT, on a background of the same P2Y12 inhibitor (clopidogrel or ticagrelor), DPI was associated with reduced thrombin generation, increased markers of cyclooxygenase-1 activity and TRAP-induced platelet aggregation and no differences in markers of P2Y12 signaling, platelet-mediated global thrombogenicity and TF-induced platelet aggregation. In an analysis according to P2Y12 inhibitor type, ticagrelor reduced markers of platelet-mediated global thrombogenicity, P2Y12 signaling and rates of high platelet reactivity compared to clopidogrel. CONCLUSIONS Compared to DAPT with aspirin and a P2Y12 inhibitor, the use of a P2Y12 inhibitor in adjunct to a vascular dose of rivaroxaban as part of a DPI strategy is associated with similar effects on platelet-mediated global thrombogenicity but reduced thrombin generation. A DPI strategy with ticagrelor is associated with enhanced antithrombotic efficacy, the clinical implications of which warrant larger scale investigations. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03718429.
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Affiliation(s)
- Mattia Galli
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Latonya Been
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Patrick Abou Jaoude
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andrea Rivas
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Sida Jia
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Naji Maaliki
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Chang Hoon Lee
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Andres M Pineda
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Siva Suryadevara
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Daniel Soffer
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Martin M Zenni
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tobias Geisler
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Lisa K Jennings
- Department of Cardiology and Angiology, University of Tübingen, Tübingen, Germany
| | - Theodore A Bass
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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22
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Dangas G, Baber U, Sharma S, Giustino G, Sartori S, Nicolas J, Goel R, Mehta S, Cohen D, Angiolillo DJ, Zhang Z, Camaj A, Cao D, Briguori C, Dudek D, Escaned J, Huber K, Collier T, Kornowski R, Kunadian V, Moliterno DJ, Ohman EM, Weisz G, Gil R, Krucoff MW, Kaul U, Oldroyd KG, Sardella G, Shlofmitz R, Witzenbichler B, Kastrati A, Han YL, Steg PG, Pocock S, Gibson CM, Mehran R. Safety and efficacy of ticagrelor monotherapy according to drug-eluting stent type: the TWILIGHT-STENT study. EUROINTERVENTION 2022; 17:1330-1339. [PMID: 34881696 PMCID: PMC9743248 DOI: 10.4244/eij-d-21-00721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND In the TWILIGHT trial, ticagrelor monotherapy after a short course of dual antiplatelet therapy (DAPT) was shown to be a safe bleeding avoidance strategy in high-risk patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). AIMS The aim of this study was to evaluate the effects of ticagrelor monotherapy after three-month DAPT in patients undergoing PCI, according to DES type. METHODS In the current sub-analysis from TWILIGHT, patients were stratified into three groups based on DES type: durable polymer everolimus-eluting stents (DP-EES), durable polymer zotarolimus-eluting stents (DP-ZES), and biodegradable polymer DES (BP-DES). Bleeding and ischaemic outcomes were assessed at one year after randomisation. RESULTS Out of 5,769 patients, 3,014 (52.2%) had DP-EES, 1,350 (23.4%) had DP-ZES and 1,405 (24.4%) had BP-DES. Compared with ticagrelor plus aspirin, ticagrelor monotherapy had significantly lower BARC type 2, 3 or 5 bleeding compared with DAPT; DP-EES (3.8% vs 6.7%; HR 0.56, 95% CI: 0.41-0.78), DP-ZES (4.6% vs 6.9%; HR 0.66, 95% CI: 0.42-1.04) and BP-DES (4.2% vs 7.9%; HR 0.52, 95% CI: 0.33-0.81; pinteraction=0.76). Ticagrelor monotherapy resulted in similar rates of death, MI, or stroke: DP-EES (4.2% vs 4.3%; HR 0.97; 95% CI: 0.68-1.37); DP-ZES (4.1% vs 3.1%; HR 1.32; 95% CI: 0.75-2.33); BP-DES (3.9% vs 4.2%; HR 0.92; 95% CI: 0.54-1.55; pinteraction=0.60). In both unadjusted and covariate-adjusted analyses, DES type was not associated with any differences in ischaemic or bleeding complications. CONCLUSIONS As compared with ticagrelor plus aspirin, ticagrelor monotherapy after a short DAPT duration lowered bleeding complications without increasing the ischaemic risk, irrespective of DES type. We observed no significant differences among DES types.
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Affiliation(s)
- George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Samin Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shamir Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - David Cohen
- St. Francis Hospital, Roslyn NY and Cardiovascular Research Foundation, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anton Camaj
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ran Kornowski
- Cardiology Department, Rabin Medical Center, Petach Tikva, Israel
| | - 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
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA
| | - Giora Weisz
- New York Presbyterian Hospital, Columbia University Medical Center, NY, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC, USA
| | - Upendra Kaul
- Batra Hospital and Medical Research Center, New Delhi, India
| | - Keith G Oldroyd
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Gennaro Sardella
- Department of Cardiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | | | | | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum Munchen, Munchen, Germany
| | - Ya-Ling Han
- Department of Cardiology, Shenyang North Hospital, Shenyang Shi, China
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - C Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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23
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Baber U. The 5W1H in antiplatelet monotherapy after percutaneous coronary intervention: what, who, where, when, why, and how? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:115-118. [PMID: 34656457 DOI: 10.1016/j.rec.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Affiliation(s)
- Usman Baber
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States.
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24
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Baber U. Antiagregación plaquetaria en monoterapia tras intervención coronaria percutánea: qué, quién, dónde, cuándo, por qué y cómo. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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25
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Vogel B, Huber K, Mehran R. Sex Difference in Bleeding Risk With P2Y12 Inhibitor Agents After Percutaneous Coronary Intervention-Reply. JAMA Cardiol 2022; 7:360-361. [PMID: 34985499 DOI: 10.1001/jamacardio.2021.5402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kurt Huber
- Department of Cardiology, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Associate Editor, JAMA Cardiology
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26
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Escaned J, Cao D, Baber U, Nicolas J, Sartori S, Zhang Z, Dangas G, Angiolillo DJ, Briguori C, Cohen DJ, Collier T, Dudek D, Gibson M, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Mehta S, Moliterno DJ, Ohman EM, Oldroyd KG, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Ticagrelor monotherapy in patients at high bleeding risk undergoing percutaneous coronary intervention: TWILIGHT-HBR. Eur Heart J 2021; 42:4624-4634. [PMID: 34662382 DOI: 10.1093/eurheartj/ehab702] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/08/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS Patients at high bleeding risk (HBR) represent a prevalent subgroup among those undergoing percutaneous coronary intervention (PCI). Early aspirin discontinuation after a short course of dual antiplatelet therapy (DAPT) has emerged as a bleeding avoidance strategy. The aim of this study was to assess the effects of ticagrelor monotherapy after 3-month DAPT in a contemporary HBR population. METHODS AND RESULTS This prespecified analysis of the TWILIGHT trial evaluated the treatment effects of early aspirin withdrawal followed by ticagrelor monotherapy in HBR patients undergoing PCI with drug-eluting stents. After 3 months of ticagrelor plus aspirin, event-free patients were randomized to 12 months of aspirin or placebo in addition to ticagrelor. A total of 1064 (17.2%) met the Academic Research Consortium definition for HBR. Ticagrelor monotherapy reduced the incidence of the primary endpoint of Bleeding Academic Research Consortium (BARC) 2, 3, or 5 bleeding compared with ticagrelor plus aspirin in HBR (6.3% vs. 11.4%; hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.35-0.82) and non-HBR patients (3.5% vs. 5.9%; HR 0.59, 95% CI 0.46-0.77) with similar relative (Pinteraction = 0.67) but a trend towards greater absolute risk reduction in the former [-5.1% vs. -2.3%; difference in absolute risk differences (ARDs) -2.8%, 95% CI -6.4% to 0.8%, P = 0.130]. A similar pattern was observed for more severe BARC 3 or 5 bleeding with a larger absolute risk reduction in HBR patients (-3.5% vs. -0.5%; difference in ARDs -3.0%, 95% CI -5.2% to -0.8%, P = 0.008). There was no significant difference in the key secondary endpoint of death, myocardial infarction, or stroke between treatment arms, irrespective of HBR status. CONCLUSIONS Among HBR patients undergoing PCI who completed 3-month DAPT without experiencing major adverse events, aspirin discontinuation followed by ticagrelor monotherapy significantly reduced bleeding without increasing ischaemic events, compared with ticagrelor plus aspirin. The absolute risk reduction in major bleeding was larger in HBR than non-HBR patients.
