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Yan K, Li J, Li Y, Zhu P, Tang X, Yuan D, Yang Y, Gao R, Yuan J, Zhao X. Inflammation modifies the platelet reactivity among thrombocytopenia patients undergoing percutaneous coronary intervention. Platelets 2024; 35:2327835. [PMID: 38655673 DOI: 10.1080/09537104.2024.2327835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/28/2024] [Indexed: 04/26/2024]
Abstract
Percutaneous coronary intervention (PCI) patients combined with thrombocytopenia (TP) are usually considered to be at low ischemic risk, receiving less proper antiplatelet therapy. However, recent studies reported a paradoxical phenomenon that PCI patients with TP were prone to experience thrombotic events, while the mechanisms and future treatment remain unclear. We aim to investigate whether inflammation modifies platelet reactivity among these patients. Consecutive 10 724 patients undergoing PCI in Fuwai Hospital were enrolled throughout 2013. High-sensitivity C-reactive protein (hsCRP) ≥2 mg/L was considered inflammatory status. TP was defined as platelet count <150×109/L. High on-treatment platelet reactivity (HTPR) was defined as adenosine diphosphate-induced platelet maximum amplitude of thromboelastogram >47mm. Among 6617 patients finally included, 879 (13.3%) presented with TP. Multivariate logistic regression demonstrated that patients with TP were associated with a lower risk of HTPR (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.53-0.76) than those without TP in the overall cohort. In further analysis, among hsCRP <2 mg/L group, patients with TP exhibited a decreased risk of HTPR (OR 0.53, 95% CI 0.41-0.68); however, in hsCRP ≥2mg/L group, TP patients had a similar risk of HTPR as those without TP (OR 0.83, 95% CI 0.63-1.08). Additionally, these results remain consistent across subgroups, including patients presenting with acute coronary syndrome and chronic coronary syndrome. Inflammation modified the platelet reactivity of PCI patients with TP, providing new insights into the mechanisms of the increased thrombotic risk. Future management for this special population should pay more attention to inflammation status and timely adjustment of antiplatelet therapy in TP patients with inflammation.
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Affiliation(s)
- Kailun Yan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawen Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yulong Li
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pei Zhu
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofang Tang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deshan Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Andò G, Lombardo L, Alagna G, Micari A, Francaviglia B, Cascone A, Capranzano P. Monotherapy with P2Y 12-inhibitors after dual antiplatelet therapy: Filling gaps in evidence. Int J Cardiol 2024; 401:131893. [PMID: 38382856 DOI: 10.1016/j.ijcard.2024.131893] [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: 01/29/2024] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Whether P2Y12 inhibitor monotherapy (P2Y12-I) is superior to aspirin following DAPT discontinuation post-PCI remains to be established. METHODS We updated our prior network meta-analysis where P2Y12-I and aspirin had been compared with DAPT or directly with each other. The focus is specifically on the available direct evidence, now consisting of the three head-to-head comparisons of P2Y12-I and aspirin in event-free PCI patients after DAPT. We include a Trial Sequential Analysis of the direct evidence based on meta-analytical literature. RESULTS The main finding reveals a 39% significantly lower risk of myocardial infarction with P2Y12-I (RR 0.61, 95% CI 0.47-0.78, p = 0.0001, I2 = 0%) with no difference in bleeding. Trial Sequential Analysis demonstrates clinically meaningful evidence for a reduction in the incidence of myocardial infarction with P2Y12-I that is also supported by statistical significance. CONCLUSIONS Accruing data highlight that P2Y12-I following DAPT discontinuation after PCI is associated with lower risk for MI and a similar risk for bleeding as compared with ASA. In light of potential limitations to the widespread adoption of life-long P2Y12-I treatment, clinicians should consider identifying selected patients who are expected to derive the highest benefit.
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Affiliation(s)
- Giuseppe Andò
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy.
| | - Luca Lombardo
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
| | - Giulia Alagna
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Antonino Micari
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Bruno Francaviglia
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
| | - Alessia Cascone
- Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Universitaria Policlinico "Gaetano Martino", Messina, Italy
| | - Piera Capranzano
- Division of Cardiology, University of Catania and Azienda Ospedaliera Universitaria Policlinico "Gaspare Rodolico", Catania, Italy
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Dangas G, Nicolas J, Harbich P, Huber K. Guideline recommendations for cangrelor should be upgraded: pros and cons. EUROINTERVENTION 2024; 20:e405-e407. [PMID: 38562067 PMCID: PMC10979382 DOI: 10.4244/eij-e-23-00070] [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: 04/04/2024]
Affiliation(s)
- George Dangas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Johny Nicolas
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Paul Harbich
- 3rd Department of Medicine, Cardiology and Intensive Care Unit, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Unit, Clinic Ottakring (former Wilhelminenhospital), Vienna, Austria
- Sigmund Freud University, Medical Faculty, Vienna, Austria
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Monaco F, Licheri M, Labanca R, Russetti F, Oriani A, Melissano G, Chiesa R, Barucco G. Association of Impedance Aggregometry-Measured Platelet Aggregation With Thromboembolic Events in Patients Who Undergo Carotid Endarterectomy: A Pilot Study. J Cardiothorac Vasc Anesth 2024; 38:771-779. [PMID: 38320918 DOI: 10.1053/j.jvca.2023.12.002] [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: 09/16/2023] [Revised: 11/29/2023] [Accepted: 12/01/2023] [Indexed: 02/08/2024]
Abstract
OBJECTIVES The aim of the current study was to assess the relationship among thrombin receptor activator peptide 6 (TRAP test), adenosine-5'-diphosphate (ADP test), arachidonic acid (ASPI test), and stroke/transient ischemic attack (TIA), using the multiple electrode aggregometry (Multiplate) in patients undergoing carotid thromboendarterectomy (CEA). DESIGN A retrospective study. SETTING Vascular surgery operating rooms of a university hospital. PARTICIPANTS One hundred thirty-one out of 474 patients undergoing CEA between November 2020 and October 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A preoperative blood sample of all enrolled patients was analyzed using the Multiplate analyzer. Receiver operating characteristics curves, were generated to test the ability of TRAP, ADP, and ASPI in discriminating perioperative thromboembolic stroke/TIA. A logistic LASSO regression model was used to identify factors independently associated with stroke/TIA. Eight patients experienced a perioperative stroke/TIA. Although all the platelet functional assays showed excellent predictive performance, an ADP value exceeding 72 U showed the highest specificity (87%) and sensitivity (68%) in discriminating patients who had a perioperative thromboembolic stroke/TIA, with a negative predictive value of 99% and a positive predictive value of 15%. After LASSO regression, an ADP >72 U and the need for a shunt during CEA were the only 2 variables independently associated with perioperative stroke/TIA. CONCLUSION Because the ADP test was independently associated with perioperative stroke/TIA, the assessment of platelet reactivity using Multiplate may offer potential utility in monitoring patients undergoing CEA.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Margherita Licheri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosa Labanca
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Russetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gaia Barucco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Gulyás Z, Horváth Z, Hajtman L, Kovács A, Kohut L, Kósa I, Tóth-Zsámboki E, Kiss RG. High platelet adrenergic activity and concomitant activation of the pituitary/medullar axis as alarming laboratory parameters in ACS survivors-the STRESS-AMI study. Front Cardiovasc Med 2024; 11:1338066. [PMID: 38450368 PMCID: PMC10914969 DOI: 10.3389/fcvm.2024.1338066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
Introduction Kinetics of stress-related biological parameters were determined in acute coronary syndrome (ACS) patients undergoing complex cardiovascular rehabilitation. Methods We determined platelet functionality in the absence/presence of a selective alpha-2 adrenergic receptor inhibitor, atipemazole parallel with salivary cortisol levels at enrolment, and at 3- and 12-months follow-up in 75 ACS patients with percutaneous coronary intervention. Results Pharmacological/non-pharmacological secondary prevention methods have been efficiently applied. Baseline aggregometry indicated platelet hyperactivity, decreasing gradually and being significantly reduced late, at 12 months (p < 0.05). Cortisol levels followed similar kinetics (p < 0.05). Baseline epinephrine-induced aggregations (EIA) significantly correlated with most of the other platelet agonists, even at subsequent time-points. Patients with upper-quartile EIA at enrolment (EIA-UQ) had significantly higher ADP- and collagen-induced aggregations at enrolment, at 3- and 12-months follow-up as well, indicating that high adrenergic response in the acute phase is accompanied by general platelet hyperactivity and predicts sustained platelet activation. In the EIA-UQ group higher cardiac biomarker release, elevated C-reactive protein and cortisol levels, and lower baseline left ventricular ejection fraction were detected.Atipemazole significantly reduced platelet aggregation induced by several platelet agonists, being most potent and comparable to full in vitro P2Y12 inhibition on collagen-induced aggregations (p < 0.05), indicating that catecholamines might serve as promt/long-term modulators of platelet function. Discussion Despite effective CCR programme and dual antiplatelet therapy, prolonged activation of sympathetic neuroendocrine system and general platelet hyperactivity can be detected up to one year in ACS patients with high adrenergic platelet activity. Moreover, initial high adrenergic activity is accompanied by clinical parameters associated to increased cardiovascular risk, therefore early identification of these patients might support complex optimal long-term therapy.
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Affiliation(s)
- Zalán Gulyás
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - Zsófia Horváth
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - László Hajtman
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - Andrea Kovács
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - László Kohut
- Cardiac Rehabilitation Institute, Central Hospital of Northern Pest—Military Hospital, Balatonfüred, Hungary
| | - István Kósa
- Cardiac Rehabilitation Institute, Central Hospital of Northern Pest—Military Hospital, Balatonfüred, Hungary
| | - Emese Tóth-Zsámboki
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
| | - Róbert Gábor Kiss
- Department of Cardiology, Central Hospital of Northern Pest—Military Hospital, Budapest, Hungary
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Lopez J, Mark J, Duarte GJ, Shaban M, Sosa F, Mishra R, Jain S, Tran A, Khizar A, Karpel D, Acosta G, Rodriguez-Guerra M. Role of genetic polymorphisms in clopidogrel response variability: a systematic review. Open Heart 2023; 10:e002436. [PMID: 37963685 PMCID: PMC10649851 DOI: 10.1136/openhrt-2023-002436] [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: 07/27/2023] [Accepted: 10/31/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Clopidogrel is a P2Y12 inhibitor that has become a mainstay treatment following percutaneous intervention with drug-eluting stent placement to decrease restenosis and its potential complications, including sudden cardiac death and ischaemic strokes in patients with significant vascular disease. AREAS COVERED As a prodrug, the metabolism and efficacy of clopidogrel are contingent on the presence of wild-type CYP450 (CYP2C19) alleles. Genetic polymorphisms and variants are well known to impair its ability to prevent major adverse cardiovascular events in these patients, with inadequate response rates as high as 30% in previous publications. Patterns of allelic frequencies are expected to exhibit similarities between individuals of the same ancestry, ethnic group or geographic region. Accordingly, we seek to further elucidate worldwide prevalence rates for genetic polymorphisms in the CYP2C19-dependent metabolism of clopidogrel and review the potential of personalised CYP2C19 genotyping in clinical practice to mitigate this high treatment resistance and its associated burden on patients. EXPERTS' COMMENTARY Our findings support the consideration of genotyping before initiation of therapy to guide adequate dosage or substitutions of other P2Y12 inhibitors to promote personalised, precision medicine and to prevent adverse events when these therapies may inevitably fail in patients with variants of the CYP450 (CYP2C19) system.
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Affiliation(s)
- Jose Lopez
- Division of Cardiovascular Disease, University of Miami Miller School of Medicine, Lantana, Florida, USA
| | - Justin Mark
- Department of Internal Medicine, University of Miami Miller School of Medicine, Fort Lauderdale, Florida, USA
| | - Gustavo J Duarte
- Division of Cardiology, Cleveland Clinic Florida, Weston, Florida, USA
| | - Mohammed Shaban
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Franklin Sosa
- Department of Internal Medicine, BronxCare Health System, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rishabh Mishra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Swati Jain
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - An Tran
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Asma Khizar
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel Karpel
- Department of Internal Medicine, HCA Florida Aventura Hospital and Medical Center, Aventura, Florida, USA
| | - Giancarlo Acosta
- Division of Cardiology, Georgia Heart Institute, Gainesville, Florida, USA
| | - Miguel Rodriguez-Guerra
- Department of Internal Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, New York, USA
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Zidar DA, Al-Kindi S, Longenecker CT, Parikh SA, Gillombardo CB, Funderburg NT, Juchnowski S, Huntington L, Jenkins T, Nmai C, Osnard M, Shishebhor M, Filby S, Tatsuoka C, Lederman MM, Blackstone E, Attizzani G, Simon DI. Platelet and Monocyte Activation After Transcatheter Aortic Valve Replacement (POTENT-TAVR): A Mechanistic Randomized Trial of Ticagrelor Versus Clopidogrel. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100182. [PMID: 37520136 PMCID: PMC10382989 DOI: 10.1016/j.shj.2023.100182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 02/22/2023] [Accepted: 03/01/2023] [Indexed: 08/01/2023]
Abstract
Background Inflammation and thrombosis are often linked mechanistically and are associated with adverse events after transcatheter aortic valve replacement (TAVR). High residual platelet reactivity (HRPR) is especially common when clopidogrel is used in this setting, but its relevance to immune activation is unknown. We sought to determine whether residual activity at the purinergic receptor P2Y12 (P2Y12) promotes prothrombotic immune activation in the setting of TAVR. Methods This was a randomized trial of 60 patients (enrolled July 2015 through December 2018) assigned to clopidogrel (300mg load, 75mg daily) or ticagrelor (180mg load, 90 mg twice daily) before and for 30 days following TAVR. Co-primary endpoints were P2Y12-dependent platelet activity (Platelet Reactivity Units; VerifyNow) and the proportion of inflammatory (cluster of differentiation [CD] 14+/CD16+) monocytes 1 day after TAVR. Results Compared to clopidogrel, those randomized to ticagrelor had greater platelet inhibition (median Platelet Reactivity Unit [interquartile range]: (234 [170.0-282.3] vs. 128.5 [86.5-156.5], p < 0.001), but similar inflammatory monocyte proportions (22.2% [18.0%-30.2%] vs. 25.1% [22.1%-31.0%], p = 0.201) 1 day after TAVR. Circulating monocyte-platelet aggregates, soluble CD14 levels, interleukin 6 and 8 levels, and D-dimers were also similar across treatment groups. HRPR was observed in 63% of the clopidogrel arm and was associated with higher inflammatory monocyte proportions. Major bleeding events, pacemaker placement, and mortality did not differ by treatment assignment. Conclusions Residual P2Y12 activity after TAVR is common in those treated with clopidogrel but ticagrelor does not significantly alter biomarkers of prothrombotic immune activation. HRPR appears to be an indicator (not a cause) of innate immune activation in this setting.