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Affiliation(s)
- Javier Escaned
- Hospital Clínico San Carlos IDISCC, Complutense University of Madrid, Madrid 28040, Spain
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Johny Nicolas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL 32209, USA
| | | | - David J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Michael Gibson
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw 02-507, Poland
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Sigmund Freud University, Medical Faculty, Vienna 1160, Austria
| | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, 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 NE7 7DN, UK
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith G Oldroyd
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Richard Shlofmitz
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Giora Weisz
- NewYork Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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27
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Lu W, Wang Y, Chen L, Li Y, Zhang R, Chen Z, Yan J, Yang M, Han B, Wang Z, He S, Chen L, Wu X, Zeng H, Ma L, Shi G, Yin J, Chen J, Ma G. Antithrombotic Therapy With Ticagrelor in Atrial Fibrillation Subjects After Percutaneous Coronary Intervention. Front Cardiovasc Med 2021; 8:745549. [PMID: 34712714 PMCID: PMC8545975 DOI: 10.3389/fcvm.2021.745549] [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: 07/22/2021] [Accepted: 09/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Warfarin, along with aspirin and clopidogrel, has long been recommended for patients with atrial fibrillation (AF) who are undergoing percutaneous coronary intervention with a drug-eluting stent (PCI-DES). However, this triple therapy has been known to increase the risk of bleeding complications. Meanwhile, there is no evidence from prospective trials on the use of ticagrelor in a dual therapy. We here aimed to compare the antiplatelet drug ticagrelor as a dual antithrombotic agent to aspirin and clopidogrel in bleeding events. Methods: In this multicenter, active-controlled, open-label, randomized trial, patients with AF taking warfarin who had undergone PCI-DES were randomly assigned to the ticagrelor therapy group (Dual group) or the clopidogrel plus aspirin therapy group (Triple group). The primary and secondary endpoints were overall bleeding events and major bleeding events, respectively, according to the Thrombolysis in Myocardial Infarction (TIMI) criteria at 6 months. Cardiovascular events [re-PCI, surgical bypass, myocardial infarction (MI), heart failure, rehospitalization due to angina pectoris, stent thrombosis and death due to cardiovascular causes] at 6 months were also recorded. Results: A total of 296 patients from 12 medical centers in China were randomized after PCI-DES to either the Dual therapy group (n = 148) or the Triple group (n = 146) for 6 months. The overall incidence of bleeding events at 6 months was 36.49% in the Dual therapy group and 35.62% in the Triple group [hazard ratio, 0.930; 95% confidence interval (CI), 0.635 to 1.361; P = 0.7088]. The incidence of the secondary endpoint over 6 months was 4.73% in the Dual therapy group and 1.37% in the Triple group (hazard ratio, 0.273; 95% CI, 0.057 to 1.315; P = 0.1056). Cardiovascular event occurrence was also comparable in both groups at 6 months (18.24 vs. 16.44%; hazard ratio, 0.845; 95% CI, 0.488 to 1.465; P = 0.5484). Conclusions: The incidence of total bleeding events in AF patients treated with ticagrelor was comparable to that in patients treated with clopidogrel plus aspirin at 6 month; Meanwhile, the incidence of cardiovascular events were also comparable between the groups. Clinical Trial Registration: MANJUSRI, ClinicalTrials.gov# NCT02206815, 2014, August 1st
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Affiliation(s)
- Wenbin Lu
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yu Wang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Lijuan Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Yongjun Li
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Rui Zhang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Zhongpu Chen
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Jinchuan Yan
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Jiangsu, China
| | - Mingming Yang
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
| | - Bing Han
- Department of Cardiology, Central Hospital of Xuzhou City, Xuzhou, China
| | - Zhirong Wang
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Shenghu He
- Department of Cardiology, Northern Jiangsu People's Hospital Affiliated With Yangzhou University, Yangzhou, China
| | - Lianglong Chen
- Department of Cardiology, Union Hospital Affiliated With Fujian Medical University, Fuzhou, China
| | - Xiang Wu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hesong Zeng
- Department of Cardiology, Tongji Hospital Affiliated With Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Likun Ma
- Department of Cardiology, Anhui Provincial Hospital, Hefei, China
| | - Guoping Shi
- Department of Cardiology, Rugao People's Hospital, Nantong, China
| | - Jianrong Yin
- Department of Cardiology, Pizhou People's Hospital Affiliated With Xuzhou Medical University, Xuzhou, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong, China
| | - GenShan Ma
- Department of Cardiology, ZhongDa Hospital Affiliated With Southeast University, Nanjing, China
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28
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Affiliation(s)
- Zuzana Motovska
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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29
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Benetou DR, Varlamos C, Pappas C, Kolokathis F, Alexopoulos D. Antithrombotics in Complex Percutaneous Coronary Interventions: Type and Duration of Treatment. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients undergoing complex percutaneous coronary intervention (PCI) are at an increased risk of atherothrombotic complications. Although dual antiplatelet therapy is the mainstay of treatment for patients undergoing PCI with stent implantation, deciding its type and duration in complex PCI patients has long been considered a challenge for clinicians. This is because the beneficial effects of prolonged treatment and/or more potent antiplatelet agents’ use in preventing ischemic events are hindered by a concomitant increase in bleeding complications. The aim of this review is to highlight current evidence regarding the optimal antithrombotic therapy regimens used in complex PCI patients, focusing on the evaluation of both safety and efficacy outcomes as well as addressing future perspectives.
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Affiliation(s)
- Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christos Pappas
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Fotios Kolokathis
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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30
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Kandzari DE, Kirtane AJ, Mehran R, Price MJ, Simon DI, Latib A, Kedhi E, Abizaid A, Worthley SG, Zaman A, Hudec M, Stoler R, Choi JW, Kanitkar M, Conradie A, Tam CCF, Walton A, Gruberg L, Ando K, Lee LC, Lung TH, Windecker S, Stone GW. Clinical outcomes according to lesion complexity in high bleeding risk patients treated with 1-month dual antiplatelet therapy following PCI: Analysis from the Onyx ONE clear study. Catheter Cardiovasc Interv 2021; 99:583-592. [PMID: 34478233 DOI: 10.1002/ccd.29939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/30/2021] [Accepted: 08/23/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To compare clinical outcomes in high bleeding risk (HBR) patients with and without complex percutaneous coronary intervention (PCI) treated with Resolute Onyx zotarolimus-eluting stents (ZES) after 1-month dual antiplatelet therapy (DAPT). BACKGROUND PCI with 1-month DAPT has been demonstrated to be safe in HBR patients treated with Resolute Onyx ZES. Whether these outcomes are consistent in patients with complex lesions is uncertain. METHODS Among HBR patients who were event-free 1 month after PCI with ZES and treated thereafter with single antiplatelet therapy (SAPT), the clinical outcomes between 1 month and 1 year were compared after complex PCI (3 vessels treated, ≥ 3 lesions treated, total stent length > 60 mm, bifurcation with ≥ 2 stents implanted, atherectomy, or left main, surgical bypass graft or chronic total occlusion PCI) versus noncomplex PCI. Propensity score adjustment was performed to adjust for baseline differences among complex and noncomplex patients. RESULTS Complex patients (N = 401, 26.6% of total) had a higher prevalence of hyperlipidemia, diabetes mellitus and previous myocardial infarction (MI). Between 1 month and 1 year, rates of MI (7.1% vs. 4.0%, p = 0.02) and cardiac death/MI (9.3% vs. 6.1%, p = 0.04) were higher among complex versus noncomplex patients, although stent thrombosis rates were similar. After adjustment for baseline characteristics, differences in outcomes were no longer significant between groups. CONCLUSIONS Higher rates of ischemic outcomes in complex PCI patients were largely explained by baseline clinical differences, rather than lesion complexity, among HBR patients treated with 1-month DAPT following PCI with Resolute Onyx ZES.
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Affiliation(s)
| | - Ajay J Kirtane
- Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York, USA.,The Cardiovascular Research Foundation, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Azeem Latib
- Montefiore Medical Center, New York, New York, USA
| | - Elvin Kedhi
- Université Libre de Brussels, Brussels, Belgium
| | | | | | - Azfar Zaman
- Freeman Hospital and Newcastle University, Newcastle upon Tyne, UK
| | - Martin Hudec
- Stredoslovenský ústav srdcových a cievnych chorôb, Banská Bystrica, Slovakia
| | - Robert Stoler
- Baylor Heart and Vascular Hospital, Dallas, Texas, USA
| | - James W Choi
- Baylor Heart and Vascular Hospital, Dallas, Texas, USA
| | | | - Andre Conradie
- Bundaberg Cardiology-Friendly Society Private Hospital, Bundaberg, Queensland, Australia
| | | | | | | | - Kenji Ando
- Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
| | | | | | - Stephan Windecker
- University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Gregg W Stone
- The Cardiovascular Research Foundation, New York, New York, USA.,The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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31
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Tavenier AH, Mehran R, Chiarito M, Cao D, Pivato CA, Nicolas J, Beerkens F, Nardin M, Sartori S, Baber U, Angiolillo DJ, Capodanno D, Valgimigli M, Hermanides RS, van 't Hof AWJ, Ten Berg JM, Chang K, Kini AS, Sharma SK, Dangas G. Guided and unguided de-escalation from potent P2Y12 inhibitors among patients with ACS: a meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:492-502. [PMID: 34459481 DOI: 10.1093/ehjcvp/pvab068] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 08/08/2021] [Accepted: 08/26/2021] [Indexed: 11/14/2022]
Abstract
AIM Optimal dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) intends to balance ischemic and bleeding risks. Various DAPT de-escalation strategies, defined as switching from a full-dose potent to a reduced dose or less potent P2Y12 inhibitor, have been evaluated in several ACS-PCI trials. We aimed to compare DAPT de-escalation to standard DAPT with full dose potent P2Y12 inhibitors in ACS patients who underwent PCI. METHODS & RESULTS PubMed, Google Scholar and Cochrane Central Register of Controlled Trials were searched for eligible randomised controlled trials. Aspirin monotherapy trials were excluded. Five randomised trials (n = 10,779 patients) that assigned DAPT de-escalation (genetically guided to clopidogrel n = 1,242; platelet function guided to clopidogrel n = 1,304; unguided to clopidogrel n = 1,672; unguided to lower dose n = 1,170) versus standard DAPT (control group n = 5,391) were included in this analysis. DAPT de-escalation was associated with a significant reduction in Bleeding Academic Research Consortium ≥ 2 bleeding (HR 0.57, 95% CI 0.42-0.78; I2 = 77%) as well as major adverse cardiac events, represented in most trials by the composite of cardiovascular mortality, myocardial infarction, stent thrombosis and stroke (HR 0.77, 95% CI 0.62-0.96; I2 = 0%). Notwithstanding the limited power, consistency was noted across various de-escalation strategies. CONCLUSION De-escalation of DAPT after PCI for ACS, both unguided and guided by genetic or platelet function testing, was associated with lower rates of clinically relevant bleeding and ischemic events as compared to standard DAPT with potent P2Y12 inhibitors based on five open-label RCTs reviewed.
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Affiliation(s)
- Anne H Tavenier
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Isala Heart Center, Zwolle, the Netherlands
| | - Roxana Mehran
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mauro Chiarito
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Davide Cao
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Carlo A Pivato
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan, Italy.,Humanitas Research Hospital IRCCS, Rozzano-Milan, Italy
| | - Johny Nicolas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Frans Beerkens
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Matteo Nardin
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samantha Sartori
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Usman Baber
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Marco Valgimigli
- Bern University Hospital, University of Bern, Bern, Switzerland; Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Arnoud W J van 't Hof
- Isala Heart Center, Zwolle, the Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Jur M Ten Berg
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,St Antonius Hospital, Nieuwegein, the Netherlands
| | - Kiyuk Chang
- Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Annapoorna S Kini
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samin K Sharma
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Dangas
- The Zena and Michael A. Weiner Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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32
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Stefanini GG, Briguori C, Cao D, Baber U, Sartori S, Zhang Z, Dangas G, Angiolillo DJ, Mehta S, Cohen DJ, Collier T, Dudek D, Escaned J, Gibson CM, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Oldroyd KG, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Ticagrelor monotherapy in patients with chronic kidney disease undergoing percutaneous coronary intervention: TWILIGHT-CKD. Eur Heart J 2021; 42:4683-4693. [PMID: 34423374 DOI: 10.1093/eurheartj/ehab533] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/07/2021] [Accepted: 07/26/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS The aim of this study was to assess the impact of chronic kidney disease (CKD) on the safety and efficacy of ticagrelor monotherapy among patients undergoing percutaneous coronary intervention (PCI). METHODS AND RESULTS In this prespecified subanalysis of the TWILIGHT trial, we evaluated the treatment effects of ticagrelor with or without aspirin according to renal function. The trial enrolled patients undergoing drug-eluting stent implantation who fulfilled at least one clinical and one angiographic high-risk criterion. Chronic kidney disease, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, was a clinical study entry criterion. Following a 3-month period of ticagrelor plus aspirin, event-free patients were randomly assigned to aspirin or placebo on top of ticagrelor for an additional 12 months. Of the 6835 patients randomized and with available eGFR at baseline, 1111 (16.3%) had CKD. Ticagrelor plus placebo reduced the primary endpoint of Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding as compared with ticagrelor plus aspirin in both patients with [4.6% vs. 9.0%; hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.31-0.80] and without (4.0% vs. 6.7%; HR 0.59, 95% CI 0.47-0.75; Pinteraction = 0.508) CKD, but the absolute risk reduction was greater in the former group. Rates of death, myocardial infarction, or stroke were not significantly different between the two randomized groups irrespective of the presence (7.9% vs. 5.7%; HR 1.40, 95% CI 0.88-2.22) or absence of (3.2% vs. 3.6%; HR 0.90, 95% CI 0.68-1.20; Pinteraction = 0.111) CKD. CONCLUSION Among CKD patients undergoing PCI, ticagrelor monotherapy reduced the risk of bleeding without a significant increase in ischaemic events as compared with ticagrelor plus aspirin.
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Affiliation(s)
- Giulio G Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan 20090, Italy.,IRCCS Humanitas Research Hospital, Rozzano, Milan 20089, Italy
| | | | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Usman Baber
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | | | | | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY 10019, USA.,St. Francis Hospital, Roslyn, NY 11576, USA
| | - Timothy Collier
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow 31-008, Poland
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid 28040, Spain
| | | | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw 02-507, Poland
| | | | - Upendra Kaul
- Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | | | - Mitchell W Krucoff
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, 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 NE7 7DN, UK
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith G Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank G81 4DY, UK
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - Giora Weisz
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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33
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Otsuka T, Ueki Y, Kavaliauskaite R, Zanchin T, Bär S, Stortecky S, Pilgrim T, Valgimigli M, Meier B, Heg D, Windecker S, Räber L. Single antiplatelet therapy with use of prasugrel in patients undergoing percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 98:E213-E221. [PMID: 33754441 DOI: 10.1002/ccd.29650] [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: 12/26/2020] [Revised: 02/04/2021] [Accepted: 03/12/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVES We aimed to assess the ischemic and bleeding risks of single antiplatelet therapy (SAPT) with prasugrel compared with standard dual antiplatelet therapy (DAPT) (aspirin plus clopidogrel for 1 year) in patients with chronic coronary syndrome (CCS) treated with new generation drug-eluting stents (DES). BACKGROUND To date, data on SAPT with potent P2Y12 inhibitors in the absence of aspirin immediately after PCI are limited. METHODS Between January 2009 and November 2019, all CCS patients undergoing percutaneous coronary intervention (PCI) enrolled to the Bern PCI registry were considered for analysis. We performed propensity score matching in a 1:4 fashion to compare patients who received SAPT with prasugrel versus standard DAPT. The primary ischemic endpoint was a composite of cardiovascular death, myocardial infarction, and stroke and the primary bleeding endpoint was BARC 3 or 5 bleeding, both assessed at 1 year. RESULTS After propensity score matching, the final study population consisted of 225 patients with SAPT and 889 with DAPT. There was no significant difference in rates of the primary ischemic (5.2% vs. 4.2%, p = .50) or the primary bleeding (1.5% vs. 2.0%, p = .60) endpoints between groups. SAPT was not associated with an increased risk of definite stent thrombosis (0.9% vs. 0.8%, p = .83). CONCLUSIONS Among selected CCS patients undergoing PCI with DES, SAPT with prasugrel was not associated with an excess of ischemic events compared with standard DAPT. No difference in bleeding was observed either. The results may serve as the basis for larger trials assessing the potential benefits and risks of SAPT.