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Affiliation(s)
- David A. Zidar
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sadeer Al-Kindi
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Chris T. Longenecker
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sahil A. Parikh
- Division of Cardiology, Center for Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, New York, USA
| | - Carl B. Gillombardo
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nicholas T. Funderburg
- Division of Medical Laboratory Science, School of Health and Rehabilitations Sciences, Ohio State University, Columbus, Ohio, USA
| | - Steven Juchnowski
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Lauren Huntington
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Trevor Jenkins
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Christopher Nmai
- New York University Grossman School of Medicine, New York, New York, USA
| | - Michael Osnard
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Mehdi Shishebhor
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven Filby
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Curtis Tatsuoka
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael M. Lederman
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Eugene Blackstone
- Department of Population Health and Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Guilherme Attizzani
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Daniel I. Simon
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Zhao Z, Dong S, Sun T, Han K, Huang X, Ma M, Yang S, Zhou Y. The association between higher FFAs and high residual platelet reactivity among CAD patients receiving clopidogrel therapy. Front Cardiovasc Med 2023; 10:1115142. [PMID: 37304959 PMCID: PMC10250738 DOI: 10.3389/fcvm.2023.1115142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 05/15/2023] [Indexed: 06/13/2023] Open
Abstract
Background Metabolic abnormalities are associated with the occurrence, severity, and poor prognosis of coronary artery disease (CAD), some of which affect the antiplatelet efficacy of clopidogrel. Free fatty acids (FFAs) is a biomarker for metabolic abnormalities, and elevated FFAs is observed among CAD patients. Whether FFAs enhances residual platelet reactivity induced by adenosine diphosphate (ADP) while using clopidogrel was unknown. The purpose of our study is exploring the issue. Method Current study included 1,277 CAD patients using clopidogrel and used logistic regression to detect whether the higher level of FFAs is associated with high residual platelet reactivity (HRPR). We additionally performed subgroup and sensitivity analyses to evaluate the stability of the results. We defined HRPR as ADP-induced platelet inhibition rate (ADPi) < 50% plus ADP-induced maximum amplitude (MAADP) > 47 mm. Results 486 patients (38.1%) showed HRPR. The proportion of HRPR among patients with higher FFAs (>0.445 mmol/L) is greater than among patients with lower FFAs (46.4% vs. 32.6%, P < 0.001). Multivariate logistic regression demonstrated that higher FFAs (>0.445 mmol/L) is independently associated with HRPR (adjusted OR = 1.745, 95% CI, 1.352-2.254). After subgroup and sensitivity analyses, the results remained robust. Conclusion The higher level of FFAs enhances residual platelet reactivity induced by ADP and is independently associated with clopidogrel HRPR.
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Affiliation(s)
- Zehao Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Shutong Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Tienan Sun
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Xin Huang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Meishi Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Shiwei Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical Center for Coronary Heart Disease, Capital Medical University, Beijing, China
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Mariethoz C, Scala E, Matthey-Guirao E, Rossel JB, Gomez FJ, Grandoni F, Marcucci C, Alberio L. Identification of High Platelet Reactivity Despite ADP P2Y 12 Inhibitor Treatment: Two Populations in the Vasodilator-Stimulated Phosphoprotein Assay and Variable PFA-P2Y Shapes of Curve. TH OPEN 2023; 7:e143-e154. [PMID: 37292433 PMCID: PMC10247305 DOI: 10.1055/a-2075-7979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/03/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction Response to ADP P2Y 12 receptor inhibition by clopidogrel can be evaluated by various techniques. Here, we compared a functional rapid point-of-care technique (PFA-P2Y) with the degree of biochemical inhibition assessed by the VASP/P2Y 12 assay. Methods Platelet response to clopidogrel was investigated in 173 patients undergoing elective intracerebral stenting (derivation cohort n = 117; validation cohort n = 56). High platelet reactivity (HPR) was defined as PFA-P2Y occlusion time <106 seconds or VASP/P2Y 12 platelet reactivity index (PRI) >50%. Results In the derivation cohort, receiver operator characteristics analysis for the ability of PFA-P2Y to detect biochemical HPR showed high specificity (98.4%) but poor sensitivity (20.0%) and a very low area under the curve (0.59). The VASP/P2Y 12 assay revealed two coexisting platelet populations with different levels of vasodilator-stimulated phosphoprotein (VASP) phosphorylation: a fraction of highly phosphorylated, inhibited platelets and another of poorly phosphorylated, reactive platelets. Analysis of the PFA-P2Y curve shape revealed different types, categorized by time of occlusion (<106 seconds, 106 to 300 seconds, >300 seconds), and pattern (regular, irregular, and atypical). Noteworthy, curves with late occlusion and permeable curves with an irregular or atypical pattern correlated with VASP-PRI >50% and smaller sizes of the inhibited platelet subpopulation. Considering the PFA-P2Y shape of the curve for the detection of HPR improved sensitivity (72.7%) and preserved specificity (91.9%), with a rather high AUC (0.823). The validation cohort confirmed the VASP/P2Y 12 assay data and the usefulness of considering the PFA-P2Y curve shape. Conclusion In patients treated with acetylsalicylic acid and clopidogrel for 7-10 days, the VASP/P2Y 12 assay reveals two coexisting subpopulations of differentially inhibited platelets, whose relative sizes predict global PRI and distinct PFA-P2Y curve patterns, indicating incomplete clopidogrel efficacy. The detailed analysis of both VASP/P2Y 12 and PFA-P2Y is necessary for optimal detection of HPR.
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Affiliation(s)
- Cyril Mariethoz
- Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
| | - Emmanuelle Scala
- Dept. of Anaesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Matthey-Guirao
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Jean-Benoît Rossel
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Francisco Javier Gomez
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Francesco Grandoni
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Carlo Marcucci
- Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
- Dept. of Anaesthesiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Lorenzo Alberio
- Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
- Division of Haematology and Central Haematology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Yi MM, Do HP, Li YC, Wang R, Zhuang Z, Xu MM, Liu T, Shao TF, Ding LP, Ge WH. Ticagrelor versus Clopidogrel in the Dual Antiplatelet Regimen for Unruptured Intracranial Aneurysm Treated with Stent-Assisted Coil Embolization: A Single-Center Cohort Study. World Neurosurg 2023; 170:e755-e765. [PMID: 36442786 DOI: 10.1016/j.wneu.2022.11.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) of aspirin plus clopidogrel is commonly used in patients with unruptured intracranial aneurysms treated with stent-assisted coil (SAC) embolization. However, the unpredictable clopidogrel efficacy of the 5%-55% nonresponders limits its use. Ticagrelor, as a potential alternative of clopidogrel, is an antiplatelet agent with low resistance rates but uncertain efficacy and safety in these patients. METHODS A single-center cohort study was performed to compare the efficacy and safety of ticagrelor with clopidogrel in the DAPT regimen in patients with unruptured intracranial aneurysms and treated with SAC. The patients with clopidogrel resistance identified as inadequate adenosine diphosphate inhibition rate determined by thromboelastography were treated with ticagrelor instead, and both drugs achieved adequate suppression of platelet aggregation when stents were implanted. The occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) and bleeding events was recorded through 6 months follow-up. RESULTS Data from 86 patients with 99 unruptured intracranial aneurysms and treated by SAC with clopidogrel were compared with those from 108 patients with 111 aneurysms and treated with ticagrelor. Neither the baseline characteristics nor the incidence of the MACCE or bleeding events differed between the groups. Ticagrelor exerted significantly higher adenosine diphosphate inhibition rate than that of the clopidogrel. Multivariable logistic regression analysis showed that the incidence of MACCE was related to hematocrit and fibrinogen levels. CONCLUSIONS Ticagrelor seemed to be as effective and safe as clopidogrel for SAC in unruptured intracranial aneurysms. Hematocrit and fibrinogen levels were independent risk factors for the incidence of MACCE.
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Affiliation(s)
- Man-Man Yi
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Nanjing Clinical Pharmacy Center, Nanjing, China
| | - Hong Phuoc Do
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Nanjing Clinical Pharmacy Center, Nanjing, China
| | - Yi-Chen Li
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Department of Pharmacy, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China; Nanjing Clinical Pharmacy Center, Nanjing, China
| | - Rong Wang
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China
| | - Zong Zhuang
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China
| | - Man-Man Xu
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China
| | - Tao Liu
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; Department of Neurosurgery, the Drum Tower Hospital Affiliated to the Medical School of Nanjing University, Nanjing, China
| | - Teng-Fei Shao
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Nanjing Clinical Pharmacy Center, Nanjing, China
| | - Lan-Ping Ding
- Nanjing Clinical Pharmacy Center, Nanjing, China; Department of Pharmacy, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei-Hong Ge
- Nanjing Drum Tower Hospital, China Pharmaceutical University, Nanjing, China; School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China; Nanjing Clinical Pharmacy Center, Nanjing, China.
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11
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Majumdar M, Hall RP, Feldman Z, Goudot G, Sumetsky N, Jessula S, Kirshkaln A, Bellomo T, Chang D, Cardenas J, Patell R, Eagleton M, Dua A. Predicting Arterial Thrombotic Events Following Peripheral Revascularization Using Objective Viscoelastic Data. J Am Heart Assoc 2023; 12:e027790. [PMID: 36565191 PMCID: PMC9973575 DOI: 10.1161/jaha.122.027790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Peripheral artery disease is endemic in our globally aging population, with >200 million affected worldwide. Graft/stent thrombosis after revascularization is common and frequently results in amputation, major adverse cardiovascular events, and cardiovascular mortality. Optimizing medications to decrease thrombosis is of paramount importance; however, limited guidance exists on how to use and monitor antithrombotic therapy in this heterogeneous population. Thromboelastography with platelet mapping (TEG-PM) provides comprehensive coagulation metrics and may be integral to the next stage of patient-centered thrombophrophylaxis. This prospective study aimed to determine if TEG-PM could predict subacute graft/stent thrombosis following lower extremity revascularization, and if objective cut point values could be established to identify those high-risk patients. Methods and Results We conducted a single-center prospective observational study of patients undergoing lower extremity revascularization. Patients were followed up for the composite end point postoperative graft/stent thrombosis at 1 year. TEG-PM analysis of the time point before thrombosis in the event group was compared with the last postoperative visit in the nonevent group. Cox proportional hazards analysis examined the association of TEG-PM metrics to thrombosis. Cut point analysis explored the predictive capacity of TEG-PM metrics for those at high risk. A total of 162 patients were analyzed, of whom 30 (18.5%) experienced graft/stent thrombosis. Patients with thrombosis had significantly greater platelet aggregation (79.7±15.7 versus 58.5±26.4) and lower platelet inhibition (20.7±15.6% versus 41.1±26.6%) (all P<0.01). Cox proportional hazards analysis revealed that for every 1% increase in platelet aggregation, the hazard of experiencing an event during the study period increased by 5% (hazard ratio, 1.05 [95% CI, 1.02-1.07]; P<0.01). An optimal cut point of >70.8% platelet aggregation and/or <29.2% platelet inhibition identifies those at high risk of thrombosis with 87% sensitivity and 70% to 71% specificity. Conclusions Among patients undergoing lower extremity revascularization, increased platelet reactivity was predictive of subacute postoperative graft/stent thrombosis. On the basis of the cut points of >70.8% platelet aggregation and <29.2% platelet inhibition, consideration of an alternative or augmented antithrombotic regimen for high-risk patients may decrease the risk of postoperative thrombotic events.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Ryan P. Hall
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Zachary Feldman
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Guillaume Goudot
- Cardiovascular Research Center, Division of CardiologyMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Natalie Sumetsky
- Department of Epidemiology and StatisticsUniversity of PittsburgPA
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Tiffany Bellomo
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - David Chang
- Healthcare Research and Policy Development, Codman Center, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Jessica Cardenas
- Center for Translational Injury ResearchUniversity of Texas–HoustonHoustonTX
| | - Rushad Patell
- Division of Hematology/OncologyBeth Israel Deaconess Medical Center/Harvard Medical SchoolBostonMA
| | - Matthew Eagleton
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of SurgeryMassachusetts General Hospital/Harvard Medical SchoolBostonMA
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12
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Majumdar M, Waller D, Poyant J, McElroy I, Lella S, Feldman ZM, Levine E, Kim Y, Nuzzolo K, Kirshkaln A, DeCarlo C, Dua A. Variability of antiplatelet response in patients with peripheral artery disease. J Vasc Surg 2023; 77:208-215.e3. [PMID: 36028157 DOI: 10.1016/j.jvs.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Antiplatelet therapy has been a pillar of management for peripheral artery disease (PAD). However, a significant subset of patients with PAD will be resistant to certain antiplatelet medications and, therefore, have an increased risk of graft and/or stent thrombosis unknown to the surgeon. At present, no point-of-care testing to identity which patients will experience benefit from these medications has been incorporated into the treatment guidelines. Thromboelastography with platelet mapping affords an opportunity to evaluate real-time coagulation dynamics and platelet function. In the present prospective, observational study, we aimed to delineate the variation in response to antiplatelet therapy in patients with PAD undergoing revascularization. METHODS All patients who were undergoing named vessel revascularization during December 2020 through April 2022 were prospectively enrolled. Platelet mapping assays were performed in three clinical phases: preoperative, postoperative inpatient, and postoperative outpatient. The distribution of platelet reactivity within patients receiving mono- vs dual antiplatelet therapy was assessed, and a between-group inferential analysis was performed. The effect of comorbidities and intervention subtype on platelet inhibition was also analyzed. RESULTS A total of 521 platelet mapping samples from 143 individual patients were analyzed using thromboelastography with platelet mapping. We found wide variability in the distribution of platelet inhibition, with a range of 0 to 100 and an interquartile range of 37.6. Although platelet inhibition with clopidogrel 75 mg was higher on average (44.8 ± 30.2) than that with aspirin 81 mg (24.6 ± 23.7) or aspirin 325 mg (27.1 ± 26.4; P = .001), clopidogrel at 75 mg demonstrated the highest variability in response. CONCLUSIONS These data have demonstrated significant variability in the response to both mono- and dual antiplatelet therapy in PAD patients undergoing lower extremity revascularization. Future research on the effect of this variability in response on the clinical outcomes could provide invaluable understanding of the perioperative thrombotic risk.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Davis Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Emma Levine
- Larner College of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
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13
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Urban L, Ingrid Š, Žolková J, Ján S, Bolek T, Samoš M. High On-Treatment Platelet Reactivity in Patients Undergoing Complex Percutaneous Coronary Interventions. Clin Appl Thromb Hemost 2023; 29:10760296231199089. [PMID: 37697705 PMCID: PMC10498693 DOI: 10.1177/10760296231199089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/03/2023] [Accepted: 08/18/2023] [Indexed: 09/13/2023] Open
Abstract
Patient response to P2Y12 inhibitor therapy is heterogeneous, and those with high on-treatment platelet reactivity (HTPR) are at an increased risk of thrombotic complications. The aim of our study was to determine whether selecting a high-risk patient group of individuals after complex percutaneous coronary intervention (PCI) would show the clinical benefit of HTPR testing for preventing thrombotic complications. Blood samples of patients after complex PCI were acquired 1 day and 1 month after the intervention. The samples were tested using vasodilator-stimulated phosphoprotein phosphorylation (VASP-P) and platelet function assay (PFA). The occurrence of clinically significant stent thrombosis with repeated revascularization of the target vessel was observed over a 1-year period. One day after PCI, 37% of patients had HTPR as established by VASP-P. One month after PCI, the percentage of patients with HTPR decreased to 30.9%. According to PFA, 1 day after PCI, 33.3% of patients had HTPR. This percentage declined to 19.8% after 1 month. All measurements identified a significantly higher proportion of HTPR in patients on clopidogrel compared to ticagrelor and prasugrel. Two cases of early stent thrombosis and 1 case of late stent thrombosis were identified. Further study of adenosine diphosphate receptor blocker on-treatment response in patients undergoing complex PCI is necessary.