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Affiliation(s)
- Tatsuhiko Otsuka
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasushi Ueki
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raminta Kavaliauskaite
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Zanchin
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sarah Bär
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Pilgrim
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dik Heg
- Institute of Social and Preventive Medicine and Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
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Angiolillo DJ, Cao D, Baber U, Sartori S, Zhang Z, Dangas G, Mehta S, Briguori C, Cohen DJ, Collier T, Dudek D, Escaned J, Gibson CM, Gil R, Huber K, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Moliterno DJ, Ohman EM, Oldroyd K, Sardella G, Sharma SK, Shlofmitz R, Weisz G, Witzenbichler B, Pocock S, Mehran R. Impact of Age on the Safety and Efficacy of Ticagrelor Monotherapy in Patients Undergoing PCI. JACC Cardiovasc Interv 2021; 14:1434-1446. [PMID: 34238553 DOI: 10.1016/j.jcin.2021.04.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/13/2021] [Accepted: 04/19/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The aim of this study was to assess the impact of age on the safety and efficacy of ticagrelor monotherapy after percutaneous coronary intervention (PCI). BACKGROUND As the risk for bleeding and ischemic complications after PCI increases with age, the authors conducted a pre-specified analysis of the TWILIGHT (Ticagrelor With Aspirin or Alone in High-Risk Patients After Coronary Intervention) trial to evaluate the possible benefits of ticagrelor monotherapy according to age. METHODS The TWILIGHT trial enrolled patients undergoing PCI with drug-eluting stents who fulfilled at least 1 clinical and 1 angiographic high-risk criterion. Age ≥65 years was a clinical entry criterion. After 3 months of dual-antiplatelet therapy with ticagrelor, event-free patients were randomized to ticagrelor plus placebo or ticagrelor plus aspirin for an additional 12 months. The primary endpoint was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding. The key secondary endpoint was the composite of all-cause death, myocardial infarction, or stroke. RESULTS A total of 3,113 patients (47.7%) were ≥65 years of age. At 1 year after randomization, ticagrelor monotherapy significantly reduced BARC type 2, 3, or 5 bleeding (4.5% vs. 8.2%; hazard ratio: 0.53; 95% confidence interval: 0.40 to 0.71) without increasing ischemic events (4.2% vs. 4.4%; hazard ratio: 0.96; 95% confidence interval: 0.68 to 1.35) compared with ticagrelor plus aspirin among patients ≥65 years of age. These findings were consistent in patients <65 years of age with respect to the primary (pinteraction = 0.62) and key secondary (pinteraction = 0.77) endpoints and across different age categories. CONCLUSIONS A strategy of ticagrelor monotherapy following 3 months of dual-antiplatelet therapy significantly reduced clinically relevant bleeding compared with ticagrelor plus aspirin without an increase in ischemic events, irrespective of age.
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Affiliation(s)
| | - Davide Cao
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Usman Baber
- The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | - Shamir Mehta
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - David J Cohen
- University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Timothy Collier
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland
| | - Javier Escaned
- Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Madrid, Spain
| | - C Michael Gibson
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Gil
- Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | | | - 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
| | - 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
| | | | - E Magnus Ohman
- Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Keith Oldroyd
- The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, United Kingdom
| | | | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA
| | | | - Giora Weisz
- NewYork-Presbyterian Hospital, Columbia University Medical Center, New York, USA
| | | | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, New York, New York, USA.
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Varlamos C, Lianos I, Benetou DR, Alexopoulos D. Left Main Disease and Bifurcation Percutaneous Coronary Intervention: Focus on Antithrombotic Therapy. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Revascularization of both left main and bifurcation lesions is currently considered an important feature of complex percutaneous coronary intervention (PCI), whereas stenting distal left main bifurcation is fairly challenging. Recent evidence shows that such lesions are associated with an increased risk of ischemic events. There is no universal consensus on the optimal PCI strategy or the appropriate type and duration of antithrombotic therapy to mitigate the thrombotic risk. Prolonged dual antiplatelet therapy or use of more potent P2Y12 inhibitors have been investigated in the context of this high-risk subset of the population undergoing PCI. Thus, while complex PCI is a growing field in interventional cardiology, left main and bifurcation PCI constitutes a fair amount of the total complex procedures performed recently, and there is cumulative interest regarding antithrombotic therapy type and duration in this subset of patients, with decision-making mostly based on clinical presentation, baseline bleeding, and ischemic risk, as well as the performed stenting strategy.
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Affiliation(s)
- Charalampos Varlamos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ioannis Lianos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despoina-Rafailia Benetou
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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36
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Verheugt FWA, Damman P, Damen SAJ, Wykrzykowska JJ, Woelders ECI, van Geuns RJM. P2Y12 blocker monotherapy after percutaneous coronary intervention. Neth Heart J 2021; 29:566-576. [PMID: 34101134 PMCID: PMC8556441 DOI: 10.1007/s12471-021-01582-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/16/2022] Open
Abstract
For secondary prevention of coronary artery disease (CAD) antiplatelet therapy is essential. For patients undergoing a percutaneous coronary intervention (PCI) temporary dual antiplatelet platelet therapy (DAPT: aspirin combined with a P2Y12 blocker) is mandatory, but leads to more bleeding than single antiplatelet therapy with aspirin. Therefore, to reduce bleeding after a PCI the duration of DAPT is usually kept as short as clinically acceptable; thereafter aspirin monotherapy is administered. Another option to reduce bleeding is to discontinue aspirin at the time of DAPT cessation and thereafter to administer P2Y12 blocker monotherapy. To date, five randomised trials have been published comparing DAPT with P2Y12 blocker monotherapy in 32,181 stented patients. Also two meta-analyses addressing this novel therapy have been presented. P2Y12 blocker monotherapy showed a 50-60% reduction in major bleeding when compared to DAPT without a significant increase in ischaemic outcomes, including stent thrombosis. This survey reviews the findings in the current literature concerning P2Y12 blocker monotherapy after PCI.
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Affiliation(s)
- F W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - P Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S A J Damen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J J Wykrzykowska
- Department of Cardiology, University Medical Centre, Groningen, The Netherlands
| | - E C I Woelders
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - R -J M van Geuns
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
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37
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Vogel B, Baber U, Cohen DJ, Sartori S, Sharma SK, Angiolillo DJ, Farhan S, Goel R, Zhang Z, Briguori C, Collier T, Dangas G, Dudek D, Escaned J, Gil R, Han YL, Kaul U, Kornowski R, Krucoff MW, Kunadian V, Mehta SR, Moliterno D, Ohman EM, Sardella G, Witzenbichler B, Gibson CM, Pocock S, Huber K, Mehran R. Sex Differences Among Patients With High Risk Receiving Ticagrelor With or Without Aspirin After Percutaneous Coronary Intervention: A Subgroup Analysis of the TWILIGHT Randomized Clinical Trial. JAMA Cardiol 2021; 6:1032-1041. [PMID: 33991416 DOI: 10.1001/jamacardio.2021.1720] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Importance Shortened dual antiplatelet therapy followed by potent P2Y12 receptor inhibitor monotherapy reduces bleeding without increasing ischemic events after percutaneous coronary intervention (PCI). Objective To explore sex differences and evaluate the association of sex with outcomes among patients treated with ticagrelor monotherapy vs ticagrelor plus aspirin. Design, Setting, and Participants This was a prespecified secondary analysis of TWILIGHT, an investigator-initiated, placebo-controlled randomized clinical trial conducted at 187 sites across 11 countries. Study participants included patients who underwent successful PCI with drug-eluting stents, were planned for discharge with ticagrelor plus aspirin, and who had at least 1 clinical and at least 1 angiographic feature associated with high risk of ischemic or bleeding events. Data were analyzed from May to July 2020. Interventions At 3 months after PCI, patients adherent to ticagrelor and aspirin without major adverse event were randomized to either aspirin or placebo for an additional 12 months along with ticagrelor. Main Outcomes and Measures The primary end point was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding at 12 months after randomization. The primary ischemic end point was a composite of death, myocardial infarction, or stroke. Results Of 9006 enrolled patients, 7119 underwent randomization (mean [SD] age, 63.9 [10.2] years; 5421 [76.1%] men). Women were older (mean [SD] age, 65.5 [9.6] years in women vs 63.4 [10.3] years in men) with higher prevalence of chronic kidney disease (347 women [21.2%] vs 764 men [14.7%]). The primary bleeding end point occurred more often in women than men (hazard ratio [HR], 1.32; 95% CI, 1.06-1.64; P = .01). After multivariate adjustment, incremental bleeding risk associated with female sex was no longer significant (adjusted HR, 1.20; 95% CI, 0.95-1.52; P = .12). Ischemic end points were similar between sexes. Ticagrelor plus placebo vs ticagrelor plus aspirin was associated with lower risk of BARC type 2, 3, or 5 bleeding in women (adjusted HR, 0.62; 95% CI, 0.42-0.92; P = .02) and men (adjusted HR, 0.57; 95% CI, 0.44-0.73; P < .001; P for interaction = .69). Ischemic end points were similar between treatment groups in both sexes. Conclusions and Relevance These findings suggest that the higher bleeding risk in women compared with men was mostly attributable to baseline differences, whereas ischemic events were similar between sexes. In this high-risk PCI population, the benefits of early aspirin withdrawal with continuation of ticagrelor were generally comparable in women and men. Trial Registration ClinicalTrials.gov Identifier: NCT02270242.
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Affiliation(s)
- Birgit Vogel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City
| | - David J Cohen
- St Francis Hospital, Roslyn, New York.,Cardiovascular Research Foundation, New York, New York
| | - Samantha Sartori
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Samin K Sharma
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Serdar Farhan
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ridhima Goel
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Zhongjie Zhang
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Timothy Collier
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - George Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Dariusz Dudek
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Javier Escaned
- Department of Cardiology, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Calle del Prof Martin Lagos, Madrid, Spain
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Ya-Ling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning Sheng, China
| | - Upendra Kaul
- Department of Cardiology, Batra Hospital and Medical Research Centre, New Delhi, India
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel
| | - Mitchell W Krucoff
- Department of Cardiology, Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Shamir R Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, Canada
| | | | - E Magnus Ohman
- Department of Cardiology, Duke University Medical Center-Duke Clinical Research Institute, Durham, North Carolina
| | - Gennaro Sardella
- Department of Cardiology, Policlinico Umberto I University, Roma, Italy
| | | | - C Michael Gibson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Kurt Huber
- Department of Cardiology, Wilhelminenhospital, Vienna, Austria.,Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
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38
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Santos-Gallego CG, Badimon J. Overview of Aspirin and Platelet Biology. Am J Cardiol 2021; 144 Suppl 1:S2-S9. [PMID: 33706986 DOI: 10.1016/j.amjcard.2020.12.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 12/11/2020] [Indexed: 12/31/2022]
Abstract
Aspirin (ASA) has historically been one of the most important drugs in cardiology and has long been the cornerstone of antiplatelet therapy. Although its role in acute coronary syndrome remains undisputed, emerging data suggest that reappraisal of the efficacy of long-term ASA in some primary and secondary prevention may be warranted. The aim of this review is to place these new results in the context of previous evidence on aspirin by appraising the current body of evidence on its use of for cardiovascular diseases. This overview first summarizes the history of the discovery of aspirin, as well as its pharmacology and the concept of ASA resistance. We subsequently recapitulate the evidence of ASA on primary prevention and secondary prevention starting from the classical studies in order to serve as an introductory background to the examination of the most recent clinical trials that will be performed in the rest of the articles of this Supplement. Although the benefit of ASA in acute coronary syndrome remains incontrovertible, emerging evidence challenge the universal need for primary prevention, or for lifelong treatment in secondary prevention or all adults with stable coronary disease who are at highest risk for ASA-induced bleeding. The role of aspirin is quickly changing in recent times and this review provides a review for the clinician about the current role of this drug in cardiovascular care.
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39
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Sinnaeve PR, Adriaenssens T. Dual Antiplatelet Therapy De-escalation Strategies. Am J Cardiol 2021; 144 Suppl 1:S23-S31. [PMID: 33706987 DOI: 10.1016/j.amjcard.2020.12.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/11/2020] [Indexed: 01/09/2023]
Abstract
Dual antiplatelet therapy (DAPT), the combination of aspirin (ASA), and a P2Y12 inhibitor, protects against stent thrombosis and new atherothrombotic events after a stent implantation or an acute coronary syndrome, but exposes patients to an increased risk of bleeding. In most current practices, the P2Y12 inhibitor is stopped at 6 to 12 months and ASA is continued indefinitely. The advent of safer stents, with less risk of stent thrombosis, has challenged this standard of care, however. A number of alternative strategies involving earlier de-escalation of the antiplatelet therapy have therefore been proposed. In these approaches, standard DAPT is switched to a less potent antithrombotic combination at an earlier time-point than recommended by guidelines. Three different de-escalation variations have been tested to date. The first one maintains DAPT but switches from the potent P2Y12 inhibitors ticagrelor or prasugrel to either a lower dose or to clopidogrel, while maintaining ASA. The 2 other approaches involve changing DAPT to a single antiplatelet at some earlier time-point after the percutaneous coronary intervention procedure, by stopping either the P2Y12 inhibitor or ASA. These strategies have all demonstrated some benefit in clinical trials so far, but especially the contribution of ASA in secondary prevention is clearly evolving as its role in increasing bleeding complications while not providing increased ischemic benefit is becoming more and more clear. In contemporary practice, the type and duration of DAPT should now be based on an individualized decision, and the de-escalation strategies, if used wisely, can be added to the existing options.
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Affiliation(s)
- Peter R Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Tom Adriaenssens
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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40
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van der Sangen NMR, Rozemeijer R, Chan Pin Yin DRPP, Valgimigli M, Windecker S, James SK, Buccheri S, ten Berg JM, Henriques JPS, Voskuil M, Kikkert WJ. Patient-tailored antithrombotic therapy following percutaneous coronary intervention. Eur Heart J 2021; 42:1038-1046. [PMID: 33515031 PMCID: PMC8244639 DOI: 10.1093/eurheartj/ehaa1097] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/03/2020] [Accepted: 12/24/2020] [Indexed: 12/12/2022] Open
Abstract
Dual antiplatelet therapy has long been the standard of care in preventing coronary and cerebrovascular thrombotic events in patients with chronic coronary syndrome and acute coronary syndrome undergoing percutaneous coronary intervention, but choosing the optimal treatment duration and composition has become a major challenge. Numerous studies have shown that certain patients benefit from either shortened or extended treatment duration. Furthermore, trials evaluating novel antithrombotic strategies, such as P2Y12 inhibitor monotherapy, low-dose factor Xa inhibitors on top of antiplatelet therapy, and platelet function- or genotype-guided (de-)escalation of treatment, have shown promising results. Current guidelines recommend risk stratification for tailoring treatment duration and composition. Although several risk stratification methods evaluating ischaemic and bleeding risk are available to clinicians, such as the use of risk scores, platelet function testing , and genotyping, risk stratification has not been broadly adopted in clinical practice. Multiple risk scores have been developed to determine the optimal treatment duration, but external validation studies have yielded conflicting results in terms of calibration and discrimination and there is limited evidence that their adoption improves clinical outcomes. Likewise, platelet function testing and genotyping can provide useful prognostic insights, but trials evaluating treatment strategies guided by these stratification methods have produced mixed results. This review critically appraises the currently available antithrombotic strategies and provides a viewpoint on the use of different risk stratification methods alongside clinical judgement in current clinical practice.