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Affiliation(s)
- Lukáš Urban
- Department of Internal Medicine I., Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
- Department of Cardiology, University Hospital Martin, Martin, Slovakia
| | - Škorňová Ingrid
- Department of Hematology and Transfusiology, Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
| | - Jana Žolková
- Department of Hematology and Transfusiology, Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
| | - Staško Ján
- Department of Hematology and Transfusiology, Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
| | - Tomáš Bolek
- Department of Internal Medicine I., Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
| | - Matej Samoš
- Department of Internal Medicine I., Jessenius Faculty of Medicine, Comenius University, University Hospital Martin, Martin, Slovakia
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14
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Pontis A, Delavenne X, Verdier MC, Hodin S, Andriamaharo A, Gueret P, Nedelec-Gac F, Bachelot-Loza C, Gaussem P, Gouin-Thibault I. Impact of age on in vitro metabolism of clopidogrel: a potential explanation for high on-treatment platelet reactivity in the elderly? Res Pract Thromb Haemost 2023; 7:100014. [PMID: 36891520 PMCID: PMC9986101 DOI: 10.1016/j.rpth.2022.100014] [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: 05/25/2022] [Accepted: 11/07/2022] [Indexed: 01/08/2023] Open
Abstract
Background High on-treatment platelet reactivity has been reported in 30% of patients on clopidogrel and 50% in elderly patients; however, little is known about the mechanisms of this biological resistance. One hypothesis is an age-related impaired hepatic metabolism of the prodrug clopidogrel, leading to a lower formation of its active metabolite (clopidogrel-AM). Objectives To compare the levels of clopidogrel-AM formed in vitro using "old" and "young" human liver microsomes (HLMs) and their consequences on platelet functions. Methods We developed an in vitro model using "old" (73.6 ± 2.3 years) and "young" (51.2 ± 8.5 years) HLMs, added to platelet-rich plasma from 21 healthy donors with or without clopidogrel (50 μM) and incubated at 37 °C for 30 (T30) and 45 minutes (T45). Clopidogrel-AM was quantified by liquid chromatography-mass spectrometry/mass spectrometry method. Platelet aggregation was performed by light transmission aggregometry. Results The generation of clopidogrel-AM increased over time and reached concentrations comparable with those reported in treated patients. At T30, mean clopidogrel-AM concentrations were significantly higher with "young" (8.56 μg/L; 95% CI, 5.87-11.24) than with "old" HLMs (7.64 μg/L; 95% CI, 5.14-10.14; P = .002); and at T45, 11.40 μg/L; 95% CI (7.57-15.22) vs 10.63 μg/L, 95% CI (7.10-14.15), P = .02 (n = 21). Despite a significant inhibition of platelet aggregation, no significant difference was found in light transmission aggregometry (adenosine diphosphate, 10 μM) after clopidogrel metabolism by "old" or "young" HLMs, probably because of low sensitivity of the method to small variations of clopidogrel-AM. Conclusion In this original model combining metabolic and functional approaches, less clopidogrel-AM was produced with HLMs from older patients. This provides support for a decreased CYP450 activity that may contribute to high on-treatment platelet reactivity in elderly patients.
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Affiliation(s)
- Adeline Pontis
- Laboratoire d'Hématologie, Pontchaillou University Hospital, Rennes, France
- INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S 1085, University of Rennes, Rennes, France
| | - Xavier Delavenne
- Laboratoire de Pharmacologie Toxicologie, Saint-Etienne University Hospital, Saint-Etienne, France
- INSERM, UMR_S1059, Université de Lyon, Saint-Etienne, France
| | - Marie-Clémence Verdier
- INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S 1085, University of Rennes, Rennes, France
- Laboratoire de Pharmacologie Clinique, Pontchaillou University Hospital, Rennes, France
| | - Sophie Hodin
- Laboratoire de Pharmacologie Toxicologie, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Annie Andriamaharo
- Laboratoire de Pharmacologie Clinique, Pontchaillou University Hospital, Rennes, France
| | - Pierre Gueret
- Laboratoire d'Hématologie, Pontchaillou University Hospital, Rennes, France
| | | | | | - Pascale Gaussem
- Université de Paris Cité, Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- Service d'Hématologie Biologique, AP-HP, Université de Paris, Hôpital Européen Georges Pompidou, Paris, France
| | - Isabelle Gouin-Thibault
- Laboratoire d'Hématologie, Pontchaillou University Hospital, Rennes, France
- INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S 1085, University of Rennes, Rennes, France
- Correspondence Isabelle Gouin-Thibault, Laboratoire d'Hématologie, Pontchaillou University Hospital, INSERM, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR_S 1085, University of Rennes, 35000, Rennes, France.
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15
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Aluvilu A, Ferro A. Role of platelet function testing in acute coronary syndromes: a meta-analysis. Open Heart 2022; 9:openhrt-2022-002129. [PMID: 36581378 PMCID: PMC9806016 DOI: 10.1136/openhrt-2022-002129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/13/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE This meta-analysis aimed to evaluate whether using platelet function testing (PFT) in acute coronary syndromes (ACS) to personalise antiplatelet therapy including a P2Y12 antagonist offers any clinical benefits to indicate incorporation into routine practice. METHODS A search was conducted on five databases for randomised controlled trials (RCTs) conducted between 1 January 2000 and 17 July 2022, which included an ADP-specific platelet function assays and P2Y12 antagonists as part of dual antiplatelet therapy (DAPT) and have reported the efficacy and/or safety outcomes. The reported event frequencies were used to calculate the risk ratios (RRs) with a 95% CI. The χ2 heterogeneity statistical test and sensitivity analysis were used for heterogeneity assessment. RESULTS Five RCTs with 7691 patients were included in the analysis. No significant risk reduction was seen in major adverse cardiovascular events (RR=0.95, p=0.42), individual cardiac events (cardiovascular death: RR=0.76, p=0.26; myocardial infarction: RR=0.96, p=0.74; stent thrombosis: RR=0.92, p=0.83; stroke: RR=0.91, p=0.72; target vessel revascularisation: RR=1.06, p=0.47) and overall clinical outcome (RR=0.90, p=0.22). There was also no difference in the rate of bleeding between PFT-guided and standard therapies (major bleeding: RR=0.97, p=0.78, minor bleeding: RR=0.89, p=0.19 and any bleeding: RR=1.04, p=0.33). CONCLUSION Compared with standard DAPT with P2Y12 antagonists, using PFT to adjust antiplatelet therapy does not improve clinical outcomes. Therefore, the positions of key guidelines on routine testing in ACS should remain unchanged. In addition, the study highlights the need for well-designed and powered RCTs and standardised testing methodologies to provide reliable findings and definitive conclusions.
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Affiliation(s)
- Anastasia Aluvilu
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King’s College London, London, UK
| | - Albert Ferro
- School of Cardiovascular and Metabolic Medicine and Sciences, British Heart Foundation Centre of Research Excellence, King’s College London, London, UK
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16
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Zhao Z, Ma M, Huang X, Sun T, Han K, Yang S, Zhou Y. Elevated serum C1q is an independent predictor of high residual platelet reactivity in CAD patients receiving clopidogrel therapy. Front Immunol 2022; 13:969984. [PMID: 36248871 PMCID: PMC9561631 DOI: 10.3389/fimmu.2022.969984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/15/2022] [Indexed: 12/03/2022] Open
Abstract
Background Inflammation increases the risk of thrombosis in coronary artery disease (CAD) patients and affects the antiplatelet efficacy of clopidogrel. C1q interacts with platelets to activate platelets and induce thrombosis by participating in and regulating the inflammatory response. Whether C1q affects adenosine diphosphate (ADP)-induced platelet reactivity during clopidogrel therapy was unclear and our study aimed to explore the issue. Method We enrolled 1,334 CAD patients receiving clopidogrel therapy and evaluated the association between C1q level and high residual platelet reactivity (HRPR) using logistic regression and restricted cubic spline (RCS). HRPR was defined as ADP-induced maximum amplitude (MAADP) > 47 mm plus ADP-induced platelet aggregation (ADPi) < 50%. Results A total of 516 patients (38.7%) performed HRPR. The frequency of HRPR increases with the increase in C1q level (26.3%, 38.4%, 43.2%, and 46.7% for the 1st to 4th quartile of C1q). The result of multivariate logistic regression demonstrated elevated C1q as an independent predictor for HRPR (2nd quartile: OR = 1.722, 95% CI 1.215–2.440; 3rd quartile: OR = 2.015, 95% CI 1.413–2.874; 4th quartile: OR = 2.362, 95% CI 1.631–3.421, compared to the 1st quartile). RCS depicted the nonlinear relationship between C1q and HRPR risk (p for non-linear < 0.05). Conclusion The current research is the first to explore the association of C1q and ADP-induced platelet reactivity and to demonstrate elevated C1q as an independent risk factor for HRPR in CAD patients during clopidogrel therapy.
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Affiliation(s)
- Zehao Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
| | - Meishi Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
| | - Xin Huang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
| | - Tienan Sun
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
| | - Kangning Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
| | - Shiwei Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
- *Correspondence: Shiwei Yang, ; Yujie Zhou,
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Disease, Beijing, China
- Beijing Key Laboratory of Precision Medicine of Coronary Atherosclerotic Disease, Clinical center for coronary heart disease, Capital Medical University, Beijing, China
- *Correspondence: Shiwei Yang, ; Yujie Zhou,
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17
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Gelbenegger G, Grafeneder J, Gager GM, Siller-Matula JM, Schwameis M, Jilma B, Schoergenhofer C. Advanced pharmacodynamics of cangrelor in healthy volunteers: a dose-finding, open-label, pilot trial. Thromb J 2022; 20:19. [PMID: 35422039 PMCID: PMC9008922 DOI: 10.1186/s12959-022-00377-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 03/23/2022] [Indexed: 12/24/2022] Open
Abstract
Background High on-treatment platelet reactivity (HTPR) remains a major problem in the acute management of ST-elevation myocardial infarction (STEMI), leading to higher rates of stent thrombosis and mortality. We aimed to investigate a novel, prehospital treatment strategy using cangrelor and tested its pharmacodynamic effects in a model using healthy volunteers. Methods We conducted a dose-finding, open-label, pilot trial including 12 healthy volunteers and tested three ascending bolus infusions of cangrelor (5 mg, 10 mg and 20 mg) and a bolus infusion followed by a continuous infusion via an intravenous (IV) flow regulator. Platelet function was assessed using multiple electrode aggregometry (MEA), vasodilator-stimulated phosphoprotein phosphorylation assay (VASP-P) and the platelet function analyzer. In an ex vivo experiment, epinephrine was used to counteract the antiplatelet effect of cangrelor. Results All cangrelor bolus infusions resulted in immediate and pronounced platelet inhibition. Bolus infusions of cangrelor 20 mg resulted in sufficient platelet inhibition assessed by MEA for 20 min in 90% of subjects. Infusion of cangrelor via the IV flow regulator resulted in sufficient platelet inhibition throughout the course of administration. Ex vivo epinephrine, in concentrations of 200 and 500 ng/mL was able to partially reverse the antiplatelet effect of cangrelor in a dose-dependent manner. Conclusions Weight-adapted bolus infusions followed by a continuous infusion of cangrelor via IV flow regulator result in immediate and pronounced platelet inhibition in healthy subjects. Cangrelor given as weight-adapted bolus infusion followed by a continuous infusion using an IV flow regulator may be a viable treatment approach for effective and well controllable prehospital platelet inhibition. Trial registration EC (Medical University of Vienna) 1835/2019 and EudraCT 2019-002792-34. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00377-z.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Juergen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Gloria M Gager
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.,Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Schoergenhofer
- Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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18
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Rovati G, Contursi A, Bruno A, Tacconelli S, Ballerini P, Patrignani P. Antiplatelet Agents Affecting GPCR Signaling Implicated in Tumor Metastasis. Cells 2022; 11:725. [PMID: 35203374 PMCID: PMC8870128 DOI: 10.3390/cells11040725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Metastasis requires that cancer cells survive in the circulation, colonize distant organs, and grow. Despite platelets being central contributors to hemostasis, leukocyte trafficking during inflammation, and vessel stability maintenance, there is significant evidence to support their essential role in supporting metastasis through different mechanisms. In addition to their direct interaction with cancer cells, thus forming heteroaggregates such as leukocytes, platelets release molecules that are necessary to promote a disseminating phenotype in cancer cells via the induction of an epithelial-mesenchymal-like transition. Therefore, agents that affect platelet activation can potentially restrain these prometastatic mechanisms. Although the primary adhesion of platelets to cancer cells is mainly independent of G protein-mediated signaling, soluble mediators released from platelets, such as ADP, thromboxane (TX) A2, and prostaglandin (PG) E2, act through G protein-coupled receptors (GPCRs) to cause the activation of more additional platelets and drive metastatic signaling pathways in cancer cells. In this review, we examine the contribution of the GPCRs of platelets and cancer cells in the development of cancer metastasis. Finally, the possible use of agents affecting GPCR signaling pathways as antimetastatic agents is discussed.
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Affiliation(s)
- Gianenrico Rovati
- Department of Pharmaceutical Sciences, University of Milan, 20122 Milan, Italy;
| | - Annalisa Contursi
- Laboratory of Systems Pharmacology and Translational Therapies, Center for Advanced Studies and Technology (CAST), School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy; (A.C.); (A.B.); (S.T.); (P.B.)
- Department of Neuroscience, Imaging and Clinical Science, School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Annalisa Bruno
- Laboratory of Systems Pharmacology and Translational Therapies, Center for Advanced Studies and Technology (CAST), School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy; (A.C.); (A.B.); (S.T.); (P.B.)
- Department of Neuroscience, Imaging and Clinical Science, School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Stefania Tacconelli
- Laboratory of Systems Pharmacology and Translational Therapies, Center for Advanced Studies and Technology (CAST), School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy; (A.C.); (A.B.); (S.T.); (P.B.)
- Department of Neuroscience, Imaging and Clinical Science, School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Patrizia Ballerini
- Laboratory of Systems Pharmacology and Translational Therapies, Center for Advanced Studies and Technology (CAST), School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy; (A.C.); (A.B.); (S.T.); (P.B.)
- Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Paola Patrignani
- Laboratory of Systems Pharmacology and Translational Therapies, Center for Advanced Studies and Technology (CAST), School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy; (A.C.); (A.B.); (S.T.); (P.B.)
- Department of Neuroscience, Imaging and Clinical Science, School of Medicine, “G. d’Annunzio” University, 66100 Chieti, Italy
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19
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Effect of ionic liquids and deep eutectic solvents on the enantiomeric separation of clopidogrel by cyclodextrin-electrokinetic chromatography. Quantitative analysis in pharmaceutical formulations using tetrabutylammonium l-aspartic acid combined with carboxymethyl-γ-cyclodextrin. Microchem J 2021. [DOI: 10.1016/j.microc.2021.106815] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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20
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Verdoia M, Rolla R, Pergolini P, Gioscia R, Nardin M, Negro F, Viglione F, Suryapranata H, Kedhi E, De Luca G. Low hemoglobin predicts high-platelet reactivity and major cardiovascular ischemic events at long-term follow-up among ACS patients receiving dual antiplatelet therapy with ticagrelor. Catheter Cardiovasc Interv 2021; 98:1309-1316. [PMID: 33527669 DOI: 10.1002/ccd.29512] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/15/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Reduced levels of hemoglobin (Hb) represent an established marker of impaired outcomes and increased cardiovascular risk in patients with coronary artery disease, challenging the management of dual antiplatelet therapy (DAPT). However, while anemia has emerged as an independent predictor of suboptimal platelet inhibition in patients receiving clopidogrel, no study has so far evaluated the impact of Hb levels on high-on treatment platelet reactivity (HRPR) with ticagrelor and their prognostic consequences, that were the aim of the present study. METHODS Patients on DAPT with ASA + Ticagrelor (90 mg/twice a day) after percutaneous coronary revascularization for ACS were scheduled for platelet function assessment 30-90 days post-discharge. Aggregation tests were performed by multiple electrode aggregometry. Suboptimal platelet inhibition (HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). The primary study endpoint was defined as the occurrence of major cardiovascular events (a composite of cardiovascular death, recurrent acute coronary syndrome [MI], target vessel revascularization) at longest available follow-up. RESULTS We included 397 patients that were divided according to tertiles values of Hb (< 12.7, 12-7-14.09, ≥14.1 g/dl). Patients with lower Hb were older and displayed a more severe cardiovascular risk profile. Mean levels of platelet reactivity were enhanced in patients with lower Hb after stimulation with TRAP peptide (TRAP test, p = .03) and ADP (p = .02). Elevated platelet reactivity (HRPR) on Ticagrelor was more frequent among patients with reduced Hb (16.4% vs. 12% vs. 5.4%, p = .005, adjusted OR [95%CI] = 1.71[0.996;3.01], p = .056). At a mean follow-up of 820.9 ± 553.4 days, 21.4% of the patients experienced the primary composite endpoint, with a higher rate of events in patients with lower Hb (27.6% vs. 22.6% vs. 13.5%, p = .006, adjusted HR [95%CI] = 1.51[1.12; 2.03], p = .006), mainly driven by a higher rate of recurrent ACS. After correction for baseline differences lower Hb tertiles but not HRPR emerged as independent predictor of MACE (adjusted HR [95%CI] = 0.98[0.50; 1.92], p = .95). CONCLUSIONS In the present study, we demonstrated that among patients on DAPT with ASA and ticagrelor after PCI for ACS, lower Hb levels are independently associated with a higher rate of HRPR and an increased rate of major ischemic events, and especially for recurrent ACS, although with no impact on survival. Neutral prognostic effect of HRPR was observed across Hb tertiles.
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Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, Biella, Italy.,Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Roberta Rolla
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Patrizia Pergolini
- Clinical Chemistry, Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Rocco Gioscia
- Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | - Matteo Nardin
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Federica Negro
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy
| | - Filippo Viglione
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy.,Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
| | | | - Elvin Kedhi
- Department of Cardiology, ISALA Hospital, Zwolle, The Netherlands
| | - Giuseppe De Luca
- Department of Translational Medicine, Eastern Piedmont University, Novara, Italy.,Azienda Ospedaliera-Universitaria "Maggiore della Carità", Eastern Piedmont University, Novara, Italy
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21
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Li J, Yuan D, Jiang L, Tang X, Xu J, Song Y, Chen J, Qiao S, Yang Y, Gao R, Xu B, Yuan J, Zhao X. Similar Inflammatory Biomarkers Reflect Different Platelet Reactivity in Percutaneous Coronary Intervention Patients Treated With Clopidogrel: A Large-Sample Study From China. Front Cardiovasc Med 2021; 8:736466. [PMID: 34671655 PMCID: PMC8521006 DOI: 10.3389/fcvm.2021.736466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Platelet reactivity is closely associated with adverse events in percutaneous coronary intervention (PCI) patients. Inflammation plays a crucial role in the development of coronary heart disease (CHD). Aim: To investigate the association of inflammatory biomarkers such as leukocyte count and high-sensitivity C reactive proteins (hs-CRP) with platelet reactivity in PCI patients treated with clopidogrel. Method: We examined 10,724 consecutive PCI patients in Fuwai hospital from January 2013 to December 2013. High on-treatment platelet reactivity (HTPR) was defined as adenosine diphosphate (ADP)-induced platelet maximum amplitude [MA(ADP)] of thromboelastogram (TEG) > 47 mm, and low on-treatment platelet reactivity (LTPR) MA(ADP) < 31 mm. Results: Finally, 6,772 PCI patients treated with clopidogrel who had the results of postoperative TEG were enrolled. Among them, 2,070 (30.57%) presented HTPR and 2,568 (37.92%) presented LTPR. As for LTPR, multivariate logistic regression showed that leukocyte count (OR: 1.153, 95% CI 1.117–1.191) and hs-CRP (OR: 0.920, 95% CI 0.905–0.936) were independent predictors, along with diabetes mellites, hemoglobin, platelet count and glucose. As for HTPR, multivariate logistic regression showed that leukocyte count (OR: 0.885, 95% CI 0.854–0.917) and hs-CRP (OR: 1.094, 95% CI 1.077–1.112) were independent predictors, along with sex, hemoglobin, platelet count and glucose. Conclusions: This was the first large real-world study reporting that both leukocyte count and hs-CRP were the independent factors for platelet reactivity in PCI populations treated with clopidogrel, among which higher leukocyte count was associated with more LTPR while higher hs-CRP was associated with more HTPR, providing new insights on individualized antiplatelet therapy.
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Affiliation(s)
- Jiawen Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Deshan Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin Jiang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaofang Tang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingjing Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jue Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shubin Qiao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuejin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Runlin Gao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Xu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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22
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Schilling U, Dingemanse J, Ufer M. Pharmacokinetics and Pharmacodynamics of Approved and Investigational P2Y12 Receptor Antagonists. Clin Pharmacokinet 2021; 59:545-566. [PMID: 32056160 DOI: 10.1007/s40262-020-00864-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Coronary artery disease remains the major cause of mortality worldwide. Antiplatelet drugs such as acetylsalicylic acid and P2Y12 receptor antagonists are cornerstone treatments for the prevention of thrombotic events in patients with coronary artery disease. Clopidogrel has long been the gold standard but has major pharmacological limitations such as a slow onset and long duration of effect, as well as weak platelet inhibition with high inter-individual pharmacokinetic and pharmacodynamic variability. There has been a strong need to develop potent P2Y12 receptor antagonists with more favorable pharmacological properties. Prasugrel and ticagrelor are more potent and have a faster onset of action; however, they have shown an increased bleeding risk compared with clopidogrel. Cangrelor is highly potent and has a very rapid onset and offset of effect; however, its indication is limited to P2Y12 antagonist-naïve patients undergoing percutaneous coronary intervention. Two novel P2Y12 receptor antagonists are currently in clinical development, namely vicagrel and selatogrel. Vicagrel is an analog of clopidogrel with enhanced and more efficient formation of its active metabolite. Selatogrel is characterized by a rapid onset of action following subcutaneous administration and developed for early treatment of a suspected acute myocardial infarction. This review article describes the clinical pharmacology profile of marketed P2Y12 receptor antagonists and those under development focusing on pharmacokinetic, pharmacodynamic, and drug-drug interaction liability.
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Affiliation(s)
- Uta Schilling
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland.
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
| | - Mike Ufer
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Hegenheimermattweg 91, 4123, Allschwil, Switzerland
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23
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Moulias A, Papageorgiou A, Alexopoulos D. Platelet Function Testing and Genotyping for Tailoring Treatment in Complex PCI Patients. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Dual antiplatelet therapy (DAPT), comprising aspirin and a P2Y12 receptor inhibitor, is considered the cornerstone of treatment in patients who have undergone percutaneous coronary intervention (PCI). Patients with complex PCI (C-PCI) constitute a special PCI subpopulation, characterized by increased ischemic risk. Identifying the optimal DAPT strategy is often challenging and remains controversial in this setting. In an attempt to balance ischemic and bleeding risks in C-PCI patients receiving DAPT, treatment individualization regarding potency and duration has evolved as a feasible approach. Platelet function testing and genotyping have been evaluated in several trials with conflicting and mostly neutral results. The aim of this review is to critically appreciate the role of these tools for antiplatelet treatment tailoring specifically in C-PCI patients. Because existing evidence is limited, dedicated future studies are warranted to elucidate the utility of platelet function testing and genotyping in C-PCI.
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Affiliation(s)
- Athanasios Moulias
- Department of Cardiology, General University Hospital of Patras, Patras, Greece
| | | | - Dimitrios Alexopoulos
- Second Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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24
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Kobari Y, Inohara T, Saito T, Yoshijima N, Tanaka M, Tsuruta H, Yashima F, Shimizu H, Fukuda K, Naganuma T, Mizutani K, Yamawaki M, Tada N, Yamanaka F, Shirai S, Tabata M, Ueno H, Takagi K, Watanabe Y, Yamamoto M, Hayashida K. Aspirin Versus Clopidogrel as Single Antithrombotic Therapy After Transcatheter Aortic Valve Replacement: Insight From the OCEAN-TAVI Registry. Circ Cardiovasc Interv 2021; 14:e010097. [PMID: 34003663 DOI: 10.1161/circinterventions.120.010097] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Yusuke Kobari
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Taku Inohara
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Tetsuya Saito
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Nobuhiro Yoshijima
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Makoto Tanaka
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.).,Japanese Red Cross Ashikaga Hospital, Tochigi, Japan (M. Tanaka)
| | - Hikaru Tsuruta
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Fumiaki Yashima
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.).,Saiseikai Utsunomiya Hospital, Tochigi, Japan (F. Yashima)
| | - Hideyuki Shimizu
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | - Keiichi Fukuda
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
| | | | | | | | | | | | | | - Minoru Tabata
- Tokyo Bay Urayasu-Ichikawa Medical Center, Chiba, Japan (M. Tabata)
| | | | | | | | - Masanori Yamamoto
- Toyohashi Heart Center, Japan (M. Yamamoto).,Nagoya Heart Center, Japan (M. Yamamoto)
| | - Kentaro Hayashida
- Keio University School of Medicine, Tokyo, Japan (Y.K., T.I., T.S., N.Y., M. Tanaka, H.T., F. Yashima, H.S., K.F., K.H.)