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Affiliation(s)
- Niels M R van der Sangen
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Rik Rozemeijer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Dean R P P Chan Pin Yin
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
| | - Marco Valgimigli
- Department of Cardiology, Cardiocentro Ticino, Via Tesserete 48, 6900 Lugano, Switzerland
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Freiburgstrasse 18, 3010 Bern, Switzerland
| | - Stefan K James
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds Väg 38, 751 85 Uppsala, Sweden
| | - Sergio Buccheri
- Department of Medical Sciences and Uppsala Clinical Research Center, Uppsala University, Dag Hammarskjölds Väg 38, 751 85 Uppsala, Sweden
| | - Jurriën M ten Berg
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
- Department of Cardiology, University Medical Center Maastricht, P. Debyelaan 25, 6229 HX Maastricht, the Netherlands
| | - José P S Henriques
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands
| | - Wouter J Kikkert
- Department of Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Oosterparkstraat 9, 1091 AC Amsterdam, the Netherlands
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One-Year COMBO Stent Outcomes in Acute Coronary Syndrome: from the COMBO Collaboration. Cardiovasc Drugs Ther 2021; 35:309-320. [PMID: 33515411 DOI: 10.1007/s10557-020-07087-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The COMBO biodegradable polymer sirolimus-eluting stent includes endothelial progenitor cell capture (EPC) technology for rapid endothelialization, which may offer advantage in acute coronary syndromes (ACS). We sought to analyze the performance of the COMBO stent by ACS status and ACS subtype. METHODS The COMBO collaboration (n = 3614) is a patient-level pooled dataset from the MASCOT and REMEDEE registries. We evaluated outcomes by ACS status, and ACS subtype in patients with ST segment elevation myocardial infarction (STEMI) or non-STEMI (NSTEMI) versus unstable angina (UA). The primary endpoint was 1-year target lesion failure (TLF), composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Secondary outcomes included stent thrombosis (ST). RESULTS We compared 1965 (54%) ACS and 1649 (46.0%) non-ACS patients. ACS presentations included 40% (n = 789) STEMI, 31% (n = 600) NSTEMI, and 29% (n = 576) UA patients. Risk of 1-year TLF was greater in ACS patients (4.5% vs. 3.3%, HR 1.51 95% CI 1.01-2.25, p = 0.045) without significant differences in definite/probable ST (1.1% vs 0.5%, HR 2.40, 95% CI 0.91-6.31, p = 0.08). One-year TLF was similar in STEMI, NSTEMI, and UA (4.8% vs 4.8% vs. 3.7%, p = 0.60), but definite/probable ST was higher in STEMI patients (1.9% vs 0.5% vs 0.7%, p = 0.03). Adjusted outcomes were not different in MI versus UA patients. CONCLUSIONS Despite the novel EPC capture technology, COMBO stent PCI was associated with somewhat greater risk of 1-year TLF in ACS than in non-ACS patients, without significant differences in stent thrombosis. No differences were observed in 1-year TLF among ACS subtypes.
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42
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Hennigan BW, Good R, Adamson C, Parker WAE, Martin L, Anderson L, Campbell M, Serruys PW, Storey RF, Oldroyd KG. Recovery of platelet reactivity following cessation of either aspirin or ticagrelor in patients treated with dual antiplatelet therapy following percutaneous coronary intervention: a GLOBAL LEADERS substudy. Platelets 2020; 33:141-146. [PMID: 33356730 DOI: 10.1080/09537104.2020.1863937] [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] [Indexed: 10/22/2022]
Abstract
Cessation of one component of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) has been associated with increased risk of ischemic events but it is uncertain whether discontinuation of aspirin is preferable to discontinuation of the oral P2Y12 inhibitor. The GLOBAL LEADERS study compared two antiplatelet strategies following PCI, cessation of aspirin at 1 month with continued ticagrelor monotherapy for 23 months versus standard DAPT for 12 months followed by aspirin monotherapy for a further 12 months. We assessed recovery of platelet reactivity after withdrawal of either aspirin or ticagrelor at 1 month and 12 months, respectively, in this study. Platelet aggregation (PA) was assessed before cessation of DAPT ('baseline') and after 2, 7, and 14 days post-cessation using Multiplate whole-blood aggregometry with collagen, thrombin-receptor-activating peptide (TRAP), adenosine diphosphate (ADP) and arachidonic acid (AA) as agonists. Following cessation of aspirin at 1 month, there was marked recovery of PA induced by AA (baseline [mean ± SD]: 11.1 ± 7.4 U vs. 14 days: 64.9 ± 19.6 U, p < .0001) and collagen (37.4 ± 22.9 U vs. 79.8 ± 13.8 U, p < .0001), whereas PA induced by ADP (18.6 ± 6.6 vs. 69.1 ± 20.5, p < .0001) and collagen (34.4 ± 18.7 U vs. 43.0 ± 21.0, p = .0018) recovered following cessation of ticagrelor at 12 months. There were no significant changes in TRAP-induced PA in either group. In conclusion, cessation of either component of DAPT leads to substantial increase in platelet reactivity with differential effects on different pathways of platelet activation when aspirin or the P2Y12 inhibitor is stopped. Further work is required to determine which patients receive net benefit from long-term continuation of DAPT.
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Affiliation(s)
- Barry W Hennigan
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Richard Good
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Carly Adamson
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - William A E Parker
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Lynn Martin
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Lynne Anderson
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Michael Campbell
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, University Road, Galway, Ireland.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Keith G Oldroyd
- Department of Cardiology, Golden Jubilee National Hospital, Glasgow, UK
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Capodanno D, Angiolillo DJ. When Less Becomes More: Insights on the Pharmacodynamic Effects of Aspirin Withdrawal in Patients With Potent Platelet P2Y 12 Inhibition Induced by Ticagrelor. J Am Heart Assoc 2020; 9:e019432. [PMID: 33302757 PMCID: PMC7955356 DOI: 10.1161/jaha.120.019432] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Davide Capodanno
- Division of CardiologyPoliclinico "G. Rodolico‐San Marco"University of CataniaItaly
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Galli M, Capodanno D, Andreotti F, Crea F, Angiolillo DJ. Safety and efficacy of P2Y 12 inhibitor monotherapy in patients undergoing percutaneous coronary interventions. Expert Opin Drug Saf 2020; 20:9-21. [PMID: 33180563 DOI: 10.1080/14740338.2021.1850691] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Antiplatelet therapy represents a key strategy for the prevention of thrombotic complications in patients with both acute and chronic coronary syndromes, particularly those undergoing percutaneous coronary intervention (PCI). Nevertheless, dual antiplatelet therapy (DAPT) is associated with a bleeding risk proportionate to its duration. Ever growing appreciation of the prognostic implications associated with bleeding and the development of safer stent platforms over the past years have led to a number of novel antiplatelet treatment strategies being tested among patients undergoing PCI. Areas covered: P2Y12 inhibitor monotherapy after ashort course DAPT has emerged as ableeding reduction strategy to mitigate such risk while still preventing thrombotic complications. In this review we describe the latest evidence regarding the safety and efficacy of P2Y12 inhibitor monotherapy in patients undergoing PCI in different clinical settings. Expert opinion: P2Y12 inhibitor monotherapy after a brief period of DAPT has emerged as an effective approach to reduce the risk of bleeding without any tradeoff in efficacy (i.e., thrombotic complications). This strategy has shown consistent findings in a number of different clinical settings of patients undergoing PCI. Nevertheless, unanswered questions on the ideal patient and the precise P2Y12 monotherapy regimen warrant further investigation.