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25
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Qu J, Zhang H, Rao C, Chen S, Zhao Y, Sun H, Song Y, Liu S, Wang L, Feng W, Wang S, Hu S, Zheng Z. Dual Antiplatelet Therapy with Clopidogrel and Aspirin Versus Aspirin Monotherapy in Patients Undergoing Coronary Artery Bypass Graft Surgery. J Am Heart Assoc 2021; 10:e020413. [PMID: 33998246 PMCID: PMC8483527 DOI: 10.1161/jaha.120.020413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background The optimal antiplatelet therapy after coronary artery bypass grafting remains unclear. We evaluated the association of dual antiplatelet therapy (DAPT) with clopidogrel plus aspirin and clinical outcomes among patients undergoing coronary artery bypass grafting. Methods and Results A total of 18 069 consecutive patients who underwent primary isolated coronary artery bypass grafting between 2013 and 2017 were identified from a contemporary registry, and 10 854 (60.1%) received DAPT with clopidogrel plus aspirin as determined by claimed prescriptions after surgery. Cox regression models with inverse probability of treatment weighting were used to examine the associations between DAPT and outcomes. Patients who received DAPT, compared with those who received aspirin monotherapy, had a lower incidence of a composite of all-cause death, myocardial infarction, stroke, or repeat revascularization at 6 months (2.9% versus 4.2%; inverse probability of treatment weighting-adjusted hazard ratio [HR], 0.65; 95% CI, 0.55-0.77; P<0.001) as well as death (HR, 0.61; 95% CI, 0.41-0.90), myocardial infarction (HR, 0.55; 95% CI, 0.40-0.74), and stroke (HR, 0.58; 95% CI, 0.46-0.74). The incidence of major bleeding did not differ significantly between the 2 groups (HR, 1.11; 95% CI, 0.69-1.78). Similar results were noted across multiple subgroups as well as when using different analytic methods. Conclusions Among patients undergoing coronary artery bypass grafting, DAPT with clopidogrel plus aspirin as secondary prevention was associated with reduced risk of major adverse cardiovascular and cerebrovascular events within 6 months as compared with aspirin monotherapy, and there was no significant increase in major bleeding.
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Affiliation(s)
- Jianyu Qu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Heng Zhang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Chenfei Rao
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Sipeng Chen
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Information Center Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Yan Zhao
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Hansong Sun
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Yunhu Song
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Sheng Liu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Liqing Wang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Wei Feng
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Shuiyun Wang
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Shengshou Hu
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
| | - Zhe Zheng
- National Clinical Research Center for Cardiovascular Diseases State Key Laboratory of Cardiovascular Disease Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China.,Department of Cardiovascular Surgery Fuwai HospitalNational Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical College Beijing People's Republic of China
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26
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Gelbenegger G, Erari-Canyurt U, Grafeneder J, Jilma B, Lesiak M, Komosa A, de Caterina R, Postula M, Siller-Matula JM. Optimal duration and combination of antiplatelet therapies following percutaneous coronary intervention: a meta-analysis. Vascul Pharmacol 2021; 138:106858. [PMID: 33753284 DOI: 10.1016/j.vph.2021.106858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/22/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The ideal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) is still unknown. In this meta-analysis, we aimed to compare very short-term (1-3 months), short-term (6 months), standard-term (12 months) and long-term (>12 months) DAPT durations for efficacy and safety. METHODS Overall DAPT comparisons were classified as "any shorter-term"/"any longer-term" DAPT. The primary outcome was a composite of major adverse cardiovascular events (MACE: non-fatal myocardial infarction, non-fatal stroke and cardiovascular death). The primary safety outcome was major bleeding. RESULTS Twenty-six studies comprising 103.394 patients were included. Compared with standard-term DAPT duration, very short-term DAPT duration with subsequent drop of aspirin (RR 1.06, 95% CI, 0.95-1.18, p = 0.26) or drop of the P2Y12 inhibitor (RR 0.92, 95% CI, 0.72-1.16, p = 0.47) was not associated with a higher risk of MACE. Any longer-term compared with any shorter-term DAPT durations led to a significantly lower risk of MACE (RR 0.88, 95% CI, 0.81-0.96, p = 0.002), but a significantly higher risk of BARC 3-5 major bleeding events (RR 1.63, 95% CI, 1.22-2.17, p = 0.001). In the ACS subgroup receiving prasugrel or ticagrelor but not clopidogrel, any longer-term DAPT duration was associated with a significantly lower risk of MACE compared to any shorter-term DAPT duration (RR 0.84, 95% CI, 0.77-0.92, p = 0.0001). CONCLUSION DAPT may be shortened to 1-3 months in patients with low ischemic but high bleeding risk followed by aspirin or P2Y12 monotherapy. Prasugrel or ticagrelor based DAPT may be extended to >12 months in case of high ischemic and low bleeding risk. PROSPERO REGISTRATION NO CRD42020163719.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ummahan Erari-Canyurt
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jürgen Grafeneder
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Komosa
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Raffaele de Caterina
- University of Pisa, Pisa, Italy; Fondazione Villa Serena per la Ricerca, Città S. Angelo, Pescara, Italy
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland.
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27
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Shi GX, Zhao ZH, Yang XY, Lin M, Chen ZX. Correlation study of CYP2C19 gene polymorphism and clopidogrel resistance in Han Chinese patients with cerebral infarction in Guizhou region. Medicine (Baltimore) 2021; 100:e24481. [PMID: 33578542 PMCID: PMC7886463 DOI: 10.1097/md.0000000000024481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 12/31/2020] [Indexed: 01/05/2023] Open
Abstract
This study conducts a correlation exploration of CYP2C19 gene polymorphism and clopidogrel resistance in Han Chinese patients with cerebral infarction in Guizhou Region.A total of 270 Han Chinese patients with cerebral infarction, who were hospitalized in our hospital from January 2016 to January 2018, are selected. These patients were divided into 2 groups, clopidogrel resistance group (n = 60) and clopidogrel sensitive group (n = 210). According to the TEG results, the CYP2C19 gene polymorphism detection was carried out by using the PCR-RFLP method, while IL-6 level in the patient's blood was measured by using the ELISA method.The resistance group occupies 22.22%. The platelet inhibition ratio of the resistance group was 23 ± 7%, which was significantly lower than that of the sensitive group (65 ± 13%), and the difference was statistically significant (P < .05). The Logisitic regression analysis revealed that the history of diabetes, history of high blood pressure, increase in low density lipoprotein and CYP2C19 mutant gene were independent risk factors of clopidogrel resistance. After treatment, the serum IL-6 level of patients in the resistance group was 17.21 ± 0.98 ng/L, which was significant higher than that of patients in the sensitive group (11.21 ± 0.68 ng/L), and the difference was statistically significant (P < .05).Patients with cerebral infarction in Guizhou region have a higher occurrence rate of clopidogrel resistance. Clopidogrel resistance not only will weaken the anti-inflammatory action of the drug, but also correlates with the patient's CYP2C19 mutant gene and blood lipid level.
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Affiliation(s)
- Guo-Xian Shi
- Department of Neurology, Guizhou Aerospace Hospital, Zunyi
| | - Zi-He Zhao
- Department of Dermatology, Beijing Chinese Medicine Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xiao-Yan Yang
- Department of Neurology, Guizhou Aerospace Hospital, Zunyi
| | - Mu Lin
- Department of Neurology, Guizhou Aerospace Hospital, Zunyi
| | - Zhou-Xue Chen
- Department of Neurology, Guizhou Aerospace Hospital, Zunyi
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28
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Yang J, Yu Q, Xu Z, Zheng N, Zhong J, Li J, Liu Y, Xu H, Su J, Ji L, Chen X. Clopidogrel Resistance Is Associated With DNA Methylation of Genes From Whole Blood of Humans. Front Genet 2021; 11:583215. [PMID: 33519892 PMCID: PMC7844369 DOI: 10.3389/fgene.2020.583215] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/26/2020] [Indexed: 12/31/2022] Open
Abstract
Antiplatelet therapy has become a cornerstone in the treatment of coronary heart disease (CHD). However, due to high-residual-platelet-reactivity, clopidogrel resistance (CR) is a common phenomenon, and it is rarely known about the relationship between CR and epigenetic changes. This study compared the whole genomic methylation patterns of blood samples from patients with CR (n = 6) and non-CR (n = 6) with the Human Methylation 850K BeadChip assay. We explored differentially methylated CpG sites, genes, and pathways using bioinformatics profiling. The CR and control groups showed significantly different DNA methylation at 7,098 sites, with 979 sites showing hypermethylation and 6,119 sites showing hypomethylation. The pyrosequencing method was used to validate four differentially methylated CpG loci (cg23371584, cg15971518, cg04481923, cg22507406), confirming that DNA methylation was associated with the risk of CR (30 CR vs. 30 non-CR). The relative mRNA expression of the four genes (BTG2, PRG2, VTRNA2-1, PER3) corresponding to the loci above was also associated with CR, suggesting that alterations in DNA methylation may affect the expression of these four genes, eventually resulting in CR. Additionally, differentially methylated sites are partially related to genes and pathways that play key roles in process of circadian entrainment, insulin secretion, and so on. Hence, the mechanism and biological regulation of CR might be reflected through these epigenetic alterations, but future research will need to address the causal relationships.
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Affiliation(s)
- Jin Yang
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, China
| | - Qinglin Yu
- Department of Traditional Chinese Internal Medicine, Ningbo No. 1 Hospital, Ningbo, China
| | - Zhifeng Xu
- Department of Cardiology, Zhenhai People's Hospital, Ningbo, China
| | - Nan Zheng
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, China.,Department of Cardiology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jinyan Zhong
- Department of Cardiology, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jiyi Li
- Department of Cardiology, Yuyao People's Hospital of Zhejiang Province, Yuyao, China
| | - Yahui Liu
- Key Laboratory, Ningbo No. 1 Hospital, Ningbo, China
| | - Hongyu Xu
- Department of Gerontology, Ningbo No. 1 Hospital, Ningbo, China
| | - Jia Su
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, China
| | - Lindan Ji
- Department of Biochemistry, School of Medicine, Ningbo University, Ningbo, China
| | - Xiaomin Chen
- Department of Cardiology, Ningbo No. 1 Hospital, Ningbo, China
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29
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Molecular Drivers of Platelet Activation: Unraveling Novel Targets for Anti-Thrombotic and Anti-Thrombo-Inflammatory Therapy. Int J Mol Sci 2020; 21:ijms21217906. [PMID: 33114406 PMCID: PMC7662962 DOI: 10.3390/ijms21217906] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular diseases (CVDs) are the leading cause of death globally-partly a consequence of increased population size and ageing-and are major contributors to reduced quality of life. Platelets play a major role in hemostasis and thrombosis. While platelet activation and aggregation are essential for hemostasis at sites of vascular injury, uncontrolled platelet activation leads to pathological thrombus formation and provokes thrombosis leading to myocardial infarction or stroke. Platelet activation and thrombus formation is a multistage process with different signaling pathways involved to trigger platelet shape change, integrin activation, stable platelet adhesion, aggregation, and degranulation. Apart from thrombotic events, thrombo-inflammation contributes to organ damage and dysfunction in CVDs and is mediated by platelets and inflammatory cells. Therefore, in the past, many efforts have been made to investigate specific signaling pathways in platelets to identify innovative and promising approaches for novel antithrombotic and anti-thrombo-inflammatory strategies that do not interfere with hemostasis. In this review, we focus on some of the most recent data reported on different platelet receptors, including GPIb-vWF interactions, GPVI activation, platelet chemokine receptors, regulation of integrin signaling, and channel homeostasis of NMDAR and PANX1.
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30
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Biesinger BS, Gasecka A, Perkmann T, Wojta J, Lesiak M, Grygier M, Eyileten C, Postuła M, Filipiak KJ, Toma A, Hengstenberg C, Siller-Matula JM. Inflammatory state does not affect the antiplatelet efficacy of potent P2Y12 inhibitors in ACS. Platelets 2020; 32:498-506. [PMID: 32501749 DOI: 10.1080/09537104.2020.1766670] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Inflammation leads to atherosclerosis and acute coronary syndromes (ACS). We performed a prospective, observational study to assess association between the concentrations of inflammatory markers (high sensitivity C-reactive protein, hsCRP; high sensitivity interleukin6, hsIL-6; soluble CD40 ligand, sCD40 L) and platelet reactivity in 338 patients with ACS treated with ticagrelor and prasugrel. We also assessed whether hsCRP, hsIL-6, and sCD40 L are associated with standard inflammatory markers (white blood cell [WBC] and fibrinogen), and whether they differ according to patient diabetic status and pre-treatment with statins. Concentrations of hsCRP and concentrations of hsIL-6 and sCD40 L were assessed using turbidimetric assay and enzyme-linked immunosorbent assay, respectively. Platelet reactivity was measured using multiple electrode aggregometry. There was only a weak inverse correlation between hsIL-6 and platelet reactivity (r≤-0.125). In contrast, concentration of hsIL6 and hsCRP positively correlated with WBC and fibrinogen (r ≥ 0.199). Insulin-dependent diabetes mellitus (IDDM) was associated with higher concentration of hsIL-6 (p = .014), whereas pre-treatment with statins - with lower concentration of hsIL-6 (p = .035). In conclusion, inflammatory state does not affect the antiplatelet efficacy of potent P2Y12 inhibitors in the acute phase of ACS, confirming the safety and efficacy of potent P2Y12 inhibitors in patients with a high inflammatory burden.
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Affiliation(s)
- Benedikt S Biesinger
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University Of Warsaw, Warsaw, Poland
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Pozna, Poland
| | - Marek Grygier
- 1 Department of Cardiology, Poznan University of Medical Sciences, Pozna, Poland
| | - Ceren Eyileten
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsow, Warsaw, Poland
| | - Marek Postuła
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsow, Warsaw, Poland
| | - Krzysztof J Filipiak
- 1 Chair and Department of Cardiology, Medical University Of Warsaw, Warsaw, Poland
| | - Aurel Toma
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsow, Warsaw, Poland
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31
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Patti G, Micieli G, Cimminiello C, Bolognese L. The Role of Clopidogrel in 2020: A Reappraisal. Cardiovasc Ther 2020; 2020:8703627. [PMID: 32284734 PMCID: PMC7140149 DOI: 10.1155/2020/8703627] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/31/2020] [Indexed: 01/01/2023] Open
Abstract
Antiplatelet therapy is the mainstay of treatment and secondary prevention of cardiovascular disease (CVD), including acute coronary syndrome (ACS), transient ischemic attack (TIA) or minor stroke, and peripheral artery disease (PAD). The P2Y12 inhibitors, of which clopidogrel was the first, play an integral role in antiplatelet therapy and therefore in the treatment and secondary prevention of CVD. This review discusses the available evidence concerning antiplatelet therapy in patients with CVD, with a focus on the role of clopidogrel. In combination with aspirin, clopidogrel is often used as part of dual antiplatelet therapy (DAPT) for the secondary prevention of ACS. Although newer, more potent P2Y12 inhibitors (prasugrel and ticagrelor) show a greater reduction in ischemic risk compared with clopidogrel in randomized trials of ACS patients, these newer P2Y12 inhibitors are often associated with an increased risk of bleeding. Deescalation of DAPT by switching from prasugrel or ticagrelor to clopidogrel may be required in some patients with ACS. Furthermore, real-world studies of ACS patients have not confirmed the benefits of the newer P2Y12 inhibitors over clopidogrel. In patients with very high-risk TIA or stroke, short-term DAPT with clopidogrel plus aspirin for 21-28 days, followed by clopidogrel monotherapy for up to 90 days, is recommended. Clopidogrel monotherapy may also be used in patients with symptomatic PAD. In conclusion, there is strong evidence supporting the use of clopidogrel antiplatelet therapy in several clinical settings, which emphasizes the importance of this medication in clinical practice.
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Affiliation(s)
- Giuseppe Patti
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Giuseppe Micieli
- Dipartimento di Neurologia d'Urgenza, IRCCS Fondazione Istituto Neurologico Nazionale C. Mondino, Pavia, Italy
| | - Claudio Cimminiello
- Studies and Research Center of the Italian Society of Angiology and Vascular Pathology (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), Milan, Italy
| | - Leonardo Bolognese
- Dipartimento Cardio Neuro Vascolare, Ospedale, San Donato, Arezzo, Italy
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32
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Jeżewski MP, Kubisa MJ, Eyileten C, De Rosa S, Christ G, Lesiak M, Indolfi C, Toma A, Siller-Matula JM, Postuła M. Bioresorbable Vascular Scaffolds-Dead End or Still a Rough Diamond? J Clin Med 2019; 8:E2167. [PMID: 31817876 PMCID: PMC6947479 DOI: 10.3390/jcm8122167] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/02/2019] [Accepted: 12/04/2019] [Indexed: 02/06/2023] Open
Abstract
Percutaneous coronary interventions with stent-based restorations of vessel patency have become the gold standard in the treatment of acute coronary states. Bioresorbable vascular scaffolds (BVS) have been designed to combine the efficiency of drug-eluting stents (DES) at the time of implantation and the advantages of a lack of foreign body afterwards. Complete resolution of the scaffold was intended to enable the restoration of vasomotor function and reduce the risk of device thrombosis. While early reports demonstrated superiority of BVS over DES, larger-scale application and longer observation exposed major concerns about their use, including lower radial strength and higher risk of thrombosis resulting in higher rate of major adverse cardiac events. Further focus on procedural details and research on the second generation of BVS with novel properties did not allow to unequivocally challenge position of DES. Nevertheless, BVS still have a chance to present superiority in distinctive indications. This review presents an outlook on the available first and second generation BVS and a summary of results of clinical trials on their use. It discusses explanations for unfavorable outcomes, proposed enhancement techniques and a potential niche for the use of BVS.
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Affiliation(s)
- Mateusz P. Jeżewski
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Michał J. Kubisa
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Ceren Eyileten
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Division of Cardiology, “Magna Graecia” University, 88100 Catanzaro, Italy; (S.D.R.); (C.I.)
| | - Günter Christ
- Department of Cardiology, 5th Medical Department with Cardiology, Kaiser Franz Josef Hospital, 31100 Vienna, Austria;
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, 1061701 Poznań, Poland;
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Division of Cardiology, “Magna Graecia” University, 88100 Catanzaro, Italy; (S.D.R.); (C.I.)
| | - Aurel Toma
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 231090 Vienna, Austria;
| | - Jolanta M. Siller-Matula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 231090 Vienna, Austria;
| | - Marek Postuła
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology, Medical University of Warsaw, 02091 Warsaw, Poland; (M.P.J.); (M.J.K.); (C.E.); (M.P.)
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33
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Ostrowska M, Kubica J, Adamski P, Kubica A, Eyileten C, Postula M, Toma A, Hengstenberg C, Siller-Matula JM. Stratified Approaches to Antiplatelet Therapies Based on Platelet Reactivity Testing. Front Cardiovasc Med 2019; 6:176. [PMID: 31850373 PMCID: PMC6901499 DOI: 10.3389/fcvm.2019.00176] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023] Open
Abstract
Antiplatelet therapy with P2Y12 receptor inhibitors (clopidogrel, prasugrel, ticagrelor, cangrelor) is a cornerstone of medical therapy after percutaneous coronary interventions. Significant prevalence of high on-treatment platelet reactivity (HTPR) on clopidogrel treatment led to introduction of more potent P2Y12 inhibitors: prasugrel (a third generation thienopyridine), ticagrelor, and cangrelor (cyclopentyl-triazolo-pyrimidines). Nevertheless, more potent platelet inhibition and resulting low on-treatment platelet reactivity (LTPR) has led to increased risk of major bleeding events. These limitations resulted in a need for an individualized antiplatelet therapy approach. This review discusses the current role and future perspectives of diagnostic tools such as platelet function testing to optimize antiplatelet therapy with a focus on deescalating therapies to reduce bleeding risks.
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Affiliation(s)
- Małgorzata Ostrowska
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Piotr Adamski
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Aldona Kubica
- Department of Health Promotion, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Ceren Eyileten
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Aurel Toma
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Jolanta M Siller-Matula
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland.,Department of Cardiology, Medical University of Vienna, Vienna, Austria
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34
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Gender-based differences in platelet function and platelet reactivity to P2Y12 inhibitors. PLoS One 2019; 14:e0225771. [PMID: 31774869 PMCID: PMC6881030 DOI: 10.1371/journal.pone.0225771] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 11/12/2019] [Indexed: 12/03/2022] Open
Abstract
Background Gender influences platelet biology. Women have a larger platelet count, but gender-based differences in platelet function remain debated. We performed a study addressing gender-based differences in platelet function using point-of-care platelet function tests (PFT). Methods The patient population consisted of 760 cardiac surgery patients where preoperative PFT (multiple-electrode aggregometry [MEA]) were available. Platelet count and function at the ADPtest and TRAPtest were compared in the overall population and separately in patients with or without residual effects of P2Y12 inhibitors. Results Women had a significantly (P = 0.001) higher platelet count but a non-significantly higher platelet reactivity to ADP. In clopidogrel-treated patients, the platelets ADP reactivity was significantly (P = 0.031) higher in women, and platelet count was the main determinant of platelet hyper-reactivity. Within patients under full clopidogrel effects, women with a platelet count ≥ 200,000 cells/μL had a significantly (P = 0.023) higher rate of high-on-treatment platelet reactivity (HTPR, 45.5%) with respect to males with a platelet count < 200,000 cells/μL (11.9%), with a relative risk of 6.2 (95% confidence interval 1.4–29). Conclusions Our findings confirm that women have a larger platelet count than men, and that this is associated to a trend towards a higher platelet reactivity. HTPR is largely represented in women with a high platelet count. This generates the hypothesis that women requiring P2Y12 inhibitors could potentially benefit from larger doses of drug or should be treated with anti-platelet agents with a low rate of HTPR.
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Atasoy D, Kandasamy N, Hart J, Lynch J, Yang SH, Walsh D, Tolias C, Booth TC. Outcome Study of the Pipeline Embolization Device with Shield Technology in Unruptured Aneurysms (PEDSU). AJNR Am J Neuroradiol 2019; 40:2094-2101. [PMID: 31727754 DOI: 10.3174/ajnr.a6314] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 09/20/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The recently introduced Pipeline Flex Embolization Device with Shield Technology (Pipeline Shield) is the third generation of Pipeline flow-diverter devices. It has a new stent-surface modification, which reduces thrombogenicity. We aimed to evaluate clinical and radiographic (safety and efficacy) outcomes of the Pipeline Shield. MATERIALS AND METHODS The 30-day and 1-year mortality and morbidity rates and the 6- and 18-month radiographic aneurysm occlusion outcomes for procedures performed between March 2016 and January 2018 were analyzed. 3D-TOF-MRA was used for follow-up. RESULTS Forty-four attempted Pipeline Shield procedures were performed for 41 patients with 44 target aneurysms (total of 52 aneurysms treated). A total of 88.5% of devices were inserted in the anterior circulation, and 11.5%, in the posterior circulation; 49/52 (94.2%) aneurysms were saccular; and 1/52 (1.9%) was fusiform. One (1.9%) aneurysm was an iatrogenic pseudoaneurysm, and 1 (1.9%) was a dissecting aneurysm. Seventy-one percent (35/49) of the saccular aneurysms were wide-neck (neck, >4 mm), 34.6% (18/52) were large (≥10 mm), and 3.8% (2/52) were giant (≥25 mm). The mean aneurysm sac maximal diameter was 9.0 mm, and the mean neck width was 5.0 mm. The cumulative mortality and morbidity rates were 2.3% and 6.8% at 1 year, respectively. The adequate occlusion rate was 78.8% at 6 months and 90.3% at 18 months. CONCLUSIONS In this pragmatic and non-industry-sponsored study, the occlusion rates and safety outcomes were similar to those seen in previously published studies with flow-diverter devices and earlier generation Pipeline Embolization Devices.
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Affiliation(s)
- D Atasoy
- From Karadeniz Technical University (D.A.), Farabi Hospital, Trabzon, Turkey
| | - N Kandasamy
- Departments of Neuroradiology (N.K., J.H., J.L., T.C.B.)
| | - J Hart
- Departments of Neuroradiology (N.K., J.H., J.L., T.C.B.)
| | - J Lynch
- Departments of Neuroradiology (N.K., J.H., J.L., T.C.B.)
| | - S-H Yang
- Department of Radiology (S.-H.Y.), Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Radiology (S.-H.Y.), School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - D Walsh
- Neurosurgery (D.W., C.T.), King's College Hospital National Health Service Foundation Trust, London, UK
| | - C Tolias
- Neurosurgery (D.W., C.T.), King's College Hospital National Health Service Foundation Trust, London, UK
| | - T C Booth
- Departments of Neuroradiology (N.K., J.H., J.L., T.C.B.) .,School of Biomedical Engineering and Imaging Sciences (T.C.B.), King's College London, London, UK
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Kapedanovska-Nestorovska A, Dimovski AJ, Sterjev Z, Matevska Geskovska N, Suturkova L, Ugurov P, Mitrev Z, Rosalia R. The AKR1D1*36 ( rs1872930) Allelic Variant Is Independently Associated With Clopidogrel Treatment Outcome. Pharmgenomics Pers Med 2019; 12:287-295. [PMID: 31695473 PMCID: PMC6814350 DOI: 10.2147/pgpm.s222212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS The present observational cohort study evaluated the association between the AKR1D1*36 (rs1872930) allele and the risk of major adverse cardiovascular and cerebrovascular events (MACCE) in clopidogrel treated patients. METHODS We screened 198 consecutive cardiovascular patients on clopidogrel therapy admitted in October to November 2010 with cardiovascular or cerebrovascular symptoms; of these 118 met the study protocol entry criteria; the median age of the cohort was 62.5 years (IQR 57-66 years), and 55% were females. RESULTS The median follow up time was 38.5 (IQR 24-48) months; Kaplan-Meier/Log-rank analysis showed that patients carrying the AKR1D1*36 allelic variant have a shorter event-free-survival compared to wild type patients, hazard ratio = 2.193 (95% CI, 1.091 to 4.406); p = 0.0155. Multivariable Cox regression analysis confirmed the AKR1D1*36 allele as an independent risk factor (HR = 2.36; 95% CI, 1.34 to 4.18) and identified 3 other risk factors for MACCE; previous percutaneous interventions (PCI), HR = 2.78; (95% CI, 1.34 to 5.78), and a history of myocardial infarction, HR = 2.62; (95% CI, 1.48 to 4.64) at baseline and the previously reported CYP2C19*2 polymorphism (HR = 2.33; 95% CI, 1.33 to 4.06). CONCLUSION The AKR1D1*36 (rs1872930) variant is independently associated with a higher risk for MACCE and shorter event-free survival time.