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Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy.,Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., P.O. "G. Rodolico," Azienda Ospedaliero Universitaria "Policlinico-Vittorio Emanuele", University of Catania , Catania, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS , Rome, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine , Jacksonville, Florida, United States
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Kandzari DE, Kirtane AJ, Windecker S, Latib A, Kedhi E, Mehran R, Price MJ, Abizaid A, Simon DI, Worthley SG, Zaman A, Choi JW, Caputo R, Kanitkar M, McLaurin B, Potluri S, Smith T, Spriggs D, Tolleson T, Nazif T, Parke M, Lee LC, Lung TH, Stone GW. One-Month Dual Antiplatelet Therapy Following Percutaneous Coronary Intervention With Zotarolimus-Eluting Stents in High-Bleeding-Risk Patients. Circ Cardiovasc Interv 2020; 13:e009565. [PMID: 33167705 PMCID: PMC7665241 DOI: 10.1161/circinterventions.120.009565] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Despite treatment guidance endorsing shortened dual antiplatelet therapy (DAPT) duration in high bleeding risk (HBR) patients after drug-eluting stents, limited evidence exists to support these recommendations. The present study was designed to examine the safety and effectiveness of 1-month DAPT duration following percutaneous coronary intervention with zotarolimus-eluting stents in HBR patients. Methods: Onyx ONE Clear was a prospective, multicenter, nonrandomized study evaluating the safety and effectiveness of 1-month DAPT followed by single antiplatelet therapy in HBR patients undergoing percutaneous coronary intervention with Resolute Onyx drug-eluting stents. The primary analysis of cardiac death or myocardial infarction between 1 month and 1 year was performed in the prespecified one-month clear population of patients pooled from the Onyx ONE US/Japan study and Onyx ONE randomized controlled trial. One-month clear was defined as DAPT adherence and without major adverse events during the first month following percutaneous coronary intervention. Results: Among patients enrolled in Onyx ONE US/Japan (n=752) and Onyx ONE randomized controlled trial (n=1018), 1506 patients fulfilled one-month clear criteria. Mean HBR characteristics per patient was 1.6 with 44.7% having multiple risks. By 2 months and 1 year, respectively, 96.9% and 89.3% of patients were taking single antiplatelet therapy. Between 1 month and 1 year, the rate of the primary end point was 7.0%. The 1-sided upper 97.5% CI was 8.4%, less than the performance goal of 9.7% (P<0.001). Conclusions: Among HBR patients who were event free before DAPT discontinuation at 1 month, favorable safety and effectiveness through 1 year support treatment with Resolute Onyx drug-eluting stents as part of an individualized strategy for shortened DAPT duration following percutaneous coronary intervention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT03647475.
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Affiliation(s)
- David E Kandzari
- Department of Interventional Cardiology, Piedmont Heart Institute, Atlanta, GA (D.E.K.)
| | - Ajay J Kirtane
- Department of Interventional Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital (A.J.K., T.N.).,Cardiovascular Research Foundation, New York, NY (A.J.K., G.W.S.)
| | - Stephan Windecker
- Department of Cardiovascular Diseases, University Hospital, University of Bern, Switzerland (S.W.)
| | - Azeem Latib
- Department of Interventional Cardiology, Montefiore Medical Center, New York, NY (A.L.)
| | - Elvin Kedhi
- Department of Cardiology, Isala Zwolle, the Netherlands (E.K.)
| | - Roxana Mehran
- Department of Cardiology, School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P.)
| | - Alexandre Abizaid
- Department of Interventional Cardiology, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil (A.A.)
| | - Daniel I Simon
- Department of Interventional Cardiology, University Hospitals Cleveland Medical Center, OH (D.I.S.)
| | | | - Azfar Zaman
- Department of Cardiology, Freeman Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom (A.Z.)
| | - James W Choi
- Department of Interventional Cardiology, Baylor Scott and White Heart and Vascular Hospital, Dallas, TX (J.W.C.)
| | - Ronald Caputo
- Department of Interventional Cardiology, St. Joseph's Hospital, Syracuse, NY (R.C.)
| | - Mihir Kanitkar
- Department of Interventional Cardiology, Huntsville Hospital, AL (M.K.)
| | - Brent McLaurin
- Department of Interventional Cardiology, Anmed Health Medical Center, Anderson, SC (B.M.)
| | - Srinivasa Potluri
- Department of Interventional Cardiology, The Heart Hospital Baylor Plano, TX (S.P.)
| | - Timothy Smith
- Department of Interventional Cardiology, The Christ Hospital, Cincinnati, OH (T.S.)
| | - Douglas Spriggs
- Department of Interventional Cardiology, Morton Plant Hospital, Clearwater, FL (D.S.)
| | | | - Tamim Nazif
- Department of Interventional Cardiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital (A.J.K., T.N.)
| | - Maria Parke
- Coronary and Structural Heart Division, Medtronic, Santa Rosa, CA (M.P., L.C.L., T.-H.L.)
| | - Lilian C Lee
- Coronary and Structural Heart Division, Medtronic, Santa Rosa, CA (M.P., L.C.L., T.-H.L.)
| | - Te-Hsin Lung
- Coronary and Structural Heart Division, Medtronic, Santa Rosa, CA (M.P., L.C.L., T.-H.L.)
| | - Gregg W Stone
- Cardiovascular Research Foundation, New York, NY (A.J.K., G.W.S.).,Department of Cardiology, School of Medicine at Mount Sinai, New York, NY (R.M., G.W.S.)
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46
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Baber U, Mehran R. Extending the aspirin-free paradigm to patients with acute coronary syndrome: is it time to change guidelines? EUROINTERVENTION 2020; 16:620-622. [PMID: 33095164 DOI: 10.4244/eijv16i8a115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Usman Baber
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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47
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Baber U, Dangas G, Angiolillo DJ, Cohen DJ, Sharma SK, Nicolas J, Briguori C, Cha JY, Collier T, Dudek D, Džavik V, Escaned J, Gil R, Gurbel P, Hamm CW, Henry T, Huber K, Kastrati A, Kaul U, Kornowski R, Krucoff M, Kunadian V, Marx SO, Mehta S, Moliterno D, Ohman EM, Oldroyd K, Sardella G, Sartori S, Shlofmitz R, Steg PG, Weisz G, Witzenbichler B, Han YL, Pocock S, Gibson CM, Mehran R. Ticagrelor alone vs. ticagrelor plus aspirin following percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes: TWILIGHT-ACS. Eur Heart J 2020; 41:3533-3545. [DOI: 10.1093/eurheartj/ehaa670] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/08/2020] [Accepted: 07/29/2020] [Indexed: 01/09/2023] Open
Abstract
AbstractAims The aim of this study was to determine the effect of ticagrelor monotherapy on clinically relevant bleeding and major ischaemic events in relation to clinical presentation with and without non-ST elevation acute coronary syndromes (NSTE-ACS) among patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES).Methods and results We conducted a pre-specified subgroup analysis of The Ticagrelor With Aspirin or Alone in High Risk Patients After Coronary Intervention (TWILIGHT) trial, which enrolled 9006 patients with high-risk features undergoing PCI with DES. After 3 months of dual antiplatelet therapy (DAPT) with ticagrelor plus aspirin, 7119 adherent and event-free patients were randomized in a double-blind manner to ticagrelor plus placebo versus ticagrelor plus aspirin for 12 months. The primary outcome was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 bleeding while the composite of all-cause death, myocardial infarction (MI), or stroke was the key secondary outcome. Among patients with NSTE-ACS (n = 4614), ticagrelor monotherapy reduced BARC 2, 3, or 5 bleeding by 53% [3.6% vs. 7.6%; hazard ratio (HR) 0.47; 95% confidence interval (CI) 0.36–0.61; P < 0.001) and in stable patients (n = 2503) by 24% (4.8% vs. 6.2%; HR 0.76; 95% CI 0.54–1.06; P = 0.11; nominal Pint = 0.03). Rates of all-cause death, MI, or stroke among those with (4.3% vs. 4.4%; HR 0.97; 95% CI 0.74–1.28; P = 0.84) and without (3.1% vs. 3.2%; HR 0.96; 95% CI 0.61–1.49; P = 0.85) NSTE-ACS were similar between treatment arms irrespective of clinical presentation (Pint = 0.96).Conclusion Among patients with or without NSTE-ACS who have completed an initial 3-month course of DAPT following PCI with DES, ticagrelor monotherapy reduced clinically meaningful bleeding events without increasing ischaemic risk as compared with ticagrelor plus aspirin. The benefits of ticagrelor monotherapy with respect to bleeding events were more pronounced in patients with NSTE-ACS.Trial registrationClinicaltrials.gov identifier: NCT02270242.