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Affiliation(s)
- Aleksandra Kapedanovska-Nestorovska
- Center for Biomolecular and Pharmaceutical Analysis, Faculty of Pharmacy, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Aleksandar J Dimovski
- Center for Biomolecular and Pharmaceutical Analysis, Faculty of Pharmacy, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
- Research Center for Genetic Engineering and Biotechnology “Georgi D.Efremov”, Macedonian Academy of Sciences and Arts, Skopje, Republic of North Macedonia
| | - Zoran Sterjev
- Center for Biomolecular and Pharmaceutical Analysis, Faculty of Pharmacy, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Nadica Matevska Geskovska
- Center for Biomolecular and Pharmaceutical Analysis, Faculty of Pharmacy, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Ljubica Suturkova
- Center for Biomolecular and Pharmaceutical Analysis, Faculty of Pharmacy, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Petar Ugurov
- Semi Intensive Care Unit, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Zan Mitrev
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Rodney Rosalia
- Department of Clinical Research, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
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Winter M, Schneeweiss T, Cremer R, Biesinger B, Hengstenberg C, Prüller F, Wallner M, Kolesnik E, von Lewinski D, Lang IM, Siller‐Matula JM. Platelet reactivity patterns in patients treated with dual antiplatelet therapy. Eur J Clin Invest 2019; 49:e13102. [PMID: 30882911 PMCID: PMC6593782 DOI: 10.1111/eci.13102] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/06/2019] [Accepted: 03/12/2019] [Indexed: 01/24/2023]
Abstract
AIM The aim of the present study was to investigate the patterns of platelet reactivity and discriminators of therapeutic response to dual antiplatelet therapy (DAPT) with aspirin and ticagrelor or prasugrel in patients with acute coronary syndrome (ACS). DESIGN In this multicentre prospective observational study, 492 patients with ACS were enrolled. Platelet aggregation was determined by multiple electrode aggregometry after stimulation with adenosine diphosphate (ADP) or arachidonic acid (AA) as agonists in the maintenance phase of treatment with prasugrel or ticagrelor. RESULTS Age emerged as the strongest variable influencing aspirin response status: The mean AA-induced platelet aggregation in patients <49 years of age was 49% higher than in those >49 years (13.1 U vs 8.8 U; P = 0.011). The second strongest discriminator of aspirin response was sex: Male patients had a 40% higher AA-induced platelet aggregation values than female patients (9.5 U vs 6.8 U; P = 0.026). Platelet count emerged as the only variable influencing ADP antagonists response status showing that patients with platelet count >320 g/L displayed higher ADP-induced platelet aggregation. About 12% of patients had high on-treatment platelet reactivity (HTPR) to aspirin, 3% and 4% a HTPR to prasugrel and ticagrelor, respectively, and only 2% displayed HTPR to dual antiplatelet therapy. CONCLUSION When potent platelet inhibitors as prasugrel and ticagrelor are administered with aspirin, HTPR to DAPT plays only a marginal role.
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Affiliation(s)
- Max‐Paul Winter
- Department of CardiologyMedical University of ViennaViennaAustria
| | | | - Rolf Cremer
- Department of CardiologyMedical University of ViennaViennaAustria
| | | | | | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory DiagnosticsMedical University of GrazGrazAustria
| | - Markus Wallner
- Department of CardiologyMedical University of GrazGrazAustria
| | - Ewald Kolesnik
- Department of CardiologyMedical University of GrazGrazAustria
| | | | - Irene M. Lang
- Department of CardiologyMedical University of ViennaViennaAustria
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Hengstenberg C, Siller-Matula JM. Shedding Light on Long-Term Effects of Early Antiplatelet Strategies After Fibrinolytic Treatment in STEMI. J Am Coll Cardiol 2019; 73:2829-2831. [DOI: 10.1016/j.jacc.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 04/14/2019] [Indexed: 11/28/2022]
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Warlo EMK, Arnesen H, Seljeflot I. A brief review on resistance to P2Y 12 receptor antagonism in coronary artery disease. Thromb J 2019; 17:11. [PMID: 31198410 PMCID: PMC6558673 DOI: 10.1186/s12959-019-0197-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background Platelet inhibition is important for patients with coronary artery disease. When dual antiplatelet therapy (DAPT) is required, a P2Y12-antagonist is usually recommended in addition to standard aspirin therapy. The most used P2Y12-antagonists are clopidogrel, prasugrel and ticagrelor. Despite DAPT, some patients experience adverse cardiovascular events, and insufficient platelet inhibition has been suggested as a possible cause. In the present review we have performed a literature search on prevalence, mechanisms and clinical implications of resistance to P2Y12 inhibitors. Methods The PubMed database was searched for relevant papers and 11 meta-analyses were included. P2Y12 resistance is measured by stimulating platelets with ADP ex vivo and the most used assays are vasodilator stimulated phosphoprotein (VASP), Multiplate, VerifyNow (VN) and light transmission aggregometry (LTA). Discussion/conclusion The frequency of high platelet reactivity (HPR) during clopidogrel therapy is predicted to be 30%. Genetic polymorphisms and drug-drug interactions are discussed to explain a significant part of this inter-individual variation. HPR during prasugrel and ticagrelor treatment is estimated to be 3–15% and 0–3%, respectively. This lower frequency is explained by less complicated and more efficient generation of the active metabolite compared to clopidogrel. Meta-analyses do show a positive effect of adjusting standard clopidogrel treatment based on platelet function testing. Despite this, personalized therapy is not recommended because no large-scale RCT have shown any clinical benefit. For patients on prasugrel and ticagrelor, platelet function testing is not recommended due to low occurrence of HPR.
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Affiliation(s)
- Ellen M K Warlo
- 1Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Pb 4956 Nydalen, 0424 Oslo, Norway.,2Faculty of Medicine, University of Oslo, Oslo, Norway.,3Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Harald Arnesen
- 1Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Pb 4956 Nydalen, 0424 Oslo, Norway.,2Faculty of Medicine, University of Oslo, Oslo, Norway.,3Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Ingebjørg Seljeflot
- 1Center for Clinical Heart Research, Department of Cardiology, Oslo University Hospital, Pb 4956 Nydalen, 0424 Oslo, Norway.,2Faculty of Medicine, University of Oslo, Oslo, Norway.,3Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Laizure SC, Hu ZY, Potter PM, Parker RB. Inhibition of carboxylesterase-1 alters clopidogrel metabolism and disposition. Xenobiotica 2019; 50:245-251. [DOI: 10.1080/00498254.2019.1612535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- S. Casey Laizure
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Zhe-Yi Hu
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Philip M. Potter
- Department of Chemical Biology and Therapeutics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Robert B. Parker
- Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, USA
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Nishikawa M, Takeda Y, Isomura N, Tanigawa T, Nanasato M, Tsukahara K, Kimura K, Takayama T, Hirayama A, Kato M, Nishikawa H, Nishimura Y, Isshiki T, Yokoi H. Association between High Platelet Reactivity Following Dual Antiplatelet Therapy and Ischemic Events in Japanese Patients with Coronary Artery Disease Undergoing Stent Implantation. J Atheroscler Thromb 2019; 27:13-24. [PMID: 31092743 PMCID: PMC6976717 DOI: 10.5551/jat.48934] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM Although high on-treatment platelet reactivity (HTPR) with dual antiplatelet therapy (DAPT) correlates with long-term adverse outcomes in patients undergoing percutaneous coronary intervention, the correlation in Japanese patients remains unclear. Therefore, we examined the relationship between platelet reactivity during DAPT with aspirin and clopidogrel and 1-year clinical outcomes following successful coronary stent implantation. METHODS A prospective, multicenter registry study (j-CHIPS) was conducted in patients undergoing coronary stenting and receiving aspirin and clopidogrel at 16 hospitals in Japan. A VerifyNow point-of-care assay was used to assess platelet reactivity, and a cutoff value to define HTPR was established. RESULTS Between February 2011 and May 2013, 1047 patients were prospectively enrolled, of which 854 patients with platelet function evaluation at 12-24 h after PCI were included in the final analysis. After 1 year of follow-up, the incidence of the primary endpoint (a composite of all-cause mortality, myocardial infarction, stent thrombosis, and ischemic stroke) was significantly higher in patients with HTPR than in those without (5.9% vs. 1.5%, p=0.008), and HTPR showed a modest ability to discriminate between patients who did and did not experience major adverse cardiac and cerebrovascular events (area under the curve, 0.60; 95% confidence interval, 0.511-0.688, p=0.039). HTPR status did not identify patients at risk for major or minor bleeding events. CONCLUSION HTPR was significantly associated with adverse ischemic outcomes at 1 year after PCI in Japanese patients receiving maintenance DAPT, indicating its potential as a prognostic indicator of clinical outcomes in this high-risk patient population.
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Affiliation(s)
| | | | - Naoei Isomura
- Department of Cardiology, Showa University Northern Yokohama Hospital
| | | | - Mamoru Nanasato
- Cardiovascular Center, Japanese Red Cross Nagoya Daini Hospital
| | | | | | - Tadateru Takayama
- Department of Cardiovascular Medicine, Nihon University Itabashi Hospital
| | - Atsushi Hirayama
- Department of Cardiovascular Medicine, Nihon University Itabashi Hospital
| | | | | | - Yuki Nishimura
- Clinical Research Support Center, Mie University Hospital
| | | | - Hiroyoshi Yokoi
- Cardiovascular Center, Fukuoka Sanno Hospital.,Division of Cardiology, Kokura Memorial Hospital
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Davis BH, Dillon C, Cai A, Williams III LA, Pamboukian SV, Limdi NA. Between a rock and a hard place: a high-risk patient with resistance to multiple P2Y 12 antagonists. Pharmacogenomics 2019; 20:475-481. [PMID: 31124414 PMCID: PMC6563016 DOI: 10.2217/pgs-2018-0201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/01/2019] [Indexed: 01/14/2023] Open
Abstract
Impaired response to P2Y12 receptor antagonists, such as clopidogrel and prasugrel, can have devastating consequences for patients that require prolonged or indefinite therapy with these agents, including those with a left ventricular assist device (LVAD). While loss-of-function (LOF) alleles in CYP2C19 have been elucidated as contributing to high on treatment platelet reactivity (HTPR) during clopidogrel therapy, genetic variations in the metabolic pathway of prasugrel have not been shown to elicit this same effect. Moreover, limited studies have assessed the effect of coexisting genetic variations in pharmacokinetic and pharmacodynamic pathways. Herein, we report a left ventricular assist device patient exhibiting high on treatment platelet reactivity during clopidogrel and prasugrel therapy. Genotyping revealed variants in pharmacokinetic (CYP2B6), and pharmacodynamic pathways, with multiple variants in P2Y12, the target receptor.
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Affiliation(s)
- Brittney H Davis
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA 35294
| | - Chrisly Dillon
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA 35294
| | - Anping Cai
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA 35294
| | - Lance A Williams III
- Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, AL, USA 35249
| | - Salpy V Pamboukian
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA 35242
| | - Nita A Limdi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA 35294
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Leonardi S, Franzone A, Piccolo R, McFadden E, Vranckx P, Serruys P, Benit E, Liebetrau C, Janssens L, Ferrario M, Zurakowski A, van Geuns RJ, Dominici M, Huber K, Slagboom T, Buszman P, Bolognese L, Tumscitz C, Bryniarski K, Aminian A, Vrolix M, Petrov I, Garg S, Naber C, Prokopczuk J, Hamm C, Steg G, Heg D, Juni P, Windecker S, Valgimigli M. Rationale and design of a prospective substudy of clinical endpoint adjudication processes within an investigator-reported randomised controlled trial in patients with coronary artery disease: the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY). BMJ Open 2019; 9:e026053. [PMID: 30852547 PMCID: PMC6429932 DOI: 10.1136/bmjopen-2018-026053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The GLOBAL LEADERS is an open-label, pragmatic and superiority randomised controlled trial designed to challenge the current treatment paradigm of dual antiplatelet therapy (DAPT) for 12 months followed by aspirin monotherapy among patients undergoing percutaneous coronary intervention. By design, all study endpoints are investigator reported (IR) and not subject to formal adjudication by an independent Clinical Event Committee (CEC), which may introduce detection, reporting or ascertainment bias. METHODS AND ANALYSIS We designed the GLOBAL LEADERS Adjudication Sub-StudY (GLASSY) to prospectively implement, in a large sample of patients enrolled within the GLOBAL LEADERS trial (7585 of 15 991, 47.5%), an independent adjudication process of reported and unreported potential endpoints, using standardised CEC procedures, in order to assess whether 23-month ticagrelor monotherapy (90 mg twice daily) after 1-month DAPT is non-inferior to a standard regimen of DAPT for 12 months followed by aspirin monotherapy for the primary efficacy endpoint of death, non-fatal myocardial infarction, non-fatal stroke or urgent target vessel revascularisation and superior for the primary safety endpoint of type 3 or 5 bleeding according to the Bleeding Academic Research Consortium criteria.This study will comprehensively assess the comparative safety and efficacy of the two tested antithrombotic strategies on CEC-adjudicated ischaemic and bleeding endpoints and will provide insights into the role of a standardised CEC adjudication process on the interpretation of study findings by quantifying the level of concordance between IR-reported and CEC-adjudicated events. ETHICS AND DISSEMINATION GLASSY has been approved by local ethics committee of all study sites and/or by the central ethics committee for the country depending on country-specific regulations. In all cases, they deemed that it was not necessary to obtain further informed consent from individual subjects. TRIAL REGISTRATION NUMBER NCT01813435.