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Affiliation(s)
- Usman Baber
- Department of Cardiology, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - George Dangas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | | | - David Joel Cohen
- Department of Cardiology, University of Missouri-Kansas CIty, Kansas City, MO 64110, USA
| | - Samin Kumar Sharma
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Johny Nicolas
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Carlo Briguori
- Department of Cardiology, Clinica Mediterranea, 80122 Napoli NA, Italy
| | - Jin Yu Cha
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Timothy Collier
- Department of Cardiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | - Dariusz Dudek
- The 2nd Department of Cardiology Jagiellonian University Medical College, Swietej Anny 12, 31-008 Krakow, Poland
| | - Vladimir Džavik
- Department of Interventional Cardiology, Research and Innovation in Interventional Cardiology and Cardiac Intensive Care, Peter Munk Cardiac Centre, University Health Network, 200 Elizabeth St, Toronto, ON M5G 2CA, Canada
| | - Javier Escaned
- Department of Cardiology, Instituto de Investigacion Sanitaria del Hospital Clinico San Carlos and Complutense University, Calle del Prof Martin Lagos, s/n, 28040 Madrid, Spain
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 137 Woloska Str, 02-507 Warsaw, Poland
| | - Paul Gurbel
- Department of Cardiology, Sinai Hospital of Baltimore System, Baltimore, MD 21215, USA
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Clinic, Benekestrabe 2-8, 61231 Bad Nauheim, Germany
| | - Timothy Henry
- Department of Cardiology, The Carl and Edyth Lindner Center for Research and Education at the Christ Hospital, Cincinnati, OH 45219, USA
| | - Kurt Huber
- Department of Cardiology, Wilhelminenhospital, Montleartstrabe 37, 1160 Wien, Austria
| | - Adnan Kastrati
- Department of Cardiology, Deutsches Herzzentrum Munchen, Lazarettstrabe 36, 80636 Munchen, Germany
| | - Upendra Kaul
- Department of Cardiology, Batra Hospital and Medical Research Centre, New Delhi 110062, India
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Zeev Jabutinsky Rd 39, Petach Tikva 49100, Israel
| | - Mitchell Krucoff
- Department of Cardiology, Duke University Medical Center–Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Vijay Kunadian
- Department of Cardiology, Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Freeman Road, High Heaton, NE7 7DN Newcastle upon Tyne, UK
- Department of Cardiology, Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Road, High Heaton, NE7 7DN Newcastle upon Tyne, UK
| | - Steven Owen Marx
- Department of Cardiology, Columbia University Medical Center, New York, NY 10027, USA
| | - Shamir Mehta
- Department of Cardiology, Hamilton Health Sciences, Hamilton, ON L8N 3Z5, Canada
| | - David Moliterno
- Department of Cardiology, University of Kentucky, Lexington, KY 40506, USA
| | - Erik Magnus Ohman
- Department of Cardiology, Duke University Medical Center–Duke Clinical Research Institute, Durham, NC 27710, USA
| | - Keith Oldroyd
- Department of Cardiology, The West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Agamemnon St, Clydebank G81 4DY, UK
| | - Gennaro Sardella
- Department of Cardiology, Policlinico Umberto I University, 00161 Roma, Italy
| | - Samantha Sartori
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
| | - Richard Shlofmitz
- Department of Cardiology, St. Francis Hospital, Roslyn, 100 Port Washington Blvd, Roslyn, NY 11576, USA
| | - Philippe Gabriel Steg
- Department of Cardiology, Groupe Hospitalier Bichat–Claude-Bernard, 46 Rue Henri Huchard, 75018 Paris, France
| | - Giora Weisz
- Department of Cardiology, Montefiore Medical Center, The Bronx, NY 10467, USA
| | - Bernhard Witzenbichler
- Department of Cardiology, Helios Amper-Klinikum, Krankenhausstrabe 15, 85221 Dachau, Germany
| | - Ya-Ling Han
- Department of Cardiology, Shenyang North Hospital, Huanggu Qu, Shenyang Shi, Liaoning Sheng, China
| | - Stuart Pocock
- Department of Cardiology, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
| | | | - Roxana Mehran
- Department of Cardiology, The Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, One Gustave L. Levy Place, Box 1030, New York, NY 10029-6574, USA
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48
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Hong SJ, Ahn CM, Kim JS, Kim BK, Ko YG, Choi D, Jang Y, Hong MK. Effect of ticagrelor monotherapy on mortality after percutaneous coronary intervention: a systematic review and meta-analysis of randomized trials including 26 143 patients. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:48-55. [DOI: 10.1093/ehjcvp/pvaa119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/31/2020] [Accepted: 09/23/2020] [Indexed: 01/18/2023]
Abstract
Abstract
Aims
Optimal timing and strategy of antiplatelet monotherapy after dual-antiplatelet therapy (DAPT) consisting of aspirin and P2Y12 inhibitor for patients who underwent percutaneous coronary intervention (PCI) is still being debated. The aim of this study was to evaluate the effect of ticagrelor monotherapy after short-term DAPT after PCI on mortality.
Methods and results
A systematic review and meta-analysis was performed using PubMed to search for ticagrelor monotherapy after short-term DAPT comparing conventional DAPT in patients who underwent PCI. Three randomized trials encompassing 26 143 patients [ticagrelor monotherapy after 1–3 months of DAPT (n = 13 062) vs. conventional therapy (n = 13 081)] were included. The efficacy endpoint of all-cause mortality was significantly lower with the ticagrelor monotherapy group vs. the conventional therapy group [risk ratio (RR) = 0.80, 95% confidence interval (CI) 0.65–0.98; P = 0.03; I2 = 0%; number needed to treat for benefit (NNTB) = 320]. The safety endpoint of Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding was also significantly lower with the ticagrelor monotherapy group vs. the conventional therapy group (RR = 0.67, 95% CI 0.49–0.92; P = 0.01; I2 = 65%; NNTB = 156). There were no significant differences in ischaemic stroke, acute myocardial infarction, and stent thrombosis. The favourable effects of the ticagrelor monotherapy vs. the conventional therapy on all-cause mortality and BARC type 3 or 5 bleeding were consistent in the subset of patients presenting acute coronary syndromes (n = 15 157).
Conclusion
Ticagrelor monotherapy after short-term DAPT of 1–3 months was associated with decreased all-cause mortality and BARC type 3 or 5 bleeding not offset by increase of cardiac death, ischaemic stroke, acute myocardial infarction, and stent thrombosis.
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Affiliation(s)
- Sung-Jin Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Chul-Min Ahn
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Byeong-Keuk Kim
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Young-Guk Ko
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Donghoon Choi
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
| | - Myeong-Ki Hong
- Severance Cardiovascular Hospital, Yonsei University Health System, Yonsei-ro 50-1, Seodaemun-gu, 03722 Seoul, Korea
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49
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Parker WAE. Aspirin after PCI: in the twilight of its years? Platelets 2020; 31:831-833. [PMID: 32669035 DOI: 10.1080/09537104.2020.1793927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/06/2020] [Accepted: 07/06/2020] [Indexed: 12/14/2022]
Affiliation(s)
- William A E Parker
- Cardiovascular Research Unit, University of Sheffield , Sheffield, UK
- South Yorkshire Cardiothoracic Centre, Sheffield Teaching Hospitals NHS Foundation Trust , Sheffield, UK
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50
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Asad ZUA, Baber U. The Role of Aspirin After High-Risk Percutaneous Coronary Intervention: The Ticagrelor with Aspirin or Alone in High-Risk Patients After Coronary Intervention Clinical Trial Experience. Interv Cardiol Clin 2020; 9:489-498. [PMID: 32921373 DOI: 10.1016/j.iccl.2020.06.003] [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] [Indexed: 06/11/2023]
Abstract
Traditionally, aspirin has played a significant role in both primary and secondary prevention of cardiovascular disease. However, emerging antithrombotic regimens with better efficacy and safety have challenged the foundation of aspirin. Aspirin-free strategies consisting of P2Y12 inhibitor monotherapy following percutaneous coronary intervention (PCI) have now been tested in several large randomized controlled trials. In this article, we provide a contemporary overview of these data and suggest an algorithm to inform clinical decision with respect to antiplatelet pharmacotherapy after PCI.
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Affiliation(s)
- Zain Ul Abideen Asad
- Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Andrews Academic Tower, Suite 5400, 800 Stanton L. Young Boulevard, Oklahoma City, OK 73104, USA
| | - Usman Baber
- Cardiovascular Disease Section, Department of Medicine, University of Oklahoma Health Sciences Center, Andrews Academic Tower, Suite 5400, 800 Stanton L. Young Boulevard, Oklahoma City, OK 73104, USA.
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