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Affiliation(s)
- Sergio Leonardi
- University of Pavia, Department of Molecular Medicine, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Raffaele Piccolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Eugene McFadden
- Department of Cardiology, Cork University Hospital Group, Cork, Ireland
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
| | - Patrick Serruys
- Department of Cardiology, Imperial College of London, London, UK
| | - Edouard Benit
- Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Heart and Thorax Centre, Bad Nauheim, Germany
| | - Luc Janssens
- Department of Cardiology, Imelda Hospital, Bonheiden, Belgium
| | - Maurizio Ferrario
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aleksander Zurakowski
- Center of Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | | | - Marcello Dominici
- Department of Cardiology, S. Maria University-Hospital, Terni, Italy
| | - Kurt Huber
- 3rd Med Department, Cardiology and Emergency Medicine, Wilhelminenhospital, Vienna, Austria
| | - Ton Slagboom
- Department of Cardiology, OLVG, Amsterdam, The Netherlands
| | - Paweł Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Poland, Poland
| | | | - Carlo Tumscitz
- Department of Cardiology, Azienda Ospedaliero Universitaria di Ferrara Arcispedale Sant’Anna, Cona, Italy
| | - Krzysztof Bryniarski
- Jagiellonian University Medical College, The John Paul II Hospital, Krakow, Poland
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Mathias Vrolix
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ivo Petrov
- Department of Cardiology, Adzhibadem Siti Klinik Surdechno-sudovi Center, Sofia, Bulgaria
| | - Scot Garg
- Department of Cardiology, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Christoph Naber
- Department of Cardiology and Angiology, Contilia Heart and Vascular Centre, Essen, Germany
| | | | | | - Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Dik Heg
- CTU, Institute of Social and Preventive Medicine and Clinical Trials Unit, Bern, Switzerland
| | - Peter Juni
- Department of Medicine, Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Canada
| | - Stephan Windecker
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital Universitatsspital Bern, Bern, Switzerland
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Nafrialdi N, Handini NM, Instiaty I, Wijaya IP. A cost-effectiveness and safety analysis of dual antiplatelet therapy comparing aspirin–clopidogrel to aspirin–ticagrelor in patients with acute coronary syndrome. MEDICAL JOURNAL OF INDONESIA 2018. [DOI: 10.13181/mji.v27i4.3024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Background: Dual antiplatelet therapy (DAPT) using either an aspirin–clopidogrel (A–C) combination or aspirin–ticagrelor (A–T) combination has become the standard therapy for acute coronary syndrome (ACS). Ticagrelor shows better pharmacokinetic profiles but is more expensive. This study aimed to compare cost-effectiveness and safety profiles of A–C versus A–T in patients with ACS.Methods: This was a retrospective cohort study of ACS patient at the Cipto Mangunkusumo Hospital between 2014 and 2016. ACS patients treated for the first time with A–T or A–C were included. Occurrence of major adverse cardiovascular events (MACE) within 3, 6, 9, and 12 months were used as effectiveness outcomes, while safety outcomes were measured based on the incidence of adverse drug reactions (major and minor bleeding, dyspnea, and hyperuricemia). Cost-effectiveness analysis was presented as incremental cost-effectiveness ratio (ICER).Results: Data records obtained from 123 ACS patients treated with A–C and 57 ACS patients treated with A–T were evaluated. Within the first three months, the MACE rate was 15.8% in the A–T group and 31.7% in the A–C group (RR: 0.498, 95% CI: 0.259–0.957, p=0.039). There was no statistically significant difference observed in the number of MACE between groups after 6, 9, and 12 months. The A–T group had a higher incidence of major bleeding (melena) than the A–C group (5.3% vs 1.62%, p=0.681), especially in geriatric patients. Minor bleeding was observed in three patients of the A–C group, but in none of the patients in the A–T group. The cost of ICER was IDR 279,438, indicating the additional cost needed for avoiding MACE within 3 months, if A–T was used.Conclusion: The aspirin–ticagrelor combination is a clinically superior and cost-effective option for MACE prevention among ACS patients, especially during the first three months of DAPT, with a slight but not significantly higher major bleeding risk when compared to the aspirin–clopidogrel combination.
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Abstract
Patients surviving an acute coronary syndrome (ACS) remain at increased risk of ischemic events long term. This paper reviews current evidence and guidelines for oral antiplatelet therapy for secondary prevention following ACS, with respect to decreased risk of ischemic events versus bleeding risk according to individual patient characteristics and risk factors. Specifically, data are reviewed from clinical studies of clopidogrel, prasugrel, ticagrelor and vorapaxar, as well as the results of systematic reviews and meta-analyses looking at the benefits and risks of oral antiplatelet therapy, and the relative merits of shorter versus longer duration of dual antiplatelet therapy, in different patient groups.
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Affiliation(s)
- Jeffrey S Berger
- Division of Cardiology, New York University Langone Medical Center, New York, NY, USA.
- Marc and Ruti Bell Program in Vascular Biology, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY, 10016, USA.
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46
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Verdoia M, Pergolini P, Rolla R, Suryapranata H, Kedhi E, De Luca G. Impact of immature platelet fraction on platelet reactivity during prasugrel maintenance treatment. Platelets 2018; 30:915-922. [DOI: 10.1080/09537104.2018.1535707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Monica Verdoia
- Division of Cardiology, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, Eastern Piedmont University, Novara, Italy
| | - Patrizia Pergolini
- Clinical Chemistry, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, Eastern Piedmont University, Novara, Italy
| | - Roberta Rolla
- Clinical Chemistry, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, Eastern Piedmont University, Novara, Italy
| | | | - Elvin Kedhi
- Division of Cardiology, ISALA Hospital, Zwolle, The Netherlands
| | - Giuseppe De Luca
- Division of Cardiology, Azienda Ospedaliera-Universitaria “Maggiore della Carità”, Eastern Piedmont University, Novara, Italy
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47
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Lim HH, Jeong IH, An GD, Woo KS, Kim KH, Kim JM, Cha JK, Han JY. Early prediction of severity in acute ischemic stroke and transient ischemic attack using platelet parameters and neutrophil-to-lymphocyte ratio. J Clin Lab Anal 2018; 33:e22714. [PMID: 30411816 DOI: 10.1002/jcla.22714] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND It is still not easy to predict severity promptly in patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA). We investigated that platelet parameters or combinations of them could be a useful tool for early prediction of severity of AIS and TIA at admission and after 3 months. METHODS We prospectively recruited 104 patients newly diagnosed with AIS and TIA. We investigated their neutrophil-to-lymphocyte ratio (NLR) and platelet parameters. According to the Modified Rankin Scale scores, the patients were divided into two groups. RESULTS In receiver operating characteristic (ROC) curve analyses, mean platelet volume (MPV), NLR/platelet count (PLT), MPV/PLT, MPV*NLR, and MPV*NLR/PLT showed statistically significant results in both at admission and after 3 months. Values of area under ROC curves for those tests at admission were 0.646, 0.697, 0.664, 0.708, and 0.722, respectively. Also, values after 3 months were 0.591, 0.661, 0.638, 0.662, and 0.689, respectively. CONCLUSION MPV*NLR/PLT could be used as a relatively good tool for predicting severity at the time of admission and after 3 months than other parameters or combinations of them. Further studies have to be carried out to investigate the best parameter for predicting the severity of AIS and TIA.
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Affiliation(s)
- Hyeon-Ho Lim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - In-Hwa Jeong
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Gyu-Dae An
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kwang-Sook Woo
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Kyeong-Hee Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jeong-Man Kim
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University College of Medicine, Busan, Korea
| | - Jin-Yeong Han
- Department of Laboratory Medicine, Dong-A University College of Medicine, Busan, Korea
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48
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Yang A, Pon Q, Lavoie A, Crawford JJ, Harenberg S, Zimmermann RH, Booker J, Kelly S, Lavi S, Cantor WJ, Mehta SR, Bagai A, Goodman SG, Cheema AN, Dehghani P. Long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in fibrinolytic-treated STEMI patients undergoing early PCI. J Thromb Thrombolysis 2018; 45:225-233. [PMID: 29170875 DOI: 10.1007/s11239-017-1581-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3-168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = - 189.7; p < 0.001) to 24 h (71.7 vs. 27.7; Mdiff = - 44.0; p < 0.001) to end of follow-up (27.7 vs.17.9; Mdiff = - 9.9. p = 0.016) for those randomized to Ticagrelor and significant decreases in PRU only from baseline to 4 h (271.3 vs. 200.8; Mdiff = - 70.5, p = < 0.001) in patients receiving Clopidogrel, and a significantly greater proportion of patients with adequate platelet inhibition (PRU < 208) on long-term follow-up (Clopidogrel, 82.6% vs. Ticagrelor, 100.0%; p = 0.038). Our results demonstrate that in patients undergoing PCI within 24 h of fibrinolysis for STEMI, Ticagrelor provides prolonged platelet inhibition compared with Clopidogrel.
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Affiliation(s)
- Andrew Yang
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Quin Pon
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Jennifer J Crawford
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Sebastian Harenberg
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Rodney H Zimmermann
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Jeff Booker
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Sheila Kelly
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada
| | - Shahar Lavi
- London Health Sciences, University of London, London, ON, Canada
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Newmarket, ON, Canada
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Shaun G Goodman
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Asim N Cheema
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Payam Dehghani
- Prairie Vascular Research Network and Regina Qu'Appelle Health Region, University of Saskatchewan, Regina General Hospital Unit 3A (CCU), Interventional Cardiology Research Office 1440-14th Ave., Regina, SK, Canada.
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49
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Harding SA, Holley A, Wilkins B, Fairley S, Simmonds M, Larsen PD. Contemporary antiplatelet therapy in acute coronary syndromes: are there differences in outcomes and discontinuation between clopidogrel and ticagrelor? Intern Med J 2018; 47:1298-1305. [PMID: 28857445 DOI: 10.1111/imj.13595] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/10/2017] [Accepted: 08/17/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND/AIM We studied clinical outcomes and discontinuation rates in a 'real-world' population presenting with myocardial infarction treated with ticagrelor or clopidogrel. METHODS Between January 2012 and May 2015, 992 patients with acute myocardial infarction undergoing invasive management and adequately pre-treated with dual antiplatelet therapy were prospectively enrolled. Platelet aggregation was measured using the Multiplate analyser. Baseline characteristics, in-hospital outcomes and 1-year outcomes were collected. RESULTS Patients treated with ticagrelor were younger and less likely to be diabetic, have a previous myocardial infarction or present with a ST-elevation myocardial infarction (all P < 0.05). Those treated with ticagrelor also had lower CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines; 20 ± 9.4 vs 23 ± 10.1, P < 0.0001) and GRACE (119 ± 28 vs 126 ± 32, P = 0.002) scores. High platelet reactivity was greatly reduced with ticagrelor compared to clopidogrel (16.1% vs 37.0%, respectively; P < 0.0001). Non-coronary artery bypass grafting-related thrombolysis in myocardial infarction major and minor bleeding occurred at similar rates in those treated with ticagrelor and clopidogrel. Rates of drug discontinuation in those treated with ticagrelor and clopidogrel were similar in hospital (20.2% vs 16.2%, P = 0.18) and between discharge and 1 year (29.9% vs 27.9%, P = 0.63). However, discontinuation due to dyspnoea, (3.3% vs 0%, P < 0.0001) and discontinuation due to any possible drug-related adverse event (9.3% vs 2.2%, P = 0.0001) was more common in those treated with ticagrelor compared to clopidogrel CONCLUSION: Ticagrelor is paradoxically being used in lower-risk patients rather than those most likely to benefit. Ticagrelor was associated with similar rates of bleeding but higher discontinuation rates due to adverse effects compared to clopidogrel.
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Affiliation(s)
- Scott A Harding
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Cardiology, Wellington Hospital, Wellington, New Zealand.,School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Ana Holley
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, Wellington, New Zealand
| | - Ben Wilkins
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Sarah Fairley
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Mark Simmonds
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Cardiology, Wellington Hospital, Wellington, New Zealand
| | - Peter D Larsen
- Wellington Cardiovascular Research Group, Wellington, New Zealand.,Department of Surgery and Anaesthesia, University of Otago, Wellington, Wellington, New Zealand
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50
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Cameron SJ, Mix DS, Ture SK, Schmidt RA, Mohan A, Pariser D, Stoner MC, Shah P, Chen L, Zhang H, Field DJ, Modjeski KL, Toth S, Morrell CN. Hypoxia and Ischemia Promote a Maladaptive Platelet Phenotype. Arterioscler Thromb Vasc Biol 2018; 38:1594-1606. [PMID: 29724818 PMCID: PMC6023774 DOI: 10.1161/atvbaha.118.311186] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 04/17/2018] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Objective— Reduced blood flow and tissue oxygen tension conditions result from thrombotic and vascular diseases such as myocardial infarction, stroke, and peripheral vascular disease. It is largely assumed that while platelet activation is increased by an acute vascular event, chronic vascular inflammation, and ischemia, the platelet activation pathways and responses are not themselves changed by the disease process. We, therefore, sought to determine whether the platelet phenotype is altered by hypoxic and ischemic conditions. Approach and Results— In a cohort of patients with metabolic and peripheral artery disease, platelet activity was enhanced, and inhibition with oral antiplatelet agents was impaired compared with platelets from control subjects, suggesting a difference in platelet phenotype caused by the disease. Isolated murine and human platelets exposed to reduced oxygen (hypoxia chamber, 5% O2) had increased expression of some proteins that augment platelet activation compared with platelets in normoxic conditions (21% O2). Using a murine model of critical limb ischemia, platelet activity was increased even 2 weeks postsurgery compared with sham surgery mice. This effect was partly inhibited in platelet-specific ERK5 (extracellular regulated protein kinase 5) knockout mice. Conclusions— These findings suggest that ischemic disease changes the platelet phenotype and alters platelet agonist responses because of changes in the expression of signal transduction pathway proteins. Platelet phenotype and function should, therefore, be better characterized in ischemic and hypoxic diseases to understand the benefits and limitations of antiplatelet therapy.
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Affiliation(s)
- Scott J Cameron
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.) .,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
| | - Doran S Mix
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Sara K Ture
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Rachel A Schmidt
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Amy Mohan
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Daphne Pariser
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Michael C Stoner
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Punit Shah
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Lijun Chen
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - Hui Zhang
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD (P.S., L.C., H.Z.)
| | - David J Field
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Kristina L Modjeski
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.)
| | - Sandra Toth
- Division of Vascular Surgery, Department of Surgery (D.S.M., M.C.S., S.T.), University of Rochester School of Medicine, NY
| | - Craig N Morrell
- From the Aab Cardiovascular Research Institute (S.J.C., S.K.T., R.A.S., A.M., D.P., D.J.F., K.L.M., C.N.M.).,Division of Cardiology, Department of Medicine (S.J.C., C.N.M.)
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